Gender differences in health care access indicators in an urban, low-income community.

OBJECTIVES: This study examined factors associated with gender differences in health insurance coverage and having a usual source of medical care. METHODS: In-person interviews were conducted with a community sample of 695 residents of Central Harlem, New York City. Predictors of the 2 outcome variables and the interaction of key variables with gender were analyzed via logistic regression. RESULTS: No strong patterns emerged to explain gender differentials in having insurance coverage and having a usual provider. However, women employed full time had increased odds of insurance coverage, whereas employment had no similar effect among men. Public assistance evidenced a strong relationship with insurance coverage among both men and women. Socioeconomic factors and health insurance were important independent predictors of having a usual source of health care for men but had little effect among women. CONCLUSIONS: Expanding the availability of both public insurance and affordable private coverage for men living in low-income communities is an important means of reducing gender disparities in access to health care. Public assistance is an important means of enabling access to health care for men as well as women.

The adolescent years: an academic-community partnership in Harlem comes of age.

Much has been written about the potential benefits in health promotion that are possible through partnerships between academic institutions and community-based organizations, but little practical advice has been provided on how to sustain these relationships when the original grant funds have been exhausted. Here we document our experiences in Harlem, New York City, a community with grave social, structural, and physical environmental inequities, and describe the successes and failings of a partnership now in its "adolescence" between researchers at the Joseph L. Mailman School of Public Health of Columbia University and community activists at West Harlem Environmental Action (WE ACT).

Factors influencing participation in weekly support groups among women completing an HIV/STD intervention program.

Over the past three decades, the influence and importance of social support has been well documented and the findings have suggested a beneficial effect on stress-related situations, mental and physical health, and social functioning. More recently, small group/skills training behavioral interventions have demonstrated success in changing behaviors which affect the transmission of sexually transmitted diseases, including HIV among populations at risk for these diseases. Studies of support groups to date have been conducted exclusively in research settings where women are offered financial incentives for participation. Little is known about the willingness of women to participate in ongoing support groups after successfully completing a skills training intervention. The present study examines the factors that may influence participation among women in a weekly support group after completing a structured, six session HIV/STD intervention. Both quantitative and qualitative data are collected from 265 women in the intervention arm of a multi-site randomized controlled behavioral intervention trial. Results reveal that less than a quarter (22%) of women participated in at least one support group. Participation varied significantly by site, ranging from 34% to 15% (p = .008). Participation was also strongly linked to recent use of domestic violence services. Qualitative data indicated that although monetary incentives play some role in the woman's decision to participate, other factors are also important. These include program outreach, support group size, salience of the group content, consistency of group leadership from the intervention to the support group, and use of peer leaders along with professional facilitators. Implications for design of post-intervention support groups programs are discussed.

The diffusion of innovation in AIDS treatment: zidovudine use in two New Jersey cohorts.

OBJECTIVE: This study investigates patterns of utilization of zidovudine (ZDV) by gender, race, risk group, and other respondent characteristics following approval of this treatment. STUDY POPULATION: Longitudinal observational data were used on a demographically diverse population participating in New Jersey's Medicaid waiver program for persons with symptomatic HIV disease. DATA EXTRACTION METHODS: Claims data were merged with administrative data on demographic characteristics, risk group, and functional status. Periods of ZDV utilization were determined by analysis of pharmacy claims. DESIGN: The proportion of respondents ever using ZDV (treatment incidence) and the proportion of time on ZDV among users (treatment persistence) were analyzed for a cohort enrolling in 1987 and 1988, and for a cohort enrolling in 1989 and 1990, with follow-up of utilization through August 1992. For each cohort, bivariate analyses were used to compare incidence and persistence by patient subgroup; logistic regression was used to investigate the predictors of incidence in a multivariate model; and OLS regression was used to analyze proportion of time on ZDV among those with any ZDV use. PRINCIPAL FINDINGS: For the 1987-1988 cohort, substantial race, gender, and risk group differences in utilization were observed, even though all participants in this Medicaid population had financial coverage for ZDV treatment. Treatment incidence was significantly lower for blacks than for others in bivariate comparison (45 percent versus 63 percent had any use of ZDV) and in a logistic regression controlling for a variety of demographic and health status indicators (relative risk .46, CI .31 a variety of demographic and health status indicators (relative risk .46, CI .31 to .69). Treatment persistence differences were also substantial in the 1987-1988 cohort: among ZDV users, women, blacks, and injection drug users (IDUs) had significantly less persistence in use, and the gender and risk group differences were significantly in a multivariate model. In the 1989-1990 cohort, however, both incidence and persistence of treatment converged: no significant differences were observed across demographic groups. CONCLUSIONS: Less-advantaged subgroups lagged in access to this new therapy, suggesting the presence of nonfinancial barriers to care. However, these initial differences subsequently converged. RELEVANCE/IMPACT: Socioeconomic differences have been observed in access to newly introduced treatments for a variety of diseases, reflecting nonfinancial as well as financial barriers to care. Such differences may or may not disappear as use of therapies becomes institutionalized. Monitoring patterns of treatment initiation as well as persistence of treatment over time, using merged data from claims and administrative files, can provide important information on the diffusion of treatments and the extent to which initial disparities are or are not reduced over time.

New Jersey's Medicaid waiver for acquired immunodeficiency syndrome.

This article contains data from a study of New Jersey's home and community-based Medicaid waiver program for persons with symptomatic human immunodeficiency virus illness. Major findings include lower hospital costs and utilization for waiver participants compared with general Medicaid acquired immunodeficiency syndrome admissions in New Jersey. Average program expenditures were $2,400 per person per month. Based on study findings, it is evident that the waiver program is an important means of providing financial benefits and access to services and that comprehensive case management is a critical factor in assuring program quality.

Health through three life stages: a longitudinal study of urban black adolescents.

This is a study of life stage coherence and change in perceived health status and morbidity reports over a 15 year interval bounding adolescence. Data were obtained through personal home interviews with a representative sample (N = 426) of urban black youths who were interviewed at three successive life stages: first when they were adolescents ages 12-17, 6-8 years later when they were ages 18-23, and 7-8 years after that when they were ages 26-31. Results showed that health decline was neither continuous nor progressive over the three life stages. Instead, a dramatic increase in morbidity reports occurring between adolescent and post adolescent measurement was succeeded by stabilization in the following 7 year interval. One interpretation of these findings is that they reflect the stressfulness of the adolescent life stage in the urban black youth cohort. The congruence of this interpretation with Mechanic and Angel's theory of differential health synchrony over the life course and also with Antonovsky's theory of sense of coherence in explaining variations in perceived health is discussed. The study, finally, pointed up a serious methodological impediment to attempting comparative life span health studies such as this, namely, the difficulty in arriving at equivalently comprehensive and sensitive health symptom indicators at different life stages.