Lu Ann Aday

Access to medical care in the U.S.: realized and potential.

This paper seeks to provide a framework for understanding differential access to medical care in the U.S. population and to suggest ways to achieve equity of access. The framework is provided by a behavioral model of health services utilization which suggests a sequence of predisposing, enabling and illness variables that determine the number of times people will visit a physician. The model is operationalized using a path analytic technique. The data come from a national survey of the noninstitutionalized U.S. population conducted in late 1975 and early 1976. The results suggest services are generally equitably distributed since age and level of illness are the main determinants of the number of services people receive. However, remaining inequities might be reduced by providing people who report no regular source of medical care with a familiar entry into the health service system.

Equity of Access to Medical Care: A Conceptual and Empirical Overview

This paper summarizes the major ethical considerations in the conceptualization and measurement of the equity of access concept, presents national and community data on the most current profile of access in the United States, and discusses the implications of these conceptual and empirical issues. Changes in health care policy and the future of the “equity of access” objective in the U.S. are also discussed.

Impact of pain on self-rated health in the community-dwelling older adults.

&NA; This study examined the impact of pain on self‐rated health status in the community‐dwelling older adults using the 1993 public release data of the Asset and Health Dynamics Among the Oldest Old (AHEAD). AHEAD is a population‐based household survey designed to examine the dynamic interactions between health, family, and economic variables among US older adults. Results showed that 33% of the older adults reported frequent pain and 20% reported significant pain resulting in activity limitation. Controlling for clinical health status, socio‐demographic characteristics, and access to medical care, logistic regression analyses showed that those who often have pain were more than twice as likely (odds ratio (OR)=2.63; confidence interval (CI)=2.35, 2.95; P=<0.0001) to perceive their health status to be ‘poor’. Other predictors (P<0.01) include functional impairment (OR=2.78), chronic diseases (OR=1.89), minority status (OR=1.88), education (OR=1.77), and physician visits (OR=1.64). This study documents the adverse impact of pain on self‐rated health as well as the fact that the experience of pain and poor subjective health and well‐being is greatest among the most socially disadvantaged older adults (minorities and those with the least education). The findings suggest that treating and controlling pain may significantly enhance the subjective health and well‐being of community‐dwelling older adults.

Stress and Coping in African American Grandparents Who Are Raising Their Grandchildren

This study investigated the degree of stress in 50 African American grandparents (M = 63.12 years) who are raising their grandchildren and identified the importance of caregiver characteristics, the caregiving situation, and specific coping strategies that influence stress. Data were collected via interview at senior centers and churches in Harris County, Texas. The instruments used to measure stress and coping were the Parenting Stress Index and the Ways of Coping Questionnaire. Of grandparents, 94% reported a clinically significant level of stress. Use of professional counseling, special school programs, and length of caregiving longer than 5 years were associated with less stress. Coping strategies significantly correlated with less stress included accepting responsibility, confrontive coping, self-control, positive reappraisal, planful problem solving, and distancing. This study adds to the limited information about custodial grandparents and suggests counseling, support groups, and education to help them manage stress associated with their caregiving situation more effectively.

Economic and noneconomic barriers to the use of needed medical services.

This paper introduces an index of access to medical care that describes the use of services relative to the actual need for care. Findings on this particular measure suggest that, contrary to the implications of much of the existing literature, the poor continue to use fewer services–relative to the disability they experience–than do the nonpoor. Further, despite the advent of publicly financed economic solutions to these access differentials–Medicaid and Medicare, in particular–organizational barriers to entry, such as the long queues to obtain service and long travel times to care in some areas, still exist. The implications of these findings for the evaluation of existing and proposed national health policy efforts are discussed.

Health Insurance and Utilization of Medical Care for Children with Special Health Care Needs

Based on analyses of the 1988 National Center for Health Statistics, National Health Interview Survey, Child Health Supplement, this study examines the insurance coverage and utilization of physicians, hospitals, and prescribed medicine among the 9.6 million U.S. children with special health care needs, defined as children who had one or more selected chronic conditions that caused them to experience pain, discomfort, or being upset often or all of the time in the last year, or who were limited in their major childhood activities (playing or going to school) as a result of these or other impairments or health problems. The findings confirmed that substantial variation in access to routine medical care exists among these children. Though health status is an important predictor of which children use services in general, poor, minority children who lived with their mother or someone other than their parents, or those without insurance or an identifiable regular medical provider were most likely to experience financial barriers to access or were less apt to seek care than other children with comparable needs. Access to routine medical care remains particularly problematic for these subsets of children with special health care needs.

Mail Versus Internet Surveys Determinants of Method of Response Preferences Among Health Professionals

The authors evaluated determinants of response to Internet-based surveys in a sample (n = 5600) of Texas healthcare professionals. Participants were given the option of responding by mail or over the Web (response, 66%). Internet respondents were younger (p < .001), had worked fewer years in healthcare (p < .001), and were more likely to be male (p < .001) and to work in a hospital (p = .007). Missing questionnaire items were significantly higher among Web responders with regard to age, sex, race, body mass index, and smoking (p < .001). In the final multivariate logistic regression, only male gender (odds ratio [OR] = 2.09, 95% CI = 1.56-2.80) and younger age remained significantly associated with response over the Internet. Age quartile and responding electronically were inversely associated. Taken together with a priori knowledge of the demographic and professional profile of a study population, these findings can be useful in planning and implementation of surveys among healthcare workers.

Safety climate and its association with injuries and safety practices in public hospitals in Costa Rica

Abstract In response to growing concern for occupational health and safety in the public hospital system in Costa Rica, a cross sectional survey of 1,000 hospital-based health care workers was conducted in 1997 to collect baseline data that are being used to develop worker training programs in occupational health in Costa Rica. The objectives of this survey were to: 1) describe the safety climate within the national hospital system, 2) identify factors associated with safety, and 3) evaluate the relationship between safety climate and workplace injuries and safety practices of employees. The safety climate was found to be very poor. The two most significant predictors of safety climate were training and administrative support for safety. Safety climate was a statistically significant predictor of workplace injuries and safety practices, respectively, and there was an underreporting rate of 71% of workplace injuries. These findings underscore the need for improvement of the safety climate in the public hospital system in Costa Rica.

Ethnicity and adolescent depression: the case of Chinese Americans.

This paper is concerned with whether an instrument developed in the U.S. may identify lower rates of major depression among Chinese, because its content may not cover culture-specific symptoms of depression. Data were obtained from approximately 952 Anglo and Chinese American middle school students, aged 10 to 17 years, in the Teen Life Changes Survey conducted in the spring of 1994. We investigated the hypothesis that rates of missing values would be higher, the mean score for total depression items would be lower, and internal consistency reliability and construct validity of the DSM Scale for Depression (DSD) would be lower for Chinese American adolescents compared with Anglo American adolescents. We also examined whether response functions on the DSD item would differ for these two groups. Only the latter was observed. Five of 26 items in the DSD exhibited differential functioning between Anglo and Chinese students. The results suggest that the lower prevalence of depression was not due to the ethnocentric character of the instrument in the Chinese sample. Stronger immunity to depression or other cultural factors may contribute to the lower rate of depression for the Chinese American adolescents in the Teen Life Changes study.

Measuring health state preferences for hemophilia: development of a disease-specific utility instrument

Summary.  Generic and disease‐specific instruments have been used to assess health‐related quality of life (HRQoL) in hemophilia. However, HRQoL measures also need to reflect patient preferences for various hemophilia health states. The goal of this project was to develop a disease‐specific utility instrument that measures patient preferences for various health states unique to hemophilia. The visual analog scale (VAS) and the standard gamble (SG) methods were used. Study participants (n = 128) were tested and stratified into paediatric and adult groups. Test–retest reliability was demonstrated for both instruments, with r = 0.91 for the VAS and r = 0.79 for the SG. When comparing results by age group, statistically significant differences were observed between paediatric and adult participants with the SG instrument (P = 0.045), with older participants taking more risk overall. However, no significant differences based on age were seen when using the VAS (P = 0.636). Statistically significant differences were observed between the VAS and SG instruments within both the paediatric and adult groups (P < 0.0001). In general, the SG yielded higher preference scores than the VAS for the majority of health states. Results derived from the SG instrument indicate that age can influence patients’ preferences regarding their state of health. This can have implications for considering treatment options based on the mean age of the population under consideration. Both instruments demonstrated reliability and validity indicating that they could be used to assess patient preferences in hemophilia. However, preference score differences indicate that the two measures may not be interchangeable.