"I probably have access, but I can't afford it": expanding definitions of affordability in access to contraceptive services among people with low income in Georgia, USA.

BACKGROUND: Disparities in rates of contraceptive use are frequently attributed to unequal access to and affordability of care. There is a need to better understand whether common definitions of affordability that solely relate to cost or to insurance status capture the reality of individuals' lived experiences. We sought to better understand how individuals with low incomes and the capacity for pregnancy conceptualized one domain of contraceptive access-affordability --in terms of health system and individual access and how both shaped contraceptive care-seeking in the US South. METHOD: Between January 2019 to February 2020, we conducted twenty-five life-history interviews with low-income individuals who may become pregnant living in suburban counties in Georgia, USA. Interviews covered the ways individual and health system access factors influenced care-seeking for family planning over the life course. Interview transcripts were analyzed using a thematic analysis approach to identify experiences associated with individual and health system access. RESULTS: Affordability was identified as a major determinant of access, one tied to unique combinations of individual factors (e.g., financial status) and health system characteristics (e.g., cost of methods) that fluctuated over time. Navigating the process to attain affordable care was unpredictable and had important implications for care-seeking. A "poor fit" between individual and health system factors could lead to inequities in access and gaps in, or non-use of contraception. Participants also reported high levels of shame and stigma associated with being uninsured or on publicly funded insurance. CONCLUSIONS: Affordability is one domain of contraceptive access that is shaped by the interplay between individual factors and health system characteristics as well as by larger structural factors such as health and economic policies that influence both. Assessments of the affordability of contraceptive care must account for the dynamic interplay among multilevel influences. Despite the expansion of contraceptive coverage through the Affordable Care Act, low-income individuals still struggle with affordability and disparities persist.

Addressing the Community Resource and Social Service Needs of Families During the COVID-19 Pandemic: Perspectives of Home Visiting Staff and Clients in Georgia.

INTRODUCTION: Home visiting programs provide support services to families and their children to promote positive health outcomes. This study sought to describe strategies employed by home visiting programs during the early phase of the COVID-19 pandemic to address the community resource and social service needs of home visiting clients in Georgia. METHODS: We conducted a mixed methods study between December 2020 and April 2021 using online surveys and key informant interviews of home visiting staff and clients from 21 program sites. Structured content analysis was conducted of the triangulated data to elicit thematic findings. RESULTS: Due to the pandemic-induced economic conditions, clients expressed increased demand for housing, employment, and childcare support services. Staff experienced challenges with client referrals to these services because of interruptions in social service availability and transitions to virtual services. In response to these challenges, home visiting programs strengthened existing community partnerships and created new collaborations with local agencies to fill any gaps in services. DISCUSSION: Home visiting programs in Georgia provided critical linkages to community resources for families during the early phase of the pandemic. Preserving this essential home visiting service in future national emergencies will require improved coordination of community resources and social services.

Maternal health equity in Georgia: a Delphi consensus approach to definition and research priorities.

BACKGROUND: Pregnancy-related mortality in the United States is the greatest among all high-income countries, and Georgia has one of the highest maternal mortality rates-almost twice the national rate. Furthermore, inequities exist in rates of pregnancy-related deaths. In Georgia, non-Hispanic Black women are nearly 3 times more likely to die from pregnancy-related complications than non-Hispanic White women. Unlike health equity, a clear definition of maternal health equity is lacking, overall and in Georgia specifically, but is needed to reach consensus and align stakeholders for action. Therefore, we used a modified Delphi method to define maternal health equity in Georgia and to determine research priorities based on gaps in understanding of maternal health in Georgia. METHODS: Thirteen expert members of the Georgia Maternal Health Research for Action Steering Committee (GMHRA-SC) participated in an iterative, consensus-driven, modified Delphi study comprised of 3 rounds of anonymous surveys. In round 1 (web-based survey), experts generated open-ended concepts of maternal health equity and listed research priorities. In rounds 2 (web-based meeting) and 3 (web-based survey), the definition and research priorities suggested during round 1 were categorized into concepts for ranking based on relevance, importance, and feasibility. Final concepts were subjected to a conventional content analysis to identify general themes. RESULTS: The consensus definition of maternal health equity created after undergoing the Delphi method is: maternal health equity is the ultimate goal and ongoing process of ensuring optimal perinatal experiences and outcomes for everyone as the result of practices and policies free of interpersonal or structural bias that tackle current and historical injustices, including social, structural, and political determinants of health impacting the perinatal period and life course. This definition highlights addressing the current and historical injustices manifested in the social determinants of health, and the structural and political structures that impact the perinatal experience. CONCLUSION: The maternal health equity definition and identified research priorities will guide the GMHRA-SC and the broader maternal health community for research, practice, and advocacy in Georgia.

Implementation of Title X Family Planning Services in Primary Care: A Qualitative Study of a Primary Care Network in Georgia.

CONTEXT: There is increasing interest and value in integrating family planning services into primary care. Title X services provide an opportunity to expand low-cost access to these services. This study sought to identify and describe implementation factors that influenced the integration of a package of Title X services into a unique primary care setting within a Georgia primary care network whose community health center sites are primarily federally qualified health centers. METHODS: We used an implementation science approach and were guided by the Consolidated Framework for Implementation Research. From December 2019 to September 2020, we conducted interviews with administrators and providers working at grantee and sub-grantee organizations about their experiences integrating Title X services into their existing practice. RESULTS: Factors associated with the Inner Setting were especially important for integrating Title X in these settings. Participants identified specific needs related to resources such as electronic medical record (EMR) and reporting templates. Contextually specific clinical training for provision of long-acting reversible contraception and sexual health counseling, as well as administrative training for reporting and documentation efforts, was particularly needed. Grantee and sub-grantee organizations were able to leverage internal and external networks and adaptations to the intervention to successfully implement Title X services and to expand reach to new clients. CONCLUSIONS: Integrating family planning into primary care may expand access to low-income and underserved populations. Approaches that incorporate flexibility and provide tailored resources for primary care settings such as EMR and reporting templates and trainings, and that leverage multiple forms of support and knowledge sharing, may be particularly important for helping to implement Title X services.

Stakeholder perspectives on the advantages and challenges of expanded school mental health services for publically-insured youth.

Although partnerships between community-based mental health (MH) organizations and school systems to deliver MH services on school grounds (i.e., expanded school mental health, ESMH services) are growing, qualitative research is needed about stakeholders' perspectives on ESMH services. This study collected qualitative data from caregivers, MH providers, and MH administrators recruited from three MH organizations to understand their perspectives regarding potential advantages and challenges associated with ESMH services. The three MH organizations were located in three regions of Georgia and the majority of youth served by the organizations were enrolled in Medicaid. We conducted four focus groups with 33 caregivers and 13 semistructured interviews with MH administrators and providers, and we implemented a thematic content analysis. Caregivers, providers, and MH administrators described how ESMH services could improve MH services by (a) facilitating appointment attendance through the reduction of logistical barriers to care (including geographic barriers, missed class time, and missed work time) and (b) enhancing communication between providers and teachers. However, some participants also described logistical issues with ESMH services including school space constraints and challenges scheduling appointments. In addition, some caregivers expressed concerns about peer stigma if MH services are delivered at school (vs. the clinic). Providers and MH administrators discussed problems with low caregiver engagement and challenges collaborating with school personnel that stem from lack of understanding of MH problems and treatment. Although ESMH services can improve MH treatment among low-income youth, MH providers and MH administrators may consider collaborating with school personnel to proactively develop strategies to address challenges to its success. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Prior Authorization Policies and Preferred Drug Lists in Medicaid Plans: Stakeholder Perspectives on the Implications for Youth with ADHD.

This qualitative study describes how Medicaid policies create challenges for the delivery and receipt of mental health treatment for low-income youth in Georgia. We conducted focus groups with caregivers of Medicaid-enrolled children with ADHD and semi-structured interviews with providers and administrators at four safety net clinics that provided mental health care to these youth. Stakeholders reported that prior authorization policies for psychosocial services, restrictiveness of preferred drug lists, and changes in preferred drug lists in Medicaid plans created barriers to treatment continuity and quality for youth with ADHD and led to more administrative burden for safety-net clinics serving these youth.

Georgia's Medicaid Family Planning Waiver: Working Together with Title X to Enhance Access to and Use of Contraceptive and Preventive Health Services.

PURPOSE: We sought to assess the impact of Georgia's family planning demonstration waiver upon access to and use of contraceptive and preventive health services within Title X and Medicaid. PROCEDURES: Georgia Title X and Medicaid data for January 2009 through December 2013 (before and after the waiver), restricting Title X data to women targeted by the waiver (18-44 years, incomes from 25% and 50% through 200% of the federal poverty level [FPL]) was assembled by quarter and marginal effects of the changes before and after waiver implementation were derived using multivariate regression models. FINDINGS: After implementation, there was a significant increase in the probability of Title X clients in the waiver-targeted age and income ranges who had Medicaid versus no insurance and who exited the encounter with higher effectiveness contraceptive methods, including long-acting reversible contraceptives (LARCs), and with cervical cytology and sexually transmitted infection testing. In the Medicaid data from 2009 to 2013, there was an increase in the mean number of encounters per enrollee (2.19 vs. 2.42) and in LARC users; however, the percentage of all Georgia women living under 200% of the FPL with a family planning encounter in Title X and Medicaid decreased from 19% to 15%. CONCLUSIONS: Our findings suggest that implementation of the Georgia family planning demonstration waiver contributed to the increased use of higher effectiveness contraceptive methods, including LARCs, within the Medicaid and Title X programs as well as the increased use of preventive screenings among Title X clients. However, when the full population of low-income Georgia women targeted by the waiver was considered, a greater percentage was not served over the demonstration period.

Facilitators and barriers to cervical cancer screening, diagnosis, and enrollment in Medicaid: experiences of Georgia's Women's Health Medicaid Program enrollees.

Although cervical cancer incidence and mortality rates have declined in the USA, African American women have a higher incidence rate of cervical cancer and a higher percentage of late-stage diagnosis than white women. Previous analyses by the authors showed that, even after adjusting for age, provider location, and availability, African American women were almost half as likely as white women to be diagnosed or enter Medicaid while at an early stage of their cervical cancer. To understand why these differences exist, we undertook a qualitative examination of the cervical cancer experiences of women enrolled in Georgia's Women's Health Medicaid Program (WHMP). Life history interviews were conducted with 24 WHMP enrollees to understand what factors shaped their cervical cancer experiences, from screening through enrollment in Medicaid. We also examined whether these factors differed by race in order to identify opportunities for increasing awareness of cervical cancer screening among underserved women. Results suggest that many women, especially African Americans, lacked understanding and recognition of early symptoms of cervical cancer, which prevented them from receiving a timely diagnosis. Additionally, participants responded positively to provider support and good communication but wished that their doctors explained their diagnosis more clearly. Finally, women were able to enroll in Medicaid without difficulty due largely to the assistance of clinical staff. These findings support the need to strengthen provider education and public health efforts to reach low-income and minority communities for screening and early detection of cervical cancer.

Breast cancer treatment experiences by race and location in Georgia's Women's Health Medicaid Program.

BACKGROUND: This study seeks to understand the breast cancer treatment patterns and experiences of women enrolled in Georgia's Breast and Cervical Cancer Prevention and Treatment Act program, the Women's Health Medicaid Program (WHMP), and whether these experiences vary by race or location. METHODS: We conducted a mixed-methods analysis of WHMP breast cancer enrollees by race and urban/rural location. Quantitative analysis used a hazard rate model approach to identify differences in the timing of diagnosis, enrollment into Medicaid, and various modalities of treatment for 810 enrollees. Qualitative analysis used a systematic retrieval and review of coded data from 34 in-depth disease life history interview transcripts to a complete, focused analysis of enrollees' cancer treatment experiences. FINDINGS: African-American women began treatment, on average, 6 days later after diagnosis than White women, driven by delays of one month among African-American women with late-stage cancers. This time delay for African-American women was not significant on multivariate analysis of time from enrollment to treatment. Once enrolled in WHMP, women reported gaining access to equitable breast cancer treatment regardless of race or location, with the exception of breast reconstruction, for which some women in our sample reported barriers to care. CONCLUSIONS: The equitable access to cancer treatment and other health services provided by WHMP to low-income, uninsured women in Georgia with breast cancer makes it a critical health care safety net program in Georgia, the need for which will continue through the implementation of the Affordable Care Act.

Efforts by commercial health plans to increase Chlamydia trachomatis screening among their members.

BACKGROUND: The screening rate for Chlamydia trachomatis (Ct) is below 38% nationally, despite the high prevalence of Ct nationally and the low cost of both the screening test and the treatment. The purposes of this study are (a) to ascertain what activities commercial health plans have attempted (if any) to increase their Ct screening rates and (b) to identify barriers to improving Ct screening rates in commercial health plans. METHODS: Qualitative research methods were used, including structured interviews. In-depth telephone interviews with commercial health plans were conducted to identify health plan activities that led to high Ct screening rates by providers. Plans were selected, which were either in the top or in the bottom quarter of all plans or had either an increase or decrease in Ct screening rates of at least 3 percentage points over the previous 2 to 3 years. Interviews were restricted to plans reporting Ct screening rates to the National Committee for Quality Assurance for at least 3 years, plans with enrollment of at least 500 commercially insured women aged 15 to 26 years, and plans that were not staff model-managed care plans. A total of 35 structured interviews were completed with a response rate of 64%. RESULTS: Overall Ct screening rates in commercial health plans are quite low, with a median rate of 35%. All interviewed plans-both successful and not successful-reimbursed for Ct screening and used clinical guidelines. All but 3 plans had some type of intervention in place designed to improve Ct screening rats. The interventions varied-some aimed at providers, others at patients, and others at data collection-but the health plans were actively trying to improve screening rates. Health plans identified several barriers to improving screening rates in the commercially insured population. These include difficulties in identifying sexually active members for screening, limited health plan resources to target the problem, concerns about contacting minors, and cultural barriers to discussing sexually transmitted diseases. CONCLUSIONS: Both high- and low-performing plans are actively trying to increase the Ct screening rates. However, efforts to date have not been successful, suggesting the need for alternative approaches to address existing barriers.

Nursing homes' preparedness plans and capabilities.

OBJECTIVES: To assess nursing homes' capabilities to evacuate or shelter-in-place during a disaster and to determine their actual preparedness-related capacity. DESIGN: A 27-question survey assessing disaster preparedness plans and capabilities in nursing homes. Respondents and nonresponders were compared based on characteristics from the Nursing Home Compare Web site using t tests for continuous variables and chi2 test for categorical variables. Probit regression was used to estimate the relationships between nursing home characteristics and dichotomous measures of preparedness. SETTING: Web and paper surveys of nursing home administrators. PARTICIPANTS: Nursing home administrators in California, Florida, and Georgia. MAIN OUTCOME MEASURES: Number of disaster drills, days supply of emergency food and water, evacuation transportation and destination. RESULTS: All facilities reported conducting at least one disaster drill per year. Only 55 percent of facilities used a template to develop their disaster plans and 74 percent of facilities reported that they discuss their disaster plans with local or state emergency management officials. Most facilities (81 percent) have generators. All but 19 (7 percent) of nursing homes are able to shelter-in-place for 2 days or longer. Ambulance services are the most common form of transportation (76 percent). Most facilities (73 percent) plan to evacuate residents to nursing homes affiliated with their corporate group. DISCUSSION: Almost all respondents conducted disaster drills, discussed preparedness with local officials, and were able to shelter-in-place for at least 2 days. However, many facilities rely on resources that may not be available during a large disaster.

Recruitment for the National Breast and Cervical Cancer Early Detection Program.

BACKGROUND: To reduce disparities in breast and cervical cancer in the U.S., it is essential that programs such as CDC's National Breast and Cervical Cancer Early Detection Program (NBCCEDP) use evidence-based strategies. Recommendations for interventions to increase breast and cervical cancer screening have been disseminated by national public health organizations. To increase screening, cancer control planners would benefit from use of evidence-based strategies for recruitment of participants in their communities. PURPOSE: The purpose of the study was to inventory recruitment activities for cancer screening within NBCCEDP programs and assess if activities used to increase cancer screening are evidence-based. METHODS: Interviews were conducted with 61 recruitment coordinators in 2008 to elicit their recruitment activities, use of evidence-based resources, and barriers to using evidence-based interventions (EBIs). Study data were analyzed in 2009. RESULTS: Of the 340 activities reported, many were categorized as educational materials, one-on-one education, mass media, group education, and special events. Two thirds of inventoried activities matched an EBI. Coordinators reported that colleagues and the CDC are their primary sources of information about EBIs and few coordinators had used evidence-based resources. Lack of money or funding, questionable applicability to priority populations, limited staffing or staff time, and insufficient evidence-based research were the most important barriers to EBI use. CONCLUSIONS: Although the majority of NBCCEDP recruitment activities were evidence-based, one third were not. Additional training and technical assistance are recommended to help public health agencies adopt the use of these strategies.

A qualitative evaluation of a health literacy intervention to improve medication adherence for underserved pharmacy patients.

OBJECTIVE: To evaluate the implementation of a health literacy intervention to improve medication adherence among patients in an inner-city health system. METHODS: Interviews with pharmacists and focus groups with pharmacy patients were conducted one month and six months after beginning the intervention. Patients and pharmacists described their experiences with the intervention, consisting of an automated telephone call reminder system, an illustrated medication schedule, and pharmacist training in clear health communication. RESULTS: Despite initial technical problems, patients and pharmacists reported positive experiences. Pharmacists thought the intervention made counseling easier. Patients appreciated the design and portability of the illustrated medication schedule and found the reminder calls helpful as well. CONCLUSION: Successful health literacy interventions require tools that are easy to comprehend, accessible, and personalized to the special needs and interests of the target population. Moreover, providers must be well-trained, and adequate resources must be provided to assure the fidelity of the intervention's implementation.