Barriers to rural health care from the provider perspective.

INTRODUCTION: Rural populations routinely rank poorly on common health indicators. While it is understood that rural residents face barriers to health care, the exact nature of these barriers remains unclear. To further define these barriers, a qualitative study of primary care physicians practicing in rural communities was performed. METHODS: Semistructured interviews were conducted with primary care physicians practicing in rural areas within western Pennsylvania, the third largest rural population within the USA, using purposively sampling. Data were then transcribed, coded, and analyzed by thematic analysis. RESULTS: Three key themes emerged from the analysis addressing barriers to rural health care: (1) cost and insurance, (2) geographic dispersion, and (3) provider shortage and burnout. Providers mentioned strategies that they either employed or thought would be beneficial for their rural communities: (1) subsidize services, (2) establish mobile and satellite clinics (particularly for specialty care), (3) increase utilization of telehealth, (4) improve infrastructure for ancillary patient support (ie social work services), and (5) increase utilization of advanced practice providers. CONCLUSION: There are numerous barriers to providing rural communities with quality health care. Barriers that are encountered are multidimensional. Patients are unable to obtain the care they need because of cost-related barriers. More providers need to be recruited to rural areas to combat the shortage and burnout. Advanced care-delivery methods such as telehealth, satellite clinics, or advanced practice providers can help bridge the gaps caused by geographic dispersion. Policy efforts should target all these aspects in order to appropriately address rural healthcare needs.

A Qualitative Analysis of Resident Adverse Event Reporting: What's Holding Us Back.

This study utilized focus groups of residents, who report adverse events at differing rates depending on their hospital site, to better understand barriers to residents' reporting and identify modifiable aspects of an institution's culture that could encourage resident event reporting. Focus groups included residents who rotated at 3 hospitals and represented 4 training programs. Focus groups were audio recorded and analyzed using qualitative methods. A total of 64 residents participated in 8 focus groups. Reporting behavior varied by hospital culture. Residents worried about damage to their professional relationships and lacked insight into the benefits of multiple reports of the same event or how human factors engineering can prevent errors. Residents did not understand how reporting affects litigation. Residents at other academic institutions likely experience similar barriers. This study illustrates that resident reporting is modifiable by changing hospital culture, but hospitals have only a few opportunities to mishandle reporting before resident reporting attitudes solidify.

"I Don't Feel Like the Odd One": Utilizing Content Analysis to Compare the Effects of Social Media Use on Well-Being Among Sexual Minority and Nonminority US Young Adults.

PURPOSE: Although there is evidence of associations between social media (SM) use and mental well-being among the general population, these associations among lesbian, gay, and bisexual (LGB) persons are poorly understood. This study compared the influence of SM experiences on mental well-being between LGB and non-LGB persons. DESIGN AND SETTING: Online cross-sectional survey. PARTICIPANTS: National sample of 2408 US adults aged 18 to 30 years. METHOD: We asked participants to provide examples of when SM affected their well-being separately in good and bad ways. We coded, summed, and used rate ratios (RRs) to compare responses of LGB and non-LGB individuals. Thematically similar codes were described and grouped into categories. RESULTS: Most responses described positive SM effects. However, of 6 codes that were significantly more frequent among LGB respondents, only social capital (RR = 1.58, 95% confidence interval [CI], 1.17-2.12) described a positive effect. Five codes described negative effects of SM for LGB users: negative emotional contagion (RR = 1.28, 95% CI, 1.04-1.58), comparison with others (RR = 1.28, 95% CI, 1.01-1.62), real-life repercussions (RR = 1.86, 95% CI, 1.18-2.94), envy (RR = 2.49, 95% CI, 1.48-4.19), and need for profile management (RR = 2.32, 95% CI, 1.07-5.03). CONCLUSION: These findings suggest that, for LGB persons, gaining social capital from SM is valuable for establishing and maintaining connections. Increased negative SM experiences may pose a risk for the mental well-being of LGB individuals.

"The Financial Is the Main Issue, It's Not Even the Child": Exploring the Role of Finances in Men's Concepts of Fatherhood and Fertility Intention.

Despite demonstrable need, men's utilization of sexual and reproductive health services remains low. This low utilization may particularly affect low-income men, given the disproportionate prevalence of unintended pregnancy in low-income populations. Bolstering men's utilization of sexual and reproductive health services requires understanding the services that are most relevant to them. Semistructured interviews about fatherhood, fertility intention, and contraceptive use were conducted with 58 low-income Black and White men in Pittsburgh, Pennsylvania. The interviews were analyzed using content analysis to determine common themes that were most relevant to the men interviewed. The primacy of financial stability emerged as a dominant theme in men's perceptions of fatherhood readiness, successful fathering, and fertility intentions. However, men had children despite feeling financially unprepared, and their contraceptive use was not always congruent with their stated fertility intentions. Some men described financial services as a feature of family planning services that they would find useful. Because of the salience of financial stability in preparation for fatherhood, integrating financial counseling and job skills training into the context of sexual and reproductive health services could be a useful structural intervention to increase men's use of family planning services and to provide them with the support they say they need as fathers.

Family Planning and Counseling Desires of Women Who Have Experienced Miscarriage.

OBJECTIVE: To explore initial pregnancy intentions and postmiscarriage family planning needs and counseling preferences of women experiencing spontaneous abortion. METHODS: We conducted semistructured qualitative interviews with women who recently experienced spontaneous abortion to explore their feelings about conception, pregnancy, and miscarriage; their future family planning goals; and contraceptive counseling preferences. Two trained coders utilized an inductive, iterative approach to code transcripts and identify themes using Atlas.ti software to organize the analysis. RESULTS: We interviewed 26 women reporting varied intentions in their recent pregnancies: 54% were trying to conceive, 27% were not trying but not preventing, and 19% were attempting to avoid pregnancy. Participants reported a range of feelings about the pregnancy diagnoses and eventual miscarriages with some relatively unemotional ("a little disappointed…suffering for two months for nothing") and others feeling devastated by their pregnancy losses ("in shock," "for it to be taken away was crushing"). Varying character and intensity of emotional reactions were seen across the range of initial pregnancy intentions. Some participants had consistent childbearing plans before and after miscarriage, whereas others experienced their pregnancies and losses as clarifying events leading to changed goals moving forward ("it was a wake-up call"). Although family planning needs were inconsistently addressed after spontaneous abortion, women were generally receptive to the idea of contraceptive counseling, though they had different preferences regarding timing, ranging from immediately to weeks later. CONCLUSION: Women's reproductive goals after spontaneous abortion cannot be inferred based on initial pregnancy intention or emotional reactions to pregnancy loss. Health care providers should offer family planning counseling to all women after spontaneous abortion, remaining responsive to individual patient needs.

"Without bodily autonomy we are not free": exploring women's concerns about future access to contraception following the 2016 US presidential election.

OBJECTIVE: Following the 2016US presidential election, social media posts and news stories amplified concerns about the potential for reduced access to contraception under the incoming administration and urged women to seek long-acting reversible contraception. We aimed to describe women's concerns about future access to contraception, in their own words. STUDY DESIGN: A social-media-based, anonymous online survey assessing thoughts and concerns about future access to contraception was distributed to reproductive-aged US women for 1 week in mid-January 2017. Participants who were concerned about future access to contraception could share their thoughts and feelings in an open-ended comments box. We qualitatively analyzed 449 written responses for content and themes, with the goal of characterizing key concerns. RESULTS: Women who provided written comments had a mean age of 28years; 85% were white, 88% had at least a college degree, and 93% identified as Democratic or Democratic-leaning. Women were highly concerned about future affordability of contraceptive methods due to potential loss of insurance, reduced insurance coverage for contraceptive methods and reduced access to low-cost care at Planned Parenthood. Many also worried about increased restrictions on abortion. Participants' concerns regarding access to contraception and abortion centered around themes of reproductive and bodily autonomy, which women described as fundamental rights. CONCLUSIONS: Women in this study expressed considerable fear and uncertainty regarding their future access to contraception and abortion following the 2016US presidential election. The potential for restricted access to affordable contraception and abortion was viewed as an unacceptable limitation on bodily autonomy. IMPLICATIONS: As the future of US health care policy is debated, many women are concerned about the impact of policy changes on their ability to access affordable contraception and abortion, which many view as essential to the preservation of bodily and reproductive autonomy.

Current perspectives on psychological insulin resistance: primary care provider and patient views.

BACKGROUND: Psychological insulin resistance (PIR) refers to reluctance of providers to prescribe and patients to take insulin. Processes and tools have been developed to address PIR. The purpose of this qualitative study was to examine current understanding and opinions of insulin therapy of primary care providers (PCPs) and patients with type 2 diabetes (both naive to insulin and insulin users). SUBJECTS AND METHODS: Providers (n=23 PCPs) and patients (n=96) participated in 1:1 interviews and 12 racially/ethnically diverse focus groups, respectively, conducted by trained qualitative researchers using pilot-tested scripts. Participants examined insulin devices and needles while specific questions were asked about insulin therapy. Recorded sessions were transcribed and analyzed. RESULTS: Salient themes related to injection resistance, patient adherence, health system barriers, and education emerged during the sessions. Provider knowledge about insulin injection devices and approaches varied and was often limited, particularly regarding needle sizes, which influenced prescribing practices and patient education. Other barriers included limited time and personnel. However, PCPs placed priority on continuing education on devices, needles, insulin adjustment, educational approaches, and cost. Patient focus groups revealed a strong desire for knowledge on injection logistics, particularly by insulin users who felt that they had received inadequate education. Most patients had limited experience with tools like shorter needles but would consider injecting if presented. Those who had self-injection experience were more willing to accept insulin. Cost concerns and need for information were frequently reported. CONCLUSIONS: Findings reveal that programs and tools designed to address problems associated with PIR have yet to be fully realized.