Angela Wangari Walter

Methamphetamine Use and Dental Problems Among Adults Enrolled in a Program to Increase Access to Oral Health Services for People Living with HIV/AIDS

Objective. We examined the association between methamphetamine (meth) use and dental problems in a large sample of HIV-positive adults. Methods. We gathered data from 2,178 interviews across 14 sites of the U.S. Health Resources and Services Administration HIV/AIDS Bureaus Special Projects of National Significance Innovations in Oral Health Care Initiative from May 2007 to August 2010. We used multivariate generalized estimating equations to test the association between meth use and dental problems, adjusting for potential confounders. Results. Past and current meth use was significantly associated with more dental problems. The study also found that poor self-reported mental health status, fewer years since testing positive for HIV, a history of forgoing dental care, less frequent teeth brushing, poor self-reported oral health status, oral pain, grinding or clenching teeth, some alcohol use, more years of education, and self-reported men-who-have-sex-with-men HIV risk exposure (compared with other exposure routes) were significantly associated with dental problems. Conclusion. Individuals who are HIV-positive with a history of meth use experience access barriers to oral health care and more dental problems. Our study demonstrated that it is possible to recruit this population into dental care. Findings suggest that predisposing, enabling, and need factors can serve as demographic, clinical, and behavioral markers for recruiting people living with HIV/AIDS into oral health programs that can mitigate dental problems.

Leadership Matters: How Hidden Biases Perpetuate Institutional Racism in Organizations

ABSTRACT Leadership sets the tone in organizations. Even with a positive view on race by leaders, powerful hidden biases and blind spots continue to persist among professionals and their organizations. Few models for organizational change are geared towards addressing institutional racism. Interpersonal and institutional cultural responsiveness can improve community engagement, work place culture, and strengthen organizations. Using the social work profession as an exemplar, this paper describes barriers to organizational and institutional change. The roles of organizational leadership and culture are discussed. Recommendations for addressing and establishing organizational change consistent with the values of inclusion and cultural diversity are provided.

Retention of People Living with HIV/AIDS in Oral Health Care

Objective. We identified factors associated with retention in oral health care for people living with HIV/AIDS (PLWHA) and the impact of care retention on oral health-related outcomes. Methods. We collected interview, laboratory value, clinic visit, and service utilization data from 1,237 HIV-positive patients entering dental care from May 2007 to August 2009, with at least an 18-month observation period. Retention in care was defined as two or more dental visits at least 12 months apart. We conducted multivariate regression using generalized estimating equations to explore factors associated with retention in care. Results. In multivariate analysis, patients who received oral health education were 5.91 times as likely (95% confidence interval 3.73, 9.39) as those who did not receive this education to be retained in oral health care. Other factors associated with care retention included older age, taking antiretroviral medications, better physical health status, and having had a dental visit in the past two years. Patients retained in care were more likely to complete their treatment plans and attend a recall visit. Those retained in care experienced fewer oral health symptoms and less pain, and better overall health of teeth and gums. Conclusions. Retention in oral health care was associated with positive oral health outcomes for this sample of PLWHA. The strongest predictor of retention was the receipt of oral health education, suggesting that training in oral health education is an important factor when considering competencies for new dental professionals, and that patient education is central to the development of dental homes, which are designed to engage and retain people in oral health care over the long term.

Access to oral health care and self-reported health status among low-income adults living with HIV/AIDS.

Objective. We identified factors associated with improved self-reported health status in a sample of people living with HIV/AIDS (PLWHA) following enrollment in oral health care. Methods. Data were collected from 1,499 enrollees in the Health Resources and Services Administration HIV/AIDS Bureaus Special Projects of National Significance Innovations in Oral Health Care Initiative. Data were gathered from 2007–2010 through in-person interviews at 14 sites; self-reported health status was measured using the SF-8™ Health Surveys physical and mental health summary scores. Utilization records of oral health-care services provided to enrollees were also obtained. Data were analyzed using general estimating equation linear regression. Results. Between baseline and follow-up, we found that physical health status improved marginally while mental health status improved to a greater degree. For change in physical health status, a decrease in oral health problems and lack of health insurance were significantly associated with improved health status. Improved mental health status was associated with a decrease in oral health problems at the last available visit and no pain or distress in ones teeth or gums at the last available visit. Conclusion. For low-income PLWHA, engagement in a program to increase access to oral health care was associated with improvement in overall well-being as measured by change in the SF-8 Health Survey. These results contribute to the knowledge base about using the SF-8 to assess the impact of clinical interventions. For public health practitioners working with PLWHA, findings suggest that access to oral health care can help promote well-being for this vulnerable population.

Implications of Medicaid coverage in a program for Latino substance users.

BACKGROUND This cross-sectional study explored baseline differences between Medicaid covered and uninsured clients (n=368) in the Project La Voz, a community outreach program targeting Latino substance users. METHODS Independent variables included client demographics, health status and health service use; the dependent variable was Medicaid coverage vs. uninsured. Bi-variate analyses and three binomial logistic regression models were conducted. RESULTS The first logistic regression model examining client characteristics indicated that La Voz enrollees with Medicaid coverage were more likely to be women, reside in stable housing, and report poor health status. Employment and educational status were not significantly associated with having Medicaid. A second model, examining the association between health care utilization in the past 30 days and Medicaid coverage, indicated that LaVoz enrollees with Medicaid were significantly more likely to have entered substance use treatment. In the third model, client characteristics and health care use were examined in one model; all variables remained significant except for gender. IMPLICATIONS FOR PROGRAM PLANNING: Massachusetts recent health care reform efforts include substance abuse treatment benefits through Medicaid. Specific strategies are needed to ensure that Latinos substance abusers, particularly those who are homeless, gain Medicaid coverage and then have access to needed services.

Mental Health Services Utilization and Expenditures Among Children Enrolled in Employer-Sponsored Health Plans

BACKGROUND AND OBJECTIVES: Mental illness in children increases the risk of developing mental health disorders in adulthood, and reduces physical and emotional well-being across the life course. The Mental Health Parity and Addiction Equity Act (MHPAEA, 2008) aimed to improve access to mental health treatment by requiring employer-sponsored health plans to include insurance coverage for behavioral health services. METHODS: Investigators used IBM Watson/Truven Analytics MarketScan claims data (2007–2013) to examine: (1) the distribution of mental illness; (2) trends in utilization and out-of-pocket expenditures; and (3) the overall effect of the MHPAEA on mental health services utilization and out-of-pocket expenditures among privately-insured children aged 3 to 17 with mental health disorders. Multivariate Poisson regression and linear regression modeling techniques were used. RESULTS: Mental health services use for outpatient behavioral health therapy (BHT) was higher in the years after the implementation of the MHPAEA (2010–2013). Specifically, before the MHPAEA implementation, the annual total visits for BHT provided by mental health physicians were 17.1% lower and 2.5% lower for BHT by mental health professionals, compared to years when MHPAEA was in effect. Children covered by consumer-driven and high-deductible plans had significantly higher out-of-pocket expenditures for BHT compared to those enrolled PPOs. CONCLUSIONS: Our findings demonstrate increased mental health services use and higher out-of-pocket costs per outpatient visit after implementation of the MHPAEA. As consumer-driven and high-deductible health plans continue to grow, enrollees need to be cognizant of the impact of health insurance benefit designs on health services offered in these plans.

Facilitators and barriers to family engagement and retention of young children in mental health care: A qualitative study of caregivers’ perspectives

ABSTRACT This study examines facilitators and barriers that influence family engagement and retention of children in mental healthcare from the parent and caregiver perspective. Researchers recruited and interviewed parents and caregivers (n=18) from urban community health and early childcare centers. The study team analyzed the data and identified barriers to retention in care, including stigma, lack of integrated health care services,and a shortage of providers with the expertise in early childhood mental health care. Social workers, case managers, parent peers, and community support groups helped facilitate parent and caregiver engagement and retention of children in care. Education,community support programs, and integrated healthcare systems would improve access to quality early childhood mental health care.

Access to care among children with disabilities enrolled in the MassHealth CommonHealth Buy-In program:

Children with disabilities utilize more health-care services and incur higher costs than other children do. Medicaid Buy-In programs for children with disabilities have the potential to increase access to benefits while reducing out-of-pocket costs for families whose income exceeds Medicaid eligibility. This study sought to understand how parents and caregivers of Massachusetts children with disabilities perceive access to care under CommonHealth, Massachusetts’s Medicaid Buy-In program. Parents and caregivers (n = 615) whose children were enrolled in CommonHealth participated in a survey assessing the impact of the program. Qualitative data were coded across five access domains—availability, accessibility, accommodation, affordability, and acceptability. Data suggest that CommonHealth improves access to care for children with disabilities by providing the benefits that were limited in scope or unavailable through other insurance before enrollment and by making available services more affordable. Policy and administrative changes could improve the program and further increase access to care for children with complex, costly conditions. Adopting a Medicaid Buy-In program may be an effective way for states to create a pathway to Medicaid for children with disabilities whose family income is too high for Medicaid and who have unmet needs and/or whose families incur high out-of-pocket costs for their care.

Preventing Opioid Use Disorders among Fishing Industry Workers

Fishing industry workers are at high risk for work-related musculoskeletal disorders (MSDs) and injuries. Prescription opioids used to treat pain injuries may put these workers at increased risk for developing substance disorders. Using a Community-Based Participatory Research approach, formative research was conducted to inform the eventual development of relevant interventions to prevent and reduce opioid use disorders among fishing industry workers. Qualitative interviews (n = 21) were conducted to assess: knowledge and attitudes about opioid use disorders; features of fishing work that might affect use and/or access to treatment; and community and organizational capacity for prevention and treatment. Participants reported numerous pathways connecting commercial fishing with opioid use. The combination of high stress and physically tasking job duties requires comprehensive workplace interventions to prevent chronic pain and MSDs, in addition to tailored and culturally responsive treatment options to address opioid use disorders in this population. Public health programs must integrate workplace health and safety protection along with evidence-based primary, secondary, and tertiary interventions in order to address opioid use disorders, particularly among workers in strenuous jobs.

Are decreases in drug use risk associated with reductions in HIV sex risk behaviors among adults in an urban hospital primary care setting

Drug use is associated with increased sexual risk behaviors. We examined whether decreases in drug use risk are associated with reduction in HIV-related sex risk behaviors among adults. Data was from a cohort of participants (n = 574) identified by drug use screening in a randomized trial of brief intervention for drug use in an urban primary care setting. Inverse probability of treatment weighted (IPTW) logistic regression models were used to examine the relationship between decreases in drug use risk and sex-related HIV risk behavior reduction from study entry to six months. Weights were derived from propensity score modeling of decreases in drug use risk as a function of potential confounders. Thirty seven percent of the study participants (213/574) reported a decrease in drug use risk, and 7% (33/505) reported decreased sex-related HIV risk behavior at the six-month follow-up point. We did not detect a difference in reduction of risky sexual behaviors for those who decreased drug use risk (unadjusted: OR 1.32, 95% CI 0.65–2.70; adjusted OR [AOR] 1.12, 95% CI 0.54–2.36). Adults who screened positive for high drug use risk had greater odds of reducing sex risk behavior in unadjusted analyses OR 3.71, 95% CI 1.81–7.60; but the results were not significant after adjusting for confounding AOR 2.50, 95% CI 0.85–7.30). In this primary care population, reductions in HIV sex risk behaviors have complex etiologies and reductions in drug use risk do not appear to be an independent predictor of them.