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One of every six adolescents lacks health care coverage, and many adolescents avoid medical care regardless of whether it is covered. In this chapter, the author explores health care financing, programs that guarantee services, access to care in a reformed health care system, organization of services, and other factors affecting chronically ill adolescents.
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UNLABELLED: The results suggest social cognitive theory variables associated with the adoption of exercise are changeable in a brief worksite intervention. Self-regulation techniques and outcome-expectancy value improved, but self-efficacy did not improve for the treatment group. One possible explanation is, the intervention did not adequately address the ability to overcome barriers to exercise faced by participants in the intervention. Another explanation may be the effect of experiencing the barriers to exercise faced by subjects during the first 4 weeks of a self-regulated exercise program. Before engaging in exercise, the participants had a perceived level of confidence to overcome barriers to exercise. Once faced with real barriers to exercise, the subjects may have reevaluated their ability to overcome these barriers. It is interesting that the comparison group reported small decreases in all social cognitive theory variables measured in this study. The comparison group received a program of assessment, instruction, and access to facilities that is common to many worksite-based fitness promotion programs. Clearly, this approach did not have a favorable impact on psychosocial variables associated with exercise adherence. These results may be explained by a reevaluation of beliefs and perceived capabilities to exercise, once faced with the real experiences and barriers related to the adoption of an exercise program. The small decreases in social cognitive theory variables in the comparison group may explain high dropout rates in many fitness center programs and warrant further study. IMPLICATIONS: Health promotion specialists at the worksite need intervention programs that are safe, effective, and efficient for their employees. This intervention was based in the classroom, and no exercise was performed during class. This is appealing to employees who do not have access to shower facilities at the worksite. Moreover, in many interventions, subjects exercise during class and have limited time to learn specific skills to help them adopt and maintain exercise outside the structure of the intervention. Having established favorable changes in social cognitive theory constructs attributable to the intervention, a follow-up study should be conducted to determine the extent to which these changes predict adherence to regular exercise. These studies would establish the causal linkages between social cognitive theory constructs and regular exercise. LIMITATIONS: There were specific limitations, and the results should be interpreted cautiously. The sample size was relatively small, although similar to other exercise intervention research reviewed by Dishman. Another limitation of the sample was no random assignment to treatment or comparison group. The results apply only to the subjects who volunteered for this study. The measure of outcome-expectancy value is the most vulnerable of those used to measure outcome expectations and outcome expectancies. It is possible that the results of the study would be substantially altered if a better measure were available. The data were collected through self-administered questionnaires. It was assumed the subjects would provide accurate information, but reliance on self-reported data introduces potential sources of error.
We describe the outreach echocardiography program at our tertiary care referral center in southeast Minnesota. Cardiac sonographers from our institution transport ultrasonographic imaging equipment to regional hospitals and clinics where they perform complete transthoracic echocardiographic examinations. Digital images from standard 2-dimensional, color flow, and Doppler echocardiography are transferred to our clinic for interpretation by a cardiologist. The outreach program enables physicians without access to echocardiography to use this powerful diagnostic tool in the local evaluation of patients with suggested or known heart disease. We detail the organization of our outreach echocardiography program and emphasize the team approach that facilitates optimal image acquisition, prompt interpretation, and timely reporting of results.
PURPOSE: Heart failure (HF) care in the Netherlands is going through a lot of changes. Nurses have increasingly important roles in providing optimal care for these chronically ill patients. In this study, we describe the current number of HF management programs and the role of the nurses in these programs. METHOD: Data were collected by a national survey as part of a European HF clinic survey of the UNITE study group of the Working Group on Cardiovascular Nursing between February and March 2003 to 142 hospitals in the Netherlands. RESULTS: In 60% of the hospital locations, there is a HF management program. Most of the programs are organized as HF outpatient clinics. In all HF programs, cardiologists and nurses are involved. Other health care providers involved are, amongst others, general practitioners (29%), dieticians (59%), physical therapists (47%), social workers (30%) and psychologists (17%). All programs offer follow-up after discharge from the hospitals and in most of the programs patients have increased access to a health care provider. Behavioural interventions (68%), psychosocial counselling (64%), patient education (88%) and support of the informal caregivers (59%) are important components. In 90% of the programs (restricted), physical examination is the responsibility of the HF nurse and in 65% of the programs nurses are involved in optimizing medical treatment. Financial support and education of HF nurses is still unstructured and diverse. CONCLUSION: There is a rise in the number of HF programs in the Netherlands. There is diversity in content and intensity of these programs and the role of the nurse is not clearly defined yet. Research and discussion on the subject of optimal effective HF care and the role of the HF nurse is still needed.
The coming decades will bring dramatic increases in morbidity and mortality from cancer in the developing world. The burden of cancer is increasing globally, with an expected 20 million new cases per year in 2020, half of which will be in low- and middle-income countries. Despite an already overwhelming burden of health problems, developing countries must somehow address this cancer pandemic and their alarming share of cancer illness. Many large-scale and innovative worldwide initiatives have been launched in the fight against cancer. These programs represent colossal efforts to expand resources for health education among people and healthcare workers in developing countries and to increase awareness of cancer prevention. Many novel evidence-based and culturally-relevant programs are being implemented for screening and early prevention of common cancers. Several key initiatives are supporting clinical research, guideline development, oncology training, and appropriate technology transfer, such as access to electronic medical literature. Treatment programs are expanding access and quality of radiologic and pharmacologic therapies for cancer. These initiatives represent an unprecedented level of and cooperation among international agencies, governmental and nongovernmental organizations, international foundations, scientific societies, local institutions, and industry. This review examines the scope of need in response to the increasing burden of cancer in the developing world and major initiatives that have been created to respond to these needs.
Many community-based internists and family physicians lack familiarity with geriatrics knowledge and best practices, but they face overwhelming fiscal and time barriers to expanding their skills and improving their behavior in the care of older people. Traditional lecture-and-slide-show continuing medical education (CME) programs have been shown to be relatively ineffective in changing this target group's practice. The challenge for geriatrics educators, then, is to devise CME programs that are highly accessible to practicing physicians, that will have an immediate and significant effect on practitioners' behavior, and that are financially viable. Studies of CME have shown that the most effective programs for knowledge translation in these circumstances involve what is known as active-mode learning, which relies on interactive, targeted, and multifaceted techniques. A systematic literature review, supplemented by structured interviews, was performed to inventory active-mode learning techniques for geriatrics knowledge and skills in the United States. Thirteen published articles met the criteria, and leaders of 28 active-mode CME programs were interviewed. This systematic review indicates that there is a substantial experience in geriatrics training for community-based physicians, much of which is unpublished and incompletely evaluated. It appears that the most effective methods to change behaviors involved multiple educational efforts such as written materials or toolkits combined with feedback and strong communication channels between instructors and learners.
Richard E. Clark in his widely published comprehensive studies and meta-analyses of the literature on computer assisted instruction (CAI) has decried the lack of carefully controlled research, challenging almost every study which shows the computer-based intervention to result in significant post-test proficiency gains over a non-computer-based intervention. We report on a randomized study in a medical school setting where the usual confounders found by Clark to plague most research, were carefully controlled. PlanAlyzer is a microcomputer-based, self-paced, case-based, event-driven system for medical education which was developed and used in carefully controlled trials in a second year medical school curriculum to test the hypothesis that students with access to the interactive programs could integrate their didactic knowledge more effectively and/or efficiently than with access only to traditional textual "nonintelligent" materials. PlanAlyzer presents cases, elicits and critiques a student's approach to the diagnosis of two common medical disorders: anemias and chest pain. PlanAlyzer uses text, hypertext, images and critiquing theory. Students were randomized, one half becoming the experimental group who received the interactive PlanAlyzer cases in anemia, the other half becoming the controls who received the exact same content material in a text format. Later in each year there was a crossover, the controls becoming the experimentals for a similar intervention with the cardiology PlanAlyzer cases. Preliminary results at the end of the first two full trials shows that the programs have achieved most of the proposed instructional objectives, plus some significant efficiency and economy gains. 96 faculty hours of classroom time were saved by using PlanAlyzer in their place, while maintaining high student achievement. In terms of student proficiency and efficiency, the 328 students in the trials over two years were able to accomplish the project's instructional objectives, and the experimentals accomplished this in 43% less time than the controls, achieving the same level of mastery. However, in spite of these significant efficiency findings, there have been no significant proficiency differences (as measured by current factual and higher order multiple choice post-tests) between the experimental and control groups. Very careful controls were used to avoid what Clark has found to be the most common confounders of CAI research. Accordingly, this research proved Clark's rival hypothesis, that the computer, in itself, does not appear to contribute to proficiency gains, at least as measured by our limited post-testing. Clark's position is that the computer is primarily a vehicle--as is either a pill or a hypodermic needle for delivering a drug.(ABSTRACT TRUNCATED AT 400 WORDS)
The Teenage Access Project (TAP) was supported by the Special Projects of National Significance Program to expand and ensure access to health and support services for disadvantaged, human immunodeficiency virus (HIV)-positive, and at-risk adolescent and young adult women aged 10-21 years by: (a) preventing further HIV transmission through empowerment and reduction of risk behavior, (b) providing HIV counseling and testing to increase screening of young women, and (c) facilitating referrals to medical and psychosocial services through the TAP activities. TAP served 403 young people (82% African-American and 83% young women). The basic elements of the TAP service model components were: (a) outreach to community agencies serving high-risk, disadvantaged young women; (b) My Individual Responsibility Reduces Our Risk (MIRROR), a six-module risk-reduction and empowerment activity specifically designed for young women in Jefferson County, using a small group format; and (c) the Adolescent Testing Center (ATC), a center for age and culturally appropriate HIV testing, pre- and posttest counseling, risk assessment, and referrals. HIV testing and pre- and posttest counseling were provided confidentially in both clinical and community settings. More than 200 participated in the MIRROR activity. A total of 101 young women received HIV counseling and testing services.
This study examines whether the mechanism through which a methadone maintenance treatment site offers seven treatment-related and support services is related to whether a patient receives such services. Mechanisms include the provision of services on-site, at another program site, or through formal or informal linkage arrangements. Analysis was conducted on a nationally representative sample of methadone treatment sites. Providing services on-site was found to be positively related to patient access to a majority of services, whereas, in general, offering services at another program site or through formal or informal linkages was not found to be effective. Not-for-profit or public ownership of treatment sites was also found to be positively related to patient access.
Good mental health provides an essential foundation for normal growth and development through adolescence and into adulthood. Many adolescents, however, experience mental health problems that significantly impede the attainment of their full potential. The majority of these adolescents do not receive needed mental health services, in part because of financial obstacles to care. This article reviews the magnitude and impact of mental health problems during adolescence and highlights the importance of insurance coverage in assuring access to mental health services for adolescents. Significant limitations in private health insurance coverage of mental health services are outlined. Recent federal and state efforts to move toward parity in private insurance coverage between mental and physical health services are discussed, including an explanation of the role of Medicaid and the State Children's Health Insurance Program (SCHIP) in providing access to mental health services for adolescents. Finally, other elements that would facilitate financial access to essential mental health services for adolescents are presented.
States are gradually developing programs to support families with special needs, but progress is uneven. Some States offer exemplary models and others offer virtually nothing to support families. Value-based, family-centered, accessible, equitable family support programs are greatly needed in every State by the year 2000, at the latest. This will send a message to people with disabilities and their families that we value them, care about them, and want them to be part of their communities. In the words of some family support program participants: "Even though our daughter has multiple handicaps, our desire is to care for her at home, in a loving environment that all children should have the opportunity to experience." "It allows us to keep our daughter at home and file the possibility of putting her in an institution."
In late 1982, as an alternative to Medicaid, Arizona implemented a prepaid, competitively bid medical care program--the Arizona Health Care Cost Containment System (AHCCCS). Before its introduction, the poor had been cared for primarily by a network of county-supported centers. Impact of the AHCCCS initiative was examined by surveying comparable samples of poor persons in pre-AHCCCS 1982, and in 1984, after the program was in place. Both before and since AHCCCS, Arizona has had very restrictive eligibility requirements; to examine the program's impact on both eligible persons and the so-called "notch" group, the samples consist of individuals with family incomes within 200 percent of the program's financial criterion. Telephone surveys revealed that overall a lower proportion of the poor were enrolled in AHCCCS in 1984 than participated in county programs in 1982. However, access to care increased for AHCCCS enrollees in 1984, compared to county patients in 1982--and a greater proportion of 1984 AHCCCS enrollees than their 1982 counterparts in the county programs had at least one medical encounter in the 12 months preceding the surveys. For its enrolled population, then, AHCCCS may be a viable alternative to conventional Medicaid programs and to previous efforts at providing care at county sites. But the poor financially ineligible for AHCCCS are experiencing decreased opportunities for health services. The conclusions address the policy implications of the findings.
A number of state-level pharmaceutical assistance programs have been established as a result of the growing recognition of the role of pharmaceuticals in the long-term care of the elderly. However, existing research does not provide a coherent expectation for patterns of use by rural and urban elderly. The data for this analysis are drawn from a larger study of the Pennsylvania Pharmaceutical Assistance Contract for the Elderly (PACE). PACE provides prescription medicines for elderly who meet income requirements. The research project was designed to assess the characteristics of PACE program participants and non-participants on a wide range of issues. Chi-square analysis and regression models were used to assess the association between rural and urban residence and access to the PACE Program. The results indicate that rural/urban status of the elderly is not a significant predictor of the use of PACE. Other traditional variables (e.g., health self-rating and physician visits) did predict difference in the pattern of use.
This study evaluates the factors associated with initiation of services in the Boston HAPPENS Program, which is a collaborative network of care consisting of multiservice outreach agencies, community health centers and hospitals, for human immunodeficiency virus (HIV)-positive and hard to reach youth who are 12-24 years old. The program served 2116 youth who were 19.8 +/- 2.9 years old; 64% female; 45% youth of color; 16% gay/lesbian, bisexual, or undecided; and 10% homeless or runaway. At first contact with the program, 56% received outreach services; and 91% received a health intervention. Among those receiving a health intervention, 55% had HIV counseling and testing services, 49% medical care, 24% case management, and 9% mental health services. HIV-positive youth needed more contacts before a first medical visit than those who were HIV-negative or untested (p < 0.001). Different kinds of service sites reached different populations of at-risk youth. Logistic regression modeling showed that for young women, older age, lesbian-bisexual orientation, substance use, high-risk sexual behaviours, and receiving outreach services at first contact were independent predictors of initiation of services at outreach agencies; however, unprotected sex with males, and pregnancy were associated with a greater likelihood of care at hospitals or community health centers. For young men, older age, Asian/other ethnicity, and substance abuse were associated with care at outreach agencies; however, positive HIV status and unprotected sex with females were associated with care at hospitals or community health centers. Comprehensive networks of care offering a continuum of services and a variety of entry routes and types of care sites are needed to connect underserved youth to health care.
Emerging models of prevention focus on population-level risk reduction through enumerating antecedent conditions that are linked to subsequent expressions of disorder and dysfunction. The authors discuss the essential ingredients for successful prevention programs--comprehensiveness, fidelity, and intensity. The authors describe how to mount prevention programs to increase feasibility, access, and effectiveness. Suicide is an epidemic of low frequency in the general population and therefore does not receive appropriate attention in public health prevention campaigns. They argue for nesting suicide prevention programs within existing public health preventive intervention programs and provide some examples of how to reduce vulnerabilities and risk conditions for subsequent suicidal behaviors.
Bowel continence is one of the most difficult challenges for patients with spina bifida. Incontinence acts as a social stigma for children and a barrier for adults seeking employment. We present an algorithm for stepwise decision-making in construction of personalized continence programs for greater likelihood of success. The protocol contains 13 assessment points including; stool consistency, frequency and amount; mobility; level of paraplegia: diet; medication; anal/rectal canal tone; prior programs attempted; family routines; age; accessibility; and learning issues. Based on outcomes of these assessments, an individualized bowel program is constructed. The algorithm helps the practitioner and patient decide on components and indicators of a successful continence program. The recommended program might include timed toileting, suppository, continence enema, and ACE procedure, or a combination. Evaluation and patient education address adequate fluid/fiber, appropriate toileting equipment, and use of stool softeners/laxatives. Descriptions are available. Key elements in monitoring a continuing plan for continence include: the degree of constipation and its etiology; changing age; family availability for assistance until interdependence is optimal; wheelchair accessibility of the toilet; and ability to transfer to and from the toilet. Use of the algorithm allows for careful decision-making based on information from the patient and family. This has led to greater success in bowel continence in children with spina bifida.
DNA sequences that are involved in the control of gene expression in eukaryotes have been collected in conjunction with the proteins binding to and acting through them (TRANSFAC data set). To make these data accessible, the TRANSFAC retrieval program (TRP) has been developed as a database management system which is based upon the network model. This database model possesses particular advantages for data management of a complex structure. The aim of TRP is to provide an easily handled statistical basis for a computational approach to transcription control.