We investigated the perception and attitudes of health care providers who manage patients with diabetes mellitus on the routine employment of an oral health assessment tool (OHAT) in diabetes management. A survey was conducted among health care providers practicing in underserved areas (N=54). Most providers acknowledged that oral health has an impact on diabetes, with participants identifying poor periodontal health as a contributing factor, and that untreated periodontitis influences patients' response to diabetes therapy. Conversely, health care professionals responded in the affirmative that blood glucose levels affect oral health, and the status of periodontal health and maintenance differs between patients with diabetes and other patients. Most providers also acknowledged that their institution currently has no OHAT for patients with diabetes. Despite this, most health care professionals are willing to incorporate an OHAT in their current diabetes self-management education curricula.
Universal health care aims to provide effective and affordable health services to everyone. However, immigrant women often experience worse maternal and child health outcomes than their indigenous counterparts, including higher risks of mental health issues, premature child births, and maternal mortality. This study examined the barriers and facilitators to maternal health service use among immigrants in the Tamale Metropolis in Ghana. Using a qualitative approach, 30 immigrant women, including pregnant women and new mothers, were recruited through snowball sampling. Key informant interviews were conducted at six health facilities. The findings identified barriers to accessing care, such as language difficulties, concerns about privacy, and perceived discrimination. On the other hand, supportive factors included social support, perceived quality of care, accessibility of National Health Insurance, and outreach programs. To improve maternal and child health services for immigrant women, it is essential to address these barriers and strengthen the supportive factors.
Community health centers in rural communities provide primary care and other health services that are essential, particularly given the closures and reductions of services by rural hospitals. The centers play a critical role in delivering affordable and accessible care as part of the safety-net health care system for low-income, publicly insured, and uninsured patients. In this commentary, we highlight several key considerations related to community health centers in rural communities and reflect on the sustainability of the centers, given the current focus on budgetary cuts and changing landscape of funding streams. Recent federal policy changes undermine Americans' social safety-net services through community health centers, particularly for rural communities, putting millions at risk of losing access to the care they depend on. Now, more than ever, rural communities must use their collective voice to fight for access to health care and lift up the essential role of community health centers.
Food is medicine (FIM) partnerships are increasing. There are no standard practices that integrate user-centered design (UCD) in screening, referral, and enrollment process for FIM programs. This mixed-methods study, based on UCD principles and the Fogg Behavior Model, used quantitative and qualitative data to understand multiple users' perspectives on screening, referral, and enrollment processes for a Health Care by Food™ pilot study. Most eligible participants (73%) enrolled in the study. Patients who were eligible but did not participate expressed embarrassment about discussing their food situation, lack of understanding of the type of foods being offered, and not wanting to take resources from others. Health care providers found the screening and referral process easy to implement. Patients who enrolled in the study found the process acceptable. User-informed screening, referral, and enrollment processes can support the creation of more acceptable systems to connect people with needed food resources.
Transitions Clinic Network (TCN) programs facilitate continuity of care for people with chronic conditions recently released from incarceration. Despite widespread implementation of TCN programs and their association with positive reentry outcomes, studies have yet to examine clients' perspectives on the programs' most helpful traits for overcoming reentry barriers to health care. Therefore, we interviewed 19 clients from the TCN-affiliated North Carolina Formerly Incarcerated Transition (NC FIT) Program. Respondents' identified reentry barriers included financial challenges, difficulties with health care system navigation, and insufficient community resources. They reported that NC FIT helped overcome barriers by paying for medications and medical visits and helping them enroll in health care coverage. Respondents said that NC FIT community health workers' ability to foster positive client relationships was foundational to effective service delivery. Findings are considered in the context of recent Medicaid expansion in NC and the need to expand health care reentry services throughout the state.
Few studies have examined whether the variation of health care infrastructure and workforce had potential impacts on COVID-19 mortality in rural counties. Linking national datasets, we stratified 1,548 rural and 1,148 urban U.S. counties using 2021 COVID-19 median mortality rates (19.5 vs. 14.0 per 10,000 population, respectively) as a cut-point for high and low mortality to compare sociodemographics, vaccination status, access to health centers and hospitals, and health care workforce supply between and within rural and urban counties. High-mortality (compared with low-mortality) rural counties had a higher percentage of residents who were older, Black and/or Hispanic, less educated, in poverty, and uninsured. Among all county groupings, high-mortality rural counties had the lowest percentage of residents with a complete COVID-19 vaccination series, were least likely to have a hospital or virtual patient services, and had the fewest hospital-based personnel and population-adjusted advanced-practice registered nurses. Rural communities experiencing these health care gaps require targeted health policy and resources.
The article examines the similarities and differences related to health among women experiencing homelessness (N=292) across four countries with different cultures and income levels: Spain (n=136), Argentina (n=72), Puerto Rico (n=54), and Nicaragua (n=30). Data were collected through a structured interview, in order to ensure the homogeneity of the data and to reduce potential reading or comprehension difficulties. Results show that women experiencing homelessness interviewed in all four countries perceived their own health status as poor, with high rates of women reporting medically diagnosed severe or chronic illnesses and/or disabilities. Women who had been diagnosed with a severe or chronic illness were older on average, had experienced homelessness for longer, and consumed sedatives or tranquilizers, had used drugs, and had attempted suicide to a greater extent than those without such diagnoses. Univariate analyses were complemented by multivariate ones to identify women who were at higher health risk. Results from logistic regression suggest that increasing age, excessive drug use, and having attempted suicide are significant predictors of suffering a diagnosed severe or chronic illness among women experiencing homelessness. These findings may help guide future prevention strategies and detect indicators of especially negative outcomes, while recognizing the importance of the context, as women experiencing homelessness in countries with lower income levels face situations of increased vulnerability in relation to health issues.
Geographic barriers and long travel distances contribute significantly to urban/rural health disparities, making online technology use a vital tool for improving individual and community health in rural areas. However, factors related to technology use, particularly in the Deep South (a historically under-resourced U.S. region characterized by high poverty, limited access to healthcare and education, and a predominantly African American population), remain understudied. Guided by the notion of a digital divide, we explore social determinants of online technology use for seeking health information among rural residents through a cross-sectional survey (N=157). Multiple linear regression analysis (R2=.52) revealed that lower social isolation was associated with reduced online technology use. In contrast, greater social media use, higher education, and improved health literacy were linked to increased use. These findings underscore the need for coordinated efforts among researchers, practitioners, and policymakers to expand access to (and engagement with) health-related online technologies in rural communities.
This scoping review synthesizes findings from 25 articles examining health literacy (HL) and clinical trials (CTs). Key factors contributing to low HL include poverty, limited education, older age, and limited English proficiency. Three thematic categories emerged: 1) barriers to recruitment and participation, 2) perceptions and comprehension of CT processes, and 3) interventions to improve knowledge and participation. Health literacy was found to influence willingness to participate in CTs, with higher HL associated with greater participation, especially in lower-burden trials. Misconceptions about CTs were prevalent among underserved populations. Interventions such as animated videos and simplified consent forms showed mixed effectiveness. A mapping exercise revealed gaps in existing HL frameworks, including provider bias and lack of target population involvement in trial design. Addressing these gaps through inclusive, culturally responsive strategies may improve comprehension, trust, and participation among underserved populations. Further research is needed to refine and evaluate HL interventions across CT contexts.
Community health centers (CHCs) should be important partners in research with academic health centers (AHCs). While persistent barriers to CHC-AHC partnerships have been described, our understanding of the potential solutions to these barriers is limited. This study aims to identify recommendations to support sustainable research partnerships between CHCs and AHCs to advance community-engaged health research. We conducted a qualitative study using interviews with CHC-based participants from three community health care organizations and researchers from one AHC. Twenty-five participants completed 12 individual interviews and six small group interviews. Five specific barriers to operationalizing research partnerships between CHCs and AHCs were identified, along with several recommendations to address these barriers. Recommendations are categorized into two domains-the first set calls for practical steps for researchers to adopt when conducting research, while the second set calls for deliberate, and leadership-led activities that support the creation of systemwide research partnerships between CHCs and AHCs.
Native patients face persistent health disparities and barriers to care, yet medical education has historically lacked content addressing these issues. To bridge this gap, the Duke University School of Medicine integrated a Native health thread into its first-year medical curriculum. Developed by medical students and faculty, the thread aimed to enhance students' understanding of Native health disparities, cultural competency, and the lived experiences of Native patients and physicians. The thread included lectures, experience-sharing sessions, and a self-directed learning activity. Pre- and post-thread surveys assessed students' awareness, attitudes, and behaviors. Students entered the thread highly motivated to learn and engage with Native communities. Following the intervention, they reported increased knowledge and greater comfort discussing Native health issues. This mandatory curricular thread effectively improved cultural competency, knowledge, and satisfaction among medical students. Future efforts will evaluate the thread's long-term impact on clinical practice and expand opportunities for direct patient engagement.
Over one in four caregivers in the United States report having received a diagnosis of depression, compared with less than 10% of the general adult population. We conducted a cross-sectional analysis of the 2022-2023 Behavioral Risk Factor Surveillance Survey using 23 demographic, comorbidity, or caregiving variables for 30,961 surveyed caregivers. The rate of caregivers reporting a diagnosis of depression was compared between these variables. We then conducted a chi-square automatic interaction detection analysis to determine the order of significance among these variables in predicting depression rates. The greatest differential in depression rates is based on the age of the caregiver (35.3% younger than 55 versus 21.6% 55 and older; p < .001). Among both age groups, income was the second greatest factor in predicting caregiver depression (35.4% with less than $50,000 and 21.6% with $50,000 or more; p < .001). Analysis of the factors associated with the greatest caregiver depression rates informs strategies to triage community funds and resources.
The Pre to 3 Program in Vanderburgh County, Indiana (United States) was designed to affect maternal-infant health in medically underserved populations through community health worker (CHW) led initiatives. This program provides free, hands-on support for infants, parents, and families from the first trimester of pregnancy until the child's third birthday. The CHW-driven Pre to 3 Program demonstrates improved outcomes in breastfeeding initiation, safe sleep practices, adequate prenatal care, child vaccination rates, food security, housing stability, and employment status. The Vanderburgh County Health Department Pre to 3 Program presents the state of Indiana, and similarly medically underserved counties, the opportunity to improve maternal-infant health through expanded implementation. With increased financial resources, and subsequently more program personnel, there is significant potential for positive impact on the health outcomes of high-risk communities.
To investigate racism in the health care setting experienced by American Indian and Alaska Native people and its influence on health care engagement. Data were collected via self-report surveys administered in person at two community powwows in Denver, Colorado in 2021 and 2022. Approximately one-third (29.8%) of American Indian and/or Alaska Native respondents reported having a health care visit where they felt uncomfortable due to their race. Of those, 51% were less likely to see a doctor in the future because of these experiences. Experiences were categorized as racial microaggressions and overt racism. American Indian and Alaska Native people experience racial microaggressions and overt racism during health care visits, leading to decreased likelihood of engaging with health care in the future.
Vision loss in high-risk populations may be prevented in many cases with the early detection and management of eye diseases. The Kress Vision Program (KVP) is a free-of-charge community-based vision screening, referral, and treatment program for uninsured New Yorkers. This retrospective analysis describes the prevalence of ocular diseases among participants seen at the KVP, as well as the referral rates, treatment, and follow-up at an academic ophthalmology department. From October 2020-January 2023, 26 community-based organizations (CBOs) referred 887 participants, and 618 (69.7%) were screened; participants were predominantly female (70.9%) and Hispanic (63.9%), and had an income less than 100% of the federal poverty level (74.8%). Of 305 (49.4%) patients referred for further care, 238 (78%) attended their appointment. Common referrals included glaucoma suspect (85) or needing a comprehensive (61), retinal (76), or cataract evaluation (35). By establishing relationships with CBOs, the KVP improves eye care utilization in a high-risk population, serving as an effective model for a free vision screening and treatment program.
Evaluate the association between reported homelessness and inpatient resource use among Medicare beneficiaries, and investigate variation therein. Cross-sectional study of 6.3 million 2022 Medicare inpatient claims from 3,200 U.S. hospitals, examining the association between homelessness and three outcomes: cost, length of stay (LOS), and non-intensive care days using multilevel models. Robustness checks were conducted on five cross-sectional clinical subgroups. Among Medicare inpatient discharges, 0.63% reported homelessness, with teaching hospitals reporting 0.67%, in contrast to 0.55% in non-teaching hospitals. Overall, homelessness is associated with $829 (p<.001) higher costs and 2.45 (p<.001) longer LOS, primarily days outside of intensive care. For some patient subpopulations, the homelessness-cost association was greater than the national $829 magnitude. Reported homeless rates vary by hospital type and involve different hospital resources depending on hospital and patient type, including higher costs and longer inpatient hospital stays.
Rural Medicaid enrollees face barriers to dental care. We evaluated outcomes of a dental clinic co-located within a health center in Jefferson County, a rural Health Professional Shortage Area (HPSA) in Washington state. In this mixed-methods study, we conducted 33 interviews and inductively coded the data. Using Medicaid data for adult enrollees, linear regression estimated dental use changes after clinic establishment by location of care (Jefferson County vs. elsewhere). We identified three domains. The clinic 1) provided affordable, accessible care meeting community needs; 2) faced challenges including extensive waitlists and staff shortages; 3) could address challenges by expanding clinic facilities and services offered. Adult Medicaid enrollees' dental care use increased 8.3% in Jefferson County (95% CI 4.1, 12.5) and declined 3.5% elsewhere (95% CI -6.3, -0.65) after the clinic was established. A co-located dental clinic addressed barriers to care for rural Medicaid enrollees, yet challenges persist.
There is a growing population of adults under 65 with disabilities needing to access long-term care (LTC). Rural areas are seeing this population rise while also experiencing growing nursing home closures. Medicaid, the largest payer of LTC, already pays for more LTC in rural areas than in urban areas. Therefore, state Medicaid expansion may increase insurance coverage for newly eligible individuals needing to use rural nursing homes. Using LTC Focus from 2011-2019, this paper conducts a Callaway Sant'Anna Difference-in-Differences analysis to understand the impacts of Medicaid expansion on rural nursing home admission demographics. Results indicated no significant effect of expansion on the percentage of Medicaid-dependent admissions and the percentage of under-65 admissions. Expansion was associated with a decrease in the percentage of admissions accounted for by Black individuals (-0.97** CI: -1.62, -0.33) in the included counties. More research must be conducted to study why the percent of Black admissions declined.
To prepare for future crises, providers who serve people experiencing homelessness may benefit from reviewing and incorporating lessons learned from responses to the COVID-19 pandemic. We present results of a rapid qualitative analysis of data from three focus groups with permanent supportive housing staff and four focus groups with clients in four large U.S. cities from July-August 2022. Clients and staff described how the pandemic challenged organizational practices and client-provider interactions, affected mental health and substance use, and produced mixed effects on housing and homelessness. Both clients and staff emphasized the importance of relationships and agreed that effective practices included providing vaccination at supportive housing sites and incorporating virtual options for therapy and support groups. Client and staff perspectives are synthesized to provide lessons learned and recommendations for responding to future public health events, like the COVID-19 pandemic; the analysis is framed using the socioecological model.
Black birthing people are three times more likely to die from pregnancy-related causes than White birthing people. This disparity is related to racism and implicit bias. The project's goal was to evaluate the effect of a novel anti-racism curriculum on the ability of health care providers to address implicit biases. Attendees of grand rounds education for the Department of Obstetrics and Gynecology at one academic institution were eligible. Pre- and post-intervention surveys were conducted annually. Results were analyzed through paired t-tests. Anti-racism curriculum participants had a statistically significant difference in their understanding of disparities and comfort speaking about instances of bias after participation. There was no significant difference in knowledge of historical context. Although most participants had previous anti-racism training, participants lacked comfort discussing disparities with peers and those in positions of leadership prior to this curriculum, which empowered participants to address racism in actionable ways.