Teaching health-care trainees empathy and homelessness IQ through service learning, reflective practice, and altruistic attribution.

This article describes a novel inter-professional curriculum designed to address the needs of homeless patients in a Midwestern region of the United States which has high rates of poverty. The curriculum is intended for healthcare trainees coming from undergraduate pre-medical programs, nursing, pharmacy, social work, clinical psychology, medical school and post-graduate medical training in family medicine, medicine-pediatrics, and psychiatry. The clinical component is specifically designed to reach destitute patients and the curriculum is structured to reverse commonly held myths about homelessness among the trainees, thereby improving their Homelessness Information Quotient, the ability to more fully understand homelessness. Participants across all disciplines and specialties have shown greater empathy and helper behavior as determined by qualitative measures. Learners have also developed a greater understanding of health-care systems allowing them to more consistently address social determinants of health identified by the authors as their Disparity Information Quotient. This article outlines the process of initiating a homeless service program, a curriculum for addressing common myths about homelessness and the effective use of narrative methods, relational connections, and reflective practice to enable trainees to process their experience and decrease burnout by focusing on the value of altruism and finding meaning in their work.

Cost-related medication nonadherence and cost-saving strategies used by elderly Medicare cancer survivors.

OBJECTIVES: This study was conducted to compare cost-related medication nonadherence among elderly Medicare enrollees with and without cancer and to describe the strategies cancer survivors used to offset the costs of medications. METHODS: Using the 2005 Medicare Current Beneficiary Survey and Medicare claims, we compared self-reported cost-related medication nonadherence (CRN), spending less on basic needs to afford medicines, and cost reduction strategies among elderly beneficiaries with and without cancer. Descriptive statistics and logistic regression models were used to characterize and compare these populations. RESULTS: In a nationally representative sample of 9,818 non-institutionalized elderly Medicare enrollees, 1,392 (14%) were classified as cancer survivors based on Medicare claims. Cancer survivors were older, more highly educated, more likely to be male and non-Hispanic, and more likely to have multiple comorbidities, poorer health status, and employer-paid medication coverage. While 10% of cancer survivors and 11% without cancer reported CRN, about 6% and 9% (p = 0.004) of those with and without cancer, respectively, reported spending less on basic needs to offset the costs of medications. Cancer survivors who reported CRN (n = 143) had lower income (62.2% versus 48.6%, p = 0.11) and were more likely to be African-American (13.0% versus 6.4%, p = 0.033) and have non-employer-based medication insurance (p = 0.002) compared to those who did not report CRN. In adjusted analyses, CRN among the two groups was similar, but with some subgroup differences noted by gender and cancer type. Use of cost reduction strategies was mostly similar among cancer survivors and those without cancer. CONCLUSION: Cost-related medication nonadherence medication is common among elderly Medicare beneficiaries, but appears to be similar among those with and without cancer.

Economic impact of terminal illness and the willingness to change it.

OBJECTIVE: To gather pilot data on the economic impact of terminal illness on families and on the feasibility of training caregivers as a method of stemming illness-related poverty. DESIGN: Exploratory, descriptive study involving semistructured interviews with patient and caregiver dyads. SETTING: Pallium India Palliative Care Clinic in Trivandrum, Kerala, India. PARTICIPANTS: Eleven patient-caregiver dyads (22 individual participants) visiting Pallium India in 2008. METHODS: Trained interviewers conducted face-to-face interviews consisting of 114 questions with the patient and caregiver separately. Questions covered topics of economic impact of illness on household, family, and individual. Questions included if the illness had so impacted families that they needed to sell assets or significantly reduce work and/or schooling. RESULTS: All families reported that patients were obliged to give up work as a result of illness. In seven families, the caregiver also had to change work habits. All respondents stated illness had forced them to sell assets. Ten households reported that their children were obliged to miss school due to the illness. All respondents indicated they would use trained caregivers to help with the care burden if available. Nine respondents thought that use of trained caregivers would have reduced or prevented some of the household's illness-related change. Nine caregivers said they would be interested in becoming a trained caregiver. CONCLUSION: These data indicate that a definitive study would be feasible and would reveal how much assistance caregiver training could lend to household socio-economic resilience.

Latina breast cancer survivors' lived experiences: diagnosis, treatment, and beyond.

Latina breast cancer survivors are not benefiting from advances in psychosocial interventions. Despite their greater breast cancer burden, there is a dearth of information about this population. This qualitative study examined the experiences of 18 immigrant Latina breast cancer survivors along the survivorship continuum, from diagnosis to long-term survivorship. The authors conducted separate focus groups with women in the acute, reentry, and long-term survivorship stages. Through grounded theory analysis, the authors uncovered 5 themes of experience: perceptions of psychological well-being, impact of diagnosis, impact of treatment, need for social support, and development of new attitudes. Some themes were applicable across all survivorship stages, whereas others were more salient at a particular stage. Within themes, the authors identified experiences reported in the general literature (i.e., the debilitating effect of chemotherapy) and distinct cultural experiences (i.e., fear that a cancer diagnosis leads to certain death). Results suggest that treatments tailored for each survivorship stage are more likely to be effective than generic interventions. These findings have the potential to lessen health disparities in utilization of psychosocial treatments by Latina breast cancer survivors.

Depression and cost-related medication nonadherence in Medicare beneficiaries.

CONTEXT: Treatment for depression can be expensive and depression can affect the use of other medical services, yet there is little information on how depression affects the prevalence of cost-related medication nonadherence (CRN) in elderly patients and patients with disabilities. OBJECTIVE: To quantify the presence of CRN in depressed and nondepressed elderly Medicare beneficiaries and nonelderly Medicare beneficiaries with disabilities prior to the implementation of the Medicare Drug Benefit. DESIGN AND SETTING: 2004 Medicare Current Beneficiary Survey. PARTICIPANTS: Depressed and nondepressed elderly Medicare beneficiaries and beneficiaries with disabilities. MAIN OUTCOME MEASURES: Cost-related medication nonadherence included taking smaller doses or skipping doses of a prescription to make it last longer, or failing to fill a prescription because of cost, controlling for health insurance status, comorbid conditions, age, race, sex, and functional status. RESULTS: In a nationally representative sample of 13 835 noninstitutionalized elderly Medicare enrollees and Medicare enrollees with disabilities, 44% of beneficiaries with disabilities and 13% of elderly beneficiaries reported being depressed during the previous year. Among enrollees with disabilities reporting depressive symptoms, 38% experienced CRN compared with 22% of enrollees with disabilities who did not report depressive symptoms. Among elderly enrollees who reported depressive symptoms, 19% experienced CRN, compared with 12% of elderly enrollees who did not report such symptoms. In adjusted analyses, depressive symptoms remained a significant predictor of CRN in both groups (persons with disabilities: odds ratio, 1.7; 95% confidence interval, 1.3-2.3; elderly persons: odds ratio, 1.4; 95% confidence interval, 1.1-1.7). CONCLUSIONS: Depressive symptoms were associated with CRN in elderly Medicare enrollees and Medicare enrollees with disabilities. Providers should elicit information on economic barriers that might interfere with treatment of Medicare beneficiaries with depression.

Indigenous healing practices and self-medication amongst pregnant women in Cape Town, South Africa.

This study was conducted in and around Cape Town, South Africa, at two primary obstetric facilities and in the antenatal clinics of two secondary hospitals. Findings show that majority of the Xhosa speaking women follow indigenous healing practices for both themselves and their babies because of the need to "strengthen" the womb against sorcery, to prevent childhood illnesses, and to treat symptoms they perceive that biomedical services would not be able to treat. Self-medication with non-prescribed drugs, herbs and Dutch remedies was common practice amongst the Afrikaans speaking women for both themselves and their babies. Herbs and Dutch remedies were mainly used to treat indigenous illness (baarwind) while non-prescribed over-the-counter drugs were used to treat minor ailments associated with pregnancy. There is, therefore, an urgent need to bridge the gap between orthodox and indigenous medical systems through reciprocal learning and by acknowledging each other's roles.

Utilization of health care services among adults attending a health fair in South Los Angeles County.

A bilingual survey was developed to collect information regarding socio-demographics, access to medical and dental care, health insurance coverage, perceived health status, and use of folk medicine providers from 70 adults presenting to a health fair in South Los Angeles County. Ninety-seven percent of respondents were foreign-born. Seventy-nine percent reported having no health insurance during the year prior to survey. Of the uninsured, 61 percent lacked a doctor visit and 76 percent lacked a dental visit during the previous year. The high cost of care was the most frequently cited barrier to seeking medical (58 percent) and dental (67 percent) care even when respondents felt it was necessary. Respondents who felt they needed medical attention but did not seek it had a lower perceived health status (7.0 +/- 2.2) than those who did (8.0 +/-2.0). Among respondents perceiving themselves in poor health, only 17 percent were insured. Relatively few respondents (7.2 percent) reported seeing a folk healer during the past year. Our results support the argument that the medically indigent in some localities face serious financial, as well as less salient, barriers to access. These local conditions reflect inadequate enforcement by local governments in correcting the difficult problems indigent populations face in accessing medical and dental care.

Drug compliance among hypertensive patients in Kassala, eastern Sudan.

A cross-sectional study of hypertensive patients was conducted and drug compliance was estimated. Factors associated with compliance, status of blood pressure control and occurrence of complications were assessed. Compliance was 59.6% as measured with the pill count method. We found 92% of compliant patients had controlled blood pressure in comparison with 18% of non-compliant patients, and 30.1% of the compliant patients had complications in comparison with 46.3% of the non-compliant patients. While the compliance rate was reasonable, 36.8% of patients were non-compliant because they could not afford to buy antihypertensive drugs. Inability to buy drugs was negatively and significantly associated with compliance. These patients experienced uncontrolled blood pressure and other complications.

Development of a brief test to measure functional health literacy.

We describe the development of an abbreviated version of the Test of Functional Health Literacy in Adults (TOFHLA) to measure patients' ability to read and understand health-related materials. The TOFHLA was reduced from 17 Numeracy items and 3 prose passages to 4 Numeracy items and 2 prose passages (S-TOFHLA). The maximum time for administration was reduced from 22 minutes to 12. In a group of 211 patients given the S-TOFHLA, Cronbach's alpha was 0.68 for the 4 Numeracy items and 0.97 for the 36 items in the 2 prose passages. The correlation (Spearman) between the S-TOFHLA and the Rapid Estimate of Adult Literacy in Medicine (REALM) was 0.80, although there were important disagreements between the two tests. The S-TOFHLA is a practical measure of functional health literacy with good reliability and validity that can be used by health educators to identify individuals who require special assistance to achieve learning goals.

Whither the almshouse? Overutilization and the role of the emergency department.

The problem of emergency department (ED) overutilization or "inappropriate" utilization is commonly conceptualized in terms of inadequate access to appropriate primary medical care. Although medical care access is a critical issue, a focus on increased access to medical care as the sole solution to "inappropriate" ED utilization may obscure other, perhaps equally relevant, issues from consideration. This article reports findings from an ethnographic study focusing on heavy users (HUs) of EDs in two inner-city hospitals. Drawing on fieldwork and on interviews with HU patients and ED clinicians, I argue that the emergence of heavy ED utilization as both a clinical and policy problem is a function not merely of unmet medical care needs for individuals, but of "almshouse" needs in a changing health care context. The emergence of ED overutilization as a problem occurs in the context of market forces that are contributing to shifts in the role of EDs and in the moral boundaries of accepted ED practice. If the problem of heavy ED use is more broadly conceptualized in terms of this role shift, not solely in terms of medical care access, a different set of issues and priorities for research, policy, and clinical practice emerges.

Living on the edge: dietary strategies of economically impoverished women in Cali, Colombia.

Economically impoverished women in Cali, Colombia, have restricted access to food in a city where food is abundant. Ethnographic observations, interviews and 2 day food records were used to better understand the coping strategies used by a group of these women (n = 85) to maintain adequate levels of energy intake. Anthropometric indicators of nutritional status were normal for the group. Interview data revealed that the ability to purchase food was a concern for 58% of the women. When faced with a restricted ability to purchase food, the women indicated they made compromises in meal composition, reduced portion sizes, and/or reduced the number of meals. They also relied on relatives, friends, neighbors, store credit, or local government programs for access to food. Changes in meal composition were identified in 17.1% of all diet records (n = 509). Low energy intake (defined as energy intake < or = 1.27 x BMR) was identified in 17.1% of all diet records. Carbohydrate consumption was significantly greater on low-energy intake days. The adequate nutritional status of this group of women suggests that their coping strategies are usually adequate to maintain energy intake, but the presence of uncertainty, the frequency of compromises in diet composition, and the frequency of low-energy intake days suggest that these women are at risk for undernutrition.

Health locus of control among HIV-positive indigent women.

The authors explored the multidimensional construct of health locus of control among 14 indigent HIV-positive women who attended one of two southwestern city health clinics. An exploratory survey design was used to compare the mean responses of the subjects on the Multidimensional Health Locus of Control (MHLC) Scales with established normative data. The women believed they had control over their health, yet felt powerful others and chance determine their health outcomes. These findings are drawn from high scores on both the Internal and External MHLC Scales. Findings imply that these women may not view themselves as having any control in the dichotomous world of acute and chronic illness. Authors recommend that nurses should encourage their patients to participate in the management of their health care.

Drug use behavior under the constraints of a Medicaid prescription cap.

Limiting the number of prescriptions reimbursed per month is a cost-containment measure used by state Medicaid programs. The purpose of this study was to identify and examine the strategies used by patients who exceed the limits of the cap. Nineteen patients identified by community pharmacists as meeting this criterion were interviewed in their homes by a member of the project team. The sample consisted predominantly of women. Seven of the 19 individuals reported that they had altered the way they took their medication, primarily by reducing the frequency of dosing, to make the medication last longer. Eight individuals reported that, at some time during the past year, they did not obtain a prescribed medication because of the prescription cap. These medications were prescribed for a variety of conditions, including diabetes, asthma, and congestive heart failure. Patients made the purchase/nonpurchase decision based primarily on importance of the condition for which the medication was prescribed. What was deemed important, however, could change over time as a result of changing symptoms. Patients obtained some help from friends, family, and health care professionals in coping with the constraints of the prescription cap. However, the cap forced a significant group of patients into noncompliance, and thus placed them at risk for poor health outcomes.

Medical students' attitudes toward providing care for the underserved. Are we training socially responsible physicians?

OBJECTIVE: To investigate the association between attitudes toward caring for the medically indigent and years of medical training. DESIGN: Questionnaire comparing attitudes of first-year medical students (MS-Is) and fourth-year medical students (MS-IVs). SETTING: Southwest medical school. PARTICIPANTS: A total of 83 (67%) male and 41 (33%) female MS-I and 65 (73%) male and 24 (27%) female MS-IV volunteers. MAIN OUTCOME MEASURE: Self-report, attitudinal scale developed for this study that provided a measure of overall attitudes, perceived societal expectations, physician/student responsibility, personal efficacy, and provision of basic services and expensive procedures. RESULTS: Overall attitudes were significantly less favorable for MS-IVs (95% confidence interval [CI], 99.6 to 106.2) than MS-Is (95% CI, 109.5 to 114.3, P < .0001). Except for basic services (P = .46), MS-IVs had worse attitudes on all attitudes subscales. Male MS-IVs reported significantly less favorable attitudes than male MS-Is in the areas of general attitudes (P = .03) and physician/student responsibility (P = .01). Female medical students showed no significant differences across classes (P > .05). Except for physician/student responsibility, female medical students' attitudes were more favorable than those of males, regardless of class. CONCLUSIONS: The MS-IVs are less favorably inclined toward caring for the medically indigent than MS-Is, though these differences are apparent only for males. Further research is needed to explore why females appear to be more resistant to attitude changes, and what educational interventions are necessary to better train physicians to respond to national health care issues.

Medically indigent women seeking abortion prior to legalization: New York City, 1969-1970.

If the efforts now underway to limit access to abortion services in the United States are successful, their greatest impact will be on women who lack the funds to obtain abortions elsewhere. There is little published information, however, about the experience of medically indigent women who sought abortions under the old, restrictive state laws. This article details the psychiatric evaluation of 199 women requesting a therapeutic abortion at a large municipal hospital in New York City under a restrictive abortion law. Thirty-nine percent had tried to abort the pregnancy. Fifty-seven percent had concrete evidence of serious psychiatric disorder. Forty-eight percent had been traumatized by severe family disruption, gross emotional deprivation or abuse during childhood. Seventy-nine percent lacked emotional support from the man responsible for the pregnancy, and the majority were experiencing overwhelming stress from the interplay of multiple problems exacerbated by their unwanted pregnancy.

PIP: A series of 199 medically indigent women who applied for therapeutic abortion at Bellview Hospital in New York City from December 1968-April 1970 is discussed by a psychiatric staff member who evaluated the patients as part of their application. At that time, abortion candidates were required to have 2 psychiatrists state that pregnancy was a risk to their life. They ranged from 14-41 years old; 30% were Black, 23% Hispanic; 62% were never-married, 20% were married. 56% had been pregnant before, 8% had prior induced abortions. 15% had infants or twins 1 year old. 22% were on public assistant, 42% had low-paying jobs, 20% were students. 75% successfully obtained hospital abortions. Of the remaining 49, 6 had spontaneous or clandestine abortions, 6 obtained induced abortion illegally, 9 decided to carry their pregnancy to term included 4 who attempted self abortion and 4 who attempted suicide during the pregnancy. 57% showed objective evidence of serious psychiatric disturbance, not including depression, anxiety, or threatened suicide. The 10 who were not recommended for abortion for lack of psychiatric grounds included a mother of a mentally retarded and a brain-damaged child and 5 other children, and a retarded woman abandoned by her husband. The 5 minors who were not approved for lack of parental consent included an 18-year old whose father had attempted to strangle her and whose mother abused her. 3 of these minors obtained abortions illegally. During the application process, which normally took 2 weeks, or after approval, 23 were lost to follow-up. Those lost during the process included 4 with severe psychiatric diagnoses, and 4 who attempted self-abortion. In the group there were 33% who had attempted abortion, 5% whose pregnancy was a result of rape, 11 who abused their children, 7 who did not have custody of their children, and 79 whose relationship with the father was marked by lack of support, abuse, marital conflict, or the partner was dead, ill, or dying. The prevalence of poverty, family pathology, severe stress, and psychopathology was presented in detail. It is likely that the ability to care for children of the index pregnancy in the women for whom abortion was refused was impaired. The author believes that the psychosocial pathology in this population has increased, and that newly enacted restrictions on abortion would be even more stressful for today's indigent women.

Care for the underinsured: who should pay?

Inner-city medically underinsured adults describe their preferences for health care and willingness to pay for health care services. The responses of 146 patients attest to the burden of administrative and economic responsibility placed on the public health care sector for indigent patient care. The results of this survey address the information required by the nurse managers who must balance patient needs against administrative pressures to generate revenue from patient fees.