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Background: Most transgender people face different conditions of health vulnerability on a daily basis. In the Brazilian context, no research review has been found on such situations in the light of the theoretical conceptualization of multidimensional vulnerability. This research aimed to identify and analyze components of social and/or programmatic vulnerability that interfere with access to health care for trans people in Brazil. Methods: The scoping review followed the JBI Manual and the PRISMA-ScR list. Brazilian studies published in any language, in the period 2019-April 2023, in the NCBI/PubMed, Web of Science, EMBASE, Scopus, SciELO, and LILACS databases were selected. The inclusion criteria included: original research with a sample of transgender people aged 18 years and over; and research contemplating conditions of social and/or programmatic vulnerability. Three reviewers independently selected the articles. The extracted and mapped data included components of these dimensions, according to the theoretical framework, as well as characteristics of the studies, for the synthesis of the descriptive analysis. Results: A total of 46 studies were included. Social and programmatic vulnerability components were present in 67% of the studies. Among the main findings, the social dimension included discrimination, situations of violence in different contexts and social exclusion; prejudice and school dropout, homelessness, informal work and precarious income; and harmful use of alcohol and/or other drugs. The programmatic dimension encompassed disrespect for the use of the social name and institutional discrimination; hormone therapy without professional monitoring and scarcity of specialized services; lack of integration between Primary Health Care (PHC) and specialized care and insufficient PHC involvement; distortions between what is contained in public health policies and the practice in the services. A higher percentage (61%) of studies with trans women and 7% with trans men were observed; inequalities in regional distribution; predominance of HIV and AIDS and mental health themes; and similar percentages in the various methodological approaches and publications in national and foreign journals. Conclusion: The identified situations of vulnerability contribute mainly to supporting the formulation and implementation of new public policies in comprehensive health that are more comprehensive and inclusive, which mitigate the current social and health inequities. [ABSTRACT FROM AUTHOR]

BACKGROUND: Mobile medical clinics have been used for decades to provide primary and preventive care to underserved populations. While several studies have examined their return on investment and impact on chronic disease management outcomes in the Mid-Atlantic and East Coast regions of the United States, little is known about the characteristics and clinical outcomes of adults who receive care aboard mobile clinics on the West Coast region. Guided by the Anderson Behavioral Model, this study describes the predisposing, enabling, and need factors associated with mobile medical clinic use among mobile medical clinic patients in Southern California and examines the relationship between mobile clinic utilization and presence and control of diabetes and hypertension. METHODS: We conducted a retrospective cohort study of 411 adults who received care in four mobile clinic locations in Southern California from January 1, 2018, to December 31, 2019. Data were collected from patient charts on predisposing (e.g., sex, race, age), enabling (e.g., insurance and housing status), and need (e.g., chronic illness) factors based on Andersens Behavioral Model. Zero-truncated negative binomial regression was used to examine the association of chronic illness (hypertension and diabetes) with number of clinic visits, accounting for potential confounding factors. RESULTS: Over the course of the 2-year study period, 411 patients made 1790 visits to the mobile medical clinic. The majority of patients were female (68%), Hispanic (78%), married (47%), with a mean age of 50 (SD = 11). Forty-four percent had hypertension and 29% had diabetes. Frequency of mobile clinic utilization was significantly associated with chronic illness. Patients with hypertension and diabetes had 1.22 and 1.61 times the rate of mobile medical clinic visit than those without those conditions, respectively (IRR = 1.61, 95% CI, 1.36-1.92; 1.22, 95% CI, 1.02-1.45). CONCLUSIONS: Mobile clinics serve as an important system of health care delivery, especially for adults with uncontrolled diabetes and hypertension.

The Ventanillas de Salud (VDS - Health Windows) are a culturally sensitive outreach program within the 49 Mexican Consulates in the United States that provides information and health care navigation support to underserved and uninsured Mexican immigrants. During the COVID-19 pandemic the VDS rapidly transitioned to remote operations adding new services. Based on the EquIR implementation framework, this qualitative study investigates how adaptations to improve emergency preparedness were performed. We conducted motivational interviews with three actors - six VDS coordinators, eight partner organizations, and ten VDS users- in two VDS, Los Angeles and New York, to document specific needs of the target population and identify implementation processes to adapt and continue operating. The VDS adapted their model by adding new services for emerging needs, by switching service provision modalities, and by expanding the network of partner organizations. According to the VDS staff, these adaptations increased their topics, depth, reach, and diversified their users. Users had mostly positive opinions about the VDS adaptation, although they highlighted some heterogeneity across service provision. The VDS is a public health intervention able to serve a marginalized population and its implementation offers valuable lessons to complement health systems and to improve preparedness and resiliency for future crises.

Abstract Background Mobile medical clinics have been used for decades to provide primary and preventive care to underserved populations. While several studies have examined their return on investment and impact on chronic disease management outcomes in the Mid-Atlantic and East Coast regions of the United States, little is known about the characteristics and clinical outcomes of adults who receive care aboard mobile clinics on the West Coast region. Guided by the Anderson Behavioral Model, this study describes the predisposing, enabling, and need factors associated with mobile medical clinic use among mobile medical clinic patients in Southern California and examines the relationship between mobile clinic utilization and presence and control of diabetes and hypertension. Methods We conducted a retrospective cohort study of 411 adults who received care in four mobile clinic locations in Southern California from January 1, 2018, to December 31, 2019. Data were collected from patient charts on predisposing (e.g., sex, race, age), enabling (e.g., insurance and housing status), and need (e.g., chronic illness) factors based on Andersen’s Behavioral Model. Zero-truncated negative binomial regression was used to examine the association of chronic illness (hypertension and diabetes) with number of clinic visits, accounting for potential confounding factors. Results Over the course of the 2-year study period, 411 patients made 1790 visits to the mobile medical clinic. The majority of patients were female (68%), Hispanic (78%), married (47%), with a mean age of 50 (SD = 11). Forty-four percent had hypertension and 29% had diabetes. Frequency of mobile clinic utilization was significantly associated with chronic illness. Patients with hypertension and diabetes had 1.22 and 1.61 times the rate of mobile medical clinic visit than those without those conditions, respectively (IRR = 1.61, 95% CI, 1.36–1.92; 1.22, 95% CI, 1.02–1.45). Conclusions Mobile clinics serve as an important system of health care delivery, especially for adults with uncontrolled diabetes and hypertension.

Abstract The Ventanillas de Salud (VDS – “Health Windows”) are a culturally sensitive outreach program within the 49 Mexican Consulates in the United States that provides information and health care navigation support to underserved and uninsured Mexican immigrants. During the COVID-19 pandemic the VDS rapidly transitioned to remote operations adding new services. Based on the EquIR implementation framework, this qualitative study investigates how adaptations to improve emergency preparedness were performed. We conducted motivational interviews with three actors – six VDS coordinators, eight partner organizations, and ten VDS users– in two VDS, Los Angeles and New York, to document specific needs of the target population and identify implementation processes to adapt and continue operating. The VDS adapted their model by adding new services for emerging needs, by switching service provision modalities, and by expanding the network of partner organizations. According to the VDS staff, these adaptations increased their topics, depth, reach, and diversified their users. Users had mostly positive opinions about the VDS adaptation, although they highlighted some heterogeneity across service provision. The VDS is a public health intervention able to serve a marginalized population and its implementation offers valuable lessons to complement health systems and to improve preparedness and resiliency for future crises.

Abstract Background Extending Universal Health Coverage (UHC) requires identifying and addressing unmet healthcare need and its causes to improve access to essential health services. Unmet need is a useful monitoring indicator to verify if low incidence of catastrophic health spending is not a result of foregone services due to unmet needs. This study assesses the trend, between 2011 and 2019, of prevalence and reasons of unmet healthcare need and identifies population groups who had unmet needs. Method The unmet healthcare need module in the Health and Welfare Survey (HWS) 2011–2019 was used for analysis. HWS is a nationally representative household survey conducted by the National Statistical Office biennially. There are more than 60,000 respondents in each round of survey. The Organisation for Economic Co-operation and Development (OECD) standard questions on unmet need and reasons behind were applied for outpatient (OP), inpatient (IP) and dental services in the past 12 months. Data from samples were weighted to represent the Thai population. Univariate analysis was applied to assess unmet need across socioeconomic profiles. Results The annual prevalence of unmet need between 2011 and 2019 was lower than 3%. The prevalence was 1.3–1.6% for outpatient services, 0.9% - 1.1% for dental services, and lower than 0.2% for inpatient care. A small increasing trend was observed on dental service unmet need, from 0.9% in 2011 to 1.1% in 2019. The poor, the elderly and people living in urban areas had higher unmet needs than their counterparts. Long waiting times was the main reason for unmet need, while cost of treatment was not an issue. Conclusion The low level of unmet need at less than 3% was lower than OECD average (28%), and was the result of UHC since 2002. Regular monitoring using the national representative household survey to estimate annual prevalence and reasons for unmet need can guide policy to sustain and improve access by certain population groups.

他言語要約 (日本語) 背景 日本において、外国人住民は日本人に比べて保健医療へのアクセスバリアがあり、健康のアウトカムもよくないことが知られている。しかし、外国人住民の保健医療に関する状況は大きく変化し続けており、「取り残された」人を特定することは困難である。そこで本研究では、NGOの無料健康相談を受けた外国人住民を対象に、「医療機関を受診するように勧められた」「医療機関を紹介された」ことを保健医療へのアクセスバリアを示唆する代理指標として、これらに関連する要因を明らかにすることを目的とした。. 方法 愛知県内の複数の会場で外国人住民を対象とした無料健康相談会を行っているNGOの活動記録を用いて二次データ分析を行った。保険加入を含む参加者特性を明らかにした上で、二変量分析(χ2検定) および多変量分析 (log-binomial回帰分析)を行い保健医療へのアクセスバリアと関連する要因を明らかにした。. 結果 抽出された608例のうち、相談時に医療機関への受診を勧められたのは164例(27.5%)、医療機関への紹介は72例(11.8%)であった。公的保険に加入していない人は、公的保険に加入している人に比べて、医療機関への受診を勧められる割合 (prevalence)が1.56倍(95%信頼区間 [CI]:1.19–2.05)高かった。仕事をしていない人および学生は、専門職者に比べて医療施設への紹介を有意に多く受けており、prevalence ratioはそれぞれ3.28(95%信頼区間 [CI]:1.64–6.57) および2.77(95%CI,1.18–6.46) であった。. 結論 大多数は保険に加入していたが、無料健康相談を利用する前に正式な医療制度へのアクセスが制限されていたことを示唆する、医療機関を受診するよう勧められた参加者が30%近くいた。本研究結果は、保険に加入していない人、仕事をしていない人、学生など、保健医療へのアクセスが脆弱だと考えられる人たちを示した。誰もが「取り残されない」ようにするために、エビデンスを更新しながら、脆弱な人々へ必要な支援を提供することが肝要である。.

Abstract Background Aboriginal and Torres Strait Islander people do not enjoy equal access to specialist health services that adequately meet their needs. Clinical genetics services are at the vanguard of realising the health benefits of genomic medicine. As the field continues to expand in clinical utility and implementation, it is critical that Aboriginal and Torres Strait Islander people are able to participate and benefit equally to avoid further widening of the existing health gap. This is the first study to explore barriers to accessing clinical genetics services among Aboriginal and Torres Strait Islander people, which has been acknowledged as a key strategic priority in Australian genomic health policy. Methods A participatory design process engaged a majority-Aboriginal Project Reference Group and Aboriginal End-User Group. 63 semi-structured interviews were conducted with Aboriginal and/or Torres Strait Islander people who had accessed the government-funded clinical genetics service in Western Australia, Queensland or the Northern Territory between 2014 and 2018. The sample included patients, parents and carers. Participants were asked to recount their ‘patient journey’, from referral through to post-appointment and reflect on their perceptions of genetics and its implications for the health of themselves and their families. Analysis tracked chronological service engagement, followed by an inductive thematic approach. Results Barriers to access and engagement were present at each stage of the patient journey. These included challenges in obtaining a referral, long waiting periods, limited genetic literacy, absence of Aboriginal support services, communication challenges and lack of adequate psychosocial support and follow-up after attendance. Participants’ overall experiences of attending a genetic health service were varied, with positive perceptions tied closely to a diagnosis being achieved. The experience of (and expectation for) recognition of cultural identity and provision of culturally safe care was low among participants. Unaddressed concerns continued to cause significant distress in some people years after their appointment took place. Conclusions There is significant scope for improving the care provided to Aboriginal and Torres Strait Islander people at clinical genetics services. Immediate attention to minimising logistical barriers, developing relationships with Aboriginal Community Controlled Health Services and providing practical and specific cultural safety training for practitioners is required at the service-level. Our findings strongly support the development of guidelines or policies recognising the collective cultural needs of Aboriginal and Torres Strait Islander people in relation to genomic health care.

Abstract Background Utilization of primary-care and specialist physicians seems to be associated differently with socioeconomic status (SES). This review aims to summarize and compare the evidence on socioeconomic inequalities in consulting primary-care or specialist physicians in the general adult population in high-income countries. Methods We carried out a systematic search across the most relevant databases (Web of Science, Medline) and included all studies, published since 2004, reporting associations between SES and utilization of primary-care and/or specialist physicians. In total, 57 studies fulfilled the eligibility criteria. Results Many studies found socioeconomic inequalities in physician utilization, but inequalities were more pronounced in visiting specialists than primary-care physicians. The results of the studies varied strongly according to the operationalization of utilization, namely whether a physician was visited (probability) or how often a physician was visited (frequency). For probabilities of visiting primary-care physicians predominantly no association with SES was found, but frequencies of visits were higher in the most disadvantaged. The most disadvantaged often had lower probabilities of visiting specialists, but in many studies no link was found between the number of visits and SES. Conclusion This systematic review emphasizes that inequalities to the detriment of the most deprived is primarily a problem in the probability of visiting specialist physicians. Healthcare policy should focus first off on effective access to specialist physicians in order to tackle inequalities in healthcare. PROSPERO registration number CRD42019123222 .

Background: Access to professional health care providers in Loja Province, Ecuador can be difficult for many citizens. The Health Care Access Barrier Model (HCAB) was established to provide a framework for classification, analysis, and reporting of modifiable health care access barriers. This study uses the HCAB Model to identify barriers and themes impacting access to health care access in southern rural Ecuador. Methods: The research team interviewed 22 participants and completed 15 participant observation studies in the study area. Interviews and a single focus group session of artisans were recorded and transcribed from Spanish to English, and thematic analysis was performed. Results: The thematic analysis found financial, structural, and cognitive health care access barriers. Cost of medications, transportation, missed responsibilities at work and home, difficulty scheduling appointments, and misconceptions in health literacy were the predominant themes contributing to health care access. These pressure points provide insight on where actions may be taken to alleviate access barriers. Conclusion: Modifiable health care access barriers outlined in the HCAB are evident in the study area. Further research and implementation of programs to resolve these barriers, such as the creation of health care subcenters and/or mobile clinic, insurance coverage of specialized care, increasing availability and accessibility to affordable transportation, improving roadways, introduction of a 24/7 call center to schedule medical visits, monetary incentive for primary care physicians to practice in rural and underserved areas, provision of affordable work equipment, and emphasizing the improvement of health care literacy through education, may diminish current barriers, identify additional barriers, and improve overall health in the rural area of Loja, Ecuador and similar rural regions around the world. [ABSTRACT FROM AUTHOR]

Background: Extending Universal Health Coverage (UHC) requires identifying and addressing unmet healthcare need and its causes to improve access to essential health services. Unmet need is a useful monitoring indicator to verify if low incidence of catastrophic health spending is not a result of foregone services due to unmet needs. This study assesses the trend, between 2011 and 2019, of prevalence and reasons of unmet healthcare need and identifies population groups who had unmet needs. Method: The unmet healthcare need module in the Health and Welfare Survey (HWS) 2011–2019 was used for analysis. HWS is a nationally representative household survey conducted by the National Statistical Office biennially. There are more than 60,000 respondents in each round of survey. The Organisation for Economic Co-operation and Development (OECD) standard questions on unmet need and reasons behind were applied for outpatient (OP), inpatient (IP) and dental services in the past 12 months. Data from samples were weighted to represent the Thai population. Univariate analysis was applied to assess unmet need across socioeconomic profiles. Results: The annual prevalence of unmet need between 2011 and 2019 was lower than 3%. The prevalence was 1.3–1.6% for outpatient services, 0.9% - 1.1% for dental services, and lower than 0.2% for inpatient care. A small increasing trend was observed on dental service unmet need, from 0.9% in 2011 to 1.1% in 2019. The poor, the elderly and people living in urban areas had higher unmet needs than their counterparts. Long waiting times was the main reason for unmet need, while cost of treatment was not an issue. Conclusion: The low level of unmet need at less than 3% was lower than OECD average (28%), and was the result of UHC since 2002. Regular monitoring using the national representative household survey to estimate annual prevalence and reasons for unmet need can guide policy to sustain and improve access by certain population groups. [ABSTRACT FROM AUTHOR]

Abstract Background Young people have unique social, emotional and developmental needs that require a welcoming and responsive health system, and policies that support their access to health care. Those who are socially or culturally marginalised may face additional challenges in navigating health care, contributing to health inequity. The aim of this study was to understand health system navigation, including the role of technology, for young people belonging to one or more marginalised groups, in order to inform youth health policy in New South Wales, Australia. Methods This qualitative longitudinal study involved 2–4 interviews each over 6 to 12 months with marginalised young people aged 12–24 years living in NSW. The analysis used Nvivo software and grounded theory. Results We interviewed 41 young people at baseline who were living in rural or remote areas, sexuality and/or gender diverse, refugee, homeless, and/or Aboriginal. A retention rate of over 85% was achieved. Nineteen belonged to more than one marginalised group allowing an exploration of intersectionality. General practitioners (family physicians) were the most commonly accessed service throughout the study period. Participants were ambivalent about their healthcare journeys. Qualitative analysis identified five themes:1.Technology brings opportunities to understand, connect and engage with services2.Healthcare journeys are shaped by decisions weighing up convenience, engagement, effectiveness and affordability.3.Marginalised young people perceive and experience multiple forms of discrimination leading to forgone care.4.Multiple marginalisation makes health system navigation more challenging5.The impact of health system complexity and fragmentation may be mitigated by system knowledge and navigation support Conclusions The compounding effects of multiple discrimination and access barriers were experienced more strongly for young people belonging to mutiple marginalised groups. We identify several areas for improving clinical practice and policy. Integrating technology and social media into processes that facilitate access and navigation, providing respectful and welcoming services that recognise diversity, improving health literacy and involving professionals in advocacy and navigation support may help to address these issues.

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Background: Aboriginal and Torres Strait Islander people do not enjoy equal access to specialist health services that adequately meet their needs. Clinical genetics services are at the vanguard of realising the health benefits of genomic medicine. As the field continues to expand in clinical utility and implementation, it is critical that Aboriginal and Torres Strait Islander people are able to participate and benefit equally to avoid further widening of the existing health gap. This is the first study to explore barriers to accessing clinical genetics services among Aboriginal and Torres Strait Islander people, which has been acknowledged as a key strategic priority in Australian genomic health policy. Methods: A participatory design process engaged a majority-Aboriginal Project Reference Group and Aboriginal End-User Group. 63 semi-structured interviews were conducted with Aboriginal and/or Torres Strait Islander people who had accessed the government-funded clinical genetics service in Western Australia, Queensland or the Northern Territory between 2014 and 2018. The sample included patients, parents and carers. Participants were asked to recount their 'patient journey', from referral through to post-appointment and reflect on their perceptions of genetics and its implications for the health of themselves and their families. Analysis tracked chronological service engagement, followed by an inductive thematic approach. Results: Barriers to access and engagement were present at each stage of the patient journey. These included challenges in obtaining a referral, long waiting periods, limited genetic literacy, absence of Aboriginal support services, communication challenges and lack of adequate psychosocial support and follow-up after attendance. Participants' overall experiences of attending a genetic health service were varied, with positive perceptions tied closely to a diagnosis being achieved. The experience of (and expectation for) recognition of cultural identity and provision of culturally safe care was low among participants. Unaddressed concerns continued to cause significant distress in some people years after their appointment took place. Conclusions: There is significant scope for improving the care provided to Aboriginal and Torres Strait Islander people at clinical genetics services. Immediate attention to minimising logistical barriers, developing relationships with Aboriginal Community Controlled Health Services and providing practical and specific cultural safety training for practitioners is required at the service-level. Our findings strongly support the development of guidelines or policies recognising the collective cultural needs of Aboriginal and Torres Strait Islander people in relation to genomic health care. [ABSTRACT FROM AUTHOR]

Background: Utilization of primary-care and specialist physicians seems to be associated differently with socioeconomic status (SES). This review aims to summarize and compare the evidence on socioeconomic inequalities in consulting primary-care or specialist physicians in the general adult population in high-income countries. Methods: We carried out a systematic search across the most relevant databases (Web of Science, Medline) and included all studies, published since 2004, reporting associations between SES and utilization of primary-care and/or specialist physicians. In total, 57 studies fulfilled the eligibility criteria. Results: Many studies found socioeconomic inequalities in physician utilization, but inequalities were more pronounced in visiting specialists than primary-care physicians. The results of the studies varied strongly according to the operationalization of utilization, namely whether a physician was visited (probability) or how often a physician was visited (frequency). For probabilities of visiting primary-care physicians predominantly no association with SES was found, but frequencies of visits were higher in the most disadvantaged. The most disadvantaged often had lower probabilities of visiting specialists, but in many studies no link was found between the number of visits and SES. Conclusion: This systematic review emphasizes that inequalities to the detriment of the most deprived is primarily a problem in the probability of visiting specialist physicians. Healthcare policy should focus first off on effective access to specialist physicians in order to tackle inequalities in healthcare. PROSPERO registration number: CRD42019123222. [ABSTRACT FROM AUTHOR]

Background: People who have been in custody are more likely to experience multiple, long standing health issues. They are at high risk of illness and injury post release and experience poor access to health services both of which contribute to high rates of recidivism. The study was conducted to examine Aboriginal and non-Aboriginal former prisoners' risk of hospitalisation and rehospitalisation in the five years post release from custody and identified the common reasons for hospitalisations. Methods: Common reasons for hospital admission were identified by conducting descriptive analysis of linked data, related to former prisoners, from NSW Ministry of Health and Corrective Services NSW. This relied upon admitted patient data for 1899 patients. Of this cohort, 1075 people had been admitted to hospital at least once and remained out of custody over a five year period. The independent variables we studied included age, sex, and whether or not the person was Aboriginal. We conducted univariate and multivariate analysis on the following dependent variables: number of admissions over five years after release; more than one admission; days between custody and first hospitalisation; and days between first and second hospitalisation. Results: Mental and behavioural disorders, injuries and poisoning, and infectious or parasitic diseases were the three most common reasons for admission. Aboriginal and non-Aboriginal former prisoners had a broadly similar pattern of reasons for admission. Yet Aboriginal former prisoners were more likely than non-Aboriginal former prisoners to have a shorter mean interval between hospital admission and readmission (187 days compared to 259 days, t = 2.90, p-0.004). Conclusions: Despite poorer health among Aboriginal people, there were broadly similar patterns of reasons for admission to hospital among Aboriginal and non-Aboriginal former prisoners. There may be a number of explanations for this. The cohort was not a representative sample of the NSW prison population. There was an overrepresentation of individuals with cognitive disability (intellectual disability, acquired brain injury, dementia, fetal alcohol spectrum disorder) in the study population, which may have impacted on this group accessing hospital health care. Alternatively perhaps there were fewer presentations to hospital by Aboriginal former prisoners despite a greater need. The shorter interval between hospital admission and readmission for Aboriginal former prisoners may suggest the need for better follow up care in the community after discharge from hospital. This presents an opportunity for primary health care services to work more closely with hospitals to identify and manage Aboriginal former prisoners discharged from hospital so as to prevent readmission. [ABSTRACT FROM AUTHOR]

Introduction In Hong Kong, migrants arriving from Mainland China often have multiple roles and responsibilities while adapting to new lives in their host destination. This paper explored the factors that contribute to the inequity in health services utilisation experienced by these migrants; and, identified the elements that could constitute an effective health delivery model to address the service gap. Methods Site visits and a focus group discussion (n = 13) were held with both public and private health providers before a number of innovative health delivery models were formulated. They were then circulated among the panel in two further rounds of Delphi survey (n = 11) from March- April 2012 to systematically collect opinions and select the most endorsed health service models to serve this target population. Results Focus group members perceived that most migrants were unaware of, or even ignored, their own physical and mental health needs, and had low utilisation of healthcare services, because of their pre-occupation with daily chores and hardship as well as differing health values, practices and expectations. They further identified that the structural issues such as the healthcare setting or the operation of current service provisions had failed to meet migrants' health needs. Consequently, four new service models that incorporated professional advice and empowerment, which were identified as the two most important elements, were put forward. Thus, the model of having a nurse with social work training, supported by volunteer groups, was selected as the best option to familiarise and empower patients within the labyrinth of local healthcare services. Conclusion Implementation of a social empowerment model by way of targeted support and specific health information is recommended. Further evaluation of this model is needed to understand its effectiveness for improving health literacy and health status in this disadvantaged group in the long term. [ABSTRACT FROM AUTHOR]

Introduction Health system reforms are undertaken with the aim of improving equity of access to health care. Their impact is generally analyzed based on health care utilization, without distinguishing between levels of care. This study aims to analyze inequities in access to the continuum of care in municipalities of Brazil and Colombia. Methods A cross-sectional study was conducted based on a survey of a multistage probability sample of people who had had at least one health problem in the prior three months (2,163 in Colombia and 2,167 in Brazil). The outcome variables were dichotomous variables on the utilization of curative and preventive services. The main independent variables were income, being the holder of a private health plan and, in Colombia, type of insurance scheme of the General System of Social Security in Health (SGSSS). For each country, the prevalence of the outcome variables was calculated overall and stratified by levels of per capita income, SGSSS insurance schemes and private health plan. Prevalence ratios were computed by means of Poisson regression models with robust variance, controlling for health care need. Results There are inequities in favor of individuals of a higher socioeconomic status: in Colombia, in the three different care levels (primary, outpatient secondary and emergency care) and preventive activities; and in Brazil, in the use of outpatient secondary care services and preventive activities, whilst lower-income individuals make greater use of the primary care services. In both countries, inequity in the use of outpatient secondary care is more pronounced than in the other care levels. Income in both countries, insurance scheme enrollment in Colombia and holding a private health plan in Brazil all contribute to the presence of inequities in utilization. Conclusions Twenty years after the introduction of reforms implemented to improve equity in access to health care, inequities, defined in terms of unequal use for equal need, are still present in both countries. The design of the health systems appears to determine access to the health services: two insurance schemes in Colombia with different benefits packages and a segmented system in Brazil, with a significant private component. [ABSTRACT FROM AUTHOR]

Background: Lack of access to health care is a persistent condition for most African indigents, to which the common technical approach of targeting initiatives is an insufficient antidote. To overcome the standstill, an integrated technical and political approach is needed. Such policy shift is dependent on political support, and on alignment of international and national actors. We explore if the analytical framework of social exclusion can contribute to the latter. Methods: We produce a critical and evaluative account of the literature on three themes: social exclusion, development policy, and indigence in Africa-and their interface. First, we trace the concept of social exclusion as it evolved over time and space in policy circles. We then discuss the relevance of a social exclusion perspective in developing countries. Finally, we apply this perspective to Africa, its indigents, and their lack of access to health care. Results: The concept of social exclusion as an underlying process of structural inequalities has needed two decades to find acceptance in international policy circles. Initial scepticism about the relevance of the concept in developing countries is now giving way to recognition of its universality. For a variety of reasons however, the uptake of a social exclusion perspective in Africa has been limited. Nevertheless, social exclusion as a driver of poverty and inequity in Africa is evident, and manifestly so in the case of the African indigents. Conclusion: The concept of social exclusion provides a useful framework for improved understanding of origins and persistence of the access problem that African indigents face, and for generating political space for an integrated approach. [ABSTRACT FROM AUTHOR]

Introduction: China's New Cooperative Medical Scheme (NCMS) was brought to life in 2003 in response to the deterioration in access to health services in rural areas. Despite its fast expansion, the scheme's impacts on access to health care have raised growing concerns, in particular regarding whether and to what extent the scheme has reduced inequity in access to health care in rural China. Methods: This study examines income-related inequity in access to health care from 2004 (before the national rollout of NCMS) to 2009 (after the expansion of NCMS across the rural China) by estimating Concentration Indices over both formal health care (outpatient care, prevention care) and informal health care use (folk doctor care). Data were drawn from a longitudinal household survey dataset - China Health and Nutrition Survey (CHNS). Results: The study suggested that the level of inequity remained the same for outpatient care, and an increased favouring-poor gap in terms of folk doctor care was observed. In terms of preventive care, a favouring-rich inequity was observed both in 2004 and 2009, but the effects of inequity were narrowed. The NCMS had some effects in reducing income-related health inequity in folk doctor care and preventive care, but the contribution was rather small. The study also found that the rural better-off had started to seek for commercial insurance to cover possible financial risks from the burden of diseases. Conclusion: The study concludes that the impacts of the NCMS on improving access to formal care for the poor are limited. Without a more comprehensive insurance package that effectively targets the rural poor, the intended equity goals expected from the scheme will be difficult to realize. [ABSTRACT FROM AUTHOR]

Introduction: In countries such as Bangladesh many women may only seek skilled care at birth when complications become evident. This often results in higher neonatal mortality for women who give birth in institutions than for those that give birth at home. However, we hypothesise that this apparent excess mortality is concentrated among less advantaged women. The aim of this paper is to examine the association between place of birth and neonatal mortality in Bangladesh, and how this varies by socio-economic status. Methodology: The study is based on pooled data from four Bangladesh Demographic and Household Surveys, and uses descriptive analysis and binomial multivariate logistic regression. It uses regression models stratified for place of delivery to examine the impact of socio-economic status and place of residence on neonatal mortality. Results: Poor women from rural areas and those with no education who gave birth in institutions had much worse outcomes than those who gave birth at home. There is no difference for more wealthy women. There is a much stronger socio-economic gradient in neonatal mortality for women who gave birth in institutions than those who delivered at home. Conclusion: In Bangladesh babies from lower socio-economic groups and particularly those in rural areas have very poor outcomes if born in a facility. This suggests poorer, rural and less educated women are failing to obtain the timely access to quality maternal health care services needed to improve newborn outcomes. [ABSTRACT FROM AUTHOR]

Abstract Introduction Iranians comprise an immigrant group that has a very different cultural background from that of the mainstream Canadian population and speaks a language other than English or French; in this case mainly Farsi (Persian). Although Iranian immigrants in Toronto receive a high proportion of care from Farsi-speaking family physicians and health care providers than physicians who cannot speak Farsi, they are still not satisfied with the provided services. The purpose of this study was to identify the obstacles and issues Iranian immigrants faced in accessing health care services as seen through the eyes of Iranian health care professionals/providers and social workers working in Greater Toronto Area, Canada. Methods Narrative inquiry was used to capture and understand the obstacles this immigrant population faces when accessing health care services, through the lens of fifty Iranian health care professionals/providers and social workers. Thirty three health care professionals and five social workers were interviewed. To capture the essence of issues, individual interviews were followed by three focus groups consisting of three health care professionals and one social worker in each group. Results Three major themes emerged from the study: language barrier and the lack of knowledge of Canadian health care services/systems; lack of trust in Canadian health care services due to financial limitations and fear of disclosure; and somatization and needs for psychological supports. Conclusion Iranians may not be satisfied with the Canadian health care services due to a lack of knowledge of the system, as well as cultural differences when seeking care, such as fear of disclosure, discrimination, and mistrust of primary care. To attain equitable, adequate, and effective access to health care services, immigrants need to be educated and informed about the Canadian health care system and services it provides. It would be of great benefit to this population to hold workshops on health topics, and mental health issues, build strong ties with the community by increasing their involvement, use plain language, design informative and health related websites in both Farsi and English, and provide a Farsi speaking telephone help line to answer their health related issues.

Background: Young people have unique social, emotional and developmental needs that require a welcoming and responsive health system, and policies that support their access to health care. Those who are socially or culturally marginalised may face additional challenges in navigating health care, contributing to health inequity. The aim of this study was to understand health system navigation, including the role of technology, for young people belonging to one or more marginalised groups, in order to inform youth health policy in New South Wales, Australia. Methods: This qualitative longitudinal study involved 2–4 interviews each over 6 to 12 months with marginalised young people aged 12–24 years living in NSW. The analysis used Nvivo software and grounded theory. Results: We interviewed 41 young people at baseline who were living in rural or remote areas, sexuality and/or gender diverse, refugee, homeless, and/or Aboriginal. A retention rate of over 85% was achieved. Nineteen belonged to more than one marginalised group allowing an exploration of intersectionality. General practitioners (family physicians) were the most commonly accessed service throughout the study period. Participants were ambivalent about their healthcare journeys. Qualitative analysis identified five themes: Technology brings opportunities to understand, connect and engage with services Healthcare journeys are shaped by decisions weighing up convenience, engagement, effectiveness and affordability. Marginalised young people perceive and experience multiple forms of discrimination leading to forgone care. Multiple marginalisation makes health system navigation more challenging The impact of health system complexity and fragmentation may be mitigated by system knowledge and navigation support Conclusions: The compounding effects of multiple discrimination and access barriers were experienced more strongly for young people belonging to mutiple marginalised groups. We identify several areas for improving clinical practice and policy. Integrating technology and social media into processes that facilitate access and navigation, providing respectful and welcoming services that recognise diversity, improving health literacy and involving professionals in advocacy and navigation support may help to address these issues. [ABSTRACT FROM AUTHOR]