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People with noncancer diagnoses have poorer access to palliative care units (PCUs) or hospices compared to those with cancer diagnoses. The COVID-19 pandemic disrupted how specialist palliative care services were delivered and utilized. To determine the association between the start of the COVID-19 pandemic and PCU/hospice utilization in hospitalized individuals with cancer and noncancer diagnoses with specialist palliative care needs. Retrospective cohort study using routinely collected data. Percentages of individuals experiencing each disposition from hospital, including discharge to PCU/hospice, were calculated monthly for the total, cancer, and noncancer cohorts and were analyzed descriptively. Hospitalized individuals with specialist palliative care needs at a single academic hospital in Toronto, Canada from January 1, 2017, to September 31, 2022 (pandemic start was defined as April 1, 2020). The cohort comprised 4349 individuals (median age=78 years; 52.4% female); 3065 (70.5%) and 1284 (29.5%) had cancer and noncancer diagnoses, respectively. Among individuals with noncancer diagnoses, the most significant absolute changes were a 13.0%-decrease in in-hospital deaths (prepandemic=49.6%; postpandemic=36.6%) and a 11.6%-increase in discharges to PCU/hospice (prepandemic=35.6%; postpandemic=47.3%). Among individuals with cancer, the most significant absolute changes were a 12.8%-increase in discharges home with formal care (prepandemic=2.3%; postpandemic=15.1%) and a 7.0%-decrease in in-hospital deaths (prepandemic=29.1%; postpandemic=22.0%). Despite historically poor PCU/hospice access, the COVID-19 pandemic created circumstances that may have enabled unprecedented utilization in individuals with noncancer diagnoses in our cohort. [ABSTRACT FROM AUTHOR]

• Rural healthcare challenges: collaboration gaps stress the need for efficient rural care environments. • Untapped integrated Care: despite demand, rural facilities lack integrated care, holding untapped potential. • Benefits of integrated Care: job satisfaction and patient well-being thrive in integrated care settings. • Empowering Nurses: integrated care empowers nurses for confident management of acute health risks. • Cultural shift for quality Healthcare: collaboration framework and education enhance long-term care quality. Objectives : This study explores healthcare professionals' perceptions in rural German long-term care facilities, focusing on integrated health systems. The aim is to understand experiences, challenges, and preferences. Methods : Twenty nurses and paramedics participated in in-depth interviews. Thematic analysis was applied to transcripts, revealing key themes: acute healthcare provision, interdisciplinary collaboration, telemedicine use, and preferences for the future healthcare landscape. Results : Themes highlighted factors influencing acute care situations and the crucial role of interdisciplinary collaboration. Integrated care was infrequently encountered despite high demand in rural long-term care facilities. Conclusions : Though uncommon, integrated healthcare remains crucial in addressing long-term care facility residents' complex needs. Healthcare professionals express a strong demand for integrated care in rural areas, citing potential benefits for resident wellbeing, healthcare effectiveness, and job satisfaction. The findings guide healthcare organizations in developing institutional-level strategies for integrated care integration, emphasizing its importance in rural settings [ABSTRACT FROM AUTHOR]

In the backdrop of telemedicine's rise, this review explores its integration into oral and maxillofacial surgery (OMFS), especially given the healthcare access challenges faced by nearly 20% of the rural population in the United States of America. The study underscores the potential of telemedicine to address disparities in access to OMFS care, particularly in rural areas, by improving patient care, reducing travel needs, and fostering collaborative diagnosis and treatment. The findings advocate for broader adoption of telemedicine in OMFS, contingent upon supportive policy and infrastructure changes. [ABSTRACT FROM AUTHOR]

The Promise of Adolescence: Realizing Opportunity for All Youth report recommends several Medicaid policies to increase insurance coverage among adolescents: approve Medicaid expansion; eliminate the 5-year Medicaid waiting period for lawfully present adolescent immigrants; increase Medicaid reimbursement rates for adolescent health services to the level of Medicare; and ensure coverage and sufficient reimbursement of comprehensive health services. We designed this study to identify key advocates and factors relevant to adoption and implementation of the recommended Medicaid policies in Nebraska to highlight opportunities for additional advocacy. We conducted semistructured interviews January 2022 with 28 adolescent health and health-care access experts in Nebraska, including representatives from health care, education, government, and nonprofit sectors. We recorded the interviews and transcribed them verbatim, then coded data using NVivo software and identified key themes. Participants were unable to identify any Medicaid advocates or advocacy work focused on adolescents, but they did identify 35 organizations working to improve insurance coverage in Nebraska. Coordinated multisector, statewide coalitions secured the adoption of Medicaid expansion through a citizen-supported ballot initiative. Barriers to successful implementation include limited Medicaid outreach to citizens and lawfully present immigrants. Low state government support for increasing Medicaid reimbursement rates and providing comprehensive health services, coupled with the absence of coordinated advocacy, hinder the adoption of these recommendations. Advocacy efforts should be implemented to increase adoption and implementation of Medicaid policies recommended to increase adolescents' insurance coverage. These efforts must be built on a foundation of knowledge of state government practices and must utilize sustained partnership among multisector advocates, including adolescent-serving professionals. [ABSTRACT FROM AUTHOR]

To determine key elements of a contraception navigator program that provides a personalized approach to overcoming patient-specific barriers by a trained navigator in central Indiana. A human-centered design approach was used to engage adolescents and community stakeholders in co-design sessions. Sessions incorporated techniques, such as divergent brainwriting and journey maps, which led to the exploration of various themes that were ultimately used to inform key elements of the contraception navigator program. Adolescents aged 15–17 years (N = 35) and community stakeholders (N = 11) participated in co-design sessions. Analysis verified that the process of obtaining contraception for pregnancy prevention could be intimidating for young people. The importance of language, the presence of stigma, and the knowledge of side effects were all discussed. Essential elements of a contraceptive navigator program included building trust to ultimately co-create a plan that can overcome patient-specific barriers. Having a variety of communication methods available, as well as contraceptive side-effect support, will be essential. Using human-centered design techniques to engage adolescent and community stakeholders can help inform the development of a contraceptive navigator program. A trusted navigator that can address patient-specific barriers to contraception access both before and after contraception is obtained is a key element identified by stakeholders. [ABSTRACT FROM AUTHOR]

Le Brexit, par son ampleur, emporte de nombreuses conséquences juridiques parmi lesquelles la question de l'accès aux soins. Bien qu'un accord de sortie ait pu être trouvé entre l'Union européenne et le Royaume-Uni, des problémes se posent encore quant à la protection sociale des résidents européens et britanniques. Brexit, by its magnitude, has many legal consequences, including the issue of access to healthcare. Although an exit agreement has been reached between the European Union and the United Kingdom, problems still arise regarding the social protection of European and British residents. [ABSTRACT FROM AUTHOR]

The effect of introducing or increasing user fees for health services in low- and middle-income countries is controversial. While user fees are advocated as an effective means of generating revenue and enabling health service quality improvement, they constitute a financial barrier to access health services for the poorer. This paper contributes to the literature on the demand-side financing in health by providing evidence on the medium-term effects of introducing user fees on the utilisation of family planning, antenatal care, and delivery care services, women's access to health care, and child health status in a middle-income country setting. Using a difference-in-differences identification strategy to establish causality, we find that the introduction of user fees in Egypt had no negative effect on the utilisation of family planning and delivery care services. Further, fees did not hinder women's access to care and did not harm child health outcomes. Positive effects were even observed with respect to the utilisation of antenatal care services. Our findings are compatible with the hypothesis that the potential decrease in demand due to the user fee imposition might have been offset by an increased willingness to pay for a quality of health care that could be, at least partly, perceived as higher. • User fees do not necessarily deter utilisation of and access to health services. • Positive effects of user fees on antenatal care utilisation are observed. • Services with fees may be perceived of higher quality, raising willingness to pay. [ABSTRACT FROM AUTHOR]

Multiple states allow pharmacists to prescribe hormonal contraception but can have age restrictions. The study objective was to examine how age influences adolescents' and young adults' (AYAs) ability to self-report potential contraindications to hormonal contraception compared with physician reports (our "gold standard"). Between February 2017 and August 2018, girls aged 14–21 years and their physicians were recruited in outpatient adolescent primary and subspecialty care clinics. Screeners were completed separately for medical conditions that are potential contraindications to hormonal contraception as defined by the Centers for Disease Control Medical Eligibility Criteria. Overall, discordance was defined as differences between the patient's and provider's answers, and potential unsafe discordance was defined as AYAs underreporting of contraindications. Multivariable logistic regression was used to examine predictors of overall and unsafe discordance. Of 394 AYA/physician pairs, 45% were from subspecialty clinics, 35% identified as African American, the mean age was 16.7 ± 1.9 years, and 38% were sexually active. Fifty percent of patients reported potential contraindications to hormonal contraception. There was only an 18% rate of unsafe discordance, with no statistical difference by age but a higher rate in subspecialty clinics (28% vs. 10%). No variables were predictive of higher rates of unsafe discordance in general or subspecialty clinics. Potential overall and unsafe discordance between AYAs' and physicians' reports of medical contraindications to combined hormonal contraception were not related to younger age and thus support expansion of pharmacy access to adolescents. Pediatric subspecialists need to proactively address hormonal contraceptive needs and safety as pharmacy access expands. [ABSTRACT FROM AUTHOR]

Objective: To characterize diabetes care across healthcare facilities in six Peruvian regions.Methods: Cross-sectional study of patients with type 2 diabetes mellitus (T2DM), ranging from primary care facilities to hospital-based facilities, in six Peruvian regions. Data was collected by health staff trained between 2012 and 2016. We studied six diabetes care outcomes and four adequate diabetes care outcomes considering the healthcare facility as the exposure of interest. We estimated prevalence ratios (PR) and their 95% confidence intervals (95% CI) using Poisson regression with robust variance.Results: Data from 8879 patients with T2DM, mean age 59.1 years (SD ± 12.2), 53.6% males, was analyzed. Of these, 8096 (91.2%) were treated at primary care facilities. The proportions of patients who had HbA1c, LDL-c, and creatinine/microalbumin test performed increased with the setting of the healthcare facility. Overall, 39%-56% of patients had an adequate HbA1c control, being higher in hospital-based facilities with specialists in comparison to primary care facilities.Conclusions: We observed that the higher the setting of the facility, the higher the rate of the assessed diabetes care outcomes and adequate diabetes care for four of the six targets (fasting glucose, HbA1c, LDL-c and creatinine or microalbumin) and for three of the four targets (glucose≤130 mg/dL, HbA1c ≤7%(53 mmol/mol) and LDL-c <100 mg/dL), respectively. Substantial gaps were observed at the primary care facilities, calling for the strengthening of diabetes care. [ABSTRACT FROM AUTHOR]

Background: Cost-sharing disproportionately affects people with chronic illnesses needing more care. Our qualitative study examined lived experiences navigating insurance benefits and treatment for bipolar disorder, which requires ongoing access to behavioral specialists and psychotropic medications.Methods: Forty semi-structured telephone interviews with individuals with bipolar disorder and employer-sponsored health insurance, or their family caregivers, explored health care needs, coverage details, out-of-pocket (OOP) costs, and perspectives on value. An iterative analytic approach identified salient themes.Results: Most individuals in our sample faced an annual insurance deductible, from $350-$10,000. OOP costs for specialist visits ranged from $0-$450 and for monthly psychotropic medications from $0-$1650. Acute episodes and care for comorbidities, including medication side effects, added to cost burdens. Medication nonadherence due to OOP costs was rare; respondents frequently pointed to the necessity of medications: "whatever it takes to get those"; "it's a life or death situation." Respondents also prioritized visits to psychiatrist prescribers, though visits were maximally spaced because of cost. Psychotherapy was often deemed unaffordable and forgone, despite perceived need. Interviewees cited limited networks and high out-of-network costs as barriers to specialists. Cost-sharing sometimes led to debt, skimping on nonbehavioral care or other necessities, exacerbated or prolonged mood symptoms, and stress at home.Limitations: Volunteer respondents may not fully represent the target population.Conclusions: Many people with bipolar disorder in US employer-sponsored plans experience undertreatment, hardship, and adverse health consequences due to high cost-sharing. More nuanced insurance benefit designs should accommodate the needs of individuals with complex conditions. [ABSTRACT FROM AUTHOR]

We aimed to identify the coverage rates and use of health care and to explore barriers and facilitators of access in rural Mexico. Systematic review of the literature. We undertook a structured search in the electronic databases EMBASE, Medline, and Scopus. Inclusion criteria comprised articles published in Spanish and English during the period 1986–2018. The studies were screened and selected by two independent reviewers in accordance with predefined criteria. The review included 14 studies. Over the last 30 years, the rates of health-care coverage have increased from 30% to >50% in rural Mexico. Although the rates of health-care coverage increased, aspects such as lack of resources, language, and health-care professionals remained important barriers to health care. Cash transfer programs were identified as a facilitator. Despite increased health-care coverage of >50% in the last three decades, action is needed to fulfill the needs of rural Mexican populations. It is important to increase the number of trained health professionals who practice in rural areas. Moreover, health programs should be developed and adapted to meet the needs of rural and indigenous populations. • Type 2 diabetes and hypertension represent main health problems in Mexico. • The health-care reform was a positive step toward guaranteed health-care coverage. • Rural populations were less likely to have a clinical supervision. • Cash transfer programs were important facilitators of health-care access. • Language was a barrier to health-care access in indigenous populations. [ABSTRACT FROM AUTHOR]

The growing number of chronic conditions and functional limitations resulting from demographic changes and the aging of the population poses several challenges for health care and public health. Consequently, it plays a role in the assessment of the impact of diagnostic and treatment effects on patient satisfaction. The study aims to assess older patients' overall satisfaction with the medical care and healthcare system in Poland and to verify such factors as patient-doctor interactions, access to health care and other sociodemographic characteristics as possible determinants of patient satisfaction at the later stage of life. The survey data represent the polish part of the cross-sectional COURAGE in Europe study. Satisfaction with hospital care, outpatient care, and the healthcare system in Poland was assessed. The indices for the psychosocial dimension of the patient-doctor relationships and access to hospital/outpatient care were developed based on patients' experiences as the possibility of talking about private matters, the clarity of explanations, the involvement in decision-making process, being treated respectfully, the duration of waiting and the ease of access to a preferred doctor or other healthcare professional. The ordered probit regression models were used. The psychosocial dimension of patient-doctor relationships was associated with the satisfaction with both hospital and outpatient care. Being treated with respect (very good experience vs. bad odds ratio [OR] = 8.1, 95% confidence interval [CI]: [1.9, 34.4]) and the possibility to talk about private matters with medical team (very good experience vs. bad OR = 3.5, 95% CI: [1.1, 10.4]) during the last stay in hospital were reflected in the higher satisfaction with the healthcare system. By contrast, the involvement of patients in the decision-making process (very good experience vs. bad OR = 3.6, 95% CI: [1.8, 6.7]) or access to outpatient health care (based on developed index OR = 1.02, 95% CI: [1.01, 1.02]) were found to be significant determinants of satisfaction with the healthcare system in Poland. Other factors associated with satisfaction with hospital stay were gender and changes in health conditions, whereas achieving the expected outcome was related to satisfaction with outpatient care, and the expenditure for medicines and medical services – to satisfaction with the heathcare system. The investigation confirms an important role of doctor-patient communication skills in improving older patient satisfaction and highlights the need for identifying the psychosocial dimension of patient-doctor relationships as an important part of health care. • Ease access to care and involvement in decision making determine satisfaction for older outpatients. • Respect and talking about private matters determine satisfaction with the health care system for older inpatients. • Higher expenditure on medicines and medical services determine lower satisfaction with the health care system in Poland. [ABSTRACT FROM AUTHOR]

Migrants face many barriers when accessing health care, both structural and political, leading to unmet need and poor quality care. Yet these barriers often can be overcome. This short communication reports a workshop confronting these issues at the First World Congress on Migration, Ethnicity, Race and Health. It explores the structural factors that create barriers and the competencies that health professionals need to overcome them. It then examines how one non-governmental organization did confront, successfully, a restrictive policy adopted in the United Kingdom, through advocacy and practical action. It concludes by examining the related issue of cultural competency, drawing on experiences of a mental health unit in Athens, Greece. • Migrants face many barriers when accessing health care, both structural and political, leading to unmet need and poor quality care. • Overcoming these barriers can be achieved. • Advocacy and practical action can work. • Healthcare workers need to be aware of cultural competence. • Structural competency and barriers should be included in medical education. [ABSTRACT FROM AUTHOR]

Aims: The current study sought to identify patient-level factors related to health care use among White and minority men and women with diabetes.Methods: A sample of 447 of non-pregnant individuals with diabetes, ages 18-64, was drawn from the 2015-2016 National Health and Nutrition Examination Surveys dataset. Poisson regression models tested associations between health care use and self-rated health, depression, medical comorbidities, body mass index, marital status, number of children, income, insurance coverage, and age, stratified by gender and racial/ethnic minority status.Results: Poorer self-rated health was the only significant correlate of increased health care use among White men with diabetes whereas income and insurance were significant correlates of increased use among minority men. Among White and minority women, higher levels of depression and being single were correlated with greater health care use. Comorbid medical conditions and insurance coverage were also related to use among minority women.Conclusions: Among individuals with diabetes, health care use among White men appeared to be driven by subjective health whereas financial factors were critical among minority men. Family structure and mental health were instrumentally associated with health care use among all women. These factors can be targeted to promote equitable access to care. [ABSTRACT FROM AUTHOR]

To examine insurance-based disparities in provider-related barriers to care among children in California in the wake of changes to the insurance market resulting from the Affordable Care Act. Our sample included 6514 children (ages 0 to 11 years) from the 2014–2016 California Health Interview Survey. We examined parent reports in the past year of 1) having trouble finding a general provider for the child, 2) the child not being accepted by a provider as a new patient, 3) the child's health insurance not being accepted by a provider, or 4) any of the above. Multivariable models estimated the associations of insurance type—Medi-Cal (Medicaid), employer-sponsored insurance, or privately purchased coverage—and parent reports of these problems. Approximately 8% of parents had encountered at least one of these problems. Compared with parents of children with employer-sponsored insurance, parents of children with Medi-Cal or privately purchased coverage had over twice the odds of experiencing at least one of the barriers. Parents of children with Medi-Cal had over twice the odds of being told a provider would not accept their children's coverage or having trouble finding a general provider and 3times the odds of being told a provider would not accept their children as new patients. Parents of children with privately purchased coverage had over 3times the odds of being told a provider would not accept their children's coverage. Our study found significant disparities in provider-related barriers by insurance type among children in California. [ABSTRACT FROM AUTHOR]

Background: The relative importance of individual and country-level factors influencing access to diagnosis and treatment for depression across the world is fairly unknown.Methods: We analysed cross-national data from the WHO World Health Surveys. Depression diagnosis and access to health care were ascertained using a structured interview. Logistic Bayesian Multilevel analyses were performed to establish individual and country level factors associated with: (1) receiving a diagnosis and (2) accessing treatment for depression if a diagnosis was ascertained.Results: The sample included 7870 individuals from 49 countries who met ICD-10 criteria for depressive episode in the past 12 months. A third (32%) of these individuals had ever been diagnosed with depression in their lifetime. Among those diagnosed with depression, 66% reported to have ever received treatment for depression. Although individual factors were more important determinants of access to treatment for depression, country-level factors explained 27.6% of the variance in access to diagnosis and 24.1% in access to treatment. Access to treatment for depression improved with increasing country income. Female gender, better education, the presence of physical co-morbidity, more material assets, and living in urban areas were individual level determinants of better access.Limitations: Data on other contextual factors was not available. Unmet need was likely underestimated, since only lifetime treatment data was available.Conclusion: This study highlights major inequalities in access to a diagnosis and treatment of depression. Unlike the prevalence of depression, where contextual factors have shown to have less importance, a significant proportion of the variance in access to depression care was explained by country-level income. [ABSTRACT FROM AUTHOR]

Purpose Since restrictions on nonprescription sales were removed in 2013, levonorgestrel emergency contraception (EC) should be available without a prescription at pharmacies for consumers of all genders and ages. Using mystery callers, we assessed variations in availability of and access to EC. Methods In 2015–2016, three sets of mystery callers (two female physicians, two adolescent females, and two adolescent males) each called all licensed retail pharmacies in five U.S. cities using standardized call scripts. Scripts assessed same-day availability and subsequent access to EC for 17-year-olds. Data on various characteristics of calls were collected and compared by caller type. Results Among the 993 pharmacies called, same-day availability for EC was approximately 80%, with no differences by caller types ( p  = .34). However, 10.7% of calls made by the adolescent male caller and 8.3% made by the adolescent female caller resulted in incorrectly being told they could not obtain EC based on age, compared to only 1.6% of calls made by the physician ( p  < .01). Pharmacy staff stated correctly that EC was available over-the-counter more often to adolescent male callers (62.0%) than adolescent females (51.6%) or female physicians (57%) ( p  < .01). Physicians were more likely to be placed on hold, talk to a pharmacist, or be transferred to a pharmacist ( p  < .01) than adolescents. Conclusions Persistent barriers to accessing EC exist for adolescents despite regulatory changes to make EC available over-the-counter, especially for females. Additional work to remove these barriers is needed to assure timely access for those who require effective pregnancy prevention. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Health literacy (HL) is generally thought to be associated with positive health behaviour, appropriate health service utilisation and acceptance of interventions to maximise health outcomes. It is, therefore, increasingly suggested that evidence-based research should investigate how HL may operate in the context of universal health coverage (UHC). However, the role of HL in the relationships between elements of UHC such as access to health care and health insurance has not been widely explored. This applies in particular in Sub-Saharan Africa, although service coverage and health outcomes vary hugely between and within many countries. This article addresses this lacuna in Ghana, today one of the Africa's most promising health systems. STUDY DESIGN: It is a cross-sectional study. METHODS: The study used structured interviews to gather data from 779 rural and urban adults using a multistage cluster sampling approach. RESULTS: In a three-step multiple hierarchical linear regression model, HL (B = -.09, standard error [SE] = .04) and health insurance subscription (B = -.15, SE = .04) were found to be inversely associated with poor health-related quality of life (HRQoL). Access to health care did not predict HRQoL (B = -.02, SE = .02). However, the interaction between access to health care and HL produced a negative effect on poor HRQoL (B = -.08, SE = .03). The interaction between HL and health insurance subscription also showed a similar effect on HRQoL (B = -.10, SE = .03). Further analysis depicted that access to health care (β = -.09, P = .05) and health insurance subscription (β = -.24, P = .00) related positively to HRQoL only when HL was high. CONCLUSION: The article argues that where HL is low, even favourable policies for UHC are likely to miss set targets. While not losing sight of relevant sociocultural elements, enhancing HL should be a central strategy for policies aimed at bridging health inequalities and improving UHC. [ABSTRACT FROM AUTHOR]

Background: Patients newly insured through coverage expansion under the Affordable Care Act (ACA) may have difficulty obtaining timely primary care follow-up appointments after emergency department (ED) discharge. We evaluated the association between availability of timely follow-up appointment with practice access improvements, including patient-centered medical home (PCMH) designations or extended-hours appointments.Methods: We performed a secret-shopper audit of primary care practices in greater New Haven, Connecticut. Two callers, posing as patients discharged from the ED, called these practices requesting follow-up appointments. They followed standardized scripts varying in ED diagnosis (uncontrolled hypertension, acute back pain) and insurance status (commercial, exchange, Medicaid). We linked our findings with data from a previously completed survey that assessed practice characteristics and examined the associations between appointment availability and practice access improvements.Results: Of the 58 included primary care practices, 49 (84.5%) completed both the audit and the survey. Overall, 167/536 calls (31.2%) obtained an appointment in 7days. Practices with PCMH designation were less likely to offer appointments within 7days (23.4% vs. 33.1%, p=0.03). However, callers were more likely to obtain an appointment in 7days from practices offering after-hour appointments (36.3% vs. 27.8%, p=0.04). After adjusting for insurance type, there were no significant associations between practice improvements and 7-day appointment availability or appointment wait time.Conclusion: PCMH designation and extended-hours appointments were not associated with improved availability of timely primary care follow-up appointment for discharged ED patients. EDs should engage local clinicians and other stakeholders to strengthen linkage and care transition with outpatient practices. [ABSTRACT FROM AUTHOR]

Purpose This systematic review examines how marginalized young people access and engage with health services and navigate health-care systems in high-income countries. Methods Medline, CINAHL, PsychInfo, The University of Sydney Library database, and Google Scholar were searched to identify qualitative and quantitative original research, published from 2006 to 2017, that focused on selected definitions of marginalized young people (12 to 24 years), their parents/carers, and/or health professionals working with these populations. A thematic synthesis was undertaken identifying themes across and between groups on barriers and/or facilitators to access, engagement, and/or navigation of health-care systems. Results Of 1,796 articles identified, 68 studies in the final selection focused on marginalized young people who were homeless (n = 20), living in rural areas (n = 14), of refugee background (n = 11), gender and/or sexuality diverse (n = 11), indigenous (n = 4), low income (n = 4), young offenders (n = 2), or living with a disability (n = 2). Studies were from the United States, Australia, Canada, United Kingdom, New Zealand, and Portugal, including 44 qualitative, 16 quantitative, and 8 mixed-method study types. Sample sizes ranged from 3 to 1,388. Eight themes were identified relating to ability to recognize and understand health issues; service knowledge and attitudes toward help seeking; structural barriers; professionals' knowledge, skills, attitudes; service environments and structures; ability to navigate the health system; youth participation; and technology opportunities. Conclusions Marginalized young people experience barriers in addition to those common to all young people. Future studies should consider the role of technology in access, engagement, and health system navigation, and the impact of intersectionality between marginalized groups. [ABSTRACT FROM AUTHOR]

This paper analyzes the effects of immigration on waiting times for the National Health Service (NHS) in England. Linking administrative records from Hospital Episode Statistics (2003-2012) with immigration data drawn from the UK Labour Force Survey, we find that immigration reduced waiting times for outpatient referrals and did not have significant effects on waiting times in accident and emergency departments (A&E) and elective care. The reduction in outpatient waiting times can be explained by the fact that immigration increases natives' internal mobility and that immigrants tend to be healthier than natives who move to different areas. Finally, we find evidence that immigration increased waiting times for outpatient referrals in more deprived areas outside of London. The increase in average waiting times in more deprived areas is concentrated in the years immediately following the 2004 EU enlargement and disappears in the medium term (e.g., 3-4 years). [ABSTRACT FROM AUTHOR]

Objective: This study evaluates rural hospital staff perceptions of a telemedicine ICU (Tele-ICU) before and after implementation. Methods: We conducted a longitudinal qualitative study utilising semistructured group or individual interviews with staff from three rural ICU facilities in the upper Midwest of the United States that received Tele-ICU support. Interviews occurred pre-implementation and at two time points post-implementation. Interviews were conducted with: ICU administrators (n = 6), physicians (n = 3), nurses (n = 9), respiratory therapists (n = 5) and other (n = 1) from July 2011 to May 2013. Transcripts were analysed for thematic content. Findings: Overall, rural ICU staff viewed Tele-ICU as a welcome benefit for their facility. Major themes included: (1) beneficial where recruitment and retention of staff can be challenging; (2) extra support for day shifts and evening, night and weekend shifts; (3) reduction in the number of transfers larger tertiary hospitals in the community; (4) improvement in standardisation of care; and (5) organisational culture of rural ICUs may lead to under-utilisation. Conclusions: ICU staff at rural facilities view Tele-ICU as a positive, useful tool to provide extra support and assistance. However, more research is needed regarding organisational culture to maximise the potential benefits of Tele-ICU in rural hospitals. [ABSTRACT FROM AUTHOR]

International studies have repeatedly shown that people with lower income are more likely to experience difficulties to access medical services. Less is known on why these relations vary across countries. This study investigates whether the association between income and financial barriers to health care is influenced by national public health expenditures (PHE, in % of total health expenditure). Data from the International Social Survey Programme (2011) was used (28 countries, 23,669 respondents). Financial barriers were assessed by the individual experience of forgone care due to financial reasons. Monthly equivalent household income was included as the main predictor. Other individual-level control variables were age, gender, education, subjective health, insurance coverage and place of living. PHE was considered as a macro-level predictor, adjusted for total health expenditure. Statistically significant associations between income and forgone care were found in 21 of 28 examined countries. Multilevel analyses across countries revealed that people with lower income have a higher likelihood to forgo needed medical care (OR: 3.94, 95%-CI: 2.96–5.24). After adjustments for individual-level covariates, this association slightly decreased (OR: 2.94, 95%-CI: 2.16–3.99). PHE did not moderate the relation between income and forgone care. The linkage between health system financing and inequalities in access to health care seems to be more complex than initially assumed, pointing towards further research to explore how PHE affects the redistribution of health resources in different health care systems. [ABSTRACT FROM AUTHOR]

To examine adolescents' decision-making capacity for pharmacsist-prescribed hormonal contraception. A subset of 60 females, ages 14–21, were recruited to complete the MacArthur Competence Assessment Tool-Treatment. Overall scores were compared by age and demographic factors and variation examined. Participants scored high on the MacArthur Competence Assessment Tool-Treatment with little variation in the scores (18.8 [±1.9]/20 total points). Factors such as chronic illness, health literacy, and family affluence were not associated with of overall scores. Adolescents and young adults have the capacity to make decisions regarding contraception in the pharmacy access settings. [ABSTRACT FROM AUTHOR]

This study examined the relationship between racial/ethnic residential segregation and access to health care in rural areas. Data from the Medical Expenditure Panel Survey were merged with the American Community Survey and the Area Health Resources Files. Segregation was operationalized using the isolation index separately for African Americans and Hispanics. Multi-level logistic regression with random intercepts estimated four outcomes. In rural areas, segregation contributed to worse access to a usual source of health care but higher reports of health care needs being met among African Americans (Adjusted Odds Ratio [AOR]: 1.42, CI: 0.96-2.10) and Hispanics (AOR: 1.25, CI: 1.05-1.49). By broadening the spatial scale of segregation beyond urban areas, findings showed the complex interaction between social and spatial factors in rural areas. [ABSTRACT FROM AUTHOR]

Purpose Direct transmission of mutated tuberculosis (TB) strains is among major contributors to the worldwide epidemic of Drug-Resistant Tuberculosis. Expanding access to TB-services and decreasing diagnostic delays are acknowledged as potential solutions. We aimed to summarize evidence about links between health care acceptability barriers and TB diagnostic delays. S coping and systematic review approaches were combined to determine the depth/breadth of the literature, identify gaps, and synthesize findings. Methods Electronic data-bases, key journals, other relevant electronic sources, and references of relevant articles were selected as potential sources through a preliminary search and expertś advice. Titles and abstracts of 4046 initial records and 1796 references were screened against preliminarily developed and post-hoc inclusion/exclusion criteria. Author, year of publication, study location, study aims, overview of methods, study population, intervention type, outcomes measures and results of each included paper were extracted. Methodological quality of studies was assessed. Narrative synthesis of the study results was conducted through the thematic analysis approach. Results Patients’ negative expectations, doubts about quality of services/medications and burden of stigma, as well as providers’ discriminative attitudes towards patients’ characteristics (age, gender, ethnicity) were reported as major barriers. Scarcity and unequal distribution of the literature and lack of attention to all potential acceptability barriers were found as major gaps in the current research. Conclusion Overall, study findings indicate the significance of acceptability barriers’ role in TB diagnostic delays. Emerging character of the field is demonstrated. Recommendations about further research directions are outlined. [ABSTRACT FROM AUTHOR]

Objectives Explore (1) the characteristics of the Maine population with delayed geographic access to interventional cardiology (IC) services and (2) the effect of delayed geographic IC access on coronary mortality. Background Acute coronary syndrome (ACS), ST-segment elevated myocardial infarction (STEMI), and non-ST segment elevated myocardial infarction (NSTEMI) are highly prevalent. Coronary mortality is minimized when victims have prompt IC access. Methods The study design was (1) an exploration of census data to investigate disparities in geographic IC access and (2) a secondary analysis of administrative claims data to investigate coronary mortality relative to delayed geographic IC access. Results Delayed access was associated in the Maine population with rural residence, advanced age, high school education, and lack of health insurance. Delayed access was associated with increased unadjusted coronary mortality, but not age-adjusted coronary mortality. Conclusion Delayed geographic IC access was associated with disparity but not with increased age-adjusted coronary mortality. [ABSTRACT FROM AUTHOR]

Objective: to explore the factors which influence the timing of the initiation of a package of publically-funded antenatal care for pregnant women living in a diverse urban setting Design: a qualitative study involving thematic analysis of 21 individual interviews and six focus group discussions. Setting: Newham, a culturally diverse borough in East London, UK Participants: individual interviews were conducted with 21 pregnant and postnatal women and focus group discussions were conducted with a total of 26 health service staff members(midwives and bilingual health advocates) and 32 women from four community groups (Bangladeshi, Somali, Lithuanian and Polish). Findings: initial care-seeking by pregnant women is influenced by the perception that the package of antenatal care offered by the National Health Service is for viable and continuing pregnancies, as well as little perceived urgency in initiating antenatal care. This is particularly true when set against competing responsibilities and commitments in women's lives and for pregnancies with no apparent complications or disconcerting symptoms. Barriers to access to this package of antenatal care include difficulties in navigating the health service and referral system, which are compounded for women unable to speak English, and service provider delays in the processing of referrals. Accessing antenatal care was sometimes equated with relinquishing control, particularly for young women and women for whom language barriers prohibit active engagement with care. Conclusions and implications for practice: if women are to be encouraged to seek antenatal care from maternity services early in pregnancy, the purpose and value to all women of doing so need to be made clear across the communities in which they live. As a woman may need time to accept her pregnancy and address other priorities in her life before seeking antenatal care, it is crucial that once she does decide to seek such care, access is quick and easy. Difficulties found in navigating the system of referral for antenatal care point to a need for improved access to primary care and a simple and efficient process of direct referral to antenatal care, alongside the delivery of antenatal care which is woman-centred and experienced as empowering. [ABSTRACT FROM AUTHOR]

To evaluate the relationship of cerebral palsy (CP) motor severity, as measured by the Gross Motor Functional Classification System (GMFCS), on healthcare access. A prospective, cross-sectional cohort study. Accredited clinical motion analysis laboratory at a regional children's hospital. 72 ambulatory, adult patients with CP who had previously received care at the children's hospital participated. Ages ranged from 18-48 years (mean = 24.5). Not Applicable. Patient interviews evaluated access to healthcare services and insurance status. A physical therapist determined each participant's GMFCS level, and higher GMFCS levels correspond with higher levels of mobility impairment. Fisher's exact tests were used to identify associations between GMFCS level and access to care. GMFCS level varied with 28 GMFCS 1 patients, 29 GMFCS 2 patients, 13 GMFCS 3 patients, and 2 GMFCS 4 patients. With increasing GMFCS level, patients were more likely to report they encountered barriers accessing healthcare (p = 0.025). Patients with a higher GMFCS level were also more likely to report that their health insurance did not offer benefits or cover services that met their needs (p=0.018). Similarly, the patients with a higher GMFCS level were more likely to report that their health insurance did not allow them to see the healthcare providers they need, with a correlation that approached statistical significance (p=0.084). In this patient population, patients categorized as GMFCS 3 or 4 were also more likely to have Medicaid or Medicare than those categorized as GMFCS 1 or 2 (p=0.018). This data suggests that patients with higher GMFCS levels have less access to adequate healthcare services. Further research is warranted to identify specific barriers to healthcare access, better understand the needs of this unique population, and ensure healthcare systems are adequately providing care for patients with more severe CP. There are no conflicts of interest. [ABSTRACT FROM AUTHOR]

Background Children of heroin-using women have a higher risk of unfavorable health and developmental outcomes. Although methadone maintenance treatment (MMT) has been widely used to treat heroin-using pregnant women, potential effects on accessibility and utilization of healthcare service for their offspring are less explored. Methods We used four national registry and health insurance datasets in Taiwan from 2004 to 2009 to form a population-based matched retrospective cohort study. A total of 1056 neonates born to women in the MMT program (857 born before mother's enrollment in the MMT program [BM], 199 born after mother's enrollment in the MMT program [AM]) was established; 10 547 matched non-drug [ND] exposed neonates were identified for comparison. Outcome variables included offspring's health insurance coverage and utilization of preventive, outpatient, and emergency room cares in the first year after birth. Results Infants born to mothers on MMT were more likely to have no or incomplete insurance coverage (BM: adjusted odds ratio [aOR] = 1.29, 95% CI: 1.10–1.53; AM: aOR = 1.56, 95% CI: 1.14–2.13) as compared with the socioeconomic status-matched ND group. The BM infants appeared to have fewer preventive care visits (adjusted relative risk [aRR] = 0.85, 95% CI: 0.80–0.90), whereas the AM infants utilized outpatient and emergency room services more frequently (outpatient: aRR = 1.11, 95% CI: 1.01–1.23; emergency: aRR = 1.46, 95% CI: 1.11–1.90). Conclusions Addiction treatment and harm reduction programs for women of childbearing ages should be delivered in the coordinated framework that ensures comprehensiveness and continuity in healthcare and social services. [ABSTRACT FROM AUTHOR]

Background Asthma and hypertension are common among Emergency Department (ED) patients. Primary care providers are integral in managing these conditions, yet these patients are often in the ED. Objective To determine access to care among ED patients with asthma or hypertension and the association with sociodemographic factors and disease acuity. Methods This was a prospective, cross-sectional study of ED patients at an urban county hospital conducted between June 4 and August 31, 2008. Consenting patients were surveyed, and peak flow or blood pressure measured as appropriate. Access to disease treatment was defined as self-reported access to a primary care provider or current prescription for asthma or hypertension, or both. Descriptive statistics and multinomial logistic regression were used to analyze data. Results There were 2303 patients enrolled; 283 had asthma, 543 had hypertension, and 187 had both. Seventy-one patients (25.1%) with asthma, 151 patients (27.8%) with hypertension, and 19 patients (10.2%) with both had poor access to disease treatment. Seeking ED medical attention was related to having poor access to treatment for patients with both asthma and hypertension. Females with asthma had poor access to treatment. In hypertension patients, good access to treatment was associated with excellent/good health status, housing status, and decreasing age. Poor access to treatment was associated with increasing blood pressure. Conclusions Poor access to disease treatment and aspects of socioeconomic status were associated with seeking care in the ED. Changes in access to treatment may affect the number of patients seeking ED care, but not the severity of the presenting illness. [ABSTRACT FROM AUTHOR]

Purpose Although school health centers (SHCs) may improve access to reproductive health care services and contraception, published data on SHC service use and reproductive health impact are limited. Methods Reproductive health indicators among students at four urban high schools in a single building with an SHC in 2009 were compared with students in a school without an SHC, using a quasi-experimental research design (N = 2,076 students, 1,365 from SHC and 711 from comparison school). The SHC provided comprehensive reproductive health education and services, including on-site provision of hormonal contraception. Results Students in the SHC were more likely to report receipt of health care provider counseling and classroom education about reproductive health and a willingness to use an SHC for reproductive health services. Use of hormonal contraception measured at various time points (first sex, last sex, and ever used) was greater among students in the SHC. Most 10th–12th graders using contraception in the SHC reported receiving contraception through the SHC. Comparing students in the nonintervention school to SHC nonusers to SHC users, we found stepwise increases in receipt of education and provider counseling, willingness to use the SHC, and contraceptive use. Conclusions Students with access to comprehensive reproductive health services via an SHC reported greater exposure to reproductive health education and counseling and greater use of hormonal contraception. SHCs can be an important access point to reproductive health care and a key strategy for preventing teen pregnancy. [ABSTRACT FROM AUTHOR]

Purpose Trans*female youth (TFY) are an underserved population at risk for a variety of poor health outcomes, in part related to barriers to accessing health and mental health care. Methods We conducted a secondary analysis of data collected with 250 TFY aged 16–24 years in the San Francisco Bay Area from 2012 to 2014. Logistic regression was used to test associations between sociodemographic variables and barriers to gender identity–based medical and mental health care. Results Having a history of unstable housing was associated with significantly higher odds of problems accessing both medical care (odds ratio: 2.16, 95% confidence interval: 1.12–4.13) and mental health care due to gender identity (odds ratio 2.65, 95% confidence interval: 1.08–6.45). Conversely, identifying as genderqueer/genderfluid, Latina, or living in dependent housing was associated with access to either medical or mental health care. Conclusions Interventions are needed to address housing and discrimination barring access to health care among TFY. [ABSTRACT FROM AUTHOR]

Purpose To examine national estimates of sexual behaviors and health care access by acculturation among adolescents. Methods Using the 2006–2010 National Survey of Family Growth, four acculturation groups of Hispanic and non-Hispanic whites aged 15–24 years were analyzed by sexual behaviors and health care access. Results In analyses adjusted for demographics, English-speaking immigrants, Hispanic natives, and non-Hispanic white youth were less likely to have a partner age difference of ≥6 years (adjusted odds ratio [AOR], .28; 95% confidence interval [CI], .13–.60; AOR, .13; 95% CI, .07–.26; AOR, .16; 95% CI, .08–.32, respectively) and more likely to use a condom at the first vaginal sex (AOR, 1.99; 95% CI, 1.10–3.61; AOR, 2.10; 95% CI, 1.33–3.31; AOR, 2.39; 95% CI, 1.53–3.74, respectively) than Spanish-speaking immigrants. Non-Hispanic white youth and Hispanic natives were more likely to have a regular place for medical care (AOR, 2.07; 95% CI, 1.36–3.16; AOR, 3.66; 95% CI, 2.36–5.68, respectively) and a chlamydia test in the past 12 months (AOR, 3.62; 95% CI, 1.52–8.60; AOR, 2.94; 95% CI, 1.32–6.54) than Spanish-speaking immigrants. Conclusions Interventions to reduce risk and increase health care access are needed for immigrant Hispanic youth, particularly Spanish-speaking immigrants. [ABSTRACT FROM AUTHOR]

The two-step floating catchment area (2SFCA) method continues to be a popular measure of spatial accessibility, especially in relation to primary-level health care. Despite its popularity, most applications of the 2SFCA method are limited by the utilisation of only a single catchment size within a small geographic area. This limitation is significant to health policies which are mostly applied at the state or national scale. In this paper, a five-level dynamic catchment size was trialled within the 2SFCA method to all of Australia, with a population's remoteness used to delineate increasing catchment sizes. Initial trial results highlighted two perverse outcomes which were caused by sudden changes in catchment sizes between each level. Further refinement led to trialling an additional three-level catchment sub-type to the 2SFCA method, which created a smoother transition between remoteness levels. This study has demonstrated an effective approach to dynamically apply variable and more appropriate catchment sizes into different types of rural areas, which for the first time enables the 2SFCA method to be suitable for national-level access modelling and its potential application to health policy. [ABSTRACT FROM AUTHOR]

Purpose There has been little research on the accessibility and quality of primary care services for epilepsy and emergency hospital admissions for epilepsy. Methods We examined time trends in admissions for epilepsy in England between 2004-2005 and 2010, and the association of admission rates with population and primary care factors. The units of analysis were the registered populations of 8622 general practices. We used negative binomial regression to model indicators from the Quality and Outcomes Framework, the UK's primary care pay for performance scheme, to measure the accessibility and quality of care for epilepsy, and supply of general practitioners, after adjustment for population factors. Results The mean indirectly standardised admission rate decreased from 122.9 to 102.6 (-16.5%; P<0.001) over the study period, while the mean percentage of patients seizure free increased from 65.3% to 74.9% (P<0.001). In the multivariable analysis, a one unit increase in the percentage of seizure free adult patients on epilepsy drugs predicted a 0.20% decrease (IRR=0.9980; 95% CI: 0.9974-0.9986) in admission rate. The percentage of patients who were able to book a GP appointment over two days ahead predicted a 0.12% decrease (IRR=0.9988; 95% CI: 0.9982-0.9994). The deprivation score of practice populations (IRR=1.0179; P<0.001) and general practitioner supply (IRR=1.0022; P<0.001) were both positively associated with admission rates. Conclusion Patient access to primary care appointments and percentage of patients who have been recorded as seizure free for 12 months were associated with lower admission rates. However the effect sizes are small relative to that of population deprivation. [ABSTRACT FROM AUTHOR]

Abstract: The New Jersey Medication Assisted Treatment Initiative (NJ-MATI) sought to reduce barriers to treatment by providing free, opioid agonist treatment (OAT, methadone or buprenorphine) via mobile medication units (MMUs). To evaluate barriers to OAT, logistic regression was used to compare opioid dependent patients enrolled in NJ-MATI to those entering treatment at fixed-site methadone clinics or non-medication assisted treatment (non-MAT). Client demographic and clinical data were taken from an administrative database for licensed treatment providers. The MMUs enrolled a greater proportion of African-American, homeless, and uninsured individuals than the fixed-site methadone clinics. Compared to non-MAT and traditional methadone clients, NJ-MATI patients were more likely to be injection drug users and daily users but less likely to have a recent history of treatment. These observations suggest that the patient-centered policies associated with NJ-MATI increased treatment participation by high severity, socially disenfranchised patients who were not likely to receive OAT. [Copyright &y& Elsevier]

Abstract: Purpose: Adolescents frequently rely on emergency medical care, rather than using primary care providers (PCPs). Our objectives were to characterize a population of adolescents presenting to a large, urban emergency department (ED) and to examine the reasons why they present to the ED, rather than to their PCP's office. Methods: Adolescents ages 12 to 21 years and their parents/guardians were invited to participate and asked to complete a brief online survey. Demographic data and triage information were collected from electronic medical records. Results: Of 203 participants, 66% (n = 134) had public insurance, and 40% (n = 82) were triaged as nonurgent. Nearly all (93%, n = 189) reported having a PCP or primary clinic. The most common reasons given for presenting to the ED were participant perception of illness requiring immediate care (34%), followed by PCP referral to the ED (21%). Those with public insurance (odds ratio = 4.44; 95% CI 2.01 to 9.81) or no insurance/unknown insurance status (odds ratio = 4.77; 95% CI 1.34 to 17.01) were more likely to be triaged as nonurgent than those with private insurance. Conclusions: Many adolescents in this study were triaged as nonurgent, with several participants perceiving they were acutely ill requiring immediate physician care. Further analyses revealed that private insurance was significantly associated with urgent triage status. Future studies could educate adolescents and families about appropriate use of the ED or examine PCP offices directly to determine practices for phone triage and ED referrals of adolescents. [Copyright &y& Elsevier]

Abstract: Objective: To explore whether there are other factors besides communication difficulties that hamper access to health care services for deaf patients. Methods: Qualitative methodology using semi-structured interviews with 16 deaf participants from the National Institute for the Deaf in Worcester and 3 Key informants from the Worcester area, South Africa. Results: Communication difficulties were found to be a prominent barrier in accessing health care services. In addition to this interpersonal factors including lack of independent thought, overprotectedness, non-questioning attitude, and lack of familial communication interact with communication difficulties in a way that further hampers access to health care services. Conclusion: These interpersonal factors play a unique role in how open and accepting health services feel to deaf patients. Practice implications: Health care services need to take cognizance of the fact that providing sign language interpreters in the health care setting will not necessarily make access more equitable for deaf patients, as they have additional barriers besides communication to overcome before successfully accessing health care services. [Copyright &y& Elsevier]

Purpose: MRI of the prostate has increasingly become more important in clinical medicine because of the risk of over-detection of low-grade, low-volume prostate cancer, as well as because of the poor sampling of transrectal ultrasound-guided prostate biopsy in high-risk patients. We sought to determine the access, imaging protocols, and indications for MRI imaging of the prostate in the United States. Methods: A brief survey was sent through mailing lists to members of the Society of Abdominal Radiology and Texas Radiological Society. Results: Thirty-six academic centers responded to the survey, 88.9% of which routinely perform prostate MRI. Nine centers routinely performed imaging at 1.5T with an endorectal coil (25%), 11 performed at 3.0T without an endorectal coil (31%), and 10 performed at 3.0T with an endorectal coil (28%). All institutions used T1-weighted axial and orthogonal T2-weighted sequences. Most groups used diffusion-weighted imaging (94.7%) and dynamic contrast enhancement (81.6%). Only 21.1% of groups performing prostate MRI routinely performed MR spectroscopy as part of their protocol. Conclusions: Prostate MRI is becoming a commonly performed examination at academic institutions, with most locations performing prostate MRI at minimum standards. There is a need to educate nonacademic practices regarding the addition of functional MRI techniques to anatomic techniques, increase the number of institutions that regularly perform prostate MRI, and increase access to direct MRI-guided biopsy in institutions that perform prostate MRI on a regular basis. [Copyright &y& Elsevier]

Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) were created to provide a temporary safety net for people who become disabled to protect them from impoverishment. Currently, many people receive SSDI or SSI until they reach retirement age. This literature review explored the impact these programs have on people reaching their optimal level of health. Results show the number of people voluntarily returning to work is 0.2%, demonstrating that most people receiving disability benefits stay with the programs instead of returning to the workplace. [ABSTRACT FROM AUTHOR]

Purpose: School health centers (SHC) that provide comprehensive health care may improve access and quality of care for students; however, published impact data are limited. Methods: We evaluated access and quality of health services at an urban high school with a SHC compared with a school without a SHC, using a quasiexperimental research design. Data were collected at the beginning of the school year, using a paper and pencil classroom questionnaire (n = 2,076 students). We measured SHC impact in several ways including grade by school interaction terms. Results: Students at the SHC school were more likely to report having a regular healthcare provider, awareness of confidential services, support for health services in their school, and willingness to utilize those services. Students in the SHC school reported higher quality of care as measured by: respect for their health concerns, adequate time with the healthcare provider, understandable provider communications, and greater provider discussion at their last visit on topics such as sexual activity, birth control, emotions, future plans, diet, and exercise. Users of the SHC were also more likely to report higher quality of care, compared with either nonusers or students in the comparison school. Conclusions: Access to comprehensive health services via a SHC led to improved access to health care and improved quality of care. Impact was measureable on a school-wide basis but was greater among SHC users. [ABSTRACT FROM AUTHOR]

Abstract: Global inequalities in health have long been associated with disparities between rich and poor nations. The middle-income countries of the Levant (Lebanon, Syria and Jordan) have developed models of health care delivery that mirror the often complex make-up of their states. In Lebanon, which is characterized by political clientelism and sectarian structures, access to health care is more contingent on ethnicity and religious affiliation than on poverty. This case study of the Bedouin of the Middle Bekaa Valley of Lebanon is based on interviews with policymakers, health care providers and the Bedouin as part of a study funded by the European Commission between 2006 and 2010. The study explores the importance of considering social discrimination and political exclusion in understanding compromised health care. Three decades after the Declaration of Alma Ata (1978), which declared that an acceptable level of health care for all should be attained by the year 2000, the Bedouin community of Lebanon remains largely invisible to the government and, thus, invisible to national health care policy and practice. They experience significant social discrimination from health practitioners and policymakers alike. Their unfair treatment under the health system is generally disassociated from issues of wealth or poverty; it is manifested in issues of access and use, discrimination, and resistance and agency. Overcoming their political exclusion and recognizing the social discrimination they face are steps that can be taken to protect and promote equal access to basic reproductive and child health care. This case study of the Bedouin in Lebanon is also relevant to the health needs of other marginalized populations in remote and rural areas. [Copyright &y& Elsevier]

Abstract: Background: Despite over 500,000 adolescents with special health care needs transitioning to adulthood each year, limited information is available on their health status or their access to care after transition. Objective: To describe the change in health status and access to care of a nationally sampled, longitudinal cohort of young adults with special health care needs (ASHCN). Methods: We analyzed follow-up data collected in the 2007 Survey of Adult Transition and Health on young adults who were 14–17 years of age when their parents participated in the 2001 National Survey of Children with Special Health Care Needs. We describe changes in access to care and health status over time, and used logistic regression to identify characteristics that were associated with declining health status in this cohort. Results: 1,865 participants, aged 19–23 years, completed the Survey of Adult Transition and Health. Between 2001 and 2007, there was a 3.6 fold increase in the proportion experiencing delayed or forgone care; 10% reported a decline in health status. There was a 7.7-fold increase in the proportion reporting no insurance. In regression analysis, factors associated with declining health status between 2001 and 2007 included underlying disease severity and delayed or forgone care in young adulthood. Conclusions: We found significant deterioration in insurance coverage, usual source of care and receiving timely health care as ASHCN aged into adulthood, and that this was associated with decline in health status. Our findings suggest that further population-based analyses of health outcomes are needed to plan for interventions to assist this vulnerable population. [Copyright &y& Elsevier]

Abstract: Purpose: To determine whether social inequalities in new antidepressant treatment exist at the individual and/or neighborhood level; and their relation to access to prescribers and/or processes of care (treatment initiation and duration). Methods: We followed 316,412 inhabitants of Marseilles (aged 18–64 years) covered by the National Health Insurance Fund for 2.5 years. We analyzed new treatments (≥1 purchase of antidepressants and none in the 6 months before the first one), and new long treatments (≥4 within 6 months after the first purchase). We tested their associations with high individual disadvantage and census block deprivation in a multivariate, multilevel logistic model adjusted for consultations with general practitioners and psychiatrists to control for access to care. Results: High individual disadvantage was not associated with the probability of new treatments, but it was with lower odds of receiving new long treatments. Residing in deprived census blocks was associated with lower odds of receiving treatment for both dependent variables. Conclusions: Our results suggest that social inequalities at the individual and neighborhood levels in new antidepressant treatment occur in access to specialty care and in treatment initiation and affect its duration. Further research is warranted to improve our understanding of their mechanisms. [Copyright &y& Elsevier]

Abstract: During the past few decades, many studies on socio-economic factors and health outcomes have been developed using various methodologies with differing approaches. A bibliographic research in MEDLINE/PubMed and SCOPUS was carried out for the period 2000–2011 to describe the influence of socio-economic status (SES) on cancer survival, in particular with reference to the outcome of European research results and the results of some cases of other Western studies. This review is divided into two sections: the first describing the different approaches of the study on individuals and populations of the concept of “social class” as well as methods used to measure the association between deprivation and health (i.e. ecological level studies, deprivation indexes, etc.); and the second discussing the association between socio-economic factors and cancer survival, describing the roles of various determinants of differences in survival, such as clinical and pathological prognostic factors, together with consideration of diagnosis and treatment and some patients’ characteristics. [Copyright &y& Elsevier]

Abstract: There are over 214 million international migrants worldwide, half of whom are women, and all of them assigned by the receiving country to an immigration class. Immigration classes are associated with certain health risks and regulatory restrictions related to eligibility for health care. Prior to this study, reports of international migrant post-birth health had not been compared between immigration classes, with the exception of our earlier, smaller study in which we found asylum-seekers to be at greatest risk for health concerns. In order to determine whether refugee or asylum-seeking women or their infants experience a greater number or a different distribution of professionally-identified health concerns after birth than immigrant or Canadian-born women, we recruited 1127 migrant (and in Canada <5 years) women–infant pairs, defined by immigration class (refugee, asylum-seeker, immigrant, or Canadian-born). Between February 2006 and May 2009, we followed them from childbirth (in one of eleven birthing centres in Montreal or Toronto) to four months and found that at one week postpartum, asylum-seeking and immigrant women had greater rates of professionally-identified health concerns than Canadian-born women; and at four months, all three migrant groups had greater rates of professionally-identified concerns. Further, international migrants were at greater risk of not having these concerns addressed by the Canadian health care system. The current study supports our earlier findings and highlights the need for case-finding and services for international migrant women, particularly for psychosocial difficulties. Policy and program mechanisms to address migrants'' needs would best be developed within the various immigration classes. [Copyright &y& Elsevier]

Abstract: About 20 years after initial calls for the introduction of user fees in health systems in sub-Saharan Africa, a growing coalition is advocating for their removal. Several African countries have abolished user fees for health care for some or all of their citizens. However, fee-for-service health care delivery remains a primary health care funding model in many countries in sub-Saharan Africa. Although the impact of user fees on utilization of health services and household finances has been studied extensively, further research is needed to characterize the multi-faceted health and social problems associated with charging user fees. This ethnographic study aims to identify consequences of user fees on gender inequality, food insecurity, and household decision-making for a group of women living in poverty. Ethnographic life history interviews were conducted with 24 women in Yirimadjo, Mali in 2007. Purposive sampling selected participants across a broad socio-economic spectrum. Semi-structured interviews addressed participants'' past medical history, socio-economic status, social and family history, and access to health care. Interview transcripts were coded using the guiding analytical framework of structural violence. Interviews revealed that user fees for health care not only decreased utilization of health services, but also resulted in delayed presentation for care, incomplete or inadequate care, compromised food security and household financial security, and reduced agency for women in health care decision making. The effects of user fees were amplified by conditions of poverty, as well as gender and health inequality; user fees in turn reinforced the inequalities created by those very conditions. The qualitative data reveal multi-faceted health and socioeconomic effects of user fees, and illustrate that user fees for health care may impact quality of care, health outcomes, food insecurity, and gender inequality, in addition to impacting health care utilization and household finances. As many countries consider user fee abolition policies, these findings indicate the need to create a broader evaluation framework—one that can measure the health and socioeconomic impacts of user fee polices and of their removal. [Copyright &y& Elsevier]

Summary: One of the primary objectives of health system reform throughout the world is to guarantee that use of health care is as high for the poor as it is for the most affluent in society, once need is controlled for. The WHO ranks health systems according to evidence on such inequalities. However, in measuring equity in the use of health care, studies typically disregard the use of traditional medicines. Therefore, it is assumed that the failure to use modern health care is equivalent to not receiving any health care at all. Although traditional medicines are less effective than modern medicines, they have the potential to provide relief and cure and are commonly used. Using data from Ghana, this paper hypothesizes and finds evidence for reductions in inequality estimates once traditional medicines are taken into account. Further, it explores inequities in utilization of modern medicine (from public institutions, private sources, and by self) and traditional medicines (by self and through healers) and finds the former to be pro rich whereas the latter is pro poor. These figures are then decomposed into socioeconomic determinants to show nonneed factors to be significant contributors of horizontal inequity. [Copyright &y& Elsevier]