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The emergence of the COVID-19 pandemic significantly changed the prenatal care experience, specifically regarding medical appointments and social opportunities. It is critical to capture this change through the narratives of pregnant people, particularly those of marginalized populations, whose voices may often be underrepresented in the literature. This mixed-methods paper summarizes the experiences of 40 pregnant Black/African American (AA) women during the COVID-19 pandemic. A cross-sectional, online survey was administered between 2020 and 2021 to assess prenatal health and the impacts of the COVID-19 pandemic on patients' pregnancy experience. Coping behaviors during the pandemic were self-reported using the COPE-IS. Univariate analyses were conducted. An additional analysis of participants (n = 4) was explored through a week-long qualitative exercise using a photo documentation procedure. Photo-Elicitation Interviews (PEI) were conducted to capture and center their pandemic pregnancy experiences. Sources of stress during the pandemic varied, with the most common being financial concerns (n = 19, 47.5%). Over half of the sample (n = 18, 54.5%) self-reported increases in their positive coping behaviors during the pandemic, such as communicating with friends and family, talking to healthcare providers, listening to music, and engaging in spiritual practices–such as prayer. The four PEI study participants reflected on the impacts of social distancing on their prenatal experience and mentioned hospital and provider-related weariness due to their race. The findings of this study suggest that during the COVID-19 pandemic, Black/AA pregnant women in Charlotte, NC used social support, mindfulness practices, self-advocacy, and health literacy to navigate challenges present during their prenatal health experience. This paper highlights the personal, social, and structural experiences of pregnant women during a public health crisis so that responsive and effective programs or policies can be planned in the future. [ABSTRACT FROM AUTHOR]

Objective The primary aim of this paper is to accelerate the number of randomized experimental studies of the reliability and validity in-home tele-neuropsychological testing (tele-np-t). Method We conducted a critical review of the tele-neuropsychology literature. We discuss this research in the context of the United States' public and private healthcare payer systems, including the Centers for Medicare & Medicaid Services (CMS) and Current Procedural Terminology (CPT) coding system's telehealth lists, and existing disparities in healthcare access. Results The number of tele-np publications has been stagnant since the onset of the COVID-19 pandemic. There are less published experimental studies of tele-neuropsychology (tele-np), and particularly in-home tele-np-t, than other tele-np publications. There is strong foundational evidence of the acceptability, feasibility, and reliability of tele-np-t, but relatively few studies of the reliability and validity of in-home tele-np-t using randomization methodology. Conclusions More studies of the reliability and validity of in-home tele-np-t using randomization methodology are necessary to support inclusion of tele-np-t codes on the CMS and CPT telehealth lists, and subsequently, the integration and delivery of in-home tele-np-t services across providers and institutions. These actions are needed to maintain equitable reimbursement of in-home tele-np-t services and address the widespread disparities in healthcare access. [ABSTRACT FROM AUTHOR]

Introduction: Action 3 of the UN Decade of Healthy Ageing plan is to deliver integrated care to improve older adults' lives. Integrated care is vital in meeting the complex needs of people with dementia but little is known about how this is or could be delivered in low and middle income countries (LMIC). This paper provides insights into previously unknown care system structures and on the potential and reality of delivering integrated care in Central America for people with dementia. Methods: A social network analysis (SNA) methodology was adopted to engage with providers of services for older adults and families with dementia in Guatemala, El Salvador, Honduras, Costa Rica and Panama. Sixty-eight (68) semi-structured interviews were completed, 57 with organisations and 11 with families. Results: Across the five countries there was evidence of fragmentation and low integration within the dementia care systems. A variety of services and types of providers are present in all five countries, and high levels of diversified connections exist among organisations of differing disciplines. However, unawareness among network members about other members that they could potentially form active links with is a barrier on the path to integration. Conclusion: This innovative and robust study demonstrates SNA can be applied to evaluate LMIC care systems. Findings provide baselines of system structures and insights into where resources are needed to fortify integration strategies. Results suggest that Central American countries have the building blocks in place to develop integrated care systems to meet the needs of people with dementia, but the links across service providers are opportunistic rather than context based coordinated integration policies. [ABSTRACT FROM AUTHOR]

The article examines the effect of religious or secular hospital mergers on patients' access to health services in the U.S. Patients are losing access to many reproductive health services when their local secular hospitals merge with nearby religiously-affiliated facilities that object to those services on ethical grounds. Services banned by the merged entity may include contraception, abortions, sterilizations, in vitro fertilization, emergency contraception for rape victims, and the discussion of condom use as part of HIV prevention counseling. Formerly secular hospitals and nursing homes also restrict end-of-life choices. Recommendations to the American Public Health Association are presented.

Background: The state of evidence-based transgender healthcare in the United States has been put at risk by the spread of misinformation harmful to transgender people. Health science librarians can alleviate the spread of misinformation by identifying and analyzing its flow through systems that affect access to healthcare. Discussion: The author developed the theory of the Misinformation - Legislation Pipeline by studying the flow of antitransgender misinformation from online echo chambers through a peer-reviewed article and into policy enacted to ban medical treatments for transgender people in the state of Florida. The analysis is precluded with a literature review of currently accepted best practices in transgender healthcare, after which, the author analyzes the key report leveraged by Florida's Department of Health in its ban. A critical analysis of the report is followed by a secondary analysis of the key peer-reviewed article upon which the Florida Medicaid authors relied to make the decision. The paper culminates with a summation of the trajectory of anti-transgender misinformation. Conclusion: Misinformation plays a key role in producing legislation harmful to transgender people. Health science librarians have a role to play in identifying misinformation as it flows through the Misinformation - Legislation Pipeline and enacting key practices to identify, analyze, and oppose the spread of harmful misinformation. [ABSTRACT FROM AUTHOR]

The differential impact of the COVID‐19 pandemic on communities of color in the United States along with the civil unrest taking place in 2020 in response to the killing of unarmed Black men and women by the police have increased awareness of the structural racism pervading US society. These developments have reraised the issue of reparations for Black Americans, usually proposed in the context of providing financial compensation for the injustices of slavery to the descendants of those who were enslaved. This paper will discuss the systematic racial inequality and structural racism in US society that have significantly disadvantaged racial and ethnic minorities while giving advantages to white Americans, which most recently have resulted in significantly higher mortality and morbidity among Black, Hispanic, and Native Americans during the pandemic. The paper will conceptualize reparations within the context of theories of reparative justice. It will also consider whether reparations are owed, and if so, by whom, to whom, and in what form. The final section will offer a proposal for collective reparations to the Black community and other people of color. [ABSTRACT FROM AUTHOR]

Background: Access to clinicians competent in transgender health remains a significant barrier and contributor toward health inequity for transgender people. Studies on access and barriers to care have predominantly evaluated transgender patients' perceptions, but scant research has included the perspectives of clinicians.Aims: We conducted a qualitative study to explore how clinicians (meaning physicians and advanced practice providers, in this paper) in the United States: (1) attain and utilize information, (2) perceive barriers and facilitators, and (3) understood gaps in their professional training, in regard to practicing transgender health care.Methods: A Qualitative Descriptive approach guided our conventional content analysis of field notes and interviews with clinicians within a parent study that explored health care access among transgender adults. Transcripts were coded into meaning units that were iteratively abstracted into themes. Standard measures were performed to promote the trustworthiness of the analysis and reduce bias.Results: Participants (n = 13) consisted of physicians (n = 8), physician assistants (n = 3), and nurse practitioners (n = 2). The majority were women (n = 11), identified as White (n = 9), cisgender (n = 13), and ages ranged from 31 - 58 years. Five main themes were identified: (1) Knowledge Acquisition: Formal and Informal Pathways to Competency; (2) Perceived Challenges and Barriers: I didn't know what I was doing; (3) Power to Deny: Prescriptive Authority and Gatekeeping; (4) Stigma: This is really strange, and I can't really understand it; (5) Reflections: Strategies for Success, Rewards, and Personal Motivations.Discussion: Clinicians gained a sense of comfort and competence with mentorship, self-directed learning, clinical experience, and person-centered, harm-reduction approaches. Stigma, bias, and structural-level factors were barriers to providing care. This study offers a unique perspective of clinicians' motivations and strategies for providing gender-affirming care and elucidates how stigma impacts the delivery of gender-affirming care. [ABSTRACT FROM AUTHOR]

In 2000, the American PT Association (APTA) published its Vision statement advocating for DA (DA) to PT. This narrative review of the literature aims to identify the current state of DA in the United States (US) and compare that status to the US Military. Initial PubMed search in the English language with keywords physical therapy (PT), physiotherapy, DA, self-referral, and primary contact from the year 2000 onwards with subsequent focused searches using keywords DA/self-referral/primary contact of physical therapists/physiotherapists on outcomes/autonomous practice/economic impact/patient satisfaction yielded 103 applicable studies on the topic. This paper excluded 40 international articles to focus on US military and civilian research. Current literature supports Physical Therapists (PTs) in an initial contact role based on patient safety, satisfaction, access to care, efficiency, healthcare utilization, and potential cost savings. Despite its success in the US Military, DA to PT in the US civilians remains limited and incomplete. PTs still await unrestricted DA and privileges associated with autonomous practice including the ability to order imaging and prescribe some medications. [ABSTRACT FROM AUTHOR]

Socio-economic and geographical inequalities in breast cancer mortality have been widely described in European countries and the United States. To investigate the combined effects of geographic access and socio-economic characteristics on breast cancer outcomes, a systematic review was conducted exploring the relationships between: (i) geographic access to healthcare facilities (oncology services, mammography screening), defined as travel time and/or travel distance; (ii) breast cancer-related outcomes (mammography screening, stage of cancer at diagnosis, type of treatment and rate of mortality); (iii) socioeconomic status (SES) at individuals and residential context levels. In total, n = 25 studies (29 relationships tested) were included in our systematic review. The four main results are: The statistical significance of the relationship between geographic access and breast cancer-related outcomes is heterogeneous: 15 were identified as significant and 14 as non-significant. Women with better geographic access to healthcare facilities had a statistically significant fewer mastectomy (n = 4/6) than women with poorer geographic access. The relationship with the stage of the cancer is more balanced (n = 8/17) and the relationship with cancer screening rate is not observed (n = 1/4). The type of measures of geographic access (distance, time or geographical capacity) does not seem to have any influence on the results. For example, studies which compared two different measures (travel distance and travel time) of geographic access obtained similar results. The relationship between SES characteristics and breast cancer-related outcomes is significant for several variables: at individual level, age and health insurance status; at contextual level, poverty rate and deprivation index. Of the 25 papers included in the review, the large majority (n = 24) tested the independent effect of geographic access. Only one study explored the combined effect of geographic access to breast cancer facilities and SES characteristics by developing stratified models. [ABSTRACT FROM AUTHOR]

Introduction: Innovative interventions are needed to address the growing burden of breast cancer globally, especially among vulnerable patient populations. Given the success of Community Health Workers (CHWs) in addressing communicable diseases and non-communicable diseases, this scoping review will investigate the roles and impacts of CHWs in breast cancer screening programs. This paper also seeks to determine the effectiveness and feasibility of these programs, with particular attention paid to differences between CHW-led interventions in low- and middle-income countries (LMICs) and high-income countries (HICs).Methods: A scoping review was performed using six databases with dates ranging from 1978 to 2019. Comprehensive definitions and search terms were established for 'Community Health Workers' and 'breast cancer screening', and studies were extracted using the World Bank definition of LMIC. Screening and data extraction were protocolized using multiple independent reviewers. Chi-square test of independence was used for statistical analysis of the incidence of themes in HICs and LMICs.Results: Of the 1,551 papers screened, 33 were included based on inclusion and exclusion criteria. Study locations included the United States (n=27), Bangladesh (n=1), Peru (n=1), Malawi (n=2), Rwanda (n=1), and South Africa (n=1). Three primary roles for CHWs in breast cancer screening were identified: education (n=30), direct assistance or performance of breast cancer screening (n=7), and navigational services (n=6). In these roles, CHWs improved rates of breast cancer screening (n=23) and overall community member knowledge (n=21). Two studies performed cost-analyses of CHW-led interventions.Conclusion: This review extends our understanding of CHW effectiveness to breast cancer screening. It illustrates how CHW involvement in screening programs can have a significant impact in LMICs and HICs, and highlights the three CHW roles of education, direct performance of screening, and navigational services that emerge as useful pillars around which governments and NGOs can design effective programs in this area. [ABSTRACT FROM AUTHOR]

Background: Immigrant Latinx transgender people often migrate to the United States because of a desire for increased safety and more opportunities. However, after migrating to the United States, immigrant Latinx transgender people often struggle to access basic needs, including health care, jobs, and stable finances. These struggles are exacerbated for undocumented immigrant Latinx transgender people. There is a gap in the literature regarding needed resources for immigrant Latinx transgender community members living in the United States. Aims: Utilizing a critical intersectionality framework, the aim of the present study was to investigate the resource needs of immigrant Latinx transgender community members living in the United States. Methods: A community sample of 18 immigrant Latinx transgender people living in a large metropolitan city in Florida participated in individual semi-structured interviews to explore their community resource needs. Results: Thematic analysis revealed five themes related to resources that participants needed including: 1) Transgender healthcare/resources, 2) Public education, 3) Financial aid resources, 4) Homelessness resources, and 5) Addictions care. Two resource need-related themes were identified that pertain specifically to undocumented immigrant Latinx transgender people, including: 1) Documentation papers for access, and 2) Legal aid. Conclusions: Findings suggest that immigrant Latinx transgender community members in this study provided guidance about broad resources needed to enhance their wellness and safety, and promote liberation of community members. Participants' resource needs suggest the importance of policy and structural level changes from institutions with power that consider and enhance the wellness of immigrant Latinx transgender people. Findings also suggest the need for more tailored interventions and case work to better support immigrant Latinx transgender people. [ABSTRACT FROM AUTHOR]

Racism has resulted in significant disproportionality and disparity in the US child welfare system. Being Black is not an inherent risk factor for child abuse and neglect yet Black children are almost twice as likely to be victims of substantiated abuse and neglect claims compared to other racial groups. Addressing the disproportionality within the child welfare system due to systemic racism falls squarely under the purview of bioethics. In this paper, we briefly review the impact of racism on child welfare. We then discuss some ethical considerations that mandatory healthcare reporters should think through when determining whether to report potential abuse and neglect. Specifically, we discuss the need for a broader consideration of what constitutes harm. We then present a hypothetical composite case to illuminate where and how bias can enter the process of referral to child protective services (CPS). We encourage thoughtful reporting with consideration of social and historical context and alternative explanations for worrisome findings. We recommend using evidence, avoiding assumptions by seeking clarification from families and ensuring internal consistency. When contemplating CPS referral, medical providers should feel empowered to ask questions if there is concern for potential bias. The ultimate goal is to protect children from harm. If there are clear safety concerns—they must be addressed. However, in the many cases where the safety concern is less tangible, we need to expand our considerations of the harms that can befall children, especially children of color. [ABSTRACT FROM AUTHOR]

The COVID‐19 pandemic has had a disproportionate impact on the health of Black Americans, Latinx or Hispanic Americans, and American Indians. These disparities are deeply unjust, in part, because they are the causal result of racism at both the interpersonal and structural levels. This paper argues, however, that establishing a causal connection between racism and health disparities is not the only way to explain the injustice of these disparities. The COVID‐19 health disparities are arguably unjust because health equity is a "free‐standing" demand of justice, an obligation of reparative justice, a remedy to structural injustice, and part of dismantling pernicious racial concepts. Identifying multiple accounts of injustice may lower the evidentiary bar for our normative claims and help us to identify alternative policy pathways for ending health inequity. [ABSTRACT FROM AUTHOR]

According to the purposes for the formation of the United Nations, sophistication of institutions like the Security Council must be evaluated based on the provision of peace and how they guarantee human rights. Therefore, in case Security Council does not follow these two mentioned factors, its function would be itself a threat to the international peace and security. This analytical research is based on collecting library theoretical data related to different field studies which investigated the effects of sanctions issued by the Security Council, the United States and the European Union on citizens' health and tried to assess both their efficiency and legitimacy. The right to health is connected with the right of living. In case enough drugs, appropriate treatment and medical equipment are not provided at the proper time, both physical and mental health might be threatened and this can cause death of a large number of people. Considering the Security Council as an institution which is expected to take into account the citizens' basic rights and not to ignore its own initial objective, the present paper was an attempt to provide explanations for the above concepts and their relationships and to analyze the findings of previous field studies. The paper concluded that sanctions issued by the Security Council and the United States are potentially functioning as threats to the international peace and so these sanctions are violating the citizens' right to health. [ABSTRACT FROM AUTHOR]

Participation in adequate physical activity improves the health status of cancer survivors, enhances their survival, and reduces their risk of cancer recurrence. However, cancer survivors engage in low levels of physical activity and have limited access to rehabilitation services that could increase their participation. No optimal framework has been developed that supports physical activity participation among cancer survivors. Given the growth in numbers of cancer survivors, development of a framework may provide a pathway to facilitate timely and appropriate care. This perspective paper describes the development of the Cancer Rehabilitation to Recreation (CaReR) Framework and its practical implications. The CaReR Framework uses a tailored, stepped approach to guide health services and clinicians on the design and implementation of interventions to promote physical activity among cancer survivors. Implementation of the CaReR Framework will improve continuity and quality of care for cancer survivors and promote physical activity with the ultimate aim of improving health outcomes. [ABSTRACT FROM AUTHOR]

Background: People living in rural and remote communities commonly experience significant health disadvantages. Geographical barriers and reduced specialist and generalist services impact access to care when compared with metropolitan context. Innovative models of care have been developed for people living with chronic diseases in rural areas with the goal of overcoming these inequities. The aim of this paper was to describe the characteristics and outcomes of studies investigating innovative models of care for people living with chronic disease in rural areas of developed countries where a metropolitan comparator was included.Methods: An integrative systematic review was undertaken. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method was used to understand the empirical and theoretical data on clinical outcomes for people living with chronic disease in rural compared with metropolitan contexts and their models of care in Australia, New Zealand, United States, Canada and the United Kingdom.Results: Literature searching revealed 620 articles published in English between 1st January 2000 and 31st March 2019. One hundred sixty were included in the review including 68 from the United States, 59 from Australia and New Zealand (5), 21 from Canada and 11 from the United Kingdom and Ireland. 53% (84) focused on cardiovascular disease; 27% (43) diabetes mellitus; 8% (12) chronic obstructive pulmonary disease; and 13% (27) chronic kidney disease. Mortality was only reported in 10% (16) of studies and only 18% (29) reported data on Indigenous populations.Conclusions: This integrated review reveals that the published literature on common chronic health issues pertaining to rural and remote populations is largely descriptive. Only a small number of publications focus on mortality and comparative health outcomes from health care models in both urban and non-urban populations. Innovative service models and telehealth are together well represented in the published literature but data on health outcomes is relatively sparse. There is significant scope for further directly comparative studies detailing the effect of service delivery models on the health outcomes of urban and rural populations. We believe that such data would further knowledge in this field and help to break the deadly synergy between increased rurality and poorer outcomes for people with chronic disease. [ABSTRACT FROM AUTHOR]

In the United States, undocumented residents face unique barriers to healthcare access that render them disproportionately dependent on the emergency department (ED) for care. Consequently, ED providers are integral to the health of this vulnerable population. Yet special considerations, both clinical and social, generally fall outside the purview of the emergency medicine curriculum. This paper serves as a primer on caring for undocumented patients in the ED, includes a conceptual framework for immigration as a social determinant of health, reviews unique clinical considerations, and finally suggests a blueprint for immigration-informed emergency care. [ABSTRACT FROM AUTHOR]

The first baby has successfully been born by uterus transplantation (UTx) in the United States and the procedure is swiftly becoming a viable clinical option for patients with uterine factor infertility (UFI). This raises a practical ethical question: should health insurers finance UTx and what issues should they consider in coming to this decision? The article lays forth some of the factors that shape the decision over whether to finance UTx in the United States, including what procedures must be covered, whether UTx is more like organ transplantation or infertility treatment (which are treated differently in the United States), and the benefits and alternatives of the procedure. Then, the article explores arguments around why UTx should be financed, or at least considered along with other important medical needs. The paper argues that UTx ought to be considered along with other competing claims for healthcare services. In countries that generously cover other infertility services, it may logically follow that medical services that enable gestation should be insured when the healthcare system covers services to conceive. In the United States, however, many groups have long suffered inadequate access to medical care, in the context of infertility and more broadly. U.S. healthcare may need to be made more widely equitable, before covering UTx is seen as financially or politically possible. [ABSTRACT FROM AUTHOR]

Aim: This study examined cross-sectional population-based rates in reported need and unmet need for occupational, physical, and speech therapy services in children with autism spectrum disorder (ASD) compared with children with attention-deficit-hyperactivity disorder (ADHD) and cerebral palsy (CP).Method: The 2005-2006 and 2009-2010 (USA) National Survey of Children with Special Health Care data sets were used to compare therapy need and unmet need among children younger than 18 years with ASD (n=5178), ADHD (n=20 566), and CP (n=1183). Bivariate approaches and multivariate logistic regression using imputed data were used to identify associations between child and family characteristics, and access to therapy services.Results: After adjusting for other variables, children with ASD had a significantly greater likelihood of having an unmet therapy need compared with children with ADHD (odds ratio [OR] 1.66, 95% confidence interval [CI] 1.36-2.03), but a similar unmet need as children with CP (OR 1.30, 95% CI 0.97-1.74). Factors associated with unmet need included survey year, younger child age, no health insurance, and increased functional and behavioral difficulties.Interpretation: Children in our sample had greater unmet therapy needs in 2009 than in 2005. Caregiver-reported reasons for unmet need included cost and school resources. Research examining future trends in therapy access are warranted for children with ASD and CP.What This Paper Adds: Children with complex diagnoses of autism spectrum disorder and cerebral palsy had reported unmet need for therapy services. High costs of therapy were the primary reported reason contributing to reduced access among children. [ABSTRACT FROM AUTHOR]

Introduction: Healthcare organisations serve clients from diverse Indigenous and other ethnic and racial groups on a daily basis, and require appropriate client-centred systems and services for provision of optimal healthcare. Despite advocacy for systems-level approaches to cultural competence, the primary focus in the literature remains on competency strategies aimed at health promotion initiatives, workforce development and student education. This paper aims to bridge the gap in available evidence about systems approaches to cultural competence by systematically mapping key concepts, types of evidence, and gaps in research. Methods: A literature search was completed as part of a larger systematic search of evaluations and measures of cultural competence interventions in health care in Canada, the United States, Australia and New Zealand. Seventeen peer-reviewed databases, 13 websites and clearinghouses, and 11 literature reviews were searched from 2002 to 2015. Overall, 109 studies were found, with 15 evaluating systems-level interventions or describing measurements. Thematic analysis was used to identify key implementation principles, intervention strategies and outcomes reported. Results: Twelve intervention and three measurement studies met our inclusion criteria. Key principles for implementing systems approaches were: user engagement, organisational readiness, and delivery across multiple sites. Two key types of intervention strategies to embed cultural competence within health systems were: audit and quality improvement approaches and service-level policies or strategies. Outcomes were found for organisational systems, the client/practitioner encounter, health, and at national policy level. Discussion and implications: We could not determine the overall effectiveness of systems-level interventions to reform health systems because interventions were context-specific, there were too few comparative studies and studies did not use the same outcome measures. However, examined together, the intervention and measurement principles, strategies and outcomes provide a preliminary framework for implementation and evaluation of systems-level interventions to improve cultural competence. Identified gaps in the literature included a need for cost and effectiveness studies of systems approaches and explication of the effects of cultural competence on client experience. Further research is needed to explore the extent to which cultural competence improves health outcomes and reduces ethnic and racially-based healthcare disparities. [ABSTRACT FROM AUTHOR]

This paper examines how an overseas medical student can improve the life of a kamlari, an indentured servant girl in Nepal. I argue that physicians and students should not only provide care for the health and well-being of patients but also act to ameliorate the suffering of their patients, particularly when patients' social, cultural, economic, and political vulnerabilities overshadow their immediate clinical needs. I also address the point that medical schools need to offer courses on health advocacy and activism in order to promote health equity and social justice for all. [ABSTRACT FROM AUTHOR]

Increasing numbers of young transgender people are now using medical technologies to achieve a physical gender transition. However, the procedures of physical gender transition might cause temporary or permanent sterility. Thus many transgender people are now using fertility preservation technologies. Nonetheless, they can experience dilemmas in making reproductive and family-building decisions and face challenges in gaining access to and utilizing fertility preservation services. Based on qualitative research conducted with transgender men and women who used reproductive technologies for preserving their fertility before or during their physical transition, this paper contributes to the discourse of reproductive choice by the inclusion of transgender people's experience. [ABSTRACT FROM AUTHOR]

Racial-ethnic minorities receive lower quality and intensity of health care compared with whites across a wide range of preventive, diagnostic, and therapeutic services and disease entities. These disparities in health care contribute to continuing racial-ethnic disparities in the burden of illness and death. Several national medical organizations and the Institute of Medicine have issued position papers and recommendations for the elimination of health care disparities. However, physicians in practice are often at a loss for how to translate these principles and recommendations into specific interventions in their own clinical practices. This paper serves as a blueprint for translating principles for the elimination of racial-ethnic disparities in health care into specific actions that are relevant for individual clinical practices. We describe what is known about reducing racial-ethnic disparities in clinical practice and make recommendations for how clinician leaders can apply this evidence to transform their own practices. [ABSTRACT FROM AUTHOR]

In 2003, Ruth Faden and eighteen other colleagues argued that a "problem of unequal biological access" is likely to arise in access to therapies resulting from human embryonic stem cell research. They showed that unless deliberate steps are taken in the United States to ensure that the human embryonic stem cell lines available to researchers mirrors the genetic diversity of the general population, white Americans will likely receive the benefits of these therapies to the relative exclusion of minority ethnic groups. Over the past five years the problem of unequal biological access has not received much attention from politicians, bioethicists and even many researchers in the United States, in spite of the widely held belief in the country that there is an obligation to prevent and correct ethnic disparities in access to medical care. The purpose of this paper is to increase awareness of the problem of unequal biological access and of the need to do more than is currently being done to ensure that ethnic disparities in access to human embryonic stem cell-based therapies do not arise. Specifically, this paper explains why the problem of unequal biological access will likely arise in the United States in such a way that white Americans will disproportionately receive most of the benefits of the therapies resulting from human embryonic stem cell research. It also argues for why there is an obligation to prevent these ethnic disparities in access from happening and outlines four steps that need to be taken towards meeting this obligation. [ABSTRACT FROM AUTHOR]

Background: This paper addresses the health care system from a global perspective and the importance of human resources management (HRM) in improving overall patient health outcomes and delivery of health care services. Methods: We explored the published literature and collected data through secondary sources. Results: Various key success factors emerge that clearly affect health care practices and human resources management. This paper will reveal how human resources management is essential to any health care system and how it can improve health care models. Challenges in the health care systems in Canada, the United States of America and various developing countries are examined, with suggestions for ways to overcome these problems through the proper implementation of human resources management practices. Comparing and contrasting selected countries allowed a deeper understanding of the practical and crucial role of human resources management in health care. Conclusion: Proper management of human resources is critical in providing a high quality of health care. A refocus on human resources management in health care and more research are needed to develop new policies. Effective human resources management strategies are greatly needed to achieve better outcomes from and access to health care around the world. [ABSTRACT FROM AUTHOR]

Objectives. The purpose of this survey was to evaluate attitudes toward acupuncture among pain medicine fellowship directors. Additional goals were to assess the availability of acupuncture at academic medical centers and ascertain the inclusion of this modality in fellowship curricula. Methods. Electronic and paper surveys were distributed to the 97 American College of Graduate Medical Education pain medicine fellowship directors during January and February, 2014. Directors were queried about their referral patterns to acupuncture, as well as their perceptions of the utility of acupuncture for common pain conditions. They were asked about the availability of acupuncture at their institution, and whether acupuncture was included in the fellowship curriculum. Results. Sixty-seven percent of fellowship directors (65/97) completed the questionnaire. A majority of directors (83%) reported acupuncture is available to patients at their institution, and reported that acupuncture is a modality that they discuss with patients when creating a treatment plan for chronic pain (72%). The majority of programs include acupuncture as part of didactic (63%) and clinical (52%) education. Time constraints, lack of qualified teaching personnel, and cost to patients were cited as barriers to inclusion. The majority of fellowship directors considered acupuncture a safe and worthwhile option for common pain conditions. Conclusion. Results from this survey indicate that acupuncture is widely available to patients at academic medical centers, integrated into many pain fellowship curricula, and considered a useful modality by physician leaders in the field of pain medicine. This sentiment, paired with the flexibility of national guidelines for pain fellowship curricula, suggests a trend toward greater inclusion of this modality in academic medicine. [ABSTRACT FROM AUTHOR]

Background: Health care organizations need to be responsive to the needs of increasingly diverse patient populations. We compared the contents of six publicly available approaches to organizational responsiveness to diversity. The central questions addressed in this paper are: what are the most consistently recommended issues for health care organizations to address in order to be responsive to the needs of diverse groups that differ from the majority population? How much consensus is there between various approaches?Methods: We purposively sampled six approaches from the US, Australia and Europe and used qualitative textual analysis to categorize the content of each approach into domains (conceptually distinct topic areas) and, within each domain, into dimensions (operationalizations). The resulting classification framework was used for comparative analysis of the content of the six approaches.Results: We identified seven domains that were represented in most or all approaches: organizational commitment, empirical evidence on inequalities and needs, a competent and diverse workforce, ensuring access for all users, ensuring responsiveness in care provision, fostering patient and community participation, and actively promoting responsiveness. Variations in the operationalization of these domains related to different scopes, contexts and types of diversity. For example, approaches that focus on ethnic diversity mostly provide recommendations to handle cultural and language differences; approaches that take an intersectional approach and broaden their target population to vulnerable groups in a more general sense also pay attention to factors such as socio-economic status and gender.Conclusions: Despite differences in labeling, there is a broad consensus about what health care organizations need to do in order to be responsive to patient diversity. This opens the way to full scale implementation of organizational responsiveness in healthcare and structured evaluation of its effectiveness in improving patient outcomes. [ABSTRACT FROM AUTHOR]

Background: Annually since 2010, the University of Wisconsin Population Health Institute and the Robert Wood Johnson Foundation have produced the County Health Rankings--a "population health checkup" for the nation's over 3,000 counties. The purpose of this paper is to review the background and rationale for the Rankings, explain in detail the methods we use to create the health rankings in each state, and discuss the strengths and limitations associated with ranking the health of communities. Methods: We base the Rankings on a conceptual model of population health that includes both health outcomes (mortality and morbidity) and health factors (health behaviors, clinical care, social and economic factors, and the physical environment). Data for over 30 measures available at the county level are assembled from a number of national sources. Z-scores are calculated for each measure, multiplied by their assigned weights, and summed to create composite measure scores. Composite scores are then ordered and counties are ranked from best to worst health within each state. Results: Health outcomes and related health factors vary significantly within states, with over two-fold differences between the least healthy counties versus the healthiest counties for measures such as premature mortality, teen birth rates, and percent of children living in poverty. Ranking within each state depicts disparities that are not apparent when counties are ranked across the entire nation. Discussion: The County Health Rankings can be used to clearly demonstrate differences in health by place, raise awareness of the many factors that influence health, and stimulate community health improvement efforts. The Rankings draws upon the human instinct to compete by facilitating comparisons between neighboring or peer counties within states. Since no population health model, or rankings based off such models, will ever perfectly describe the health of its population, we encourage users to look to local sources of data to understand more about the health of their community. [ABSTRACT FROM AUTHOR]

Introduction Accurate measurement of health inequities is indispensable to track progress or to identify needs for health equity policy interventions. A key empirical task is to measure the extent to which observed inequality in health - a difference in health - is inequitable. Empirically operationalizing definitions of health inequity has generated an important question not considered in the conceptual literature on health inequity. Empirical analysis can explain only a portion of observed health inequality. This paper demonstrates that the treatment of unexplained inequality is not only a methodological but ethical question and that the answer to the ethical question - whether unexplained health inequality is unfair - determines the appropriate standardization method for health inequity analysis and can lead to potentially divergent estimates of health inequity. Methods We use the American sample of the 2002-03 Joint Canada/United States Survey of Health and measure health by the Health Utilities Index (HUI). We model variation in the observed HUI by demographic, socioeconomic, health behaviour, and health care variables using Ordinary Least Squares. We estimate unfair HUI by standardizing fairness, removing the fair component from the observed HUI. We consider health inequality due to factors amenable to policy intervention as unfair. We contrast estimates of inequity using two fairness- standardization methods: direct (considering unexplained inequality as ethically acceptable) and indirect (considering unexplained inequality as unfair). We use the Gini coefficient to quantify inequity. Results Our analysis shows that about 75% of the variation in the observed HUI is unexplained by the model. The direct standardization results in a smaller inequity estimate (about 60% of health inequality is inequitable) than the indirect standardization (almost all inequality is inequitable). Conclusions The choice of the fairness-standardization method is ethical and influences the empirical health inequity results considerably. More debate and analysis is necessary regarding which treatment of the unexplained inequality has the stronger foundation in equity considerations. [ABSTRACT FROM AUTHOR]

Objective This paper examines how negative experiences with the health-care system create a lack of confidence in receiving medical care in seven countries: Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States. Methods The empirical analysis is based on data from the Commonwealth Fund International Health Policy Survey 2007, with nationally representative samples of adults aged 18 and over. For the analysis of the experience of cost barriers and confidence in receiving medical care, we conducted pairwise comparisons of group percentages as well as country-wise multivariate logistic regression models. Results Individuals who have experienced cost barriers show a significantly lower level of confidence in receiving safe and quality medical care than those who have not. This effect is most pronounced in the United States, where people who have foregone necessary treatment because of costs are four times as likely to lack confidence as individuals without the experience of cost barriers (adjusted odds ratio 4.00). In New Zealand, Germany, and Canada, individuals with the experience of cost barriers are twice as likely to report low confidence compared with those without this experience (adjusted odds ratios of 1.95, 2.19 and 2.24, respectively). In the Netherlands and UK, cost barriers are only a marginal phenomenon. Conclusions The fact that the experience of financial barriers considerably lowers confidence indicates that financial incentives, such as private co-payments, have a negative effect on overall public support and therefore on the legitimacy of health-care systems. [ABSTRACT FROM AUTHOR]

The Department of Veterans Affairs (VA) has been at the vanguard of information technology (IT) and use of comprehensive electronic health records. Despite the widespread use of health IT in the VA, there are still a variety of key questions that need to be answered in order to maximize the utility of IT to improve patient access to quality services. This paper summarizes the potential of IT to enhance healthcare access, key gaps in current evidence linking IT and access, and methodologic challenges for related research. We also highlight four key issues to be addressed when implementing and evaluating the impact of IT interventions on improving access to quality care: 1) Understanding broader needs/perceptions of the Veteran population and their caregivers regarding use of IT to access healthcare services and related information. 2) Understanding individual provider/clinician needs/perceptions regarding use of IT for patient access to healthcare. 3) System/Organizational issues within the VA and other organizations related to the use of IT to improve access. 4) IT integration and information flow with non-VA entities. While the VA is used as an example, the issues are salient for healthcare systems that are beginning to take advantage of IT solutions. [ABSTRACT FROM AUTHOR]

Background: Many healthcare organizations have embraced eHealth technologies in their efforts to promote patient-centered care, increase access to services, and improve outcomes.Objective: Using the Department of Veterans Affairs (VA) as a case study, this paper presents two specific eHealth technologies, the Care Coordination Home Telehealth (CCHT) Program and the My HealtheVet (MHV) personal health record (PHR) portal with integrated secure messaging, and articulates a vision of how they might be implemented as part of a patient-centric healthcare model and used in a complementary manner to enhance access to care and to support patient-centered care.Methods: Based on our experience and ongoing work with both programs, we offer a series of recommendations for pursuing and ultimately achieving this vision.Conclusion: VA's CCHT and MHV programs are examples of an expanding repertoire of eHealth applications available to patients and healthcare teams. VA's new patient-centric healthcare model represents a significant shift in the way that services are delivered and a profound opportunity to incorporate eHealth technologies like the CCHT and MHV programs into clinical practice to increase access to care, and to ensure the responsiveness of such technologies to the preferences and circumstances of patients. [ABSTRACT FROM AUTHOR]

This paper examines the geographic accessibility of tertiary health services for the rural population of Idaho. Utilizing the two most commonly used rurality definitions, we determined the spatial distribution of the rural and urban residents in Idaho. The distance to each of the tertiary healthcare facility was calculated using Geographic Information Systems (GIS). Our analysis showed a large disparity between rural and urban geographic access to tertiary healthcare and revealed that there are significant variations in the disparity depending on the rural definition used. Thus there is a need to deploy strategies to enhance rural access and to construct rurality measures that capture the local heterogeneity, given that rurality designations impact the interpretation of access problems, and the funding eligibility for healthcare programs. [ABSTRACT FROM AUTHOR]

Globalization of intellectual property (IP) protection for medicines has been advancing during the past decade. Countries are obliged to adapt their legislation as a requirement of their membership to the World Trade Organization or as a condition of being part of international trade agreements. There is a growing recognition that, in low-income countries, stronger IP protection is a barrier to access to medicines. At the same time, the number of low-income countries writing national legislation to protect IP for pharmaceutical products is growing worldwide, but little research has been done on the ways in which this process is happening at the national level. This paper aims to contribute to the understanding of the implementation of IP legislation at the national level by providing a comparative analysis of the countries that are part of the United States--Dominican Republic--Central America Free Trade Agreement (DR-CAFTA). The analysis shows three trends. First, countries have often implemented stronger IP protection than required by trade agreements. Second, some countries have adopted IP protection before signing the trade agreements. Third, the process of ratification of DR-CAFTA increased public debate around these issues, which in some cases led to IP legislation that considers public health needs. These trends suggest that industrialized countries and the pharmaceutical industry are using more tactics than just trade agreements to push for increased IP protection and that the process of national legislation is a valid arena for confronting public health needs to those of the industry. [ABSTRACT FROM AUTHOR]

While great strides have been made recently in improving end-of-life care in the United States, people with dementia often die with inadequate pain control, with feeding tubes in place, and without the benefits of hospice care. In this paper, we discuss the most important and persistent challenges to providing excellent end-of-life care for patients with dementia, including dementia not being viewed as a terminal illness; the nature of the course and treatment decisions in advanced dementia; assessment and management of symptoms; the caregiver experience and bereavement; and health systems issues. We suggest approaches for overcoming these barriers in the domains of education, clinical practice, and public policy. As the population ages, general internists increasingly will be called upon to provide primary care for a growing number of patients dying with dementia. There are great opportunities to improve end-of-life care for this vulnerable and underserved population. [ABSTRACT FROM AUTHOR]

This paper proposes a national program to restructure local public health services in the United States which are still characterized by an excessive number of very small health units. It reviews past proposals to correct this situation, and recommends specific programmatic, organizational and financial measures to strengthen the public health infrastructure and achieve an effective national network of federal, state and local public health agencies. [ABSTRACT FROM AUTHOR]

This paper examines the uses of some health status indices in measuring equity of access to medical care. Empirical examples are provided using data from national surveys of the U.S. population conducted from 1964 through 1976. A simple indicator, mean number of physician visits, suggests that between 1963 and 1976 the poor improved their position relative to the rest of the population and, indeed, currently enjoy the highest level of access. However, a second measure, the use-disability ratio indicates that the poor may still receive less care relative to their need. A third measure, the symptoms-response ratio suggests how norms of appropriate behavior might be incorporated into an access measure. [ABSTRACT FROM AUTHOR]

This graphic narrative is a storybook drawn on sketch paper with graphite and charcoal pencils and scanned into Microsoft Word. Sofia represents children of undocumented families currently living in the United States who are being denied fundamental human rights including health care, education, shelter, and food. [ABSTRACT FROM AUTHOR]

The article discusses the study on problems posed by language barriers. The authors of this paper turn to a series of papers testing innovative solutions. A pair of interpreters in a hospital ward service has been embedded. A study also compares the use of interpreters to language concordant interactions.

Background: Indigenous peoples in developed countries have reduced life expectancies, particularly from chronic diseases. The lack of access to and take up of palliative care services of Indigenous peoples is an ongoing concern. Objectives: To examine and learn from published studies on provision of culturally safe palliative care service delivery to Indigenous people in Australia, New Zealand (NZ), Canada and the United States of America (USA); and to compare Indigenous peoples' preferences, needs, opportunities and barriers to palliative care. Methods: A comprehensive search of multiple databases was undertaken. Articles were included if they were published in English from 2000 onwards and related to palliative care service delivery for Indigenous populations; papers could use quantitative or qualitative approaches. Common themes were identified using thematic synthesis. Studies were evaluated using Daly's hierarchy of evidence-for-practice in qualitative research. Results: Of 522 articles screened, 39 were eligible for inclusion. Despite diversity in Indigenous peoples' experiences across countries, some commonalities were noted in the preferences for palliative care of Indigenous people: to die close to or at home; involvement of family; and the integration of cultural practices. Barriers identified included inaccessibility, affordability, lack of awareness of services, perceptions of palliative care, and inappropriate services. Identified models attempted to address these gaps by adopting the following strategies: community engagement and ownership; flexibility in approach; continuing education and training; a whole-of-service approach; and local partnerships among multiple agencies. Better engagement with Indigenous clients, an increase in number of palliative care patients, improved outcomes, and understanding about palliative care by patients and their families were identified as positive achievements. Conclusions: The results provide a comprehensive overview of identified effective practices with regards to palliative care delivered to Indigenous populations to guide future program developments in this field. Further research is required to explore the palliative care needs and experiences of Indigenous people living in urban areas. [ABSTRACT FROM AUTHOR]