Rural-urban differences in health care unaffordability.

PURPOSE: To compare health care unaffordability in rural versus urban contexts while also examining the impact of sociodemographic/socioeconomic variables on this relationship. METHODS: We examined survey responses from the 2019-2021 National Health Interview Survey (n = 90,761). We conducted chi-squared tests comparing urban and rural subsamples and multivariable logistic regression analyses examining the associations between rurality and 3 measures of health care unaffordability while also including interactions between rurality and individual characteristics of respondents. FINDINGS: In bivariate analyses, compared to their urban counterparts, rural residents were more likely to report problems paying medical bills (15.0% vs 11.5%, P <.001) and being unable to pay medical bills (9.3% vs 7.1%, P < .001). In fully adjusted multivariable regression analyses, rural residents were significantly less likely than their urban counterparts to report being worried about paying medical bills (AOR: .915, CI: .871-.961, P < .001). We found significant interactions between rural residency and insurance type, age, income to poverty ratio, and race/ethnicity for the outcome of problems paying medical bills; and significant interactions between rural residency and income to poverty ratio and race and ethnicity for the outcome of being unable to pay medical bills. CONCLUSION: Rural residents report higher rates of 2 measures of health care unaffordability as compared to their urban counterparts. In multivariable logistic models, rural residency is not associated with higher rates of health care unaffordability; however, significant interactions exist between rural residency and individual variables demonstrating the heterogenous experiences of health care unaffordability based on these intersectional identities.

Rural-Urban Differences in Health Care Unaffordability During the Postpartum Period.

OBJECTIVE: The objective of this study was to examine health care unaffordability for rural and urban residents and by postpartum status. METHODS: We used cross-sectional survey data on female-identifying respondents ages 18-44 (n=17,800) from the 2019 to 2021 National Health Interview Study. Outcomes of interest were 3 measures of health care unaffordability. We conducted bivariate and multivariable regression models to assess the association between health care unaffordability, rurality, and postpartum status. RESULTS: Bivariate analyses showed postpartum people reported statistically significantly higher rates of being unable to pay medical bills and having problems medical paying bills, as compared with nonpostpartum people. Rural residents also reported statistically significantly higher rates of being unable to pay their medical bills and having problems paying medical bills as compared with urban residents. In adjusted models, the predicted probability of being unable to pay medical bills among postpartum respondents was 12.8% (CI, 10.1-15.5), which was statistically significantly higher than among nonpostpartum respondents. Similarly, postpartum respondents had statistically significantly higher predicted probabilities of reporting problems paying medical bills (18.4%, CI, 15.4-21.4) as compared with nonpostpartum respondents. The rural residency was not significantly associated with the health care unaffordability outcome measures in adjusted models. CONCLUSIONS: Both postpartum and rural respondents reported higher rates of being unable to pay medical bills and having problems paying medical bills; however, after adjusting for covariates, only postpartum respondents reported statistically significantly higher rates of these outcomes. These results suggest that postpartum status may present challenges to health care affordability that span the urban/rural context.

The role of prior trauma exposure and subsequent posttraumatic stress disorder in reactions to the COVID-19 pandemic: A qualitative study.

OBJECTIVE: A growing body of literature suggests that the COVID-19 pandemic is a traumatic stressor capable of causing posttraumatic stress symptoms. People with a history of trauma, particularly those with posttraumatic stress disorder (PTSD), may be particularly vulnerable to the negative mental health impacts of the pandemic. However, qualitative research exploring potential differences in the lived experiences of and reactions to COVID-19 between people with and without PTSD is lacking. METHOD: Semistructured interviews were conducted with 31 women (n = 15 women with probable PTSD, n = 16 women without probable PTSD) recruited from an ongoing U.S.-based cohort study. Themes were identified using inductive thematic analysis. RESULTS: The majority of women with PTSD described their level of fear or perceived safety related to COVID-19 as a major factor influencing their mental health during the pandemic. In contrast, women without PTSD indicated that their level of distress was largely driven by pandemic-related restrictions on normal activities and family events. Many women with PTSD also described feeling anger or frustration toward people they perceived as not taking the COVID-19 pandemic seriously. Only one participant without PTSD expressed similar feelings. CONCLUSIONS: This study found notable differences in reactions to the COVID-19 pandemic between people with and without PTSD, with findings that are likely relevant to future disasters. These findings can inform the development of preparedness policies for future disasters, pandemics, or other collective traumas to prevent distress and improve mental health, particularly for vulnerable populations such as individuals with preexisting PTSD. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Guidelines for assessment and intervention with persons with disabilities: An executive summary.

This article provides an executive summary of the American Psychological Association's (APA's) revised Guidelines for Assessment and Intervention With Persons With Disabilities. The revision was requested by the Committee on Disability Issues in Psychology and was approved by the APA Council of Representatives in February 2022. The task force updated and expanded the guidelines' empirical bases; squarely situated the guidelines in a changing sociocultural landscape (reflected in discussions of disability models, biases and barriers, language use, intersectionality, and respectful and fair assessment and intervention); and added many concrete suggestions for conceptualizing disability and working with disabled clients and their support systems. In this executive summary, we include key points from each of the 23 guidelines. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Associations of abuse and neglect with young adult health in a population-based longitudinal cohort: Findings from Project EAT.

Childhood maltreatment (abuse and neglect) is associated with a range of negative outcomes, but a gap remains in understanding of how specific maltreatment types, particularly neglect and non-familial sexual abuse, relate to health and behavior. This study examined the association of neglect and sexual abuse (both familial and non-familial), as well as familial physical and emotional abuse, with: depressive mood and eating disorders; tobacco and marijuana use; and BMI ≥ 25 kg/m2 and BMI ≥ 30 kg/m2 in young adults. Data came from Project EAT (Eating and Activity in Teens and Young Adults), a population-based longitudinal study of weight-related health from adolescence into young adulthood. Maltreatment before age 18 was retrospectively reported at ages 26-33. Risk differences (RDs) and 95% confidence intervals (CIs) were estimated for those with a given maltreatment type to those without, and also for the cumulative number of maltreatment types experienced. One in 3 participants reported abuse or neglect. All maltreatment types were associated with at least one adverse health outcome, with physical abuse being least consistently related to the outcomes. Emotional abuse showed the strongest association with depressive mood. All maltreatment types were associated with eating disorder diagnosis, tobacco use, and marijuana use (except physical abuse for eating disorder). There was little evidence of a maltreatment association with BMI ≥ 25 kg/m2; emotional abuse and neglect were associated with BMI ≥ 30 kg/m2. Prevention of maltreatment needs to be a top public health priority.

Applied ethics: Have we lost a crucial opportunity?

Comments on the article, "Guidelines for competency development and measurement in rehabilitation psychology postdoctoral training," by Stiers et al. (see record 2014-55195-001). A review of the recent publication of Stiers et al., a well-organized distillation of the functional competencies required of practitioners of Rehabilitation Psychology that evolved from the Baltimore Consensus Conference (Stiers et al., 2012), revealed a potentially important omission in the section labeled Structured Observations of Competencies in Assessment and Intervention (Table 4, p. 117). Throughout the subsections regarding Knowledge, Skills/Abilities, and Attitudes/ Values, indirect reference to the American Psychological Association (APA) Ethical Principles of Psychologists and Code of Conduct (APA, 2010) is evident without formal citation of the Code. The concepts operationalized in the APA ethical principles suffuse the content of this section of the competencies, but without direct reference to those principles. The remainder of the tables (5-7, pp. 188 -120) include explicit inclusion of knowledge of ethics in the contexts of demonstrating competencies in consultation, research and evaluation, teaching and supervision, and management and administration.

Guidelines for postdoctoral training in rehabilitation psychology.

OBJECTIVE: This article describes the methods and results of a national conference that was held to (1) develop consensus guidelines about the structure and process of rehabilitation psychology postdoctoral training programs and (2) create a Council of Rehabilitation Psychology Postdoctoral Training Programs to promote training programs' abilities to implement the guidelines and to formally recognize programs in compliance with the guidelines. METHODS: Forty-six conference participants were chosen to include important stakeholders in rehabilitation psychology, representatives of rehabilitation psychology training and practice communities, representatives of psychology accreditation and certification bodies, and persons involved in medical education practice and research. RESULTS: Consensus guidelines were developed for rehabilitation psychology postdoctoral training program structure and process and for establishing the Council of Rehabilitation Psychology Postdoctoral Training Programs. DISCUSSION: The Conference developed aspirational guidelines for postdoctoral education and training programs in applied rehabilitation psychology and established a Council of Rehabilitation Psychology Postdoctoral Training Programs as a means of promoting their adoption by training programs. These efforts are designed to promote quality, consistency, and excellence in the education and training of rehabilitation psychology practitioners and to promote competence in their practice. It is hoped that these efforts will stimulate discussion, assist in the development of improved teaching and evaluation methods, lead to interesting research questions, and generally facilitate the continued systematic development of the profession of rehabilitation psychology.

The APA Ethical Principles as a foundational competency: application to rehabilitation psychology.

OVERVIEW: Competence is a core component of ethical conduct as reflected in its addition as an ethical standard in the 2002 APA Ethics Code. Successfully operationalizing and assessing competence provides psychologists a means to improve education and training, advance the field of practice, and create a framework for accountability to the public. Much of the recent competency discussion has been in response to a proposed Cube Model, with its three axes being foundational competencies (practice building blocks, such as scientific knowledge, ethical standards), functional competencies (attributes of providing services, such as assessment, intervention), and developmental progression (acquiring increasing competence over the course of one's education and career). Ethics is included on the foundational competency axis and has been operationalized to the extent that subcomponents and benchmarks have been promulgated. The competency model as proposed faces multiple challenges, including gaining consensus regarding its components, addressing reliable and valid assessment over time, and creating a culture of acceptance. We propose the Ethical Principles as an alternative framework for conceptualizing ethics as a foundational competency given the Ethics Code is already time tested and includes a serial review process for broad discipline input and adaptability. We apply the Ethical Principles as foundational components to rehabilitation psychology training at internship, postdoctoral, and specialty levels to illustrate the model. CONCLUSION: Rehabilitation psychology should engage in the competency movement at the predoctoral and postdoctoral level. The application of the Ethical Principles as a foundational competency to rehabilitation psychology represents a first step in this dialog.

The safety of multiple re-excisions after lumpectomy for breast cancer.

BACKGROUND: Breast cancer patients may undergo multiple re-excisions after lumpectomy in an attempt to obtain clear margins and avoid mastectomy. We sought to determine the overall local recurrence rate and surgical outcome of patients undergoing two or more re-excisions and to identify predictors of success in attaining clear margins. METHODS: Retrospective review of breast cancer patients who underwent lumpectomy for invasive cancer or ductal carcinoma in situ (DCIS) from 1997 to 2007. Patients who underwent two or more re-excisions were identified and analyzed. RESULTS: We identified 3,737 patients who underwent lumpectomy over this 10-year period. 875 (23.4%) had close or positive margins requiring a second procedure; 797 (91.1%) had a re-excision; and 78 (8.9%) went directly to mastectomy. Seventy patients underwent multiple re-excisions; 66 patients had 2 re-excisions, 3 patients had 3 re-excisions, and 1 patient had 4 re-excisions. 70% (49/70) of multiple re-excision patients achieved clear margins (26 DCIS, 35 T1, 8 T2, and 1 T3 tumors). All 49 patients who successfully treated with multiple re-excisions received radiation. At a median follow-up of 64 months, 1 of 49 (2.0%) patients had an in-breast recurrence, and 1 of 49 (2.0%) patients had a distant recurrence. Statistically significant risk factors for persistently involved margins after two re-excisions included multifocality and positive lymph node status. CONCLUSION: Multiple re-excisions to obtain clear margins are a safe alternative to mastectomy for women with invasive cancer or DCIS. There is an acceptably low risk of local and systemic failure when negative margins are ultimately achieved.