Barriers to care in an ethnically diverse publicly insured population: is health care reform enough?

BACKGROUND: The Affordable Care Act provides for the expansion of Medicaid, which may result in as many as 16 million people gaining health insurance coverage. Yet it is unclear to what extent this coverage expansion will meaningfully increase access to health care. OBJECTIVE: The objective of the study was to identify barriers that may persist even after individuals are moved to insurance and to explore racial/ethnic variation in problems accessing health care services. RESEARCH DESIGN: Data are from a 2008 cross-sectional mixed-mode survey (mail with telephone follow-up in 4 languages), which is unique in measuring a comprehensive set of barriers and in focusing on several select understudied ethnic groups. We examine racial/ethnic variation in cost and coverage, access, and provider-related barriers. The study adhered to a community-based participatory research process. SUBJECTS: Surveys were obtained from a stratified random sample of adults enrolled in Minnesota Health Care Programs who self-report ethnicity as white, African American, American Indian, Hispanic, Hmong, or Somali (n=1731). RESULTS: All enrollees reported barriers to getting needed care; enrollees from minority cultural groups (Hmong and American Indian in particular) were more likely to experience problems than whites. Barriers associated with cost and coverage were the most prevalent, with 72% of enrollees reporting 1 or more of these problems. Approximately 63% of enrollees reported 1 or more access barriers. Provider-related barriers were the least prevalent (about 29%) yet revealed the most pervasive disparities. CONCLUSIONS: Many challenges to care persist for publicly insured adults, particularly minority racial and ethnic groups. The ACA expansion of Medicaid, although necessary, is not sufficient for achieving improved and equitable access to care.

Differences in sexual behaviors among unmarried sexually active students at 2- and 4-year colleges.

Sexual risk behaviors are common among college students, but differences between 2- and 4-year students have not been explicitly tested. Survey data from 9,748 unmarried sexually active Minnesota college students (in 2010 or 2011) were used multilevel logistic regression models to test differences in eight high risk sexual health behaviors and outcomes between students attending 2- vs. 4-year colleges. Odds of sex without a condom, sex without reliable birth control, unplanned pregnancy, and STIs were significantly lower among 4-year students than 2-year students, after adjusting for demographic covariates. Health promotion approaches targeted to the needs of 2- or 4-year students may be needed. For example, messaging and outreach efforts encouraging condom use may be especially beneficial for sexual health programs at 2-year colleges.

"I connect with the ringleader:" health professionals' perspectives on promoting the sexual health of adolescent males.

In-depth interviews with nine professionals in adolescent health were used to identify perceived barriers, facilitators, and innovative strategies to reach, engage, and serve adolescent males for sexual and reproductive health care. Barriers included stigma, embarrassment, and lack of social norms around sexually transmitted infection (STI) testing for men. Facilitators included crisis situations and partner support. Clinic-based approaches to reach and engage young men included developing authentic staff-youth engagement and ensuring that access to services is easy and appealing. To be innovative, providers should become part of the real-world context of adolescent males. Technology (e.g., text messaging) and social media can be utilized to target and eliminate barriers to health care among young men.

College students' preferences for health care providers when accessing sexual health resources.

OBJECTIVE: Many emerging adults (18-25 year olds) report unmet health needs and disproportionately experience problems such as sexually transmitted infections. This study was conducted to examine college students' perceptions of health care providers, specifically in the context of accessing sexual health resources. DESIGN AND SAMPLE: Students (N = 52) were recruited from five diverse colleges in one state to participate in a one-to-one interview that involved walking and virtually exploring resources on and near campus. Interviews were conducted from May to November 2010. MEASURES: Open-ended one-to-one interview questions. RESULTS: Inductive qualitative analysis yielded six themes summarizing students' perceptions of provider characteristics, health care resources, the role of their peers, and students' suggestions for strengthening health care services. Importantly, students consider a variety of staff-and their student peers-to be resources for sexual health information and services. CONCLUSIONS: Findings emphasize the importance of collaboration between health service staff and broader campus staff because students often turn to campus staff initially. Postsecondary students welcome opportunities to know a provider through interactive websites that include details about providers on campus; their decisions to seek sexual health care services are influenced by their perceptions of providers' characteristics and interpersonal skills.

Intergenerational photovoice projects: optimizing this mechanism for influencing health promotion policies and strengthening relationships.

Intergenerational photovoice groups are promising for promoting health through the topic that is explored and through group dynamics that can foster healthy relationships and communication. To investigate the potential benefits of intergenerational photovoice projects, photovoice groups were conducted in urban Minnesota, United States, and in rural Morelos, Mexico, between 2009 and 2012 with Mexican-origin adults and their adolescent relatives. Seven photovoice groups of adult-adolescent dyads met for eight sessions and developed exhibits highlighting their views on health and migration and made policy recommendations, using messages conveyed through their words and photographs. Informal process evaluation and focus groups were used to elicit feedback about photovoice project participation. Photovoice project themes were descriptively analyzed. Focus group evaluation data were thematically summarized, and facilitator reflections were descriptively summarized to identify factors associated with intergenerational photovoice groups. Seventy-five participants were recruited. Photovoice themes represented effects of migration on health, family, and well-being. The following two evaluative themes were identified: (a) participant sentiments about the benefits of photovoice participation and (b) facilitator observations of intergenerational photovoice group benefits and challenges. Participants described opportunities to learn new things and barriers to healthy relationships that the project was eliminating by providing them with time to work together. Used in health promotion, photovoice is a valuable tool that contributes to understanding the complex underlying factors influencing behaviors and health.

It's called "Going out to play": a video diary study of Hmong girls' perspectives on running away.

How do Hmong immigrant adolescent girls decide to run away, return home, leave again, or stay home? Video diaries by 11 sexually exploited runaway Hmong girls, ages 13-16, revealed four themes: "fighting restrictions," or resisting family and cultural expectations and desires to be like other American teens; "not running away, going out to play," which captured impulsive decision making; "unrestrained partying," which described runaway experiences but minimized the dangers faced; and "trying to change," or returning home because of family bonds and wanting to "be someone good." Given their limited ability to anticipate risks, interventions should focus on runaway prevention initiatives for Hmong families and teens.

Health care reform and young adults' access to sexual health care: an exploration of potential confidentiality implications of the affordable care act.

One provision of the 2010 Affordable Care Act is extension of dependent coverage for young adults aged up to 26 years on their parent's private insurance plan. This change, meant to increase insurance coverage for young adults, might yield unintended consequences. Confidentiality concerns may be triggered by coverage through parental insurance, particularly regarding sexual health. The existing literature and our original research suggest that actual or perceived limits to confidentiality could influence the decisions of young adults about whether, and where, to seek care for sexual health issues. Further research is needed on the scope and outcomes of these concerns. Possible remedial actions include enhanced policies to protect confidentiality in billing and mechanisms to communicate confidentiality protections to young adults.

Characterizing sexual health resources on college campuses.

This observational study describes the development of the college resources and sexual health inventory, the profile of sexual health promotion resources at participating colleges, and comparisons of resources across several college characteristics. 28 diverse college campuses in one Midwestern state participated. 10 domains were assessed, including characteristics of campus health services (e.g. convenience), condom programs, sexual health information, communication about resources, sexual violence resources and gay/lesbian/bisexual student resources. Scores for each measure reflected the presence or extent of each resource. Summary scores were created for the overall level of sexual health resources and for each domain. T tests and ANOVAs were used to compare resources at 2-year versus 4-year colleges, public versus private sectors, metro versus non-metro locations, and across enrollment size. Inventory scores ranged from 6 to 53. 4-year colleges offered significantly more resources than 2-year; resource levels were statistically similar across location and enrollment size. Subsequent analyses comparing campuses with and without a health center indicated that several resources which were not inherently tied to a clinic nonetheless differed significantly with having a health center. Colleges without this resource could position sexual health resources in other offices or departments or provide referrals to sexual health resources in the broader community.

Conducting go-along interviews to understand context and promote health.

Go-along interviewing is an innovative approach to obtaining contextualized perspectives by conducting mobile interviews in which the participant acts as a navigational guide of the real or virtual space within which he or she lives. In this study, we used go-along interviews to obtain college students' contextualized perceptions of sexual health resources. Seventy-eight undergraduate students showed and described the resources on and near five campuses in a Midwestern state. In this article, we focus on the methodology of go-along interviews. The go-along, a relatively new methodology in health research, is a format in which participants take an active role in shaping the interview, and it facilitates identification of resources that might be overlooked using traditional interview formats. The go-along methodology is promising for researchers wanting to ground health-promotion efforts in the context of environmental or community-based strengths and needs.

No te entiendo y tú no me entiendes: language barriers among immigrant Latino adolescents seeking health care.

PURPOSE: Immigrant Latino adolescents experience health disparities and barriers to accessing health care. The purpose of this study is to describe barriers experienced by immigrant Latino adolescents seeking U.S. health care. DESIGN: Focused ethnography using one-to-one interviews. RESULTS: Participants identified language barriers to accessing care at all stages in the process. DISCUSSION: Immigrant Latino youth experience barriers when accessing U.S. health care, resulting in negative perceptions and likelihood of reduced health seeking. IMPLICATIONS FOR PRACTICE: Health care providers can lead positive change in health care delivery resulting in minimized language barriers and improved culturally relevant care for immigrant Latino youth and their families.

Perceptions of health among immigrant Latino adolescents from Mexico.

PURPOSE: This ethnographic study describes the health-related perceptions of immigrant Latino adolescents from Mexico. METHOD: Fourteen adolescents, purposively recruited from two non-health-based community settings, participated. Each was interviewed twice and completed a visual narrative project using disposable cameras. Audiotaped transcripts and photographs were inductively analyzed. FINDINGS: Being healthy is holistically perceived by these adolescents and includes physical, mental, spiritual, social, and environmental factors. Pictures portrayed healthy and unhealthy influences and behaviors, including eating habits, exercise, self-care, relationships, garbage, and pollution. Personal responsibility was important in being healthy and in promoting one's health. Family was identified as an important source of health-related information. IMPLICATIONS: Nurses recognizing the holistic, comprehensive health-related perceptions of immigrant Latino adolescents can promote their health and design culturally and developmentally appropriate educational strategies and health interventions aimed at eliminating health disparities.

College students' sexual health: personal responsibility or the responsibility of the college?

OBJECTIVE: This article examines students' perceptions of individual and institutional responsibility for sexual health so that institutions can better provide for the needs of their students to increase academic success and healthy relationship outcomes. PARTICIPANTS: Students from 2- and 4-year colleges in 1 state (N=78). METHODS: From May through November 2010, the authors used go-along interviews to examine students' perceptions of resources for sexual health on their campuses. RESULTS: Participants believed that it is the college's responsibility to provide resources and the responsibility of students to access resources. Participants at 2-year schools wanted referrals to resources, whereas participants at 4-year schools expected resources to be available and emphasized the importance of a supportive community. CONCLUSIONS: Students at 2- and 4-year colleges have different expectations of their institutions; by making resources and referrals for sexual health available, colleges can better serve their students, which will result in improved health outcomes.

Differences in Abuse and Related Risk and Protective Factors by Runaway Status for Adolescents Seen at a U.S. Child Advocacy Centre.

OBJECTIVES: This study examined the abuse prevalence and characteristics, and risk and protective factors, among both runaway and non-runaway adolescents evaluated at a Child Advocacy Center (CAC) in Minnesota, which had implemented a referral program to assess runaways for potential sexual assault or sexual exploitation. METHODS: A cross-sectional analysis of self-report and chart data for the 489 adolescent girls who were evaluated between 2008 and 2010. Chi-square and t-tests by runaway status compared abuse experiences, trauma responses, health issues, and potential protective assets associated with resilience between runaways and non-runaways. Bivariate logistic regressions explored the relationship of these risk and protective factors to self-harm, suicide attempts, and problem substance use, separately for runaways and non-runaways who had experienced sexual abuse. RESULTS: Runaways were significantly more likely than non-runaways to have experienced severe sexual abuse, to have used alcohol and drugs, and reported problem substance use behavior, higher levels of emotional distress, more sexual partners, and they were more likely to have a sexually transmitted infection (STI). Runaways had lower levels on average of social supports associated with resilience, such as connectedness to school, family or other adults. Yet higher levels of these assets were linked to lower odds of self-harm, suicide attempt and problem substance use for both groups. CONCLUSIONS AND IMPLICATIONS: CACs should encourage referrals of runaway adolescents for routine assessment of sexual assault, and incorporate screening for protective factors in addition to trauma responses in their assessments of all adolescents evaluated for possible sexual abuse, to guide interventions.

Adolescent health literacy: the importance of credible sources for online health information.

BACKGROUND: Little research has examined adolescent health literacy and its relationship with online health information sources. The purpose of this study is to explore health literacy among a predominantly Hispanic adolescent population and to investigate whether exposure to a credible source of online health information, MedlinePlus(®), is associated with higher levels of health literacy. METHODS: An online survey was administered to a cross-sectional random sample of high school students in South Texas. Self-reported sociodemographic characteristics and data on health-information-seeking behavior and exposure to MedlinePlus(®) were collected. Health literacy was assessed by eHEALS and the Newest Vital Sign (NVS). Linear and binary logistic regressions were completed. RESULTS: Of the 261 students who completed the survey, 56% had heard of MedlinePlus(®), 52% had adequate levels of health literacy as measured by NVS, and the mean eHEALS score was 30.6 (possible range 8-40). Health literacy was positively associated with self-efficacy and seeking health information online. Exposure to MedlinePlus(®) was associated with higher eHealth literacy scores (p < .001) and increased the likelihood of having adequate health literacy (odds ratio: 2.1; 95% CI: 1.1, 4.1). CONCLUSION: Exposure to a credible source of online health information is associated with higher levels of health literacy. The incorporation of a credible online health information resource into school health education curricula is a promising approach for promoting health literacy.

Preventing sexual violence instead of just responding to it: students' perceptions of sexual violence resources on campus.

Rates of sexual assault of college students are higher than the national rates. Colleges are uniquely positioned to offer preventive education and support services to a high-risk group. This qualitative study examines students' perceptions of sexual violence resources and services. Seventy-eight female and male students, between 18 and 24 years old, belonging to various demographic groups, participated in one-to-one walking interviews on five diverse Midwest 2- and 4-year postsecondary campuses. Findings suggest that students are concerned with safety--students want more education regarding sexual violence--and they value services that offer protection from incidents of sexual violence on campus. Participants expressed mixed reactions to prevention education that combined sexual violence prevention with alcohol and drug use. Students shared positive views of the security measures on campus. They emphasized the importance of using varied mechanisms for sexual violence-related resource messaging and advised moving away from the pamphlet toward posters and online resources. Recommendations are offered to strengthen existing resources, such as prevention education and postassault interventions including sexual assault nurse examiner services, and to minimize barriers to access of sexual violence resources.

Hopefulness among non-U.S.-born Latino youth and young adults.

PROBLEM: U.S. Latino youths experience disproportionately high rates of health and social problems. There is a need to identify protective factors for reducing risky behaviors. Little is known about the protective nature of hope among immigrant Latino adolescents. METHODS: This descriptive cross-sectional study examined hope and expectations for the future in non-U.S.-born Latino adolescents and young adults (n= 98) in urban and rural areas in the midwestern United States. FINDINGS: Participants reported feeling hopeful about their future; however, differences were detected among subgroups. CONCLUSION: Findings affirm the potential of hope as a protective factor for immigrant Latino adolescents and young adults. Nurses should be aware of hopefulness when implementing mental health preventive interventions. Research is needed to identify effective mechanisms for promoting and sustaining hope.

Using community-based participatory research to develop a bilingual mental health survey for Latinos.

BACKGROUND: Despite rapid growth, Latino communities' mental health needs are unmet by existing services and research. Barriers may vary by geographic locations, but often include language, insurance coverage, immigration status, cultural beliefs, and lack of services. OBJECTIVES: The aim of this research was development of a cross-sectional instrument to assess the mental health status, beliefs, and knowledge of resources among rural and urban Latinos residing in a Midwestern state. METHODS: The purpose of this article is to describe the community-based participatory research (CBPR) process of instrument development and lessons learned. RESULTS: A culturally relevant, 100-item bilingual survey instrument was developed by community and academic partners. LESSONS LEARNED: Community-based participatory research methods are salient for sensitive health topics and varied research objectives, including instrument development. To ensure cultural and social relevance of research, community participation is crucial at all stages of research, including developing the research question and instrument.

Perceptions of mental health among recently immigrated Mexican adolescents.

Rates of anxiety, depression, and suicidal ideation are high among Latino adolescents in the U.S., many of whom are immigrants. Immigration during adolescence creates risk factors for mental health problems. The purpose of this study was to explore the health-related perceptions of Mexican-origin immigrant adolescents to inform the design of culturally and developmentally appropriate mental health services. This focused ethnography was guided by Bronfenbrenner's ecological framework and symbolic interactionism. Fourteen adolescents were recruited from two non-health-based community settings. Data from one-to-one semi-structured interviews and a visual narrative project were coded and analyzed inductively. Three thematic patterns were identified: "mentally healthy," "mentally unhealthy," and "health promotion." Increased awareness of cultural influences and immigration on Latino adolescents' mental health is needed. Mental health nurses are in a unique position to educate and to influence accessibility of services.

Air, water, land: mexican-origin adolescents' perceptions of health and the environment / Ar, água e terra: percepções de saúde ambiental de adolescentes de origem mexicana / Aire, água y tierra: percepciones de salud ambiental de adolecentes de origen mexicana

Latino adolescents are the fastest growing population sub-group in the United States (U.S.). Health disparities exist between Latino teens and the majority population of adolescents in the U.S. as evidenced by rates of health problems including asthma and depression; environmental factors contribute to these concerning trends. The objective is to describe how environmental influences are perceived by Mexican-origin immigrant adolescents. A focused ethnography guided by an ecological framework and symbolic interactionism was conducted using 1-to-1 interviewing, participant observations, and visual narratives created using disposable cameras. Fourteen participants took ?pictures of life as an immigrant Latino adolescent, with a focus on health.? Interview and photograph data were organized and analyzed using Atlas.ti software. Four themes were identified: ?Garbage is everywhere,? ?Work hurts me,? ?Air we breathe,? and ?Relaxation in nature.? Findings demonstrate comprehensive appreciation for risk and protective environmental influences on health. Nurses can utilize findings to reinforce the need to holistically assess Latino adolescent health, examining risk and protective environmental factors in the context of social determinants of health and health disparities. Findings support use of photovoice in research and that nursing theory can advance the ecological model and understanding of environmental health influences on disparities and well-being.

Adolescentes latinos constituem um subgrupo que cresce rapidamente nos EUA. Disparidades entre os adolescentes latinos e a maioria da população de adolescentes nos EUA são evidenciadas por taxas de morbidade incluindo asma e depressão; fatores ambientais contribuem para estas tendências. Objetivo do estudo é descrever como as influências ambientais são percebidas por adolescentes imigrantes de origem mexicana. Pesquisa etnográfica orientada no referencial ecológico e interacionismo simbólico na condução de entrevistas individuais, observação participante, e narrativas visuais por meio de câmeras descartáveis. Quatorze participantes ?fotografaram suas vidas como adolescentes latinos imigrantes, focando a saúde?. Entrevistas e fotografias foram organizadas e analisadas utilizando o software Altas.ti® emergindo quatro temas: ?Lixo está em todos os lugares?, ?O trabalho me machuca?, ?O ar que respiramos?, e ?Relaxamento na natureza?. Os resultados demonstram a compreensão detalhada do risco e influências protetoras do ambiente na saúde. Enfermeiros podem utilizar os resultados reforçando a necessidade de avaliação integral da saúde do adolescente latino, examinando fatores de risco e proteção ambiental no contexto dos determinantes sociais de saúde e disparidades em saúde. Resultados sustentam uso da foto-voz em pesquisa e possibilidades de avanço nas teorias de enfermagem no modelo ecológico para compreender influências da saúde ambiental nas disparidades sociais.

Adolescentes latinos constituyen subgrupo que crece rápidamente en los EEUU. Disparidades entre adolescentes latinos y la mayoría de la población de adolescentes en EEUU son evidenciadas por índices de morbidez incluyendo asma y depresión; factores ambientales contribuyen para estas tendencias. Objetivo es describir como las influencias ambientales son percibidas por adolescentes inmigrantes de origen mexicana. Investigación etnográfica orientada por referencial ecológico e interacionismo simbólico en la conducción de entrevistas individuales, observación participante, y narrativas visuales por medio de cámaras descartables. Catorce participantes ?fotograbaran sus vidas como adolescentes latinos inmigrantes, centrando la salud?. Entrevistas y fotografías fueron organizadas e analizadas utilizándose el software Atlas.ti® emergiendo cuatro temas: ?la basura asta en todos lugares?, ?El trabajo machuca?, ?el aire que nosotros respiramos?, y ?relajamiento y naturaleza?. Los resultados demuestran comprensión detallada del riesgo e influencias protectoras del ambiente en la salud. Enfermeros pueden utilizar los resultados reforzando la necesidad de evaluación integral de la salud del adolescente latino, examinando factores de riesgo y protección ambiental en el contexto de los determinantes e disparidades sociales de salud. Sustentan el uso de la fotografía en investigaciones y posibilidades de avanzos en teorías de enfermería en el modelo ecológico para comprender influencias de la salud ambiental en las disparidades y bien estar social.