Factors Associated with Access to Care and Healthcare Utilization in the Homeless Population of England

BACKGROUND:

People experiencing homelessness are known to have complex health needs, which are often compounded by poor access to healthcare. This study investigates the individual-level factors associated with access to care and healthcare utilization among homeless people in England.

METHODS:

A cross-sectional sample of 2505 homeless people from 19 areas of England was used to investigate associations with access to care and healthcare utilization.

RESULTS:

Rough sleepers were much less likely to be registered with a general practitioner (GP) (odds ratio (OR) 0.45, 95% confidence interval (CI) 0.30-0.66) than single homeless in accommodation (reference group) or the hidden homeless (OR 1.48, 95% CI 0.88-2.50). Those who had recently been refused registration by a GP or dentist also had lower odds of being admitted to hospital (OR 0.67, 95% CI 0.49-0.91) or using an ambulance (OR 0.73, 95% CI 0.54-0.99).

CONCLUSIONS:

The most vulnerable homeless people face the greatest barriers to utilizing healthcare. Rough sleepers have particularly low rates of GP registration and this appears to have a knock-on effect on admission to hospital. Improving primary care access for the homeless population could ensure that some of the most vulnerable people in society are able to access vital hospital services which they are currently missing out on.

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By:  Elwell-Sutton T1, Fok J2, Albanese F3, Mathie H3, Holland R1.

• 1Norwich Medical School, University of East Anglia, Norwich, UK.
• 2Department of Public Health, Essex County Council, Chelmsford, UK.
• 3Homeless Link, London, UK. 
• J Public Health (Oxf). 2016 Feb 18. pii: fdw008.

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Decentralizing Access to Antiretroviral Therapy for Children Living with HIV in Swaziland

BACKGROUND:

In 2007, Swaziland initiated a hub-and-spoke model for decentralizing antiretroviral therapy (ART) access for HIV-infected children (<15 years old). Decentralization was facilitated through: (1) down-referral of stable children on ART from overburdened central facilities (hubs) to primary healthcare clinics (spokes), and (2) pediatric ART initiation at spokes (spoke-initiation).

METHODS:

We conducted a nationally representative retrospective cohort study among children starting ART during 2004-2010 to assess effect of down-referral and spoke-initiation on rates of loss to follow-up (LTFU), death, and attrition (death or LTFU). Twelve of 28 pediatric ART hubs were randomly selected using probability-proportional-to-size sampling. Seven selected facilities had initiated hub-and-spoke decentralization by study start; at these facilities, 901 of 1,893 hub-initiated and maintained (hub-maintained) children, and 495 of 1,105 down-referred or spoke-initiated children were randomly selected for record abstraction. At the five hub-only facilities, 612 of 1,987 children were randomly selected. Multivariable proportional hazards regression was used to estimate adjusted hazards ratios (AHR) for effect of down-referral (a time-varying covariate) and spoke-initiation on outcomes.

RESULTS:

Among 2,008 children at ART initiation, median age was 5.0 years, median CD4 percentage 12.0%, median CD4 count 358 cells/µL, and median weight-for-age z-score -1.91. Controlling for known confounders, down-referral was strongly protective against LTFU (AHR 0.40; 95% CI, 0.20-0.79) and attrition (AHR 0.46; 95% CI, 0.26-0.83) but not mortality. Compared with hub-only children or hub-maintained children, spoke-initiated children had similar outcomes.

CONCLUSIONS:

Decentralization of pediatric ART through down-referral and spoke-initiation within a hub-and-spoke system should be continued and might improve program outcomes.

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By:  Auld AF1, Nuwagaba-Biribonwoha H, Azih C, Kamiru H, Baughman AL, Agolory S, Abrams E, Ellerbrock TV, Okello V, Bicego G, Ehrenkranz P.

• 1 Division of Global HIV/AIDS, Centers for Disease Control and Prevention, Atlanta, U.S.A 
• 2 ICAP, Columbia University, Mailman School of Public Health, New York, U.S.A 
• 3 Ministry of Health, Government of the Kingdom of Swaziland, Mbabane, Swaziland 
• 4 Division of Global HIV/AIDS, Centers for Disease Control and Prevention, Mbabane, Swaziland. 
• Pediatr Infect Dis J. 2016 Feb 4

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HIV Stigma, Testing Attitudes and Health Care Access among African-Born Men Living in the United States

The purpose of this study was to describe HIV-testing attitudes, HIV related stigma and health care access in African-born men taking part in the African Health Cup (AHC), a soccer tournament held annually to improve HIV awareness and testing. 

Venue sampling was used to collect survey and qualitative interview data related to HIV-testing attitudes, stigma and experiences associated with the AHC. The sample included 135 survey respondents and 27 interview participants. 

AHC participants were successfully accessing health care services. Although the AHC was viewed positively, HIV testing rates remain low due to stigma and privacy concerns. This population continues to have misconceptions about HIV transmission and to use condoms inconsistently. 

The AHC is a successful intervention to engage African-born men in HIV awareness and education. More work is needed to enhance these AHC aspects and address stigma and privacy concerns related to using onsite health screenings. 

Continuing to develop novel strategies to educate African-born immigrants about HIV is urgently needed.

Purchase full article at:   http://goo.gl/Il9X4Q

By:  Bova C1, Nnaji C2, Woyah A2, Duah A3.

• 1Graduate School of Nursing (http://www.umassmed.edu/gsn/), University of Massachusetts Worcester, 55 Lake Avenue North, Worcester, MA, 01655, USA. carol.bova@umassmed.edu.
• 2Africans for Improved Access Program, Multicultural AIDS Coalition, Jamaica Plain, MA, USA.
• 3Graduate School of Nursing, University of Massachusetts Worcester, 55 Lake Avenue North, Worcester, MA, 01655, USA. 
• J Immigr Minor Health. 2016 Feb;18(1):187-93. doi: 10.1007/s10903-014-0136-2

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Do Performance & Image Enhancing Drug Users in Regional Queensland Experience Difficulty Accessing Health Services?

INTRODUCTION AND AIM:

To understand health service access and needs of people who use performance and image enhancing drugs (PIED) in regional Queensland.

DESIGN AND METHODS:

Semi-structured interviews were conducted with 21 people (n = 19 men) who reported the use of a range of PIEDs, including anabolic-androgenic steroids, human chorionic gonadotropin, growth hormone, clenbuterol, tamoxifen, insulin and peptides.

RESULTS:

Participants reported accessing a range of services, including needle and syringe programs and pharmacies, for sterile injecting equipment. While PIEDs users attributed some stigma to needle and syringe programs, they were seen as an important service for injecting equipment. Participants reported receiving either positive care from health-care providers, such as general practitioners (GP), or having negative experiences due to the stigma attached with PIED use. Few participants reported disclosing their PIED use to their GP not only because of the concerns that their GP would no longer see them but also because they felt their GP was not knowledgeable about these substances.

DISCUSSION AND CONCLUSION:

Participants in the study reported no difficulty in accessing health services based on living in a regional area, with their concern focused more upon how they were viewed and treated by service staff. 

Purchase full article at:   http://goo.gl/HUYSii

By:   Dunn M1,2, Henshaw R3, McKay FH1.

• 1School of Health and Social Development, Faculty of Health, Deakin University, Victoria, Australia.
• 2National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia.
• 3Queensland Health, Brisbane, Australia. 

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Restricted Access to Antiretroviral Treatment for Undocumented Migrants: A Bottle Neck to Control the HIV Epidemic in the EU/EEA

Background

In the European Union/European Economic Area (EU/EEA), migrants from high-endemic countries are disproportionately affected by HIV. Between 2007 and 2012, migrants represented 39 % of reported HIV cases. There is growing evidence that a significant proportion of HIV acquisition among migrant populations occurs after their arrival in Europe.

Discussion

Migrants are confronted with multiple risk factors that shape patterns of population HIV susceptibility and vulnerability, which simultaneously affect HIV transmission. Undocumented migrants incur additional risks for contracting HIV due to limited access to adequate health care services, protection and justice, alongside insecure housing and employment conditions.

All EU/EEA countries have ratified a number of international and regional human rights instruments that enshrine access to health care as a human right that should be available to everyone without discrimination.

From a clinical and public health perspective, early HIV care and treatment is associated with viral suppression, improved health outcomes and reductions in transmission risks. A current challenge of the HIV epidemic is to reach the highest proportion of overall viral suppression among people living with HIV in order to impact on HIV transmission.

Although the majority of EU/EEA countries regard migrants as an important sub-population for their national responses to HIV, and despite the overwhelming evidence of the individual and public health benefits associated with HIV care and treatment, a significant number of EU/EEA countries do not provide antiretroviral treatment to undocumented migrants.

Summary

HIV transmission dynamics in migrant populations depend on the respective weight of all risk and vulnerability factors to which they are exposed, which act together in a synergistic way. People who are not linked to HIV care will continue to unwillingly contribute to the on-going transmission of HIV. Following the recommendations of the European Union Agency for Fundamental Rights, ensuring access to HIV-care for all sub-populations, including undocumented migrants, would fulfil the human rights of those populations and also strengthen the control of HIV incidence among those not currently able to access HIV care.

Below:  Availability of ART for undocumented migrants in the EU/EEA as reported in March 2014 at the occasion of the monitoring of the Dublin Declaration implementation. Source: European Centre for Disease Prevention and Control. Thematic report: Migrants. Monitoring implementation of the Dublin Declaration on Partnership to Fight HIV/AIDS in Europe and Central Asia: 2014 progress report. Stockholm: ECDC; 2015

Full article at: http://goo.gl/qWj5ku

By:   Jessika Deblonde^1*, André Sasse¹, Julia Del Amo², Fiona Burns³⁴, Valerie Delpech⁵,Susan Cowan⁶, Michele Levoy⁷, Lilana Keith⁷, Anastasia Pharris⁸, Andrew Amato-Gauci⁹and Teymur Noori⁸

¹Scientific Institute of Public Health, Epidemiology of Infectious Diseases, Juliette Wytsmanstraat 14, Brussels, 1050, Belgium

²Institute of Health Carlos III, National Center for Epidemiology, C/Sinesio Delgado 6, Madrid, 28029, Spain

³University College London, Research Department of Infection & Population Health, London WC1E 6JB, UK

⁴Royal Free London NHS Foundation Trust, Pond Street, London NW3 2QG, UK

⁵Public Health England, PHIV & STI Department, 61 Colindale Avenue, London NW9 5EQ, UK

⁶Statens Serum Institut, Department of Infectious Medicine Epidemiology, Artillerivej 5, Copenhagen S, 2300, Denmark

⁷PICUM- Platform for International Cooperation on Undocumented Migrants, Rue du Congrès 37-41 / 5, Brussels 1000, Belgium

⁸European Centre for Disease Prevention and Control, Surveillance and Response Support Unit, Tomtebodavagen 11A, Stockholm, 171 83, Sweden

⁹European Centre for Disease Prevention and Control, Office of the Chief Scientist, Tomtebodavagen 11A, Stockholm, 171 83, Sweden

 

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We Mapped the Uninsured, You'll Notice a Pattern

Via:  http://ht.ly/UZkKw  By: https://twitter.com/nytimes

Equity in Access to Health Care among Asylum Seekers in Germany: Evidence from an Exploratory Population-Based Cross-Sectional Study

Research on inequities in access to health care among asylum-seekers has focused on disparities between asylum-seekers and resident populations, but little attention has been paid to potential inequities in access to care within the group of asylum-seekers. We aimed to analyse the principles of horizontal equity (i.e., equal access for equal need irrespective of socioeconomic status, SES) and vertical equity (higher allocation of resources to those with higher need) among asylum-seekers in Germany.

We performed a secondary exploratory analysis on cross-sectional data obtained from a population-based questionnaire survey among all asylum-seekers (aged 18 or above) registered in three administrative districts in Germany during the three-month study period (N = 1017). Data were collected on health care access (health care utilisation of four types of services and unmet medical need), health care need (approximated by sex, age and self-rated health status), and SES (highest educational attainment and subjective social status, SSS). We calculated odds ratios and 95 % confidence intervals (CI) in multiple logistic regression models to analyse associations between SES indicators and access to health care under control of need.

We contacted 60.4 % (614) of the total asylum-seekers population, of which 25.4 % (N = 156) participated in the study. Educational attainment showed no significant effect on health care access in crude models, but was positively associated with utilisation of psychotherapists and hospital admissions in adjusted models. Higher SSS was positively associated with health care utilisation of all types of services. The odds of hospitals admissions for asylum-seekers in the medium and highest SSS category were 3.18 times [1.06, 9.59] and 1.6 times [0.49, 5.23] the odds of those in the lowest SSS category. After controlling for need variables none of the SES indicators were significantly associated with measures of access to care, but a positive association remained, indicating higher utilisation of health care among asylum-seekers with higher SES. Age, sex or general health status were the only significant predictors of health care utilisation in fully adjusted models. The adjusted odds of reporting unmet medical needs among asylum-seekers with “fair/bad/very bad” health status were 2.16 times [0.84, 5.59] the odds of those with “good/very good” health status.

Our findings revealed that utilisation of health services among asylum-seekers is associated with higher need (vertical equity met). Horizontal equity was met with respect to educational attainment for most outcomes, but a social gradient in health care utilisation was observed across SSS. Further confirmatory research is needed, especially on potential inequities in unmet medical need and on measurements of SES among asylum-seekers.

Full article at:  http://goo.gl/CE12dv

By:  Kayvan Bozorgmehr^1*, Christine Schneider¹² and Stefanie Joos²

¹Department of General Practice & Health Services Research, University Hospital Heidelberg, Voßstr.2, Geb. 37, Heidelberg, 69115, Germany

²Institute of General Practice and Interprofessional Care, University of Tuebingen, Tuebingen, Germany

 

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