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Biomedical subjects

L Gelberg

Publications and source records attributed to L Gelberg.

At least 19 recordsLinked to original sources
PubMed1998

The smoking gun: do clinicians follow guidelines on firearm safety counseling?

OBJECTIVES: To describe clinicians' behavior regarding firearm safety counseling practices, develop a model to predict current counseling behavior, and identify resources that might positively influence willingness to counsel according to medical guidelines. DESIGN: Four hundred sixty-five primary care Los Angeles County, California, pediatricians, family physicians, and pediatric nurse practitioners who serve families with children aged 5 years and younger received mailed questionnaires; 325 (70%) responded. MAIN OUTCOME MEASURE: Clinician self-reported behavior. RESULTS: Of the respondents, 80% stated that they should counsel on firearm safety; only 38% do so. Of those clinicians who currently counsel, only 20% counsel more than 10% of their patient families. Firearm safety counseling behavior is positively associated with a clinician being 49 years or younger (odds ratio [OR]=2.19, P=.02); a perception that counseling is beneficial (OR=2.62, P=.02); and household handgun ownership (OR=2.47, P=.02). Clinician households that report gun ownership counsel differently than those clinicians who report not possessing a household gun. There are no significant differences in the rates of counseling across specialties and crime area types. Forty-one percent of clinicians report that patient education handouts would increase their likelihood of counseling. CONCLUSIONS: In Los Angeles County gaps exist between clinicians' views of the benefits of counseling families with young children regarding firearm safety and their actual behavior. Guidelines and handouts are available from major medical organizations. Research should focus on how to get practitioners to use available materials, enabling them to better adhere to guidelines.

Adult↗
PubMed1998

Tuberculosis in homeless patients: potential for case finding in public emergency departments.

STUDY OBJECTIVES: Previous studies have had difficulty evaluating the optimal clinical site for screening homeless patients for active tuberculosis (TB). We hypothesized that homeless patients with TB would not frequently reside in shelters at the time of their diagnosis and would be more likely than other patients with TB to seek care in public hospitals, thus presenting an opportunity for screening radiography. METHODS: This registry-based survey included 743 consecutive patients with confirmed active TB in Los Angeles County. No therapeutic intervention was involved. RESULTS: When compared with patients with TB who were not homeless, homeless patients with TB were more likely to be male (93% versus 63%, P<.001), black (44% versus 15%, P<.001), living in the inner city (55% versus 7%, P<.001), and born in the United States (67% versus 32%, P<.001). They were more infectious than other patients with TB as evidenced by a trend toward more cavitary radiographic lesions (24% versus 16%, P=.11) and significantly more positive sputum smears (56% versus 41%, P=.009). Less than a third lived in congregate facilities such as shelters at the time of their diagnosis. Instead, their disease was diagnosed more often at county hospitals (54% versus 23%, P<.001) than patients with TB who were not homeless. CONCLUSION: Widespread screening for TB in shelters may miss most homeless patients with TB. Because most county-hospital homeless patients with TB initially present to emergency departments and many do not live in shelters, future cost-effectiveness studies should evaluate chest radiograph screening for all homeless ED patients.

Adult↗
PubMed1998

Why do symptomatic patients delay obtaining care for tuberculosis?

The resurgence of tuberculosis (TB) has coincided with deteriorating access to care for high-risk populations. We sought to determine what perceived access barriers delayed symptomatic TB patients from obtaining care. In order to do this, we conducted a survey in Los Angeles County, California, using a consecutive sample of patients with active TB as confirmed by the county TB control authority. The measures used in the study were a self-reported delay in seeking care of more than 60 d from symptom onset, a period sufficient to cause skin-test conversion in exposed contacts, and self-reported access barriers. The county TB registry provided supplementary clinical data. We found that one in five of the 248 symptomatic respondents (response rate: 60%) delayed obtaining care for > 60 d (mean = 74 d, SD = 216 d). During the delay, patients exposed an average of eight contacts. As compared with the rest of the sample, delay was more common in those who were unemployed (25% versus 14%), concerned about cost (27% versus 14%), anticipated prolonged waiting-room time (26% versus 14%), believed they could treat themselves (31% versus 14%), anticipated difficulty in getting an appointment (28% versus 16%), were uncertain about where to get care (33% versus 16%), and feared immigration authorities (47% versus 18%) (p < 0.05). Logistic regression revealed that uncertainty about where to get care, unemployment, and belief in the efficacy of self-treatment independently predicted delay > 60 d. Illness severity as measured by chest radiography, sputum smears, and symptoms had little impact on delay. We conclude that because access variables such as lack of employment and knowledge about where to obtain care were more closely associated with clinically significant delay than was severity of illness, these results raise concerns about the equity of access to care among TB patients. The results suggest that improving the availability of services for high-risk groups may substantially reduce TB patients' delay in obtaining care, and thus may limit the spread of the disease.

Adult↗
PubMed1997

Comparability and representativeness of clinical homeless, community homeless, and domiciled clinic samples: physical and mental health, substance use, and health services utilization.

Evaluating the representativeness of homeless samples is important for generalizing research findings on the homeless and designing interventions targeting their health needs. The present study contrasts homeless and domiciled free-clinic users (216 homeless [132 men, 84 women], 212 domiciled [102 men, 110 women]) and 531 community homeless persons (388 men, 143 women) on latent variables representing substance use, mental and physical health, appearance, life satisfaction, and health services utilization (HSU). Homeless clinic patients equalled the community sample in substance abuse and psychological problems but exceeded the sample in HSU and cleanliness. Homeless clinic users reported more substance abuse, poorer health, greater mental illness and mental HSU, less cleanliness, and lower life satisfaction than domiciled patients. Relationships among the variables are reported, and implications concerning health needs among the homeless are discussed.

Adult↗
PubMed1997

Tuberculosis skin testing among homeless adults.

OBJECTIVE: To document the prevalence of tuberculosis (TB) skin test positivity among homeless adults in Los Angeles and determine whether certain characteristics of homelessness were risk factors for TB. DESIGN: Cross-sectional study. SETTING: Shelters, soup lines, and outdoor locations in the Skid Row and Westside areas of Los Angeles. PARTICIPANTS: A representative sample of 260 homeless adults. MEASUREMENTS AND MAIN RESULTS: Tuberculosis tine test reactivity was measured. The overall prevalence of TB skin test positivity was 32%:40% in the inner-city Skid Row area and 14% in the suburban Westside area. Using multiple logistic regression, TB skin test positivity was found to be associated with living in crowded or potentially crowded shelter conditions, long-term homelessness, geographic area, history of a psychiatric hospitalization, and age. CONCLUSIONS: Homeless adults living in congested inner-city areas are at high risk of both latent and active TB. Endemic risk factors and limited access to medical care support the need for aggressive treatment of active TB cases and innovative programs to ensure completion of prophylactic regimens by homeless individuals with latent infection.

Adult↗
PubMed1997

Reliability, validity, and composition of a subset of the Centers for Disease Control and Prevention acquired immunodeficiency syndrome knowledge questionnaire in a sample of homeless and impoverished adults.

OBJECTIVES: Measures of acquired immunodeficiency syndrome (AIDS)-related knowledge that have good psychometric properties are needed to evaluate the impact of educational interventions, particularly among impoverished populations. Few measures that satisfy these requirements are available. The authors describe the psychometric characteristics and composition of a subset of 21 AIDS knowledge items from the questionnaire used by the National Center for Health Statistics. METHODS: The study was conducted with a convenience sample of women and their significant others or close friends in nine homeless shelters and 11 residential drug recovery programs in the skid row area of Los Angeles from 1991 to 1993. Trained nurses and outreach workers collected data from 486 predominately African-American adults before delivery of well-established, culturally sensitive AIDS educational intervention. A subset of 334 participants were re-interviewed 6 months later. RESULTS: A total scale score was calculated from a one-factor solution, and two subscale scores were formed based on a two-factor solution. One subscale was composed of primarily cognitive items, whereas the second subscale contained mainly transmission-related items. The internal consistency reliability of the overall scale was 0.89; the two subscales had alphas of 0.80 and 0.92. The measures have face validity, and support for convergent validity was found. Further, even though AIDS knowledge in the sample was relatively high, all three measures showed marked improvement in the subsample of respondents who were re-interviewed after receiving AIDS-related educational information. CONCLUSIONS: These measures show promise for assessing AIDS knowledge and the efficacy of AIDS education programs in vulnerable populations. The findings reported here, however, are preliminary. Test-retest reliability needs to be examined, and additional studies are needed with samples that are more culturally diverse and include socially isolated individuals.

Acquired Immunodeficiency Syndrome↗
PubMed1997

Determinants of regular source of care among homeless adults in Los Angeles.

OBJECTIVES: The authors explore the determinants of having a regular source of care in a community-based probability sample of homeless adults in Los Angeles. Results from this study should be more representative than those from previous studies of the homeless that are clinic- or shelter-based. In addition to those factors found to be barriers to regular sources of care in the general population, we hypothesized that psychosocial characteristics of the homeless and the homeless lifestyle would negatively impact their likelihood of having a regular source of care. METHODS: The authors conducted a multiple logistic regression to predict regular source of care among the homeless, using an adaptation of the Behavioral Model of health services utilization as an analytic framework. RESULTS: Fifty-seven percent of the sample reported that they had a regular source of care. Of those with a source of care, 30% reported a hospital outpatient department; 25% reported a community or homeless clinic; 23% reported a hospital emergency room; 14% reported a government clinic; and 9% reported a private physician's office as their source of care. Some factors found to be barriers to having a regular source of care in the general population (male, Hispanic, young age) also were barriers among homeless adults. Additional barriers in this sample included homelessness-related characteristics such as competing needs, long-term homelessness, and social isolation. Chronic mental illness and chronic substance dependence were not related to having a source of care among the homeless. Characteristics that increased the likelihood of having a regular source of care in the general population (poor health status, Medicaid) were not related to having a regular source of care among the homeless. CONCLUSIONS: In a context of limited resources, the distribution of regular source of care among the homeless appears to be highly inequitable. Although some of the characteristics identifying those with a regular source of care suggest differential patterns of behavior across subgroups, others suggest differential advantage in access to care and a lack of fit between the needs of the homeless and the organization of health services.

Adolescent↗
PubMed1997

Testing for human immunodeficiency virus infection among tuberculosis patients in Los Angeles.

To investigate patterns of testing for human immunodeficiency virus (HIV) infection in tuberculosis patients, we obtained data from the tuberculosis registry and from medical records of 500 tuberculosis patients in Los Angeles County. Sixty-three percent of tuberculosis patients were tested for HIV infection, and multivariate logistic regression analysis revealed that the likelihood of testing was significantly higher among males, persons between 20 and 49 yr old, individuals with HIV risk factors, and patients treated by public health care providers. A minimum of 12% of the total sample, 2% of females, 2% of those outside the ages of 20 to 49, 7% of patients without recorded HIV risk factors, and 17% of patients treated by private practitioners were infected with HIV. These results suggest that health care providers, particularly private practitioners, do not follow national recommendations for universal HIV testing of tuberculosis patients. Instead, HIV testing is preferentially performed on patients perceived to be at high risk for HIV infection. Because HIV seroprevalence is at least 2 to 7% in "low-risk" groups, failure to test these patients may result in significant missed opportunities for diagnosis and treatment of HIV coinfection.

AIDS Serodiagnosis↗
PubMed1997

Competing priorities as a barrier to medical care among homeless adults in Los Angeles.

OBJECTIVES: The role of competing priorities as a barrier to the utilization of physical health services was assessed in a subset (n = 363) of a probability sample of homeless adults in Los Angeles. METHODS: Unadjusted odds of four measures of health services utilization were calculated for those with frequent difficulty in meeting their subsistence needs. These odds were then adjusted for a range of characteristics assumed to affect the utilization of health services among the homeless. RESULTS: Before and after adjustment, those with frequent subsistence difficulty were less likely to have a regular source of care (odds ratio [OR] = 0.30, 95% confidence interval [CI] = 0.16, 0.53) and more likely to have gone without needed medical care (OR = 1.77, 95% CI = 1.04, 3.00). Subsistence difficulty had no impact on the likelihood of having an outpatient visit or having been hospitalized. Conclusions remained the same after adjustment. CONCLUSIONS: Frequent subsistence difficulty appears to be an important nonfinancial barrier to the utilization of health services perceived as discretionary among homeless adults.

Adolescent↗
PubMed1996

Physician role conflict and resulting career changes. Gender and generational differences.

OBJECTIVE: To evaluate gender and generational differences both in the prevalence of role conflict and in resulting career changes among married physicians with children. STUDY DESIGN: Cross-sectional survey. PARTICIPANTS: We sent a survey to equal numbers of licensed male and female physicians (1,412 total) in a Southern California county; of the 964 delivered questionnaires, 656 (68%) were returned completed. Our sample includes 415 currently married physicians with children, 64% male and 36% female. MEASUREMENTS AND MAIN RESULTS: The prevalence of perceived role conflict, or career changes for marriage, and of career changes for children were evaluated. Types of career changes were also evaluated. More female than male physicians (87% vs 62%, p < .001) and more younger than older female physicians (93% vs 80%, p < .01) and male physicians (79% vs 54%, p < .001) experienced at least moderate levels of role conflict. Younger female and male physicians did not differ in their rates of career change for marriage (57% vs 49%), but female physicians from both age cohorts were more likely than their male peers to have made career changes for their children (85% vs 35%, p < .001). Younger male physicians were twice as likely as their older peers to have made a career change for marriage (49% vs 28%, p < .001) or children (51% vs 25%, p < .001). The most common type of career change made for marriage or children was a decrease in work hours. CONCLUSIONS: Most physicians experience role conflict, and many adjust their careers in response. Flexible career options may enable physicians to combine professional and family roles more effectively.

Adult↗
PubMed1996

Ambulatory health services provided to low-income and homeless adult patients in a major community health center.

OBJECTIVE: The homeless are more likely than other poor and vulnerable populations to manifest serious health problems. Early research focused on needs assessments of this population; current work has shifted to examine issues of access, use of health services, and barriers to care. However, current research has not examined whether model clinics designed for the homeless have created parity with their low-income domiciled peers in terms of provision of ambulatory services. Such data are increasingly in demand as managed care looms just over the political horizon as a means of providing services to low-income patients. SETTING: A major community ambulatory health center in West Los Angeles. PATIENTS: Homeless (N = 210) and low-income domiciled (N = 250) patients. DESIGN: A medical record review of care provided over a one-year period to homeless and low-income domiciled adult patients in a major community ambulatory health center in West Lost Angeles was conducted. Data were collected on length of visits, laboratory tests, procedures, and services, immunizations, specialty clinic referrals, medications, and travel vouchers. RESULTS: On average, homeless patients were provided with as many outside laboratory tests per patient as low-income domiciled patients (1.1 vs 1.3). Further, they returned for more visits (3.4 vs 2.9), were more likely to have had longer visits (88% vs 61%), and were provided with more laboratory tests (2.3 vs 1.7), procedures and services (3.1 vs 1.1), referrals (1.3 vs 0.7), medications (4.4 vs 3.3), and travel vouchers (0.6 vs 0.2) (all p < .01). Many of the procedures and services received by the homeless were for nonmedical assistance. Preventive health services such as tuberculosis skin tests, sexually transmitted disease (STD) screening, and Pap tests were provided to both homeless and domiciled patients at low rates. CONCLUSIONS: Findings from this study on the provision of care in a major West Los Angeles community health center indicate that homeless patients receiving care from a model program designed to address their special needs will return for follow-up visits and will utilize services at least as much as low-income domiciled patients.

Adult↗
PubMed1996

The role of patient participation in the doctor visit. Implications for adherence to diabetes care.

For patients, treatment of diabetes involves complex changes in basic behaviors and adherence to complicated regimens. Understanding the factors that enable patients to adhere to diabetes treatment is the first step to designing effective interventions. Researchers of diabetes care have postulated that increasing diabetic patients' participation in medical decision making during the doctor visit is likely to improve their adherence to self-care. However, a critical review of the impact of patient participation on diabetic patients adherence to self-care is absent from the literature. We review the subject of patient participation in medical decision making and its effect on adherence to self-care for patients with diabetes. We introduce a model of the determinants of adherence to diabetes self-care that incorporates the effects of patient participation in medical decision making. In this model, we suggest three ways that patient participation can affect adherence to self-care: 1) it may have a direct effect; 2) it may affect adherence to self-care indirectly by affecting patients' understanding of their treatment regimen or the fit of their regimen with their lifestyle; and 3) perceived omissions of participation can affect adherence to self-care indirectly through an effect on patient satisfaction. Research is needed to identify more clearly which components of patient participation affect adherence to self-care and in what ways. Distinguishing patient and physician behaviors that contribute to the process of patient participation would provide a means to develop specific behavioral interventions.

Decision Making↗
PubMed1996

Homing in on the homeless: assessing the physical health of homeless adults in Los Angeles County using an original method to obtain physical examination data in a survey.

OBJECTIVE: Public policy that decreases the finding for social services may combine with the ascendancy of corporate managed care to increase the health care deficit. Assessing the health impact of these policy changes on various populations is a fundamental challenge for health services research. Disadvantaged populations, such as the homeless, are likely to be affected disproportionately. Research quality data on the physical health of such populations are difficult and expensive to obtain. In particular, physical examination data have not been available and self-reports are insufficient. Our objective: to develop and utilize a structured physical exam system enabling lay survey researchers to report reliably physical findings related to six tracer conditions in a disadvantaged population. STUDY SETTING: A field survey of homeless adults in Los Angeles County, California. Respondents were 363 homeless adults representing a subsample of a probability sample of the county's homeless adult population. STUDY DESIGN: We integrated existing measures with expert clinical opinion and original means of data collection into a structured physical exam enabling lay interviewers to identify the prevalence of vision problems, significant skin disorders, peripheral vascular disease of the lower extremities, selected podiatric disorders, hypertension, and tuberculosis in a sample of homeless adults. PRINCIPAL MEASURES: We describe lay interviewer performance in terms of mastery of the necessary material based on written and practical exams and in terms of the number of respondents successfully followed. We base our description of the instrument on the time necessary to complete it, and on the proportion of each component successfully completed during the field survey, as well as on interrater reliability. We report the prevalence of the various clinical conditions according to self-report and according to the structured limited physical exam, as well as the marginal proportion of respondents who were identified by the physical exam and not by self-report. PRINCIPAL FINDINGS: Interviewers performed the exam successfully under field conditions. Respondent acceptance of the instrument was high. Interrater agreement was 100 percent regarding the need for referral on the basis of blood pressure and vision. Kappa statistics for skin, foot, and edema findings were .67,.71, and .81, respectively. Adjusted for sampling weights, 60 percent of this population required referral for at least one of the specified conditions. For those portions of the survey for which both self-report and physical exam data were available, lay interviewers made significant percentages of referrals on the basis of physical findings alone. CONCLUSIONS: High blood pressure, poor vision, peripheral vascular diseases of the feet and legs, and significant skin conditions are prevalent among the homeless in Los Angeles County. Without physical exam data, estimates of the prevalence of these conditions will be incorrect. Researchers can use laypersons to collect reliable and valid physical exam data on disadvantaged populations. This represents a new tool for assessing and monitoring the health of these populations.

Adult↗
PubMed1995

Homeless veterans' utilization of medical, psychiatric, and substance abuse services.

This study focuses on the association between homeless veterans' prior utilization of medical, psychiatric, and substance abuse services and biopsychosocial characteristics reported at admission into a domiciliary care program. Given the large number of veterans in the US homeless population and their health care needs, understanding factors associated with health service use among homeless veterans is significant. Research participants were 429 homeless male veterans who had been admitted to the Domiciliary Care for Homeless Veterans Program site at the West Los Angeles Veterans Affairs Medical Center between February 1988 and July 1992 for treatment of medical, psychiatric, or substance disorders. Results of logistic regression analyses indicated that self-reported need (chronic medical problems, serious psychiatric symptoms, combat stress, alcohol use) and evaluated need for care (evidence of liver dysfunction) were important to veterans' use of health services in the 6 months before program admission. Predisposing social structure factors (education, residential stability, and usual sleeping place) were also significant predictors of service utilization. Overall, need factors were more strongly related to service use. Supplementary logistic regression analyses indicated that comorbidity of need factors deserves attention in understanding homeless veterans' use of services. In conclusion, it is important to attend to predisposing social structure factors as potential barriers to care for homeless veterans.

Comorbidity↗
PubMed1995

Characteristics associated with the risk of unintended pregnancy among urban homeless women: use of the Shuler Nurse Practitioner Practice Model in research.

In this pilot study, family planning practices and risk for unintended pregnancy among 50 homeless women residing in the downtown area of Los Angeles were investigated through the retrospective analysis of data collected through a wholistic clinic intake questionnaire. Those women who were least likely to use a birth control method in this study were Black, used cocaine daily, had multiple sources of emotional support, were satisfied with their sex lives, and reported access problems to family planning services (p < or = .05). Furthermore, over half of the total sample was at risk for unintended pregnancy. These at risk women were more likely to be separated from their children (p < or = .05), report current (p < or = .05) and past (p < or = .01) drug problems, have multiple sex partners (p < or = .001), engage in prostitution (p < or = .01), have a past history of sexually transmitted diseases (p < or = .05), and were least likely to be satisfied with their sex lives (p < or = .05). The findings suggest that homeless women are in great need of family planning health services, and that such services should be combined with vocational, social service, and drug treatment programs.

Adult↗
PubMed1994

Evaluating generalist education programs: a conceptual framework. Generalist program evaluation working group.

This paper provides and applies a conceptual framework and a list of guiding principles for evaluation of generalist education programs. Programs are systematic efforts to achieve specified objectives. Evaluations gather data in order to improve or appraise programs and have a continuum of purposes and methods. Descriptive evaluations characterize the structures, processes, and outcomes of programs; research evaluations definitively assess the effectiveness of a program in terms of outcomes. Intermediate outcomes are changes in knowledge, attitudes, and skills of program participants; conclusive outcomes reflect the quality of performance of graduates in actual clinical situations. Outcomes are affected by inputs--the qualities of students entering the program. Guiding principles of program evaluation ensure that data gathered are useful. The authors illustrate the guiding principles with an actual pilot study that determined that expert pediatricians, general internists, and family practitioners could agree on key generalist competencies and that explores evaluation design based on these competencies. Finally, they consider the implications of undertaking generalist education evaluation.

Adult↗