Shifts in Social Determinants of Vitamin A Supplementation Among Children Under Five in Kenya, 2003-2014.

OBJECTIVES: In Africa and Asia, 190 million preschoolers are vitamin A deficient. This study examined the social determinants of intake of vitamin A supplementation (VAS) among children aged 6-59 months during three different time periods in Kenya to identify those most vulnerable to vitamin A deficiency and highlight the varied targeting and outreach efforts; before the onset of a national restructuring and targeted distribution of VAS in children below 5 years through a twice-yearly door-to-door campaign called Child Health Weeks, during the implementation period, and several years later. METHODS: The cross-sectional, national Demographic and Health Surveys were administered in Kenya in 2003, 2008-09, and 2014. Bivariate and multivariable logistic regression analyses were used to assess variables associated with VAS among children (n = 28,239). RESULTS: An overall two-fold increase in VAS was recorded between 2003 (31.8%) and 2014 (67.5%). In 2008-09, children aged 6-11 months were the most likely to receive VAS. In 2003 and 2014, geographical regions and settings, birth order of the child, educational level of the mother, religion, wealth index, number of antenatal visits, and access to a radio were identified as being significantly associated with VAS, in at least one of the years. These determinants were not significant in 2008-09 during the initial Child Health Weeks promotion campaign. The determinants of VAS varied during the three study periods, particularly in 2008-09 when the Child Health Weeks was first implemented. CONCLUSION: As efforts to increase VAS continue, addressing child-specific determinants will be essential to reduce health disparities.

Physician Trust in the News Media and Attitudes toward COVID-19.

CONTEXT: Previous research has established the importance of primary care physicians in communicating public health directives. The implicit assumption is that, because of their expertise, doctors provide accurate and up-to-date information to their patients independent of partisan affiliation or media trust. METHODS: The authors conducted an online survey of 625 primary care physicians and used the results to test (1) whether physician trust in media outlets is consistent with their political partisanship, and (2) whether trust in media outlets influences (a) personal concern that someone in their family will get sick, (b) perceptions about the seriousness of the pandemic as portrayed in the media, and (c) trust in federal government agencies and scientists. FINDINGS: Physicians are better positioned to critically evaluate health-related news, but they are subject to the same biases that influence public opinion. Physicians' partisan commitments influence media trust, and media trust influences concern that a family member will get sick, perceptions regarding the seriousness of the pandemic, and trust in federal government agencies and scientists. CONCLUSIONS: Physician trust in specific media outlets shapes their understanding of the pandemic, and-to the extent that they trust conservative media outlets-it may limit their effectiveness as health policy messengers.

Predictors of Pediatric Frequent Emergency Department Use Among 7.6 million Pediatric Patients in New York.

OBJECTIVE: This study examines the characteristics and factors associated with frequent emergency department (ED) utilization among the pediatric population. METHODS: We conducted a pooled cross-sectional secondary analysis using the Healthcare Cost and Utilization Project State Emergency and Inpatient Databases on ED visits to all hospitals in New York from 2011 to 2016 by patients aged 0 to 21. We used multivariable logistic and negative binomial regressions to investigate the predictors of multiple ED visits in the pediatric population. RESULTS: Overall, our study included 7.6 million pediatric patients who accounted for more than 12 million ED visits. Of those, 6.2% of patients were frequent ED users (≥4 visits/year), accounting for 20.8% of all ED visits (5.4 ED visits/year on average). The strongest predictors of frequent ED use were having at least one ED visit related to asthma (aOR = 8.37 [95% CI: 6.34-11.04]), mental health disorders (aOR = 9.67 [95% CI: 8.60-10.89]), or multiple comorbidities compared to none. Larger shares of ED visits for not-emergent conditions were also associated with frequent ED use (aOR = 6.63 [95% CI = 5.08-8.65]). Being covered by Medicaid compared to private (aOR = 0.45 [95% CI: 0.42-0.47]) or no insurance (aOR = 0.41 [95% CI: 0.38-0.44]) were further associated with frequent ED use. The results from the negative binomial regression yielded consistent findings. CONCLUSIONS: Pediatric patients who exhibit increased ED use are more medically complex and have increased healthcare needs that are inextricably tied to social determinants of health. Better integrated health systems should emphasize connecting vulnerable patients to appropriate social and primary care services outside of emergency settings.

Community health worker roles and their evolving interprofessional relationships in the United States.

In the United States, growing attention to the cost of care, the social determinants of health, prevention, and population health, signals a refocusing of efforts on value-based care. Just as Accountable Care Organizations and alternative payment models exemplify this shift in attention, so does the increasing integration of Community Health Workers (CHWs) into the US health care system. CHWs are often referred to as "bridge figures," helping clients to navigate what are oftentimes complicated pathways to access a variety of needed services. The integration of CHWs into interprofessional care teams is a process that takes time, and can lead to conflict as traditional care models are disrupted. Through focus groups with CHWs in rural and urban areas of four states, this work identifies and describes three early stages in the evolving interprofessional relationships between CHWs and other care providers. These stages are characterized by: (1) a lack of knowledge and understanding of CHW roles, (2) conflict and competition, and (3) engagement and integration of CHWs into patient care teams. A better understanding of the evolving process of CHW integration is critical to facilitate education and training that will more quickly encourage the development and efficacy of modern models of interprofessional care that include CHWs.

Determinants of HIV Testing Uptake among Women (aged 15-49 years) in the Philippines, Myanmar, and Cambodia.

BACKGROUND: Many countries have been trying to eliminate Mother-to-Child transmission of the Human Immunodeficiency Virus (HIV) and achieve the 90-90-90 target goals. The targets mean that 90% of People Living with HIV (PLWHIV) know their HIV status, 90% of those who are infected receive Antiretroviral treatment (ART), and 90% of those achieve viral suppression. Despite some progress, the goals have not been met in the Philippines, Myanmar, and Cambodia, countries with relatively high or growing HIV prevalence. This study identifies the sociodemographic determinants of testing among women in these countries so that better health education and stigma reduction strategies can be developed. METHODS: Descriptive and multivariable analyses were conducted using Demographic and Health Survey data conducted in the Philippines (2017), Myanmar (2015/2016), and Cambodia (2014). The outcome variable was having ever been tested for HIV. Independent variables included knowledge and attitudes about HIV and social determinants of health. RESULTS: A significant difference in testing rates among women was observed (the Philippines: 5%, Myanmar: 19%, Cambodia: 42%). In Myanmar and Cambodia, women who had more HIV knowledge and less stigma towards PLWHIV were more likely to get tested for HIV than those who did not. Marital status, education, wealth were strong predictors for HIV testing among women. Younger women aged 15-19 and those who live in the rural areas were less likely to get HIV tested than older and those living in urban areas. Employed women were less likely to seek an HIV test than the unemployed in Myanmar and Cambodia, whereas, in the Philippines, the opposite relationship was found. CONCLUSION AND GLOBAL HEALTH IMPLICATIONS: Women with less education and those less familiar with HIV should be targeted for HIV testing interventions. Stigma reduction and different testing strategies could facilitate early screening leading to improved HIV testing among women.

Examining social determinants of undiagnosed diabetes in Namibia and South Africa using a behavioral model of health services use.

AIMS: To examine factors associated with undiagnosed diabetes in Namibia and South Africa. METHODS: This study used the most recent Demographic and Health Surveys (DHS) from Namibia (2013) and South Africa (2016). This study focused on adults at 35-64 years old. Using Andersen's Behavioral Model, potential contributing factors were categorized into predisposing factors (sex and education), enabling factors (wealth, health insurance, and residence), and a need factor (age, BMI, and high blood pressure). Separate multivariable logistic regression models were used to examine factors associated with undiagnosed diabetes in Namibia (N = 242) and South Africa (N = 525). RESULTS: In Namibia, higher odds of having undiagnosed diabetes were associated with rural residence (adjusted odds ratio (aOR) = 2.21) and age younger than 45 years old (aOR = 3.20). In South Africa, odds of having undiagnosed diabetes were higher among the poorest-to-poorer group than it was in the richer-to-richest group (aOR = 2.33). In both countries, having high blood pressure was associated with lower odds of having undiagnosed diabetes (aOR = 0.31 in Namibia; aOR = 0.21 in South Africa). DISCUSSION: Different enabling and need factors were associated with undiagnosed diabetes in these two countries, which implies potentially-different mechanisms driving the high prevalence of undiagnosed diabetes, as well as the needs for different solutions.

Frequent emergency department use in the paediatric population: A systematic literature review.

OBJECTIVE: We systematically reviewed the literature on paediatric frequent emergency department (ED) users to identify and to synthesize characteristics and factors associated with frequent ED utilization among this population in the United States. METHODS: We searched Medline (Ovid), CINAHL (Ebsco), and Embase (Ovid) to identify all relevant studies after 1990. We focused on US studies analysing paediatric frequent ED (PFED) users excluding those focused on specific subgroups. Two reviewers independently selected articles and extracted data on predisposing, enabling, behavioural, need and reinforcing factors. RESULTS: Fifteen studies met the inclusion criteria. PFED users comprised 3% to 14% of all paediatric ED users and accounted for 9% to 42% of all paediatric ED visits in 11 studies that defined frequent use as four to six ED visits per year. Most PFED users were less than 5 years old who had public insurance coverage and a regular provider. Public insurance compared to private residency in disadvantaged areas, having at least one chronic or complex condition and a history of hospitalization, were associated with frequent use. Children who had a regular primary care provider were less likely to exhibit frequent ED use. CONCLUSIONS: Minimizing unnecessary ED visits by frequent utilizers is a quality improvement and cost-saving priority for health systems. Our findings indicate that many PFED users have greater healthcare needs and face barriers accessing care in a timely manner, even though some have regular providers. To better address the needs of this vulnerable group, health systems should focus on educating caregivers and expanding access to providers in other settings.

Household motor vehicle ownership and obesity among Indian females and males: 2005-2016.

BACKGROUND: To determine associations between household motor vehicle ownership and obesity among Indian adults. METHODS: Bivariate and multivariable analyses were conducted using the 2005-2006 and 2015-2016 Indian Demographic and Health surveys, with over 800 000 respondents. RESULTS: Obesity prevalence (body mass index ≥25 kg/m2) rose in females (16.87% to 20.35%) and in males (12.55% to 18.74%). In 2005, having both types of vehicles (motorcycle/motor scooter and car) significantly increased the odds of obesity in females (OR, 1.63; 95% CI 1.50 to 1.76) and males (OR, 2.49; 95% CI 2.24 to 2.77) as well as in 2015 (OR, 1.10; 95% CI 1.07 to 1.13 and OR, 1.56; 95% CI 1.45 to 1.68, respectively). The wealthiest were more likely to be obese in 2005 (OR, 14.95; 95% CI 16.06 to 17.12 for females; OR, 12.69; 95% CI 10.17 to 15.70 for males) and in 2015 (OR, 7.69; 95% CI 7.43 to 7.95 for females and OR, 6.40; 95% CI 5.40 to 7.01 for males). Higher education levels, being younger and rural residence were significant protective factors in 2005 and 2015. CONCLUSIONS: After adjusting for confounders, motor vehicle ownership was significantly associated with obesity at both time points, but the effect of vehicle ownership presents differently by gender. With obesity prevalence increasing in India, policies promoting active vs motorized transport could attenuate this problem.

Violence against healthcare workers and other serious responses to medical disputes in China: surveys of patients at 12 public hospitals.

BACKGROUND: Workplace violence against healthcare workers is a global issue that is on the rise, with Chinese healthcare workers facing growing challenges with hospital violence. Attacks on medical staff have increased in recent years with no clear resolution. Prior research focused on policies to improve the doctor-patient relationship and better protect clinicians, but few studies addressed the patient perspective. This paper examines patients' choices when facing a medical dispute and identifies groups who are more likely to respond to conflict with violence or other serious actions. METHODS: Patient survey responses were collected in 12 leading public hospitals in five Chinese provinces with 5556 participants. The survey asked sociodemographic information, patients' attitudes (e.g., general optimism, trust in their physicians, perceived healthcare quality), and their primary response to a medical dispute. From least to most severe, the options range from "complaining within the family" to "violence." We used t-tests and Chi-square tests to explore the relationships between reactions and patient characteristics. We also performed multivariable logistic regressions to determine the impact of sociodemographics and provider trust on the seriousness of responses. RESULTS: The primary response of a third of respondents was complaining to hospital or health department officials (32.5%). Seeking legal help (26.3%) and direct negotiation with doctors (19.6%) were other frequent responses. More serious responses included 83 stating violence (1.5%), 9.7% expressing a desire to expose the issue to the news media, and 7.4% resorting to seeking third-party assistance. Patients who were more likely to report "violence" were male (OR = 1.81, p < .05), high-income earners (OR = 3.71, p < .05), or reported lower life satisfaction (OR = 1.40, p < .05). Higher trust scores were associated with a lower likelihood of a serious response, including violence (OR = 0.80, p < .01). CONCLUSION: Most respondents reported mild reactions when facing a medical dispute. Among those who reported the intent of serious reactions, some sociodemographic characteristics and the trust of physicians could be predictive. To prevent future hospital violence, this work helps identify the characteristics of patients who are more likely to seek severe approaches to medical dispute resolution, including resorting to violence. From these results, hospitals will be better able to target specific groups for interventions that build patient-provider trust and improve general patient satisfaction.

Predictors of Multiple Emergency Department Utilization Among Frequent Emergency Department Users in 3 States.

BACKGROUND: Research on frequent emergency department (ED) use shows that a subgroup of patients visits multiple EDs. This study characterizes these individuals. OBJECTIVE: The objective of this study was to determine how many frequent ED users seek care at multiple EDs and to identify sociodemographic, clinical, and contextual factors associated with such behavior. RESEARCH DESIGN: We used the 2011-2014 Healthcare Cost and Utilization Project State Emergency Department Databases data on all outpatient ED visits in New York, Massachusetts, and Florida. We studied all adult ED users with ≥5 visits in a year and defined multisite use as visits to ≥3 different sites. We estimated predictors of multisite use with multivariate logistic regressions. RESULTS: Across all 3 states, 1,033,626 frequent users accounted for 7,613,077 ED visits. Of frequent users, 25% were multisite users, accounting for 30% of the visits studied. Frequent users with at least 1 visit for mental health or substance use-related diagnosis were more likely to use multiple sites. Uninsured frequent users and those with public insurance were associated with less use of multiple EDs than those with private coverage while lacking consistent coverage by the same insurance within each year were associated with using multiple sites. CONCLUSIONS: Health policy interventions to reduce duplicative or unnecessary ED use should apply a population health perspective and engage multiple hospitals. Community-level preventive approaches and a stronger infrastructure for mental health and substance use are essential to mitigate multisite ED use.

Immigrant health access in Texas: policy, rhetoric, and fear in the Trump era.

BACKGROUND: Since the 2016 presidential election, reports have suggested that President Trump's rhetoric and his administration's proposed policies could be exacerbating barriers to accessing health care for undocumented as well as lawfully present immigrants and their families in the United States. However, very little empirical work has analyzed this possibility or detailed how these reports and rhetoric have altered the health seeking behavior of mixed immigration status families. METHODS: Using a series of focus groups throughout Texas in both English and Spanish, this qualitative study analyzes changes to health access for immigrants. We consulted Community Health Workers to better understand the barriers encountered by their otherwise hard-to-reach undocumented clients and their families as they interface with the health system, revealing key insights about the changing nature of barriers to access under the Trump administration. RESULTS: We identify four key themes about the changing nature of immigrant health access in the United States: growing fear of interacting with health and social services; that social networks are paradoxically limiting health access in the current political climate; that the administration's rhetoric and proposed policies are impeding health seeking behavior; and that children are encountering new barriers to social program participation. CONCLUSIONS: The Trump administration, its proposed immigration policies, and his rhetoric are posing new and significant barriers to health access for immigrants and their families.

Factors Influencing Trust towards Physicians among Patients from 12 Hospitals in China.

Objective We investigated the level of physician trust in China and how it is influenced by various demographic factors. MethodsWe surveyed 12 public hospitals from which inpatients were randomly selected using hospitalization ID and outpatients were selected using census sampling to participate in the interview. Trust in physicians was measured using the Chinese version of Wake Forest Physician Trust Scale. Mixed-effects and logistic models were employed to study correlates of trust. ResultsThe distribution of scale mean was left skewed, which implied a subpopulation bearing low levels of trust towards physicians. Respondents who were male, young, outpatients, unsatisfied with their life status, had high levels of education and income, and paid less attention to their health were prone to be less satisfied with their physicians. ConclusionsThe level of physician trust in China is lower compared to studies in western countries. We also found demographic factors related with significantly lower physician trust, which may help policymakers identify potential target subpopulations and be more specific with their efforts to improve patient-physician relationships.

Effect of the treatment-before-deposit policy on trust in physicians and perceived service quality among patients in 12 hospitals in China.

This study examined effects of the treatment-before-deposit policy on Chinese patients' trust in physicians and perceived service quality. This study included 3313 patients recruited from 12 hospitals in China. The research team used cross-sectional survey to examine Chinese patients' experience with the treatment-before-deposit policy, perceived service quality, and trust in their physicians. Using mediation analysis, we estimated direct and indirect effects of the treatment-before-deposit policy on patients' perceived service quality and trust in their physicians. Patients who benefitted from the treatment-before-deposit policy reported greater service quality and higher trust in their physicians. The impacts of whether patients benefitted from the policy on trust in physicians were fully mediated by perceived service quality with statistically significant indirect effect. The results support the hypothesis that the treatment-before-deposit policy improves patients' perceived service quality and trust in physicians.