Barriers to healthcare access in a non-elderly urban poor American population.

An understanding of perceived barriers to health-care is critical to improving healthcare access for all Americans. To determine perceived barriers to health-care in an urban poor population in Dayton, Ohio, a face-to-face door-to-door survey of individuals identified through targeted, stratified, area probability sampling was done. A sample of 413 non-elderly poor adults, including 19% without telephones, reported personal relevance of various barriers to healthcare access. Most frequently endorsed barriers were lack of information about free or reduced-cost health-care, anticipated cost, and difficulty accessing child-care. Seventy-four per cent of respondents reported more than one barrier. Individuals without telephones and those without health insurance reported more barriers to health-care. Reported barriers were similar for working and non-working poor, except for transportation problems, more frequently reported by non-working respondents. This study provides important data on what poor people in a medically underserved community perceive to be barriers to accessing health-care and underscores the importance of including people without telephones in the study design. Respondents who did not have telephones were more likely to report multiple barriers, particularly problems with lack of information about free or discounted medical care, child-care, and transportation. These findings suggest the importance of door-to-door surveys rather than telephone surveys for getting accurate data on the poor.

A questionnaire survey of family practice physicians' perceptions of bereavement care.

Survey responses were obtained from 113 family physicians in an exploratory investigation of bereavement care by family physicians. Respondents generally indicated that they believed that bereavement presented significant health risks to their patients and that the identification and treatment of bereaved patients was an important part of their role. However, physicians were highly variable in how they reported identifying and responding to bereaved patients in terms of counseling, addressing spiritual concerns, and medically treating symptoms. The "grief-responsive" physician is described based on these data. We document the interest and need for training in bereavement care.

"The history of health in Dayton": a community-academic partnership.

Academic institutions have always found it a challenge to persuade community members to participate in academic research projects. Starting an open dialogue is usually the critical first step. To begin this dialogue with community members in Dayton, Ohio, in 1999, staff from Wright State University decided to organize a community forum, "The History of Health in Dayton." The forum was intended as the first project of a new research organization, the Alliance for Research in Community Health (ARCH), established with federal funding from the Health Resources and Services Administration in 1998. ARCH was created as a bridge between the Department of Family Medicine of Wright State University School of Medicine and the Center for Healthy Communities, a health advocacy and service organization committed to health professions education. ARCH's mission is to improve the health of citizens of Dayton through research involving community participation. Through ARCH, community members help researchers define priorities, resolve ethical issues, refine procedures, and interpret results. Guidelines for participatory research, proposed by the National Primary Care Research Group in 1998 and adopted by the alliance, emphasize the importance of open dialogue among researchers, subjects, academics, and community members. The initial response to the forum was enthusiastic, with a majority of community residents expressing interest in attending future presentations.

Cultural issues in the primary care of South Asians.

One of the fastest growing immigrant groups in the United States is from the Indian subcontinent of South Asia. Included in this group are people from India, Sri Lanka, Bangladesh, and Pakistan. Although there is considerable heterogeneity within and between the populations of these countries, cultural similarities contribute to common challenges when South Asian immigrants are seen in primary care settings in the United States. This article describes aspects of the South Asian culture and of the acculturation process relevant to establishing rapport and providing competent biopsychosocial care to individuals and families from this region. We discuss the differing needs of recent immigrants, second-generation Americans from South Asia, and individuals temporarily in the United States for study or employment. We discuss linguistic and interpersonal style concerns in regard to the relationship between health care professionals and immigrant patients and use case material to illustrate cultural issues. We conclude with suggestions for culturally sensitive health care of South Asians.

Enhancing mammography referral in primary care.

BACKGROUND: This 1-year randomized trial tested the efficacy of behavioral techniques for increasing mammography referrals by primary care physicians in small, community practices. METHODS: Sixty-one practices were randomly assigned to one of three conditions: (1) education-only control, (2) education plus cue enhancement using mammography chart stickers, and (3) education plus cue enhancement plus feedback and token rewards. Quarterly chart audits of a defined sample (N = 11,716) of women patients 50 years of age or older were conducted to document mammography referrals, completions, and compliance. RESULTS: Referral and completion rates increased from baseline to first quarter and gradually declined thereafter. Overall, these rates were higher in the cuing conditions than in the control condition. In contrast, compliance rates in both experimental conditions increased over the year while remaining static in the control condition, demonstrating a strong and continuing effect for cue enhancement. Compliance increases were greatest for physicians who were older, nonwhite, with a second speciality, in solo practice, not members of the AMA, not residency trained, and not board certified. CONCLUSIONS: Chart stickers can significantly increase mammography utilization in small, community practices. These practices are an efficient route to reaching large numbers of older women in need of mammography screening.

Clinical decision-making and mammography referral.

BACKGROUND: Physician characteristics, practice/structural factors, and patient characteristics have all been found to influence mammography referral. The relationship of a patient's advanced age and comorbidity to the physician's decision has not received much attention. METHODS: Community-based, primary care physicians (n = 132) in two medium-sized U.S. cities completed questionnaires. RESULTS: Physicians report that they refer nearly all (89%) of the women ages 50-64 in their practice, slightly fewer of those 65-74 (83%), but many fewer (57%) of those 80 and over. Foreign medical graduates and physicians who are not board certified reported lower referral rates, and those who were residency trained reported substantially lower rates for the oldest patient group. Common reasons for not referring included assuming a gynecologist or another physician will make the referral, patient cost, comorbidity, and type of encounter, i.e., whether the patient is being seen for an acute condition. However, the lowest rate of referral was associated with believing that the patient was too old to benefit from early detection. CONCLUSIONS: Results are discussed in terms of the debate about whether guidelines should be based on patient age or functional status and the need to openly discuss and evaluate the decision rules being used.

Maximizing the referral of older women for screening mammography.

The primary care physician is in a crucial position to facilitate mammography referral of women older than 50 years. Physician underestimation of the importance of the physician role or overestimation of patient resistance can result in lost opportunities for referral. Research is summarized on the impact of physician encouragement on use of mammography and on sources of reluctance to get mammography as reported by patients. Common patients' concerns are discussed. Mammography referral can usually be accomplished successfully by raising the issue and briefly addressing patients' concerns in regard to breast cancer and screening mammography.

Informational yield of comprehensive Geriatric Home Assessment.

OBJECTIVE: The purpose of this study was to compare the relative informational yield of Geriatric Home Assessments with medical charts of patients seen in family practice settings. METHODS: The information from comprehensive Geriatric Home Assessments of 28 well-established patients, conducted by small groups of medical students in a family practice clerkship, was compared with information available in the medical charts of these patients for the previous three years. RESULTS: For no problem studied was identification in the medical chart as high as from the Geriatric Home Assessment. Problems with family/social support, inadequate dental care, and immunization deficiencies were frequently noted in the Geriatric Home Assessment but only rarely in the medical chart. Concordance between Geriatric Home Assessment and medical charts was greatest for depression/anxiety, sensory loss, smoking, dizziness, and sleep problems. CONCLUSIONS: While evaluation of the utilization of information was beyond the scope of the current study, the results suggest the potential usefulness of complementing office care with home assessments in establishing a data base for the medical management of elderly patients in primary care settings.

The importance of physician encouragement in breast cancer screening of older women.

METHODS: The relationship between physician encouragement and breast cancer screening is examined with a population-based survey of 630 women between the ages of 45 and 75. Although the women interviewed were selected on the basis of their noncompliance with mammography guidelines, nearly half had previously had at least one mammogram. RESULTS: Women reported having received more physician encouragement of breast self-examination than of mammography. Older women reported less encouragement of both screening modalities than younger women. Multivariate analyses revealed physician encouragement to be more strongly associated with screening mammography than with health status, health care utilization, attitudes, and sociodemographic characteristics: those who reported having received physician encouragement were nearly four times more likely to have ever had screening mammography. CONCLUSIONS: These and related findings are used to highlight the critical importance of physician behavior in the secondary prevention of breast cancer in older women and to identify types of patients whose needs for screening are most likely to be overlooked by physicians.

Post-abortion adjustment of health care professionals in training.

Sixty-three women students of the health care professions were surveyed about their abortion and post-abortion experiences, feelings, and attitudes. Variables predictive of short- and long-term adjustment, belief in the wisdom of the choice, and right to choose were analysed, as were effects on emotional and attitudinal responses of passage of time and pressure to abort. Most reported mild, transient, short-term negative effects, and generally benign long-term effects. Implications of the findings are discussed.

PIP: To assess the existence of a post-abortion syndrome, a questionnaire was mailed to 554 Midwestern US women in training programs to become psychologists, nurses, or physicians. Of the 338 (61%) who responded, 63 indicated a past history of abortion and provided detailed information on their post-abortion adjustment. The abortions were performed between 1963-86; 1978 was the median year. The average age at the time of abortion was 21.3 years, while the mean age of respondents at the time of the survey was 30 years. Most (72%) reported irregular or no contraceptive use before the pregnancy that was aborted. The main reasons for choosing abortion were: too young or not ready for a child (22%), potential interference with educational and career goals (19%), and financial problems in raising a child (14%). 75% received no pre-abortion counseling, although 16% subsequently entered therapy to deal with abortion-related issues. 86% still believed their abortion was a wise choice. The emotional sequelae of abortion reported by these health professionals correspond with those found in other studies: some mild distress, including guilt, depression, and anxiety, in the 3 months following the abortion followed by relief and a return to baseline mood. Also consistent with the literature was the finding of a significant association between adequate preparation for the procedure and confidence in the abortion decision and long-term adjustment. An unexpected finding was more favorable long-term adjustment in women whose sexual partners either opposed or were not informed about the abortion decision. Finally, women who recalled pressure to abort experienced more short-term symptoms and were, at the time of the survey, less supportive of abortion rights than women who were not pressured.

Emotional sequelae of abortion: implications for clinical practice.

PIP: Without ambivalence, psychotherapy would be unnecessary; however there is a great deal of ambivalence about abortion so it is a therapy issue. In our society abortion decision are made in an ambivalent environment. Even when a woman makes a free decision to have a legal abortion, an emotional sequelae can ensue. This article reviews literature and relates professional experience about the psychological problems and treatment of women before and after having an abortion. A feeling of relief is the typical reaction to an abortion for the woman. The issues involved in the decision process are the woman's own health and happiness as well as that of her future family. The issues include medical and interpersonal ones and often present a moral crisis. Issues such as education, occupation, and relationships must be considered. Three major types of reactions seem to follow an abortion. The 1st is a positive feeling of happiness and relief. The 2nd and 3rd are negative, one being socially based guilt and the other being individually based guilt. Identifying abortion related issues in psychotherapy is not always easy, since they are no usually directly presented to the therapist. They often manifest themselves as symptoms of other problems. Research suggests that unmarried young women without children have a harder time resolving all the issues involved in making an abortion decision. One effective method of discovering emotional problems is to determine the reasons for delaying an abortion. If a woman is having problems making the decision is must be for an important reason. Just as important is the aftermath of the abortion. Attempts should be made to discover as much information about the procedure itself, the recovery time and any repercussions of the procedure. Neither research nor clinical experience has shown that abortion related psychotherapy is different than other forms of treatment. Griefwork, educational approaches, reviews of the decision making process and even rituals of self-forgiveness are all possible effective treatments.^ieng

Correlates of burnout among family practice residents.

Burnout among 67 residents in four family practice training programs was explored. The residents' scores on the emotional exhaustion, depersonalization, and lack of accomplishment subscales of the Maslach Burnout Inventory were used to assess burnout. These scores were examined in relation to situational and background measures, two personality instruments (the Millon Clinical Multiaxial Inventory and the Myers-Briggs Type Indicator), and to regrets about career decisions. Few significant relationships were found between the background and situational factors and the burnout scores, but numerous relationships were found among personality measures, burnout scores, and measures of regret. The pattern of these relationships indicates the importance of interpersonal comfort and skills in mitigating burnout. Although personality factors were more predictive than demographic and situational variables of the variability in burnout among residents in the sample, the variables shared across the sample--long hours, little time for leisure activities and social contact, and compulsive personality characteristics--may contribute to the moderate level of burnout shared by these residents.

Resident physicians in family practice: who's burned out and who knows?

Sixty-seven family practice residents and 18 faculty members completed the Maslach Burnout Inventory and listed three factors they believed most responsible for resident burnout. In addition, faculty rated residents and residents rated themselves on overall burnout. Mean resident scores on the Maslach ranged from moderate to high, while global self-ratings indicated moderate burnout. Patterns did not vary across programs surveyed, postgraduate year, or gender. Faculty did not appear to be modeling burnout, since they scored in the low to moderate ranges on all Maslach subscales. Residents and faculty overwhelmingly cited time demands as the factor most responsible for resident burnout. Residency directors were more accurate than psychologist faculty in identifying which residents saw themselves as most burned out. Directors significantly underestimated the absolute level of burnout, but psychologists did not. Combined assessments of both faculty groups resulted in significantly better identification than either alone. The prevalence and patterns of burnout and difficulties in identifying affected residents are discussed in terms of the demands of residency training programs and the investment of residents and faculty in current models of medical education.

Validity of the Maslach Burnout Inventory for family practice physicians.

This study assesses the utility of Maslach's concept of burnout for family practice physicians. Maslach Burnout Inventory (MBI) subscale correlations for the 67 residents in this sample are compared with Maslach's normative sample. The residents scored in the moderate to high range on the MBI subscales. MBI interscale correlations were similar to the pattern reported by Maslach. Significant correlations between job satisfaction and five of the six MBI subscales suggest that the construct of burnout has considerable psychological import for these physicians. The validity of the emotional exhaustion subscale is demonstrated by significant correlations with self-assessed burnout, job satisfaction, and faculty assessments of resident burnout. Independent observers were most sensitive to residents' emotional exhaustion and less likely to assess accurately the less visible aspects of burnout related to depersonalization and lack of achievement, which suggests the usefulness of multiple measures for assessing the burnout phenomenon.