Disparities In Delivery Of Services Research Articles

Health disparities in service delivery in the intensive care unit: A critical ethnographic study.

The intensive care unit has structural complexities, and critically ill patients are exposed to disparities. Thus, the intensive care unit can be a potential health disparity setting. This study explored cultural knowledge associated with health disparities in the intensive care unit. This critical ethnographic study was conducted using Carspecken's approach. It was carried out in intensive care units in Western Iran from 2022 to 2023. Data collection and analysis were conducted in three interconnected stages. The initial stage involved over 300 h of field observation. In the subsequent stage, a horizon analysis was performed. Conversations with 17 informants were recorded in the final stage to enrich the dataset further. Then, the analysis process was carried out as in the previous step to uncover an implicit culture of health disparity. This research revealed the following themes: (a) extension of the impact of political, social, and cultural powers, (b) being influenced by individual diversity, (c) balancing services based on the consideration of benefits and consequences, (d) departure from professional behaviour and (e) insufficient organizational discipline. The findings of this study showed that individual diversity, political, social and cultural powers within a context of insufficient organizational discipline, and departure from professional behaviour influence the service delivery culture in the intensive care unit. Moreover, the benefits and consequences of service delivery impact its execution. These stereotypes have the potential to contribute to the emergence of health disparities. Cultural transformation is challenging because of deep-rooted stereotypes, but the reduction of disparities is possible through awareness, critical self-reflection and cultural competence. The findings of this research can prompt staff self-reflection in situations prone to disparities. Health leaders can use these findings to shape health policies at both macro and micro levels.

Vocational Rehabilitation Service Receipt, Service Expenditures, and Ruralness.

An important factor embedded within Vocational Rehabilitation (VR) delivery capacity relates to geography, such as distance from the VR office and availability of service providers or community rehabilitation programs. We explored receipt of VR job search and placement services based on distance to an urban center, demographic, and disability variables after controlling for local employment conditions. Using 2015 RSA-911 case services data, we used probit to produce estimates for each combination of service and service source (agency and purchased), and Ordinary Least Squares (OLS) and semi-parametric regression to estimate log expenditures for each service category. Being Black or living at a long distance from a metro area increased the probability of receiving agency-based services but lowered the probability of receiving purchased services. Conversely, being older and having less education lowered the probability of receiving agency services but increased the probability of receiving purchased services. Females, Blacks, and those living at a distance greater than 50 miles from a metro area received significantly lower expenditures. Systematic differences in the types of services provided call for more in-depth analysis to ensure that policies and procedures are in place to minimize sociodemographic disparities in service delivery and outcomes.

Managerial Roles as a Strategy Implementation Driver and Performance of the National Government Departments in Kenya

Performance in most of the departments in the National Government of Kenya has remained average over years resulting in disparities in service delivery. This study examined the influence of managerial roles on the performance of the departments moderated by stakeholder involvement. Drawing from the data collected from National Government heads of departments in the Counties, the study concluded that managerial roles significantly influence the performance of the departments and is significantly moderated by the stakeholder involvement. The study has significant implication on the work performance management and stakeholder management policies.

Association between timing and type of postnatal care provided with neonatal mortality: A large scale study from India.

ObjectivesThis study examines the association between quality Postnatal Care (PNC) considering timing and providers’ type on neonatal mortality. The aim extends to account for regional disparities in service delivery and mortality including high and non-high focus states.MethodsEver-married women aged 15–49 years (1,87,702) who had delivered at least one child in five years preceding the survey date surveyed in National Family Health Survey (2015–16) were included in the study. Neonatal deaths between day two and seven and neonatal deaths between day two and twenty-eight were considered dependent variables. Descriptive statistics and multivariate regression analysis were conducted.ResultsChances of early neonatal mortality were 29% (OR = 0.71; 95%CI: 0.59–0.84) among newborns receiving PNC within a day compared to ones devoid of it while 40% (OR: 0.60; 95%CI: 0.51–0.71) likelihood for the same was noted if PNC was delivered within a week. Likelihood of neonatal mortality decreased by 24% (OR: 0.76; 95%CI: 0.65–0.88) when skilled PNC was delivered within 24 hours. Receiving quality PNC by skilled providers within a day in a non-high focus state decreased the chances of neonatal mortality by 26% (OR: 0.74; 95%CI: 0.59–0.92) compared to ones who did not receive any PNC.ConclusionsNeonatal deaths were significantly associated with socioeconomic and contextual characteristics including age, education, household wealth, social group and region. Timing of PNC delivered and by a skilled healthcare provider was found significant in reducing neonatal mortality.

Primary Healthcare Quality in Conflict and Fragility: a subnational analysis of disparities using Population Health surveys

BackgroundRecent global reports highlighted the importance of addressing the quality of care in all settings including fragile and conflict-affected situations (FCS), as a central strategy for the attainment of sustainable development goals and universal health coverage. Increased mortality burden in FCS reflects the inability to provide routine services of good quality. There is also paucity of research documenting the impact of conflict on the quality of care within fragile states including disparities in service delivery. This study addresses this measurement gap by examining disparities in the quality of primary healthcare services in four conflict-affected fragile states using proxy indicators.MethodsA secondary analysis of publicly available data sources was performed in four conflict-affected fragile states: Cameroon, the Democratic Republic of Congo, Mali, and Nigeria. Two main databases were utilized: the Demographic Health Survey and the Uppsala Conflict Data Program for information on components of care and conflict events, respectively. Three equity measures were computed for each country: absolute difference, concentration index, and coefficients of mixed-effects logistic regression. Each computed measure was then compared according to the intensity of organized violence events at the neighborhood level.ResultsOverall, the four studied countries had poor quality of PHC services, with considerable subnational variation in the quality index. Poor quality of PHC services was not only limited to neighborhoods where medium or high intensity conflict was recorded but was also likely to be observed in neighborhoods with no or low intensity conflict. Both economic and educational disparities were observed in individual quality components in both categories of conflict intensity.ConclusionEach of the four conflict-affected countries had an overall poor quality of PHC services with both economic and educational disparities in the individual components of the quality index, regardless of conflict intensity. Multi-sectoral efforts are needed to improve the quality of care and disparities in these settings, without a limited focus on sub-national areas where medium or high intensity conflict is recorded.

Future of statistics for Africa: Statistics that leave no one behind, the example of making birth registration in Nigeria more inclusive

The RapidSMS is an online database system which was introduced in Nigeria in 2011 as an open source software tool for monitoring birth registration process. The innovation allows real-time tracking of the local government and regional birth registration activities with the core machinery being registration at the local levels. Birth registrars are reporting aggregated numbers and registration disaggregated in four age groups < 1, 1–4, 5–9, 10–17 by sex, geographical location and by registration centre. The center-by-center data collection mechanism reflects the children’s population data indicating where birth registration coverage varies substantially between states and in some cases between local government/community setting. The dashboard is helping to identify where non-registered children likely account for some of the most excluded and vulnerable children in Nigerian communities and where rates are often lowest for such children. These statistics are mostly found in rural areas, from poor families and with parents who have minimal or no formal education. The innovation (with its functionality improved on consistent basis) is helping to identify disparities in service delivery and facilitating prompt, evidence-based responses to areas where birth registration levels are low. It is assisting with tracking the trend of registration that will help the country reach the Sustainable Development Goals (SDGs) – birth registration-goal 16.9 by 2030. Specific focus is on how the dashboard is helping to improve data acquisition and analysis including registration coverage and not just registration events. The write up further explores how the RapidSMS is providing a platform for real-time analysis of decentralized birth registration data as an essential information for understanding efficient service delivery, improved local level registration and developing specific solutions where state level analysis and solutions are often too broad.

Enhancing the capacity and effectiveness of community health volunteers to improve maternal, newborn and child health: Experience from Kenya.

To determine whether a simple monitoring and tracking tool, Mwanzo Mwema Monitoring and Tracking Tool (MMATT), would enable community health volunteers (CHVs) in Kenya to 1) plan their workloads and activities, 2) identify the women, newborns and children most in need of accessing critical maternal, newborn and child health (MNCH) interventions and 3) improve key MNCH indicators. A mixed methods approach was used. Household surveys at baseline (n = 912) and endline (n = 1143) collected data on key MNCH indicators in the four subcounties of Taita Taveta County, Kenya. Eight focus group discussions were held with 40 CHVs to ascertain their perspectives on using the tool. Qualitative findings revealed that the CHVs found the MMATT to be useful in planning their activities and prioritizing beneficiaries requiring more support to access MNCH services. They also identified potential barriers to care at both the community and health system levels. At endline, previously pregnant women were more likely to have received four or more antenatal care visits, facility delivery, postnatal care within two weeks of delivery and a complete package of care than baseline respondents. Among women with children under 24 months, those at endline were more likely to report early breastfeeding and exclusive breastfeeding for the first six months. These results remained after adjustment for age, subcounty, gravida, mother's education and asset index. Our results demonstrate that simple tools enable CHVs to identify disparities in service delivery and health outcomes, and to identify barriers to MNCH care. Tools that enhance CHVs' ability to plan and prioritize the women and children most in need increase CHVs' potential impact.

A Cape Verdean Perspective on Disability: An Invisible Minority in New England

Abstract The disability rights movement has brought about broad change in what we see today socially in our imagination and pragmatically within the political landscape. Specifically, it has challenged what it means to be human and what it means to have the right to exist within a social democracy based on principles of equality. Yet the disability rights movement has paid little attention to how disability is understood within culturally diverse communities. Often culturally competent models have a "one-size-fits-all" approach that potentially contributes to disparities in service delivery. This approach generally ignores ethnic distinctions within broad racial/ ethnic categorizations such as black Americans and Latinos. The Cape Verdean Women’s Project explores the population of Cape Verdeans in the United States. Findings indicate that they are not only often culturally misidentified but also misunderstood especially as it relates to issues of disability. This study demonstrates how race, gender, and culture interact and often contradict mainstream disability philosophy and service practices.

American BRCA Outcomes and Utilization of Testing (ABOUT) study: a pragmatic research model that incorporates personalized medicine/patient-centered outcomes in a real world setting.

Research to date regarding identification and management of hereditary breast and ovarian cancer syndrome (HBOC) in the U.S. has been confined primarily to academic center-based studies with limited patient engagement. To begin to understand and address the current gaps and disparities in delivery of services for the appropriate identification and optimal risk management of individuals with HBOC, we designed and have initiated the American BRCA Outcomes and Utilization of Testing (ABOUT) Study. ABOUT relies on a collaborative patient advocacy, academic and industry partnership to recruit and engage U.S. individuals who are at increased risk for HBOC and investigate their experiences, decisions and outcomes. It utilizes an extensive research infrastructure, including an interactive web-based data system and electronic interfaces for secure online participation and automated data exchange. We describe the novel recruitment approach that was designed for collaboration with a national commercial health plan partner to identify all individuals for whom a healthcare provider orders a BRCA test and mail to each individual an invitation to participate and study packet. The study packet contains detailed information about the study, a baseline questionnaire and informed consent for participation in the study, for release of relevant medical and health plan records and for ongoing research engagement. This approach employs patient-reported, laboratory-reported and health plan-reported outcomes and facilitates longitudinal engagement. We believe that the type of innovative methodology and collaborative framework we have developed for ABOUT is an ideal foundation for a patient-powered research network. This approach can make substantial contributions to identifying current and best practices in HBOC, leading to improved strategies for clinical care and optimal health outcomes among individuals with high inherited risk for cancer.

Rural Population Estimates: An Analysis of a Large Secondary Data Set

Health services research often utilizes secondary data sources such as the Behavioral Risk Factor Surveillance System (BRFSS). Since 2006, the released BRFSS data do not include respondents who live in counties with 10,000 or fewer residents, and the CDC no longer offers the opportunity to access the unrestricted data set. As a result, rural residents can be underrepresented in BRFSS data after 2005. The purpose of this analysis is to examine the potential for bias introduced by rural underestimation. We utilized 6 BRFSS data sets; the 2005 full data and the 2005-2009 restricted data. We estimated population sizes for each survey year, and we compared these estimates to comparable data from the US Census intercensal estimates. We also compared estimates of preventive service utilization (mammography, Pap tests, colorectal cancer screening, and influenza vaccinations) between the two 2005 data versions. Rural populations were underrepresented, particularly with the smaller counties excluded. Remote rural residents were the most consistently underrepresented. Preventive service delivery estimates differed between the full and restricted 2005 data versions. Mammography and Pap test estimates tended to be higher in the restricted data, while colorectal cancer screening and influenza vaccinations were similar or inconsistent. These results indicate that restricting by county size introduced bias in these estimates. Having quality, nationally representative data is important to study disparities in service delivery. The potential bias introduced by the BRFSS county restriction may result in rural research being less effective for policy recommendations and interventions.

Preliminary investigation of longitudinal sociodemographic, injury and psychosocial characteristics in a group of non-English speaking Latinos with brain injury

Primary objective: To describe the sociodemographic and injury characteristics and psychosocial outcomes at 1 and 10 years post-injury in a group of Spanish-speaking individuals with traumatic brain injury.Research design: Descriptive cross-sectional and longitudinal analyses of prospectively collected data.Methods and procedures: Assessments were completed on 57 non-English speaking Latinos with TBI, injured between March 1991 and January 2008, who were treated at a Traumatic Brain Injury Model System of Care acute rehabilitation facility. Follow-up data was collected cross-sectionally at 1 year (n = 41) and 10 years (n = 23) post-injury. Longitudinal data (both Y1 and Y10) were available for 17 of those individuals.Main outcomes: Post injury employment and residence, Disability Rating Scale, Functional Independence Measure.Results: At 1 year, the majority of participants were unemployed (63.4%) and did not require assistance of another individual (58.5%) as measured by the DRS Level of Functioning. FIM scores showed that the greatest difficulty was in the area of problem-solving and memory with over half the sample needing assistance in these areas. At 10 years post-injury, 47.8% were unemployed and remained independent of assistance from a caretaker (56.5%) as measured by the DRS. FIM results revealed that slightly less than half continued to need assistance in areas of problem-solving and memory. Longitudinal changes were seen in that, over time, individuals reported more difficulties in areas of bathing and dressing, but fewer difficulties in areas including social interaction, comprehension and memory.Conclusions: Non-English-speaking Latinos with brain injury are at a double disadvantage with regard to obtaining much-needed ongoing services, ultimately impacting long-term outcomes post-injury. If such issues are not adequately addressed, as the Latino population continues to grow, disparities in service delivery and unsuccessful outcomes will continue to grow.

Bias in White: A Longitudinal Natural Experiment Measuring Changes in Discrimination

Many professions are plagued by disparities in service delivery. Racial disparities in policing, mortgage lending, and healthcare are some notable examples. Because disparities can result from a myriad of mechanisms, crafting effective disparity mitigation policies requires knowing which mechanisms are active and which are not. In this study we can distinguish whether one mechanism—statistical discrimination—is a primary explanation for racial disparities in physicians' treatment of patients. In a longitudinal natural experiment using repeated quasi-audit studies of medical students, we test for within-cohort changes in disparities from medical student behaviors as they interact with white and black patient actors. We find significant increases in medical students' disparate behaviors by patient race between their first and second years of medical school. This finding is inconsistent with statistical discrimination predictions and challenges the idea that statistical discrimination is primarily responsible for racial disparities in patient care. This paper was accepted by Jesper Sørensen, organizations.

Stakeholders' Perspectives on the Recommendations of the President's New Freedom Commission on Mental Health

Stakeholders' Perspectives on the Recommendations of the President's New Freedom Commission on Mental Health