Pamela L. Davidson

Access to Medical Care for Low-Income Persons: How do Communities Make a Difference?

This paper considers the impact of community-level variables over and above the effects of individual characteristics on healthcare acess for low-income children and adults residing in large metropolitan statistical areas (MSAs). Further, we rank MSAs’ performance in promoting healthcare access for their low-income populations. The individual-level data come from the 1995 and 1996 National Health Interview Survey (NHIS). The community-level variables are derived from multiple public-use data sources. The out-come variable is whether low-income individuals received a physician visit in the past twelve months. The proportion receiving a visit by MSA varied from 63% to 99% for children and from 62% to 83% for adults. Access was better for individuals with health insurance and a regular source of care and for those living in communities with more federally-funded health centers. Children residing in MSA

A framework for evaluating safety-net and other community-level factors on access for low-income populations.

The framework presented in this article extends the Andersen behavioral model of health services utilization research to examine the effects of contextual determinants of access. A conceptual framework is suggested for selecting and constructing contextual (or community-level) variables representing the social, economic, structural, and public policy environment that influence low-income peoples use of medical care. Contextual variables capture the characteristics of the population that disproportionately relies on the health care safety net, the public policy support for low-income and safety-net populations, and the structure of the health care market and safety-net services within that market. Until recently, the literature in this area has been largely qualitative and descriptive and few multivariate studies comprehensively investigated the contextual determinants of access. The comprehensive and systematic approach suggested by the framework will enable researchers to strengthen the external validity of results by accounting for the influence of a consistent set of contextual factors across locations and populations. A subsequent article in this issue of Inquiry applies the framework to examine access to ambulatory care for low-income adults, both insured and uninsured.

Determinants of Dental Care Utilization for Diverse Ethnic and Age Groups

Dental services utilization in the past 12 months was compared across population-based samples of African-American, Navajo, Lakota, Hispanic, and White adults participating in the WHO International Collaborative Study of Oral Health Outcomes (ICS-II) at USA research locations. Bivariate results revealed that ethnic minority groups in both age cohorts reported significantly fewer dental visits in the past 12 months compared with White adults. When dentate status was controlled for, age cohort differences were not significant in Baltimore (African-American and White) and San Antonio (Hispanic and White) research locations. In contrast, older Native Americans (65-74 years) reported visiting the dentist significantly less often compared with their middle-aged (35-44 years) counterparts. Multivariate results indicated that generalizable variables were associated with dental contact in every ICS-II USA ethnic group (i.e., dentate, usual source of dental care, oral pain). Among the diverse ethnic groups, other determinants presented a varied pattern of risk factors for underutilizing dental care. Information on ethnic-specific risk factors can be used to design culturally appropriate and acceptable oral health promotion programs. Generalizable risk factors across ethnic groups inform oral health policy-makers about changing national priorities for promoting oral health.

Toward an understanding of competency identification and assessment in health care management.

Given the revolutionary changes occurring in the health care industry, there is increasing agreement that academicians and practitioners must collaborate to identify and prioritize major educational outcomes for health care management. Several competency initiatives have been undertaken or completed in health care and health care management in the last 5 to 7 years. Health care leaders who have undertaken such endeavors reveal that the task is most formidable. This article provides: (1) a summary of progress in competency identification for health management, (2) an historical overview on competency-based education and assessment, (3) a glossary of terms used in discussions on competency-based education and training, and (4) an outline of the challenges and benefits associated with competency modeling.

Oral Health Beliefs in Diverse Populations

Using data from population-based samples of adults participating in the ICS-II USA study, and using principal components analysis, we constructed oral health belief measures corresponding to the Health Belief Model (HBM) dimensions. Tests of validity and reliability were performed. Scales measuring perceived benefit of preventive practices and seriousness of oral disease had the highest validity and reliability. We used multiple regression analysis to examine sociodemographic predictors of perceived benefits of preventive practices. Race-ethnicity and age cohort were significant predictors among Baltimore and San Antonio adults. White adults and middle-aged persons in both research locations were more likely to believe in the benefit of preventive practices. Female gender, higher educational attainment, and better self-rated health were significant indicators of more positive oral health beliefs in every research location. Results also characterize persons who place lower value on preventive practices (i.e., males, less-educated persons, and those reporting poorer self-rated health). The design of effective dental public health messages and outreach efforts requires an analysis of the individuals health orientation and the factors influencing oral health beliefs. Oral health education interventions designed to improve health beliefs should contain an evaluation component for assessing the impact of education on health practices and oral health status.

Socio-Behavioral Determinants of Oral Hygiene Practices Among USA Ethnic and Age Groups

In this study, socio-behavioral determinants of oral hygiene practices were examined across several dentate ethnic and age groups. Oral hygiene scale scores were constructed from toothbrushing and dental floss frequencies self-reported by population-based samples of middle-aged (35-44 years) and older (65-74 years) dentate adults representing Baltimore African-American and White, San Antonio Hispanic and non-Hispanic White, and Navajo and Lakota Native American persons participating in the WHO International Collaborative Study of Oral Health Outcomes (ICS-II) survey. Female gender, education, certain oral health beliefs, household income, and the presence of a usual source of care were revealed with multivariate analysis to show a significant positive relationship with higher oral hygiene scale scores (indicating better personal oral hygiene practices). Other socio-behavioral variables exhibited a more varied, ethnic-specific pattern of association with oral hygiene scale scores.

Symbiotic relationships of quality of life, health services research and other health research

Clinical biomedical research, the traditional research orientation of quality of life (QOL) researchers, is chiefly concerned with disease processes and assessing the impact of therapeutic interventions on improving health status and QOL outcomes. This paper suggests, however, that the biomedical paradigm limits utility of QOL research findings in terms of its ability to shape health policy and improve health-related QOL in populations at risk. This paper proposes that health services research (HSR) and other health research paradigms can be used to assess QOL from multiple perspectives. HSR and QOL research can be mutually beneficial. The models for understanding health services utilized in HSR may assist in defining major determinants of QOL and the interaction of QOL with its environment. Conversely, QOL measures may be used to establish the relevance of HSR to peoples well-being. The paper first defines the domain of HSR and the domain of quality of life. In order to understand their relationship, we consider what a model or paradigm for each might be, and how they would overlap. Finally, a merging of conceptual frameworks is proposed, linking QOL research to HSR and other health research. Ultimately, expanding the QOL paradigm beyond the biomedical model will promote two objectives. First, it will permit research findings to contribute more fully to shaping national health policy by considering the broader community and the delivery system factors which influence QOL. Second, researchers will be more aware of a broader range of factors affecting patients and will incorporate this in their research.

Role of community risk factors and resources on breast carcinoma stage at diagnosis

The current study investigated the individual and community determinants of breast carcinoma stage at diagnosis (BCSAD) using multiple data sources merged with cancer registry data. The literature review yielded 5 studies that analyzed cancer registry data merged with community‐level variables (1995–2004).

Effects of Community Factors on Access to Ambulatory Care for Lower-Income Adults in Large Urban Communities:

This study examines the effects of community-level and individual-level factors on access to ambulatory care for lower-income adults in 54 urban metropolitan statistical areas in the United States. Drawing on a conceptual behavioral and structural framework of access, the authors developed multivariate models for insured and uninsured lower-income adults to assess the adjusted effects of community- and individual-level factors on two indicators of access: having a usual source of care, and having at least one physician visit in the past year. Several community factors influenced access, but they did so differently for insured and uninsured adults and for the two measures of access used. The findings of this study confirm that public policies and community environment have measurable and substantial impacts on access to care, and that expanded public resources, such as Medicaid payments and safety-net clinics, can lead to measurable improvements in access for vulnerable populations residing in large urban areas.

Evaluating the Effect of Usual Source of Dental Care on Access to Dental Services: Comparisons among Diverse Populations

Data collected from the International Collaborative Study of Oral Health Outcomes USA (ICS-II) research locations were used to evaluate the relationship between having a usual source of dental care (USDC) and access to dental services. The robustness of the USDC effect after reducing simultaneity bias was tested in the population-based samples using sensitivity analysis. Logistic regression results provided evidence that USDC was the strongest and most consistent predictor of a dental visit in the past 12 months regardless of geographic location, dental care delivery system, or cultural diversity of the population. Even after removing cases that had a USDC for less than 1 or 2 years, the effect remained. From a policy perspective, USDC remains critical to understanding and explaining dental care utilization patterns. The findings suggest the need for designing interventions to increase the availability of a regular provider among vulnerable populations.