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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↗

PubMed2005

County level socioeconomic position, work organization and depression disorder: a repeated measures cross-classified multilevel analysis of low-income nursing home workers.

UNLABELLED: This study simultaneously tests the effect of county, organizational, workplace, and individual level variables on depressive disorders among low-income nursing assistants employed in US nursing homes. A total of 482 observations are used from two waves of survey data collection, with an average two-year interval between initial and follow-up surveys. The overall response rate was 62 percent. The hierarchically structured data was analyzed using multilevel modeling to account for cross-classifications across levels of data. Nursing assistants working in nursing homes covered by a single union in three states were asked about aspects of their working conditions, job stress, physical and mental health status, individual and family health-care needs, household economics and household strain. PARTICIPANTS: The 241 nursing assistants who participated in this study were employed in 34 nursing homes and lived in 49 counties of West Virginia, Ohio and Kentucky. MAIN RESULTS: The study finds that emotional strain, related to providing direct care to elderly and disabled clients, is associated with depressive disorder, as is nursing home ownership type (for-profit versus not-for-profit). However, when controlling for county level socioeconomic variables (Gini index and proportion of African Americans living in the county), neither workplace nor organizational level variables were found to be statistically significant associated with depressive disorder. CONCLUSIONS: This study supports previous findings that emotional demand in health-care environments is an important correlate of mental health. It also adds empirical evidence to support a link between financial strain and depression in US women. While this study does not find that lack of a seniority wage benefits--a factor that can conceivably exacerbate financial strain over time--is associated with depressive disorder among low-income health-care workers, it does find county level measures of poverty to be statistically significant predictors of depressive disorder. Longitudinal county level measures of low-income as predictors of depression may even offer a methodological advantage in that they are presumably more stable indicators of cumulative exposure of low income than are more transient workplace indicators. Incorporating measures of cumulative exposure to low income into empirical studies would be particularly timely given the global changes that are currently restructuring the labor force and influencing work organization and labor processes--most notably the growth in low income jobs and the deskilling of labor. Though this study provides evidence that workplace and organizational level variables are associated with depressive disorder among low-wage nursing assistants in US nursing homes, the fact that these relationships do not hold once county level measures of poverty are controlled for, suggests that more distal upstream determinants of workplace mental health problems, such economic inequality, may be at play in determining the mental health of low wage workers.

Adult↗

PubMed2006

Correlation between national income, HIV/AIDS and political status and mortalities in African countries.

OBJECTIVES: To investigate associations between mortalities in African countries and problems that emerged in Africa in the 1990s (reduction of national income, HIV/AIDS and political instability) by adjusting for the influences of development, sanitation and education. METHODS: We compiled country-level indicators of mortalities, national net income (the reduction of national income by the debt), infection rate of HIV/AIDS, political instability, demography, education, sanitation and infrastructure, from 1990 to 2000 of all African countries (n=53). To extract major factors from indicators of the latter four categories, we carried out principal component analysis. We used multiple regression analysis to examine the associations between mortality indicators and national net income per capita, infection rate of HIV/AIDS, and political instability by adjusting the influence of other possible mortality determinants. RESULTS: Mean of infant mortality per 1000 live births (IMR); maternal mortality per 100,000 live birth (MMR); adult female mortality per 1000 population (AMRF); adult male mortality per 1000 population (AMRM); and life expectancy at birth (LE) in 2000 were 83, 733, 381, 435, and 51, respectively. Three factors were identified as major influences on development: education, sanitation and infrastructure. National net income per capita showed independent negative associations with MMR and AMRF, and a positive association with LE. Infection rate of HIV/AIDS was independently positively associated with AMRM and AMRF, and negatively associated with LE in 2000. Political instability score was independently positively associated with MMR. CONCLUSIONS: National net income per capita, HIV/AIDS and political status were predictors of mortality indicators in African countries. This study provided evidence for supporting health policies that take economic and political stability into account.

Africa↗

PubMed2004

Beyond the income inequality hypothesis: class, neo-liberalism, and health inequalities.

This paper describes and critiques the income inequality approach to health inequalities. It then presents an alternative class-based model through a focus on the causes and not only the consequences of income inequalities. In this model, the relationship between income inequality and health appears as a special case within a broader causal chain. It is argued that global and national socio-political-economic trends have increased the power of business classes and lowered that of working classes. The neo-liberal policies accompanying these trends led to increased income inequality but also poverty and unequal access to many other health-relevant resources. But international pressures towards neo-liberal doctrines and policies are differentially resisted by various nations because of historically embedded variation in class and institutional structures. Data presented indicates that neo-liberalism is associated with greater poverty and income inequalities, and greater health inequalities within nations. Furthermore, countries with Social Democratic forms of welfare regimes (i.e., those that are less neo-liberal) have better health than do those that are more neo-liberal. The paper concludes with discussion of what further steps are needed to "go beyond" the income inequality hypothesis towards consideration of a broader set of the social determinants of health.

Adolescent↗

PubMed2002

Teen births, income inequality, and social capital: developing an understanding of the causal pathway.

Many studies have demonstrated a relationship between income inequality and poor health, but how does income inequality impact health? One possible explanation is that greater income inequality undermines social capital (social cohesion, civic engagement, and mutual trust in a community). We conducted path analyses of the relationship between income inequality, poverty, and teen birth rate, testing for the mediating effect of social capital in 39 US states. Birth rate was affected by both poverty and income inequality, though income inequality appeared to affect teen birth rate primarily through its impact on social capital.

Adolescent↗

PubMed2000

Using focus groups to develop a heart disease prevention program for ethnically diverse, low-income women.

Although low-income women have higher rates of cardiovascular disease (CVD) than higher-income women, health promotion and disease prevention are often low priorities due to financial, family, and health care constraints. In addition, most low-income women live in environments that tend to support and even promote high risk CVD behaviors. Low-income African-American, Hispanic, and White women constitute one of the largest groups at high risk for CVD but few heart disease prevention programs have effectively reached them. The purpose of this project was to use feedback from focus groups to generate ideas about how to best structure and implement future CVD intervention programs tailored to low-income populations. Seven focus groups were conducted with 51 low-income African-American, Hispanic, and White women from two urban and two agricultural communities in California. The women in the study shared many common experiences and barriers to healthy lifestyles, despite their ethnic diversity. Results of the focus groups showed that women preferred heart disease prevention programs that would address multiple CVD risk factors, emphasize staying healthy for themselves, teach specific skills about how to adopt heart-healthy behaviors, and offer them choices in effecting behavioral change. For health information, they preferred visual formats to written formats. They also expressed a desire to develop knowledge to help them separate health "myths" from health "facts" in order to reduce their misconceptions about CVD. Finally, they stressed that health care policies and programs need to address social and financial barriers that impede the adoption of heart-healthy behaviors.

Adult↗

PubMed1997

The influence of site of care on the content of prenatal care for low-income women.

OBJECTIVE: To assess whether site of prenatal care influences the content of prenatal care for low-income women. DESIGN: Bivariate and logistic analyses of prenatal care content for low-income women provided at five different types of care sites (private offices, HMOs, publicly funded clinics, hospital clinics, and other sites of care), controlling for sociodemographic, behavioral, and maternal health characteristics. PARTICIPANTS: A sample of 3405 low-income women selected from a nationally representative sample of 9953 women surveyed by the National Maternal and Infant Health Survey, who had singleton live births in 1988, had some prenatal care (PNC), Medicaid participation, or a family income less than $12,000/year. OUTCOME MEASURES: Maternal report of seven initial PNC procedures (individually and combined), six areas of PNC advice (individually and combined), and participation in the Women Infant Children (WIC) nutrition program. RESULTS: The content of PNC provided for low-income women does not meet the recommendations of the U.S. Public Health Service, and varies by site of delivery. Low-income women in publicly funded clinics (health departments and community health centers) report receiving more total initial PNC procedures and total PNC advice and have greater participation in the WIC program than similar women receiving PNC in private offices. CONCLUSIONS: Publicly funded sites of care appear to provide more comprehensive prenatal care services than private office settings. Health care systems reforms which assume equality of care across all sites, or which limit services to restricted sites, may foster unequal access to comprehensive PNC.

Adolescent↗

PubMed2006

The equivalence of the Child Behavior Checklist/1 1/2-5 across parent race/ethnicity, income level, and language.

This study examined the equivalence of the Child Behavior Checklist/1 1/2-5 (CBCL/1 1/2-5) in 682 parents of 2- to 4-year-old children stratified by parent race/ethnicity (African American, Latino, and non-Latino White), family income (low vs. middle-upper), and language version (Spanish vs. English). Externalizing Scale means differed by income and child gender. Internalizing Scale means differed by income and parent race/ethnicity. Differential item analyses showed that few items functioned differently by racial/ethnic, language, and income group. A confirmatory factor analysis demonstrated that the Externalizing Scale provided a good fit with the data across racial/ethnic and income groups. However, model fit was improved for the Internalizing Scale when factor weights were allowed to vary. Findings support the equivalence of the CBCL/1 1/2-5 when used with parents of low-income preschool children from African American and Latino backgrounds, although further study of the factor structure for the Internalizing Scale is recommended.

Adult↗

PubMed2005

Use and Impact of eHealth System by Low-income Women With Breast Cancer.

This article is the second of a two-part series reporting on a population-based study intended to use an eHealth system to examine the feasibility of reaching underserved women with breast cancer (Gustafson, McTavish et al., Reducing the digital divide for low-income women with breast cancer, 2004; Madison Center for Health Systems Research and Analysis, University of Wisconsin; Comprehensive Health Enhancement Support System [CHESS]) and determine how they use the system and what impact it had on them. Participants included women recently diagnosed with breast cancer whose income was at or below 250% of poverty level and were living in rural Wisconsin (n = 144; all Caucasian) or Detroit (n = 85; all African American). Because this was a population-based study all 229 participants received CHESS. A comparison group of patients (n = 51) with similar demographics was drawn from a separate recently completed randomized clinical trial. Use rates (e.g., frequency and length of use as well as type of use) as well as impact on several dimensions of quality of life and participation in health care are reported. Low-income subjects in this study logged on and spent more time on CHESS than more affluent women in a previous study. Urban African Americans used information and analysis services more and communication services less than rural Caucasians. When all low-income women from this study are combined and compared with a low-income control group from another study, the CHESS group was superior to that control group in 4 of 8 outcome variables at both statistically and practically significant levels (social support, negative emotions, participation in health care, and information competence). When African Americans and Caucasians are separated the control group's sample size becomes 30 and 21 thus reducing power. Statistical significance is retained, however, in all four outcomes for Caucasians and in two of four for African Americans. Practical significance is retained for all four outcomes. We conclude that an eHealth system like CHESS will be used extensively and have a positive impact on low-income women with breast cancer.

Breast Neoplasms↗

PubMed1987

The estimation of the health production function for low-income working men.

Health is an important variable that determines an individual's economic as well as noneconomic well-being. A healthy individual will be more productive, will contribute more toward a nation's economy, and, keeping other things constant, will have a better life overall than a sick individual. But for a low-income individual, health could be even more crucial since it could be a major factor in perpetuating his poverty. If, as a part of our social policy, we would want to improve the economic well-being of poor people, their health in general would need attention. This paper studies the production of health and the demand for medical care of low-income working men. Low-income working men are "medically indigent" because they are not eligible for Medicaid and are not adequately covered by insurance. This study provides insight into what role medical, preventive, and curative care--as well as other socioeconomic variables, such as income and education--plays in the production of the health of low-income men. It also shows the impact of price, income, and other control variables on the demand for medical care.

Adolescent↗

PubMed1992

Encouraging preventive services for low-income children. The effect of expanding Medicaid.

Every year since 1984, Congress has expanded Medicaid to cover an increasing proportion of low-income children. In this study, a multivariate analysis of data from the 1987 National Medical Expenditure Survey was used to determine whether expanded Medicaid eligibility is likely to be effective in encouraging recommended preventive visits for low-income, preschool children. For low-income children who would otherwise be uninsured, a full year of Medicaid increased the probability of any well-child visits by 17 percentage points, and compliance with the guidelines of the American Academy of Pediatrics for well-child visits increased by 13 percentage points. The generosity of Medicaid fees did not alter the magnitude of these effects. However, even if all uninsured children under 200% of the poverty line were eligible for Medicaid, low-income children would continue to lag behind other children in their use of preventive services. Factors other than insurance and income, such as the lower educational attainment of low-income mothers, explain approximately 80% of the gap between children above and below 200% of poverty. The rate of compliance with the American Academy of Pediatrics guidelines was less than 50% for all preschool children. Departures from the recommended schedule of visits were particularly pronounced in the second year of life and may interfere with children receiving the recommended immunizations in a timely manner.

Black or African American↗

PubMed2006

Out-of-pocket health spending between low-and higher-income populations: who is at risk of having high expenses and high burdens?

OBJECTIVE: We studied the effects of health insurance, health care needs, and demographic and area characteristics on out-of-pocket health care spending for low and higher income insured populations. MATERIALS AND METHODS: We used the 2002 National Survey of America's Families to analyze out-of-pocket health spending. People were classified into 3 levels of expenses based on their out-of-pocket health care spending and 3 levels of financial burden based on spending as a share of family income. We used a multinomial logit model to estimate the effect of insurance status and other factors on expense and burden levels. RESULTS: Public insurance appears to offer the best financial protection from high out-of-pocket expenses and financial burden for those who are eligible. Families with private nongroup coverage have the highest odds of being in the high-expense and high-burden categories for all incomes. For higher-income families, having a family member in fair or poor health is a significant risk factor for high out-of-pocket expenses and financial burden. Having higher penetration of health maintenance organizations in an area appears to lower the odds of being in the high-burden category for all families. CONCLUSIONS: Health insurance may not prevent people from having high health care spending. Low-income people with serious health needs appear to be financially constrained and spend less on health care relative to higher-income people, and the presence of health maintenance organizations may help reduce out-of-pocket health care spending.

Cost of Illness↗

PubMed1986

Incoming synapses and size of small granule-containing cells in a rat sympathetic ganglion after post-ganglionic axotomy.

A quantitative ultrastructural study has been made of the reaction of the incoming synapses of small granule-containing cells after axotomy of the major post-ganglionic branches of the superior cervical ganglion of the young adult rat. These cells are intrinsic and interneurone-like in this ganglion, receiving a preganglionic input and giving outgoing synapses to principal post-ganglionic neurones. Unlike their outgoing synapses, which are lost after post-ganglionic axotomy (Case & Matthews, 1986), the incoming synapses of the small granule-containing cells in axotomized ganglia increased in incidence post-operatively. The increase first became clearly evident 5-7 days post-operatively and was greater, being both more sustained and progressive, after bilateral than after unilateral axotomy. After bilateral axotomy the incidence of incoming synapses rose to more than four times that of normal ganglia and was still elevated at 128 days post-operatively, but was within normal limits at 390 days. After a unilateral lesion, increases of similar extent and time course to those in the axotomized ganglia were seen in the incoming synapses of small granule-containing cells in the uninjured contralateral ganglia. The incoming synapses of the small granule-containing cells are multifocal, i.e. show several points or active foci of synaptic specialization. The increase in synapses expressed itself both through an increased incidence of these synaptic active foci per nerve terminal and through an increase in the number of presynaptic nerve terminal profiles associated with the cells. Control observations indicated that the increase in synapses was not due to surgical stress, nor was it attributable solely to post-operative ageing. The nerve terminals which were presynaptic to the small granule-containing cells post-operatively were all of preganglionic origin: no incoming synapses or presynaptic nerve terminals remained at 2 days after a preganglionic denervation of axotomized or contralateral ganglia, at whatever stage this was performed throughout the range of survival intervals. There was some evidence that the synapses had increased by sprouting, including terminal sprouting, of the preganglionic nerve fibres. In the shorter term there was an increase in the proportion of small nerve terminal profiles. In the longer term the mean size of the terminal profiles increased, and very large terminals of unusual form were seen. After post-ganglionic axotomy, and in particular after a bilateral lesion, the small granule-containing cells became hypertrophied.(ABSTRACT TRUNCATED AT 400 WORDS)

Animals↗

PubMed2004

Multimodal treatment for ADHD among youths in three Medicaid subgroups: disabled, foster care, and low income.

OBJECTIVE: This study compared the use of treatments for attention-deficit hyperactivity disorder (ADHD) among three distinct subpopulations of Medicaid-insured youths who have very different mental health needs and patterns of service use: those with federally documented disability, those in foster care, and those in families with low income. METHODS: This one-year, cross-sectional study of community mental health services used administrative data. Individuals who were younger than 20 years, who were continuously enrolled in one Mid-Atlantic state Medicaid program, and who had two or more medical encounters associated with an ADHD diagnosis in 1998 were identified (N=1,296). Measures of the use of mental health services were the number of different classes of psychopharmacologic medications, the psychopharmacologic regimen, and the combined use of pharmacotherapy and psychotherapy treatments (multimodal treatment). RESULTS: Use of multiple psychopharmacologic agents was greater in the disabled and foster care groups compared with the low-income group. Significantly fewer mental health provider visits, but greater use of stimulant treatment only, were observed in the low-income group compared with the other groups. Youths in the disabled group were significantly more likely than youths in the low-income group, but not more likely than youths in the foster care group, to receive multimodal treatments. Children in foster care were significantly more likely than those in the other groups to use a substance abuse service. CONCLUSIONS: Among a cohort of Medicaid-enrolled youths with ADHD, co-existing psychiatric disorders and complex psychopharmacologic treatments were more common in the disabled and foster care groups than in the low-income group. Youths with disabilities were significantly more likely than youths in the low-income group to receive multimodal treatment.

Adolescent↗

PubMed2005

The status of low-income families in the post-welfare reform environment: mapping the relationships between poverty and family.

Low-income families face an enormous burden to achieve economic security since the deterioration of a guaranteed safety net. Health insurance coverage is uneven, affordable childcare falls short of demand, and wage earnings insufficiently support family needs. This analysis focuses on recent trends in family formation, the impact of policy changes on families of color and of immigrant status, and explores the daily challenges and coping strategies low-income families use to survive despite insufficient resources. Four key findings emerge from this body of knowledge: (1) Low-income families experience severe hardships when relying on cash assistance, work, or a combination of both; (2) Low-income families are resilient and resourceful; (3) Low-income families face significant barriers to using public and private services along with increasing earnings from work; and (4) The quality of life for families of color and immigrant families is directly affected by employment and service sector practices. Future research needs to focus on identifying the critical unmet needs of low-income families.

Adaptation, Psychological↗

PubMed2006

Targeting interventions for ethnic minority and low-income populations.

Although rates of childhood obesity among the general population are alarmingly high, they are higher still in ethnic minority and low-income communities. The disparities pose a major challenge for policymakers and practitioners planning strategies for obesity prevention. In this article Shiriki Kumanyika and Sonya Grier summarize differences in childhood obesity prevalence by race and ethnicity and by socioeconomic status. They show how various environmental factors can have larger effects on disadvantaged and minority children than on their advantaged white peers-and thus contribute to disparities in obesity rates. The authors show, for example, that low-income and minority children watch more television than white, non-poor children and are potentially exposed to more commercials advertising high-calorie, low-nutrient food during an average hour of TV programming. They note that neighborhoods where low-income and minority children live typically have more fast-food restaurants and fewer vendors of healthful foods than do wealthier or predominantly white neighborhoods. They cite such obstacles to physical activity as unsafe streets, dilapidated parks, and lack of facilities. In the schools that low-income and minority children attend, however, they see opportunities to lead the way to effective obesity prevention. Finally, the authors examine several aspects of the home environment-breast-feeding, television viewing, and parental behaviors-that may contribute to childhood obesity but be amenable to change through targeted intervention. Kumanyika and Grier point out that policymakers aiming to prevent obesity can use many existing policy levers to reach ethnic minority and low-income children and families: Medicaid, the State Child Health Insurance Program, and federal nutrition "safety net" programs. Ultimately, winning the fight against childhood obesity in minority and low-income communities will depend on the nation's will to change the social and physical environments in which these communities exist.

Adolescent↗

PubMed1999

Access to care for low-income women: the impact of Medicaid.

This study was undertaken to assess how low-income women with Medicaid, private insurance, or no insurance vary with regard to personal characteristics, health status, and health utilization. Data are from a telephone interview survey of a representative cross-sectional sample of 5,200 low-income women in Minnesota, Oregon, Tennessee, Florida, and Texas. On the whole, low-income women were found to experience considerable barriers to care; however, uninsured low-income women have significantly more trouble obtaining care, receive fewer recommended services, and are more dissatisfied with the care they receive than their insured counterparts. Women on Medicaid had access to care that was comparable with their low-income privately insured counterparts, but in general had significantly lower satisfaction with their providers and their plans. Future federal and state efforts should focus on expanding efforts to improve the scope and reach of health care coverage to low-income women through public or private means.

Adolescent↗

PubMedDate not supplied

Measuring health status and quality of life for US children: relationship to race, ethnicity, and income status.

OBJECTIVE: Accurately measuring the health of the increasingly diverse population of US children requires instruments that are comparable and valid across cultures, economic background, and language. This paper asks: Has the field of pediatric health status measures reached this level of comprehensiveness? METHODS: Children's health status and quality of life measures commonly used in the United States were reviewed to assess how they have included racial/ethnic minority and low-income groups. Four generic and 2 condition-specific instruments (asthma) were examined for total sample size, percent of sample from racial/ethnic and low-income groups, language availability, translation methods for US-Spanish, reading level, and separately reported psychometric findings and outcomes/scores. RESULTS: Most measures have included minority groups, usually African American or Hispanic children, although with little information by Hispanic subgroup. Children's measures have generally been tested on relatively small samples, without separate analyses by subgroups. When done, tests of reliability and validity find few differences from the general population. Some studies report information on health by racial or ethnic group, but the findings are inconclusive. Economic status is usually measured in some way, but rarely are psychometric findings examined separately by income. When differences in health outcome are reported by income, lower income children usually have poorer health. CONCLUSIONS: Much has been accomplished in advancing health status measures for children. Next-generation issues include the influence of race, ethnicity, and income on health and health reports.

Child↗