Disparities in access to appointments for contraceptive services among Black, Hispanic, White, and recently incarcerated women in Alabama, Louisiana, and Mississippi.

OBJECTIVE: To measure differences in access to contraceptive services based on history of incarceration and its intersections with race/ethnicity and insurance status. DATA SOURCES AND STUDY SETTING: Primary data were collected from telephone calls to physician offices in Alabama, Louisiana, and Mississippi in 2021. STUDY DESIGN: We deployed a field experiment. The outcome variables were appointment offers, wait days, and questions asked of the caller. The independent variables were callers' incarceration history, race/ethnicity, and insurance. DATA COLLECTION METHODS: Using standardized scripts, Black, Hispanic, and White female research assistants called actively licensed primary care physicians and Obstetrician/Gynecologists asking for the next available appointment for a contraception prescription. Physicians were randomly selected and randomly assigned to callers. In half of calls, callers mentioned recent incarceration. We also varied insurance status. PRINCIPAL FINDINGS: Appointment offer rates were five percentage points lower (95% CI: -0.10 to 0.01) for patients with a history of incarceration and 11 percentage points lower (95% CI: -0.15 to -0.06) for those with Medicaid. We did not find significant differences in appointment offer rates or wait days when incarceration status was interacted with race or insurance. Schedulers asked questions about insurance significantly more often to recently incarcerated Black patients and recently incarcerated patients who had Medicaid. CONCLUSIONS: Women with a history of incarceration have less access to medical appointments; this access did not vary by race or insurance status among women with a history of incarceration.

Area-specific covid-19 effects on health services utilization in the Democratic Republic of the Congo using routine health information system data.

BACKGROUND: Since March 2020, the COVID-19 pandemic has shocked health systems worldwide. This analysis investigated the effects of the pandemic on basic health services utilization in the Democratic Republic of the Congo (DRC) and examined the variability of COVID effects in the capital city Kinshasa, in other urban areas, and in rural areas. METHODS: We estimated time trends models using national health information system data to replicate pre-COVID-19 (i.e., January 2017-February 2020) trajectories of health service utilization, and then used those models to estimate what the levels would have been in the absence of COVID-19 during the pandemic period, starting in March 2020 through March 2021. We classified the difference between the observed and predicted levels as the effect of COVID-19 on health services. We estimated 95% confidence intervals and p-values to examine if the effect of the pandemic, nationally and within specific geographies, was statistically significant. RESULTS: Our results indicate that COVID-19 negatively impacted health services and subsequent recovery varied by service type and by geographical area. COVID-19 had a lasting impact on overall service utilization as well as on malaria and pneumonia-related visits among young children in the DRC. We also found that the effects of COVID-19 were even more immediate and stronger in the capital city of Kinshasa compared with the national effect. Both nationally and in Kinshasa, most affected services had slow and incomplete recovery to expected levels. Therefore, our analysis indicates that COVID-19 continued to affect health services in the DRC throughout the first year of the pandemic. CONCLUSIONS: The methodology used in this article allows for examining the variability in magnitude, timing, and duration of the COVID effects within geographical areas of the DRC and nationally. This analytical procedure based on national health information system data could be applied to surveil health service disruptions and better inform rapid responses from health service managers and policymakers.

The influence of health facility-level access measures on modern contraceptive use in Kinshasa, DRC.

Expanding access to family planning (FP) is a principal objective of global family planning efforts and has been a driving force of national family planning programs in recent years. Many country programs are working alongside with the international family planning community to expand access to modern contraceptives. However, there is a challenging need for measuring all aspects of access. Measuring access usually requires linking information from multiple sources (e.g., individual women and facilities). To assess the influence of access to family planning services on modern contraceptive use among women, we link four rounds of individual women and service delivery points survey data from PMA2020 in Kinshasa. Multilevel logistics regression on pooled data is performed to test the influence of facility-level access factors on individual-level contraceptive use. We add variables tailored from a conceptual framework to cover elements of access to family planning: administrative access, geographic or physical access, economic access or affordability, cognitive access, service quality, and psychological access. We find that the effect of community and facility-level access factors varies extensively but having fewer stocked-out facilities and more facilities with long-acting permanent methods (LAPM) increases the odds of using modern contraceptives among women in Kinshasa. Our study shows that reliable supply chain with a broad array of method mix will increase the odds of modern contraceptive use at community level among women in Kinshasa. Using to community-oriented practices and service delivery along with empowering women to make health-related decisions should become a priority of family planning programs and international stakeholders in the country.

Association of Simulated Patient Race/Ethnicity With Scheduling of Primary Care Appointments.

IMPORTANCE: Racial and ethnic disparities in access to health care may result from discrimination. OBJECTIVES: To identify differences in the rates at which patients belonging to racial/ethnic minority groups are offered primary care appointments and the number of days they wait for their primary care appointment and to understand the mechanisms by which discrimination occurs. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study used 7 simulated black, Hispanic, and white patient callers to request appointments from 804 randomized primary care offices in 2 urban centers in Texas from November 2017 to February 2018. Data analysis was conducted between February and December 2018. EXPOSURES: Research assistants called randomly assigned offices to schedule an appointment, supplying the same basic information. Race and ethnicity were signaled through callers' names and voices. MAIN OUTCOMES AND MEASURES: Appointment offer rates, days to appointment, and questions asked during the call. RESULTS: Of the 7 callers (age range, 18-29 years), 2 (28.6%) self-identified as non-Hispanic black, 3 (42.9%) self-identified as non-Hispanic white, and 2 (28.6%) self-identified as Hispanic. Of the 804 calls they made, 299 (37.2%) were from simulated white callers, 215 (26.7%) were from simulated black callers, and 290 (36.1%) were from simulated Hispanic callers. Overall, 582 callers (72.4%) were offered appointments. In unadjusted models, black and Hispanic callers were more likely to be offered an appointment than white callers (black callers, 32.2 [95% CI, 25.1-39.3] percentage points more likely; P < .001; Hispanic callers, 21.1 [95% CI, 13.7-28.5] percentage points more likely; P < .001). However, after adjusting for whether insurance status was revealed, this statistical significance was lost. In adjusted models, black callers were 44.0 (95% CI, 36.2-51.8) percentage points more likely to be asked about their insurance status than white callers (P < .001), and Hispanic callers were 25.3 (95% CI, 17.1-33.5) percentage points more likely to be asked about their insurance status (P < .001) than white callers. Black and Hispanic callers received appointments further in the future than white callers (black callers: marginal effect estimate, 3.650; 95% CI, 0.579 to 6.721; P = .08; Hispanic callers: marginal effect estimate, 2.644; 95% CI, -0.496 to 5.784; P = .02). CONCLUSIONS AND RELEVANCE: In this study, black and Hispanic patients were more likely to be offered an appointment, but they were asked more frequently about their insurance status than white callers. Black and Hispanic callers experienced longer wait times than white patients, indicating a barrier to timely access to primary care.

Opportunities to Improve Employee Satisfaction Within State and Local Public Health Agencies.

CONTEXT: Public health agencies will likely struggle to staff at necessary levels, given ongoing workforce shortages, the potential for mass retirement, and expanding responsibility. Although the majority of public health workers are satisfied with their jobs overall, it is critical to understand the degree to which they are satisfied and identify factors that contribute to any dissatisfaction that occurs. OBJECTIVE: This study identified opportunities for public health agencies to improve work environments and, in turn, improve employee satisfaction and retention. DESIGN: Using data from the 2014 Public Health Workforce Interest and Needs Survey, we analyze responses to the survey question, "If you wish, you may provide comments below about your level of job satisfaction." The 2966 responses (2389 from state and 542 from local public health agencies) that indicated a negative disposition were examined to understand employee dissatisfaction. SETTING: The survey was administered to a representative sample of state health departments and convenience samples of local health departments. PARTICIPANTS: Responses from employees of state and local health departments are considered. MAIN OUTCOME MEASURES: The most frequently occurring themes overall were identified. In addition, responses describing weaknesses in organizational support (specifically training, communication, workload, and innovation) were summarized. RESULTS: The most frequently occurring themes were as follows: (1) salary, specifically in relation to the merit system, performance evaluation, and workload; (2) job security with emphasis on funding, organizational transformation, and politics/government; and (3) career development related to the merit system, performance evaluation, and management. Respondents also reported opportunities in the areas of training, communication, workload, and innovation to improve satisfaction levels. CONCLUSIONS: These findings serve as a call to action for leaders in health departments as well as national public health leaders to remedy the concerns raised in their responses. Some of the solutions are within the realm of public health agency leadership, but some may fall within the realm of governors and public health leaders at the federal level. It is important to share these findings so that appropriate decision makers can address public health workforce retention and recruitment issues in the interest of retaining valuable employees.

Public Health Workforce Self-Identified Training Needs by Jurisdiction and Job Type.

CONTEXT: Ensuring adequate and appropriate training of the workforce is a crucial priority for governmental public health. This is particularly important, given the diverse backgrounds of the public health workforce; the vast majority (approximately 83%) do not have formal training in public health, and those that do have formal training in public health have limited training in management and other essential organizational skills. OBJECTIVE: The purpose of this article is to identify training needs among public health workers in specific job types and settings. DESIGN AND PARTICIPANTS: This cross section study used 2014 data from the Public Health Workforce Interests and Needs Survey. Qualitative analyses were used to code open-ended responses to questions about training needs. Needs are stratified across job types and jurisdiction. RESULTS: Eight main themes or skill areas were identified with the largest proportion indicating a need for management/leadership skills (28.2%). The second most frequent need was communication skills (21.3%). Across the 9 job types examined, general management skills were either the first or second training need for 7 job types. Among individuals who already have leadership/management positions, budgeting was the most common training need. CONCLUSIONS: Findings from this study can inform targeted strategies to address training needs for specific types of employees. Such strategies can influence the efficiency and effectiveness of public health efforts and employee satisfaction. As new public health frameworks-like Public Health 3.0 and the Chief Health Strategist-are advanced nationally, it is necessary to ensure that the workforce has the skills and abilities to implement these frameworks.

Comparison of objective measures and patients' perceptions of quality of services in government health facilities in the Democratic Republic of Congo.

OBJECTIVE: Examine the relationship between patients' perceptions of quality and the objective level of quality at government health facilities, and determine whether the pre-existing attitudes and beliefs of patients regarding health services interfere with their ability to accurately assess quality of care. DESIGN: Cross-sectional, visit-level analysis. SETTING: Three regions (Nord-Ubangi, Kasai/Kasai-Central and Maniema/Tshopo) of the Democratic Republic of Congo. PARTICIPANTS: Data related to the inpatient and outpatient visits to government health facilities made by all household members who were included in the survey was used for the analysis. Data were collected from patients and the facilities they visited. MAIN OUTCOME MEASURES: Patients' perceptions of the level of quality related to availability of drugs and equipment; patient-centeredness and safety serve compared with objective measures of quality. RESULTS: Objective measures and patient perceptions of the drug supply were positively associated (ß = 0.16, 95% CI = 0.03, 0.28) and of safety were negatively associated (ß = -0.12, 95% CI = -0.23, -0.01). Several environmental factors including facility type, region and rural/peri-urban setting were found to be significantly associated with respondents' perceptions of quality across multiple outcomes. CONCLUSIONS: Overall, patients are not particularly accurate in their assessments of quality because their perceptions are impacted by their expectations and prior experience. Future research should examine whether improving patients' knowledge of what they should expect from health services, and the transparency of the facility's quality data can be a strategy for improving the accuracy of patients' assessments of the quality of the health services, particularly in low-resourced settings.

Factors That Influence the Recruitment and Retention of Nurses in Public Health Agencies.

OBJECTIVE: Given challenges to recruiting nurses to public health and the growth in national policies focused on population health, it is crucial that public health agencies develop strategies to sustain this important group of employees. The objective of this study was to examine factors that influence nurses' decisions to work in public health agencies. METHODS: This cross-sectional study examined perspectives of nurses who worked in state and local public health departments and responded to the 2010 Council on Linkages Between Academia and Public Health Practice's survey of public health workers. We calculated the mean rating of each recruitment and retention factor for nurses and non-nurses separately and compared differences by using t tests. We then used multivariate regression analysis to examine differences in ratings by role (ie, nurse or non-nurse). RESULTS: After controlling for personal and organizational characteristics, the influence of 5 recruitment factors was significantly stronger among nurses than among non-nurses: flexibility of work schedule ( P < .001), autonomy/employee empowerment ( P < .001), ability to innovate ( P = .002), specific duties and responsibilities ( P = .005), and identifying with the mission of the organization ( P = .02). The influence of 5 retention factors was stronger among nurses than among non-nurses : autonomy/employee empowerment ( P < .001), flexibility of work schedule ( P < .001), specific duties and responsibilities ( P < .001), opportunities for training/continuing education ( P = .03), and ability to innovate ( P = .008). CONCLUSIONS: Some factors that influence nurses to begin and remain working in local governmental public health agencies, such as flexible schedules and employee autonomy, are factors that governmental public health agencies can design into positions and highlight when recruiting from health care organizations, private industry, and academia.

Exploring the barriers to rigorous monitoring and evaluation of health systems strengthening activities: qualitative evidence from international development partners.

The number of health systems strengthening (HSS) programs has increased in the last decade. However, a limited number of studies providing robust evidence for the value and impact of these programs are available. This study aims to identify knowledge gaps and challenges that impede rigorous monitoring and evaluation (M&E) of HSS, and to ascertain the extent to which these efforts are informed by existing technical guidance. Interviews were conducted with HSS advisors at United States Agency for International Development-funded missions as well as senior M&E advisors at implementing partner and multilateral organizations. Findings showed that mission staff do not use existing technical resources, either because they do not know about them or do not find them useful. Barriers to rigorous M&E included a lack suitable of indicators, data limitations, difficulty in demonstrating an impact on health, and insufficient funding and resources. Consensus and collaboration between international health partners and local governments may mitigate these challenges. Copyright © 2016 John Wiley & Sons, Ltd.

Why Do People Work in Public Health? Exploring Recruitment and Retention Among Public Health Workers.

CONTEXT: The public health workforce is critical to the functioning of the public health system and protection of the population's health. Ensuring a sufficient workforce depends on effectively recruiting and retaining workers. OBJECTIVE: This study examines factors influencing decisions to take and remain in jobs within public health, particularly for workers employed in governmental public health. DESIGN: This cross-sectional study employed a secondary data set from a 2010 national survey of US public health workers. PARTICIPANTS: Survey respondents were included in this study if they responded to at least 1 survey item related to recruitment and retention. A total of 10 859 survey responses fit this criterion. MAIN OUTCOME MEASURES: Data examined demographics of public health workers and factors that influenced decisions to take jobs in and remain in public health. RESULTS: Job security (ß = 0.42; 95% confidence interval [CI], 0.28-0.56) and competitive benefits (ß = 0.49; 95% CI, 0.28-0.70) were significantly and positively associated with governmental employees' decisions to take positions with their current employers compared with public health workers employed by other types of organizations. The same finding held with regard to retention: job security (ß = 0.40; 95% CI, 0.23-0.57) and competitive benefits (ß = 0.53; 95% CI, 0.24-0.83). Two personal factors, personal commitment to public service (ß = 0.30; 95% CI, 0.17-0.42) and wanted a job in the public health field (ß = 0.44; 95% CI, 0.18-0.69), were significantly and positively related to governmental employees deciding to remain with their current employers. CONCLUSIONS: It is important to recognize the value of competitive benefits for both current and potential employees. Public health agencies should maintain these if possible and make the value of these benefits known to policy makers or other agencies setting these benefit policies. Job security associated with governmental public health jobs also appears to offer public health an advantage in recruiting and retaining employees.

What Matters in Recruiting Public Health Employees: Considerations for Filling Workforce Gaps.

We examined factors that influence the decision to join the public health workforce. In this cross-sectional study, we used 2010 secondary data representing 6939 public health workers. Factors influencing the decision to take jobs in public health were significantly associated with specific previous employment settings. Respondents generally rated organizational factors as more influential than personal factors in terms of their decision to work in governmental public health. Leaders should consider tailoring recruitment efforts to maximize job uptake and enhance the potential for long-term retention.