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Biomedical subjects

L Gelberg

Publications and source records attributed to L Gelberg.

At least 19 recordsLinked to original sources
PubMed1997

Tuberculosis skin testing among homeless adults.

OBJECTIVE: To document the prevalence of tuberculosis (TB) skin test positivity among homeless adults in Los Angeles and determine whether certain characteristics of homelessness were risk factors for TB. DESIGN: Cross-sectional study. SETTING: Shelters, soup lines, and outdoor locations in the Skid Row and Westside areas of Los Angeles. PARTICIPANTS: A representative sample of 260 homeless adults. MEASUREMENTS AND MAIN RESULTS: Tuberculosis tine test reactivity was measured. The overall prevalence of TB skin test positivity was 32%:40% in the inner-city Skid Row area and 14% in the suburban Westside area. Using multiple logistic regression, TB skin test positivity was found to be associated with living in crowded or potentially crowded shelter conditions, long-term homelessness, geographic area, history of a psychiatric hospitalization, and age. CONCLUSIONS: Homeless adults living in congested inner-city areas are at high risk of both latent and active TB. Endemic risk factors and limited access to medical care support the need for aggressive treatment of active TB cases and innovative programs to ensure completion of prophylactic regimens by homeless individuals with latent infection.

Adult↗
PubMed1997

Testing for human immunodeficiency virus infection among tuberculosis patients in Los Angeles.

To investigate patterns of testing for human immunodeficiency virus (HIV) infection in tuberculosis patients, we obtained data from the tuberculosis registry and from medical records of 500 tuberculosis patients in Los Angeles County. Sixty-three percent of tuberculosis patients were tested for HIV infection, and multivariate logistic regression analysis revealed that the likelihood of testing was significantly higher among males, persons between 20 and 49 yr old, individuals with HIV risk factors, and patients treated by public health care providers. A minimum of 12% of the total sample, 2% of females, 2% of those outside the ages of 20 to 49, 7% of patients without recorded HIV risk factors, and 17% of patients treated by private practitioners were infected with HIV. These results suggest that health care providers, particularly private practitioners, do not follow national recommendations for universal HIV testing of tuberculosis patients. Instead, HIV testing is preferentially performed on patients perceived to be at high risk for HIV infection. Because HIV seroprevalence is at least 2 to 7% in "low-risk" groups, failure to test these patients may result in significant missed opportunities for diagnosis and treatment of HIV coinfection.

AIDS Serodiagnosis↗
PubMed1997

Competing priorities as a barrier to medical care among homeless adults in Los Angeles.

OBJECTIVES: The role of competing priorities as a barrier to the utilization of physical health services was assessed in a subset (n = 363) of a probability sample of homeless adults in Los Angeles. METHODS: Unadjusted odds of four measures of health services utilization were calculated for those with frequent difficulty in meeting their subsistence needs. These odds were then adjusted for a range of characteristics assumed to affect the utilization of health services among the homeless. RESULTS: Before and after adjustment, those with frequent subsistence difficulty were less likely to have a regular source of care (odds ratio [OR] = 0.30, 95% confidence interval [CI] = 0.16, 0.53) and more likely to have gone without needed medical care (OR = 1.77, 95% CI = 1.04, 3.00). Subsistence difficulty had no impact on the likelihood of having an outpatient visit or having been hospitalized. Conclusions remained the same after adjustment. CONCLUSIONS: Frequent subsistence difficulty appears to be an important nonfinancial barrier to the utilization of health services perceived as discretionary among homeless adults.

Adolescent↗
PubMed1996

Physician role conflict and resulting career changes. Gender and generational differences.

OBJECTIVE: To evaluate gender and generational differences both in the prevalence of role conflict and in resulting career changes among married physicians with children. STUDY DESIGN: Cross-sectional survey. PARTICIPANTS: We sent a survey to equal numbers of licensed male and female physicians (1,412 total) in a Southern California county; of the 964 delivered questionnaires, 656 (68%) were returned completed. Our sample includes 415 currently married physicians with children, 64% male and 36% female. MEASUREMENTS AND MAIN RESULTS: The prevalence of perceived role conflict, or career changes for marriage, and of career changes for children were evaluated. Types of career changes were also evaluated. More female than male physicians (87% vs 62%, p < .001) and more younger than older female physicians (93% vs 80%, p < .01) and male physicians (79% vs 54%, p < .001) experienced at least moderate levels of role conflict. Younger female and male physicians did not differ in their rates of career change for marriage (57% vs 49%), but female physicians from both age cohorts were more likely than their male peers to have made career changes for their children (85% vs 35%, p < .001). Younger male physicians were twice as likely as their older peers to have made a career change for marriage (49% vs 28%, p < .001) or children (51% vs 25%, p < .001). The most common type of career change made for marriage or children was a decrease in work hours. CONCLUSIONS: Most physicians experience role conflict, and many adjust their careers in response. Flexible career options may enable physicians to combine professional and family roles more effectively.

Adult↗
PubMed1996

Ambulatory health services provided to low-income and homeless adult patients in a major community health center.

OBJECTIVE: The homeless are more likely than other poor and vulnerable populations to manifest serious health problems. Early research focused on needs assessments of this population; current work has shifted to examine issues of access, use of health services, and barriers to care. However, current research has not examined whether model clinics designed for the homeless have created parity with their low-income domiciled peers in terms of provision of ambulatory services. Such data are increasingly in demand as managed care looms just over the political horizon as a means of providing services to low-income patients. SETTING: A major community ambulatory health center in West Los Angeles. PATIENTS: Homeless (N = 210) and low-income domiciled (N = 250) patients. DESIGN: A medical record review of care provided over a one-year period to homeless and low-income domiciled adult patients in a major community ambulatory health center in West Lost Angeles was conducted. Data were collected on length of visits, laboratory tests, procedures, and services, immunizations, specialty clinic referrals, medications, and travel vouchers. RESULTS: On average, homeless patients were provided with as many outside laboratory tests per patient as low-income domiciled patients (1.1 vs 1.3). Further, they returned for more visits (3.4 vs 2.9), were more likely to have had longer visits (88% vs 61%), and were provided with more laboratory tests (2.3 vs 1.7), procedures and services (3.1 vs 1.1), referrals (1.3 vs 0.7), medications (4.4 vs 3.3), and travel vouchers (0.6 vs 0.2) (all p < .01). Many of the procedures and services received by the homeless were for nonmedical assistance. Preventive health services such as tuberculosis skin tests, sexually transmitted disease (STD) screening, and Pap tests were provided to both homeless and domiciled patients at low rates. CONCLUSIONS: Findings from this study on the provision of care in a major West Los Angeles community health center indicate that homeless patients receiving care from a model program designed to address their special needs will return for follow-up visits and will utilize services at least as much as low-income domiciled patients.

Adult↗
PubMed1996

The role of patient participation in the doctor visit. Implications for adherence to diabetes care.

For patients, treatment of diabetes involves complex changes in basic behaviors and adherence to complicated regimens. Understanding the factors that enable patients to adhere to diabetes treatment is the first step to designing effective interventions. Researchers of diabetes care have postulated that increasing diabetic patients' participation in medical decision making during the doctor visit is likely to improve their adherence to self-care. However, a critical review of the impact of patient participation on diabetic patients adherence to self-care is absent from the literature. We review the subject of patient participation in medical decision making and its effect on adherence to self-care for patients with diabetes. We introduce a model of the determinants of adherence to diabetes self-care that incorporates the effects of patient participation in medical decision making. In this model, we suggest three ways that patient participation can affect adherence to self-care: 1) it may have a direct effect; 2) it may affect adherence to self-care indirectly by affecting patients' understanding of their treatment regimen or the fit of their regimen with their lifestyle; and 3) perceived omissions of participation can affect adherence to self-care indirectly through an effect on patient satisfaction. Research is needed to identify more clearly which components of patient participation affect adherence to self-care and in what ways. Distinguishing patient and physician behaviors that contribute to the process of patient participation would provide a means to develop specific behavioral interventions.

Decision Making↗
PubMed1996

Homing in on the homeless: assessing the physical health of homeless adults in Los Angeles County using an original method to obtain physical examination data in a survey.

OBJECTIVE: Public policy that decreases the finding for social services may combine with the ascendancy of corporate managed care to increase the health care deficit. Assessing the health impact of these policy changes on various populations is a fundamental challenge for health services research. Disadvantaged populations, such as the homeless, are likely to be affected disproportionately. Research quality data on the physical health of such populations are difficult and expensive to obtain. In particular, physical examination data have not been available and self-reports are insufficient. Our objective: to develop and utilize a structured physical exam system enabling lay survey researchers to report reliably physical findings related to six tracer conditions in a disadvantaged population. STUDY SETTING: A field survey of homeless adults in Los Angeles County, California. Respondents were 363 homeless adults representing a subsample of a probability sample of the county's homeless adult population. STUDY DESIGN: We integrated existing measures with expert clinical opinion and original means of data collection into a structured physical exam enabling lay interviewers to identify the prevalence of vision problems, significant skin disorders, peripheral vascular disease of the lower extremities, selected podiatric disorders, hypertension, and tuberculosis in a sample of homeless adults. PRINCIPAL MEASURES: We describe lay interviewer performance in terms of mastery of the necessary material based on written and practical exams and in terms of the number of respondents successfully followed. We base our description of the instrument on the time necessary to complete it, and on the proportion of each component successfully completed during the field survey, as well as on interrater reliability. We report the prevalence of the various clinical conditions according to self-report and according to the structured limited physical exam, as well as the marginal proportion of respondents who were identified by the physical exam and not by self-report. PRINCIPAL FINDINGS: Interviewers performed the exam successfully under field conditions. Respondent acceptance of the instrument was high. Interrater agreement was 100 percent regarding the need for referral on the basis of blood pressure and vision. Kappa statistics for skin, foot, and edema findings were .67,.71, and .81, respectively. Adjusted for sampling weights, 60 percent of this population required referral for at least one of the specified conditions. For those portions of the survey for which both self-report and physical exam data were available, lay interviewers made significant percentages of referrals on the basis of physical findings alone. CONCLUSIONS: High blood pressure, poor vision, peripheral vascular diseases of the feet and legs, and significant skin conditions are prevalent among the homeless in Los Angeles County. Without physical exam data, estimates of the prevalence of these conditions will be incorrect. Researchers can use laypersons to collect reliable and valid physical exam data on disadvantaged populations. This represents a new tool for assessing and monitoring the health of these populations.

Adult↗
PubMed1995

Homeless veterans' utilization of medical, psychiatric, and substance abuse services.

This study focuses on the association between homeless veterans' prior utilization of medical, psychiatric, and substance abuse services and biopsychosocial characteristics reported at admission into a domiciliary care program. Given the large number of veterans in the US homeless population and their health care needs, understanding factors associated with health service use among homeless veterans is significant. Research participants were 429 homeless male veterans who had been admitted to the Domiciliary Care for Homeless Veterans Program site at the West Los Angeles Veterans Affairs Medical Center between February 1988 and July 1992 for treatment of medical, psychiatric, or substance disorders. Results of logistic regression analyses indicated that self-reported need (chronic medical problems, serious psychiatric symptoms, combat stress, alcohol use) and evaluated need for care (evidence of liver dysfunction) were important to veterans' use of health services in the 6 months before program admission. Predisposing social structure factors (education, residential stability, and usual sleeping place) were also significant predictors of service utilization. Overall, need factors were more strongly related to service use. Supplementary logistic regression analyses indicated that comorbidity of need factors deserves attention in understanding homeless veterans' use of services. In conclusion, it is important to attend to predisposing social structure factors as potential barriers to care for homeless veterans.

Comorbidity↗
PubMed1995

Characteristics associated with the risk of unintended pregnancy among urban homeless women: use of the Shuler Nurse Practitioner Practice Model in research.

In this pilot study, family planning practices and risk for unintended pregnancy among 50 homeless women residing in the downtown area of Los Angeles were investigated through the retrospective analysis of data collected through a wholistic clinic intake questionnaire. Those women who were least likely to use a birth control method in this study were Black, used cocaine daily, had multiple sources of emotional support, were satisfied with their sex lives, and reported access problems to family planning services (p < or = .05). Furthermore, over half of the total sample was at risk for unintended pregnancy. These at risk women were more likely to be separated from their children (p < or = .05), report current (p < or = .05) and past (p < or = .01) drug problems, have multiple sex partners (p < or = .001), engage in prostitution (p < or = .01), have a past history of sexually transmitted diseases (p < or = .05), and were least likely to be satisfied with their sex lives (p < or = .05). The findings suggest that homeless women are in great need of family planning health services, and that such services should be combined with vocational, social service, and drug treatment programs.

Adult↗
PubMed1994

Evaluating generalist education programs: a conceptual framework. Generalist program evaluation working group.

This paper provides and applies a conceptual framework and a list of guiding principles for evaluation of generalist education programs. Programs are systematic efforts to achieve specified objectives. Evaluations gather data in order to improve or appraise programs and have a continuum of purposes and methods. Descriptive evaluations characterize the structures, processes, and outcomes of programs; research evaluations definitively assess the effectiveness of a program in terms of outcomes. Intermediate outcomes are changes in knowledge, attitudes, and skills of program participants; conclusive outcomes reflect the quality of performance of graduates in actual clinical situations. Outcomes are affected by inputs--the qualities of students entering the program. Guiding principles of program evaluation ensure that data gathered are useful. The authors illustrate the guiding principles with an actual pilot study that determined that expert pediatricians, general internists, and family practitioners could agree on key generalist competencies and that explores evaluation design based on these competencies. Finally, they consider the implications of undertaking generalist education evaluation.

Adult↗
PubMed1994

Does fear of immigration authorities deter tuberculosis patients from seeking care?

Physician groups are concerned that legislation requiring physicians to report illegal immigrants to immigration authorities will delay curative care. In particular, patients with tuberculosis may delay seeking care for infectious symptoms and spread the disease. We surveyed 313 consecutive patients with active tuberculosis from 95 different facilities to examine the relationship of immigration-related variables, symptoms, and delay in seeking care. Most patients (71%) sought care for symptoms rather than as a result of the efforts of public health personnel to screen high-risk groups or to trace contacts of infectious persons. At least 20% of respondents lacked legal documents allowing them to reside in the United States. Few (6%) feared that going to a physician might lead to trouble with immigration authorities. Those who did were almost 4 times as likely to delay seeking care for more than 2 months, a period of time likely to result in disease transmission. Patients potentially exposed an average of 10 domestic and workplace contacts during the course of the delay. Any legislation that increases undocumented immigrants' fear that health care professionals will report them to immigration authorities may exacerbate the current tuberculosis epidemic.

Adult↗
PubMed1994

The effects of spiritual/religious practices on psychological well-being among inner city homeless women.

As part of a larger, retrospective investigation of homeless women's wholistic family planning needs, we examined spiritual/religious practices in relationship to mental health status and substance use. Ninety-two percent of our sample reported one or more spiritual/religious practices, such as praying, attending worship services, or reading religious materials. Forty-eight percent of the women reported the use of prayer as significantly related to less use of alcohol and/or street drugs, fewer perceived worries, and fewer depressive symptoms.

Adolescent↗
PubMed1994

Health care for the homeless: a family medicine perspective.

Many factors contribute to the health problems of homeless persons, including exposure to adverse weather, trauma and crime, overcrowding in shelters, unusual sleeping accommodations, poor hygiene and nutritional status, alcoholism, drug abuse and psychiatric illness. It is common for homeless adults to have skin ailments, respiratory infections, traumatic injuries and chronic gastrointestinal, vascular, dental and neurologic disorders. Homeless children may have respiratory, ear and skin diseases, as well as special problems, including failure to thrive, developmental delay, neglect and abuse. Important questions to ask during history-taking include questions about sleeping conditions, sources of food, past psychiatric problems and substance abuse, and sources of social support. Special attention should be given to examination of the skin, teeth and feet. Supplemental food, immunizations, psychologic counseling and social service referrals should be considered for homeless pediatric patients.

Adult↗
PubMed1993

Substance use among impoverished medical patients: the effect of housing status and other factors.

Four hundred forty-three impoverished medical patients, many of whom were homeless, were studied to determine whether homelessness is an independent predictor of current substance use. Twenty-four percent of the sample of patients were frequent alcohol users (i.e., daily or almost daily), and 18% had recently used illegal drugs (cocaine, heroin, PCP, LSD). Marijuana use was not included in the drug use variable. Bivariate analyses revealed that frequent alcohol was associated with being homeless, male, less educated, a veteran, unemployed, and having more children. Frequent alcohol users also were more likely to be sexually active, have had suicidal thoughts, a previous psychiatric hospitalization or felony conviction, an accident or injury, and poor physical health. Self-reported use of illegal drugs was associated with being younger, U.S. born, never married, having a poor mood, and a mental health problem or substance use by a parent. Use of illegal drugs was associated with being homeless, male, less educated, sexually active, and having a previous felony conviction or psychiatric hospitalization. Once demographic and family characteristics were controlled for, housing status was not related to either frequent alcohol or illegal drug use. Substance use among impoverished patients was a reflection of their historical social backgrounds rather than of their current housing status. Helping these patients to obtain stable housing may not impact the substance use of homeless persons.

Adult↗
PubMed1993

Indicators of chronic homelessness among veterans.

OBJECTIVE: This study sought to develop a set of indicators of chronic homelessness as a basis for better understanding and treatment of the homeless veteran population. METHODS: Chi square analysis and the t test or Mann-Whitney U test were used to compare characteristics of veterans who reported long-term homelessness (more than 12 months total since age 18) with those of veterans who reported short-term homelessness (12 months or less). Subjects were 343 homeless male veterans receiving treatment for physical, mental, or substance abuse disorders at the West Los Angeles site of the Domiciliary Care for Homeless Veterans Program. Variables included history of homelessness, employment history, physical and mental health, substance abuse history, social and financial support, criminal history, age, ethnic group, education, military service, and program discharge status. RESULTS: Veterans experiencing long-term homelessness were more likely to be white, to have had a longer period of recent homelessness and a greater number of homeless episodes, to have a poor employment history, to have symptoms of mental and substance abuse disorders, and to have weaker social support. CONCLUSIONS: Results show that variables besides duration of lifetime homelessness are important indicators of chronic homelessness.

Adult↗