Health Care Access Barriers Research Articles

Effect of multimorbidity and psychosocial factors on posttraumatic stress symptoms among post-9/11 veterans.

Examine the association of multimorbidity and psychosocial functioning with posttraumatic stress disorder (PTSD) symptom severity reported among post-9/11 veterans. This was a secondary analysis of survey data collected from a national sample of post-9/11 veterans with at least 3 years of Department of Veterans Affairs care, stratified by comorbidity trajectory and sex (N = 1,989). Comorbidity trajectories were derived by latent class analysis to develop probabilistic combinations of physical and mental health conditions in a previous effort (Pugh et al., 2016). In this study, linear models analyzed symptom severity reported on the PTSD Checklist for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition by psychosocial factors (i.e., resilience, self-efficacy, and postdeployment social support) while controlling for sociodemographic characteristics and deployment experiences. Veterans in the mental health, pain, and polytrauma clinical triad comorbidity trajectories reported more severe PTSD symptoms than the healthy comorbidity trajectory (p < .01). All psychosocial factors were significantly associated with PTSD symptom severity, accounting for nearly 43% of variability in follow-up analyses. Confidence in self-efficacy demonstrated the strongest association among them (p < .01). Veterans experiencing multimorbidity, particularly mental health distress, reported greater PTSD symptom severity after controlling for psychosocial factors, sociodemographics, and deployment experiences. The salience of psychosocial factors in reported PTSD symptom severity underscores resilience, self-efficacy and social support as potential facilitators of functional reintegration following military service. Our analyses underscore the need to address the systemic barriers in health care access and delivery for minority patient populations in future investigations. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Dulce Digital-Me: protocol for a randomized controlled trial of an adaptive mHealth intervention for underserved Hispanics with diabetes

BackgroundBy 2034, the number of US individuals with diabetes is predicted to increase from 23.7 to 44.1 million, and annual diabetes-related spending is expected to grow from $113 to $336 billion. Up to 55% of US Hispanics born in the year 2000 are expected to develop diabetes during their lifetime. Poor healthcare access and cultural barriers prevent optimal care, adherence, and clinical benefit, placing Hispanics at disproportionate risk for costly diabetes complications. Mobile technology is increasingly prevalent in all populations and can circumvent such barriers. Our group developed Dulce Digital, an educational text messaging program that improved glycemic control relative to usual care. Dulce Digital-Me (DD-Me) has been tailored to a participant’s individual needs with a greater focus on health behavior change.MethodsThis is a three-arm, parallel group, randomized trial with equal allocation ratio enrolling Hispanic adults with low income and poorly managed type 2 diabetes (N = 414) from a San Diego County Federally Qualified Health Center. Participants are randomized to receive Dulce Digital, Dulce Digital-Me-Automated, or Dulce Digital-Me-Telephonic. The DD-Me groups include Dulce Digital components plus personalized goal-setting and feedback delivered via algorithm-driven automated text messaging (DD-Me-Automated) or by the care team health coach (DD-Me-Telephonic) over a 12-month follow-up period. The study will examine the comparative effectiveness of the three groups in improving diabetes clinical control [HbA1c, primary outcome; low-density lipoprotein cholesterol (LDL-C), and systolic blood pressure (SBP)] and patient-provider communication and patient adherence (i.e., medication, self-management tasks) over 12 months and will examine cost-effectiveness of the three interventions.DiscussionOur comparative evaluation of three mHealth approaches will elucidate how technology can be integrated most effectively and efficiently within primary care-based chronic care model approaches to reduce diabetes disparities in Hispanics and will assess two modes of personalized messaging delivery (i.e., automated messaging vs. telephonic by health coach) to inform cost and acceptability.Trial registrationNCT03130699-All items from the WHO Trial Registration data set are available in https://clinicaltrials.gov/ct2/show/study/NCT03130699.

A Cross Sectional Survey of Factors Influencing Healthcare Access in Older Women of South India

We examined the determinants of healthcare access barriers, treatment-seeking, and self-medication in older women aged 60 years and more, using a cross-sectional survey design. Using a structured interview format, we interviewed 1005 older women from 7 out of 14 districts in the state through a stratified random sampling procedure. Multiple linear regression analysis results reveal that older women's healthcare access barriers significantly increased when they experienced a long duration of multimorbidity alongside poor recognition of autonomy and basic amenities available at health facilities. However, confidentiality, the ability to pay for healthcare expenditure, and the type of health care significantly improved healthcare access. In factors influencing older women's delay in treatment-seeking, optimal instrumental functionality in daily living, optimal quality of life and access to healthcare services significantly reduced delay in treatment initiation. Whereas poor health-seeking behaviors, long duration of multimorbidity, and the quality of basic amenities at hospitals significantly increased treatment initiation delay and explained 13.6% of the variance. In factors influencing older women's use of self-medication, advancing age, living in rural areas, optimal functionality, perception of providers' respect for confidentiality were associated with increased self-medication frequency. Whereas, better wealth status, prompt attention to older women's health needs, and basic amenities at hospitals significantly reduced their self-medication practice. Therefore, the optimal functional abilities, fewer morbidities, and optimal health system responsiveness significantly reduce healthcare access barriers and self-medication while improving older women's treatment-seeking behaviors.

Social capital in the prevention and management of non-communicable diseases among migrants and refugees: a systematic review and meta-ethnography

Globally, the burden of non-communicable diseases (NCDs) falls disproportionately on underserved populations. Migrants and refugees are particularly vulnerable due to economic instability and systemic poverty. Despite the myriad of health...

Gender Dysphoria in the Pediatric Population: Initial Experience of a Transdisciplinary Group

Abstract Introduction Although there is an increasing experience in the management of transgender individuals, this has not been thoroughly explored in children. The need to establish a comprehensive and transdisciplinary management is of critical importance. In order to solve this issue, we want to report the results of a cohort of individuals with gender dysphoria (GD) seen by our transdisciplinary group from a social and clinical and health access perspective. Methods A 10-year retrospective case series of all patients that had been seen by our transdisciplinary team was reviewed. The main demographic characteristics were described, as well as impact variables in terms of diagnosis and treatment of these individuals. A social description of each individual was described. Frequency, distribution, and central tendency measures were evaluated for data presentation. IBM SPSS Statistics for Windows, version 24.0 (IBM Corp, Armonk, NY) software was used. Results Four cases of GD were included. Three had male to female dysphoria and one female to male. The median reported age of GD awareness was 6 years old (between 4 and 8 years old), and the median time between GD awareness and the 1st medical evaluation was 7 years for all individuals. The median age at gender role expression was 12 years old (between 10 and 14 years old). All patients had already assumed their experienced gender role before the 1st evaluation by our group. The median age at the 1st evaluation by our group was 13 years old (between 10 and 16 years old); three of the patients were evaluated after initiation of puberty. In the present study, individuals with GD demonstrated having health care access barriers for their transition process. Referral times are high, and individuals with GD are cared after pubertal development, which is related to suboptimal outcomes. The spectrum of GD is broad, and management must be individualized according to expectations. Conclusion Individuals with GD face multiple access barriers that limit their possibility of being seen by a transdisciplinary team. This reflects in longer waiting times that negatively impact medical management. Gender dysphoria is a wide spectrum, and individuals should be evaluated individually by a transdisciplinary team.

A cardiovascular clinic patients’ survey to assess challenges and opportunities of digital health adoption during the COVID-19 pandemic

BackgroundCOVID-19 boosted healthcare digitalization and personalization in cardiology. However, understanding patient attitudes and engagement behaviors is essential to achieve successful acceptance and implementation of digital health technologies in personalized care.ObjectiveThis study aims to understand current and future trends in wearable device and telemedicine use in the cardiology clinic patient population, recognize patients’ attitude towards digital health before and after COVID-19, and identify potential socioeconomic and racial/ethnic differences in adoption of digital health tools in a New Orleans patient population.MethodsA cross-sectional survey was distributed to Tulane Cardiology Clinic patients between September 2020 and January 2021. Basic demographic information, medical comorbidities, device usage, and opinions on digital health tools were collected.ResultsSurvey responses from 299 participants (average age = 54 years, 50.8% female, 24.4% African American) showed that digital health use was more prevalent in younger, healthier, and more educated individuals. Wearable use was also higher among White patients compared to African American patients. Patients cited costs and technology knowledge as primary deterrents for using wearables, despite being more inclined to use wearables for disease monitoring (41%). While wearable use did not increase after COVID-19 (36.6% pre-COVID vs 35.4% post-COVID, P = .77), telemedicine use rose significantly (10.8% pre-COVID vs 24.3% during COVID, P < .0001). Patients mostly noted telemedicine’s effectiveness in overcoming difficult healthcare access barriers. Additionally, most patients are in support of wearables and telemedicine either complementing or replacing routine tests and traditional clinical visits.ConclusionDemographic and socioeconomic disparities negatively impact wearable health device and telemedicine adoption within cardiovascular clinic patients. Although telemedicine use increased after COVID-19, this effect was not observed for wearables, reflecting significant economic and digital literacy challenges underlying wearable acceptance.

34.1 Improving Equity in Child Mental Health Outcomes

The aim of this study is to investigate the impact of pediatric integrated care, including peer-to-peer family support, on outcomes for children with mental health needs in a multicultural, urban safety-net system. We conducted a prospective, quasi-experimental clinical trial comparing health service utilization and spending between children nonrandomly assigned (at the clinic level) to the intervention or to usual care. We analyzed service-use data in 30-day segments for 12 months pre-post initial evaluation. Outcome variables were mental health, pediatric, and pharmacy utilization. The main explanatory variables were treatment group, time, and their interaction. In addition, we examined within-group changes (pre-post) on standardized measures of clinical functioning. Intervention youths were more likely to: be Black or Hispanic (61% vs 43%; p < 0.001); speak Spanish or Portuguese (52% vs 32%; p < 0.001); and carry multiple mental health diagnoses at baseline (42% vs 30%; p = 0.009). Doubly robust estimation results indicated that the intervention group had a 36% larger pre-post gain in outpatient mental health utilization (+15.6 pts.; standard error [SE] = 6.7) but no difference in outpatient mental health spending compared to controls. Intervention youths had 20% pre-post reductions in ED admissions (–5.6 pts.; SE = 2.2) and outpatient PH utilization (–19.2 pts.; SE = 5.2). The control group experienced no significant changes. Within-group analyses of clinical functioning, including measures of self-harm, revealed statistically significant improvement from baseline to 6 months and again from 6 months to 12 months. Overcoming mental healthcare access barriers for children and families, often mediated by structural racism, requires new models of care. In addition to significant clinical change on longitudinal measures, for the intervention group, evidence from propensity-score–weighted analyses indicate service use changes consistent with reduced health status inequity.

Barriers and Facilitators to Community Health Worker Outreach and Engagement in Detroit, Michigan: A Qualitative Study.

An effective approach to engaging populations who face health care access barriers is support from community health workers (CHWs). There is little research, however, on specific barriers and facilitators related to two key areas of CHW practice: outreach, defined as the ability to make any initial contact with the priority population, and engagement, defined as the ability to continue to work with the priority population after initial contact is made. The current qualitative study is ancillary to a randomized evaluation of a CHW-led program for Medicaid Health Plan enrollees. Implementation experiences with outreach and engagement led the evaluators to develop the current study in which health plan and nonhealth plan CHWs (n = 12) serving low-income, predominantly Black populations in Detroit participated in qualitative semistructured interviews to elucidate barriers and facilitators to outreach and engagement. All audio recordings were transcribed verbatim. The study team used inductive qualitative data analysis techniques. Barriers to outreach included inaccurate contact information and mistrust. Barriers to engagement included lack of ability to provide needed resources, leading to hopelessness and diminished trust, and discontinuity of services due to eligibility changes and terminated programs. Facilitators included adapting outreach schedules and strategies to community needs, availability of resources, and relational strategies that leveraged CHW social proximity. Further research should systematically investigate the relative success of different CHW-led outreach and engagement strategies for specific populations so as to better design and implement CHW programs.

The Role of Veterinarians in Mass Casualty Disasters: A Continuing Need for Integration to Disaster Management.

The need to prepare veterinarians to serve as part of the disaster medical response for mass casualty incidents has been recognized since at least the 1960's. The potential value of incorporating veterinarians for mass casualty disaster response has been noted by organizations throughout the world. Clinical veterinarians are highly trained medical professionals with access to equipment, medications, and treatment capabilities that can be leveraged in times of crisis. The ongoing threat of disasters with the current widespread healthcare access barriers requires the disaster management community to address the ethical constraints, training deficiencies and legal limitations for veterinary medical response to mass casualty disasters. An ethical imperative exists for veterinarians with translatable clinical skills to provide care to humans in the event of a mass casualty disaster with insufficient alternative traditional medical resources. Though this imperative exists, there is no established training mechanism to prepare veterinarians for the provision of emergency medical care to humans. In addition, the lack of clear guidance regarding what legal protections exist for voluntary responders persists as a barrier to rapid and effective response of veterinarians to mass casualty disasters. Measures need to be undertaken at all levels of government to address and remove the barriers. Failure to do so reduces potentially available medical resources available to an already strained medical system during mass casualty events.

Self-employment, entrepreneurship and barriers to healthcare access across Europe

In this paper we study the relationship between access to healthcare and different types of self-employment (distinguishing between solo self-employed and entrepreneurs, that is self-employed with employees), focusing on the main reasons and conditions behind unmet healthcare needs. The empirical analysis is based on individual data for 17 European countries from the European Social Survey (ESS) complemented with country-level indicators of health systems. We find that, conditional on a rich set of observable characteristics, it is just the solo self-employed that are significantly more likely than employees to report unmet medical needs. Barriers related to affordability are relevant especially for solo self-employed, while acceptability-related reasons matter for all the employment groups considered, albeit with different nuances. Multilevel estimates complement these results by highlighting the relevance of the interaction between individual types of self-employment status and country-level characteristics of the health systems in influencing perceived barriers in healthcare access.

Examining the role of healthcare access in racial/ethnic disparities in receipt of provider-patient discussions about smoking: A latent class analysis

Using insurance as a single indicator of healthcare access in examining the association between race/ethnicity and healthcare encounter-based interventions for smoking may not be adequate. In this study, we assessed the role of healthcare access using multifactorial measures in accounting for racial/ethnic disparities in the receipt of provider-patient discussions, defined as either being asked about smoking or advised to quit smoking by providers. We identified adult current smokers from the 2015 National Health Interview Survey. We first conducted a latent class analysis (LCA) to identify the underlying patterns of healthcare access measured by 13 indicators of healthcare access and utilization. We then used a propensity score - based weighting approach to examine racial/ethnic disparities in receiving provider-patient discussions about smoking or quitting in stratified groups by the distinct healthcare access clusters. Out of the 4134 adult current smokers who visited a doctor or a healthcare provider during the past 12 months, 3265 (79.90%) participants were classified as having high healthcare access and 869 (20.10%) participants as having low healthcare access. Compared to non-Hispanic whites, Hispanics had significantly lower odds of being asked about smoking (OR 0.46, 95% CI (0.27–0.77)) and being advised to quit (OR 0.57, 95% CI (0.34–0.97)) in the low access group, but neither association was significant in the high access group. In addition to increasing health insurance coverage, reducing other healthcare access barriers for Hispanics will likely facilitate provider-patient discussion and promote tobacco cessation among Hispanic smokers.

Health needs of accompanied refugee and asylum-seeking children in a UK specialist clinic.

To identify health needs and healthcare access barriers of accompanied refugee and asylum-seeking (RAS) children in the North East of England, and pilot a new service model to address these. Mixed-methods study (retrospective analysis of routinely collected service data, qualitative data from focus groups) of children who attended a hospital-based specialist clinic. Over two years, 80 children were referred to this service. Most frequent diagnoses (total n=104) were anaemia (n=17), neurodevelopmental (n=12), respiratory (n=12) and mental health (n=9) conditions. Mild-moderate stunting (23%), overweight and obesity (41%), stunting with obesity (9%) and micronutrient deficiencies (vitamin D (66%), vitamin A (40%) and manifest (14%) or latent (25%) iron deficiency anaemia) were highly prevalent. 62% of children had experienced psychological trauma, and 39% had abnormal results in psychosocial wellbeing screening. 21% of children required secondary or tertiary care, 8% mental health referrals, and 47% were followed up in this specialist clinic. Focus groups with families and the community report unaddressed health needs and substantial barriers of access to health care. Refugee and asylum-seeking children have substantial health needs and healthcare access barriers that are not routinely addressed. The authors propose a service model for healthcare provision.

Challenges and Effects of the COVID-19 Pandemic on Asylum Seeker Health at the U.S.-Mexico Border.

Purpose: The coronavirus disease 2019 (COVID-19) pandemic presents health care challenges to asylum seekers living in congregate encampments, including those along the U.S.-Mexico border. It is necessary to understand the impact of the pandemic among this population to address health care needs, reduce transmission, and diminish COVID-19-related morbidity.Methods: Thirty interviews were conducted with asylum seekers and health care professionals in a temporary camp in Matamoros, Mexico to determine challenges, perceptions, and effects of the COVID-19 pandemic. Interviews were coded in NVivo12 by using a team-based approach.Results: The pandemic caused significant mental health burdens but no perceived adverse physical effects, with the U.S. border closure and health care access barriers as more pressing concerns. Participants reported access to information about COVID-19 but had varied levels of knowledge and adherence to disease reduction strategies due to camp conditions. Most participants believed that they had special protection from COVID-19, including strong immune systems or from God. The nongovernmental organizations providing health care and sanitation faced multiple challenges to implement new policies to manage COVID-19. The institution of required temperature checks and quarantine of COVID-19 positive patients led to distrust, decreased seeking of health care services among asylum seekers, and possible underreporting of COVID-19 cases.Conclusion: Our findings among asylum seekers in a Matamoros camp highlight the challenges to implementing disease reduction policies in low-resource congregate camps. Policies to address disease outbreaks focusing on the social determinants of health, health care access barriers, and community engagement may be more acceptable to asylum seekers, suggesting the need for effective strategies to provide prevention information that complements such measures.

Tackling healthcare access barriers for individuals with autism from diagnosis to adulthood.

Most individuals with autism spectrum disorder (ASD)—a complex, life-long developmental disorder—do not have access to the care required to address their diverse health needs. Here, we review: (1) common barriers to healthcare access (shortage/cost of services; physician awareness; stigma); (2) barriers encountered primarily during childhood (limited screening/diagnosis; unclear referral pathways), transition to adulthood (insufficient healthcare transition services; suboptimal physician awareness of healthcare needs) and adulthood (shortage of services/limited insurance; communication difficulties with physicians; limited awareness of healthcare needs of aging adults); and (3) advances in research/program development for better healthcare access. A robust understanding of barriers to accessing healthcare across the lifespan of autistic individuals is critical to ensuring the best use of healthcare resources to improve social, physical, and mental health outcomes. Stakeholders must strengthen healthcare service provision by coming together to: better understand healthcare needs of underserved populations; strengthen medical training on care of autistic individuals; increase public awareness of ASD; promote research into/uptake of tools for ASD screening, diagnosis, and treatment; understand specific healthcare needs of autistic individuals in lower resource countries; and conduct longitudinal studies to understand the lifetime health, social, and economic impacts of ASD and enable the evaluation of novel approaches to increasing healthcare access.Impact Despite the growing body of evidence, our understanding of barriers to healthcare encountered by individuals with ASD remains limited, particularly beyond childhood and in lower resource countries.We describe current and emerging barriers to healthcare access encountered by individuals with ASD across the lifespan.We recommend that stakeholders develop evidence-informed policies, programs, and technologies that address barriers to healthcare access for individuals with ASD and consider broad, equitable implementation to maximize impact.

Improving quality, affordability, and equity of multiple sclerosis care.

ObjectiveThe prevailing approaches to selecting multiple sclerosis (MS) disease modifying therapies (DMTs) have contributed to exponential increases in societal expenditures and out‐of‐pocket expenses, without compelling evidence of improved outcomes. Guidance is lacking regarding when and in whom the benefits of preventing MS‐related disability likely outweighs the risks of highly effective DMTs (HET) and when it is appropriate to consider DMT costs. Our objective was to develop a standardized approach to improve the quality, affordability and equity of MS care.MethodsMS experts partnered with health plan pharmacists to develop an ethical, risk‐stratified, cost‐sensitive treatment algorithm. We developed a risk‐stratification schema to classify patients with relapsing forms of MS as high, intermediate or low risk of disability based on the best available evidence and, when the evidence was poor or lacking, by consensus. DMTs are grouped as highly, modestly or low/uncertain effectiveness and preferentially ranked within groups by safety based on pre‐specified criteria. We reviewed FDA documents and the published literature. When efficacy and safety are equivalent, the lower cost DMT is preferred.ResultsAssignment to the high‐risk group prompts treatment with preferred HETs early in the disease course. For persons in the intermediate‐ or low‐risk groups with cost or health care access barriers, we incorporated induction therapy with an affordable B‐cell depleting agent. Based on more favorable safety profiles, our preferred approach prioritizes use of rituximab and natalizumab among HETs and interferon‐betas or glatiramer acetate among modestly effective agents.InterpretationThe risk‐stratified treatment approach we recommend provides clear, measurable guidance in whom and when to prescribe HETs, when to prioritize lower cost DMTs and how to accommodate persons with MS with cost or other barriers to DMT use. It can be adapted to other cost structures and updated quickly as new information emerges. We recommend that physician groups partner with health insurance plans to adapt our approach to their settings, particularly in the United States. Future studies are needed to resolve the considerable uncertainty about how much variability in prognosis specific risk factors explain.

Abstract P181: Differential Clinical Outcomes Among Stroke Patients From Rural and Urban Areas in a Pilot Stroke Network

Objective: To describe the clinical features of stroke patients from rural and urban areas and to identify possible associations with clinical outcomes. Introduction: There is little information in Latin America about risk factors, treatments, and outcomes in stroke patients from rural areas and urban people. The rural population faces multiple healthcare access barriers that might influence stroke outcomes. This paper describes and analyzes clinical features in stroke patients according to their location. Methods: Prospective cohort study of Colombian stroke patients using demographic and clinical data collected between 2018 and 2020 in a high complexity hospital from southwestern Colombia, as part of a pilot stroke network consisting of rural primary centers and a mothership center. Mode of transport to the stroke center, timing, clinical characteristics, interventions, and modified Rankin scale (mRS) at discharge and 3 months were assessed. Results: We included 579 stroke patients (66.14% ischemic), with a median age of 70 years (60-81). Urban subjects showed higher prevalence of dyslipidemia (p=0.009), previous hemorrhagic stroke (p=0.036), and TIA (p=0.002). Approximately 35% of cases were initially evaluated at a rural primary care center. These subjects exhibited a higher NIHSS scores (10 IQR 5-19 vs. 5 IQR 2-13; p=0.000) with a longer window (p&lt;0.001) and were mainly transferred by ambulance (89.80%, p=0.000). Due to the severity, door-to-imaging time was shorter (p=0.001). Rural patients receive thrombolysis in 27.36% and underwent thrombectomy in 14.43%. Higher mRs at discharge (3 IQR 2-5 vs. 2 IQR 1-4; p=0.000) and three-months follow-up (3 IQR 1-6 vs. 1 IQR 0-4; p&lt;0.001) were observed. Conclusions: Rural patients from southwestern Colombia were more likely to present with severe strokes even though they had lower rates of cardiovascular risk factors. They arrived later to the stroke center, but the final diagnosis was reached faster. Nonetheless, disability was higher at discharge and 3-months follow-up.

Cultural, social, and healthcare access factors associated with delays in gastric cancer presentation, diagnosis, and treatment: A cross-sectional study

BackgroundThe aim of this study was to identify the time intervals between the demand for health services and the initiation of cancer treatment, and to explore the associated factors, in gastric cancer patients being treated in an oncology hospital in northern Brazil. MethodsThis cross-sectional study. Gastric cancer patients receiving treatment in a northern Brazil reference hospital were interviewed. A Mann-Whitney test was used to verify associations between the time intervals of access to treatment and socioeconomic factors, clinical variables, and patient difficulties, adopting a 0.05 significance level. ResultsThe average time intervals were 471.3 days between symptom onset and primary health service request and 180.9 days between diagnosis and treatment. The average time between the onset of symptoms and the treatment of gastric cancer was 747.8 days. Patients using herbal home remedies showed the longest times before seeking primary health care (p = 0.04). Delays between diagnosis and treatment were associated with unemployment (p = 0.03). High average times until oncologist appointments were related to the absence of comorbidities (p = 0.004). Personal difficulties and a lack of hospital beds were associated with long time intervals to specialist appointments and between diagnosis and treatment. Personal difficulties were associated with long time intervals between the onset of symptoms and the treatment of gastric cancer. ConclusionGastric cancer patients faced delays and healthcare access barriers in a region with high mortality for this disease. Appropriate interventions are necessary to reduce delays and better control the disease. Policy SummaryIn this paper we have explored the barriers to access to diagnosis and treatment for patients with gastric cancer in a major cancer centre in Northern Brazil. The results will inform strategies for improving timely access to critical cancer services.

Prevalence of Dental Caries Among Costa Rican Male Students Aged 12-22 Years Using ICDAS-II

Objective: Dental decay is a public health challenge in Low- and Middle-Income Countries, particularly for young people, often confronted to healthcare access barriers. The aim of this study was to determine the prevalence and severity of dental caries among young male students in Costa Rica. Study design: A cross-sectional study was performed in 428 Costa Rican male students aged 12-22 years, who attended a nonprofit social welfare boarding school in 2019. A clinical examination was ran by three calibrated examiners following the International Caries Detection and Assessment System (ICDAS-II). Results: Caries prevalence was estimated at 83%, 15% have lost a tooth due to dental decay, 61% have at least one filled tooth, 36% have at least one filled and decayed tooth. The most frequent caries lesions were codes 2-Inactive (46.7%), and code 1-Inactive (23.8%). DMFT indicated a mean index using ICDAS-II 1-6&gt;0 codes of 7.89. Using ICDAS-II 3-6&gt;0 as threshold, the index decreases to 3.94. Finally, the lower and upper first permanent molars were found to be the most affected teeth. Conclusions: Dental caries experience represents a significant public health burden in young people, requiring better access to public dental healthcare.

Empowerment and health care access barriers among currently married women in Myanmar

BackgroundAlthough Myanmar is moving to attain UHC in 2030, health care utilization indicators are still low, especially among women. Women’s health outcomes are determined by the lack of access to health care, and many factors influence this condition. The objective of the present work was to identify the association between women’s empowerment and barriers to accessing health care among currently married women in Myanmar.MethodWe performed a secondary analysis using the Myanmar Demographic and Health Survey (2015–16), including 7759 currently married women aged 15–49 years. The outcome variable, barriers to accessing health care, were asked about in terms of whether the respondent faced barriers to getting permission to go, getting money to go, the distance to the health facility, and not wanting to go alone. The variables were recoded into zero, one, and more than one barrier. After performing the exploratory factor analysis for women’s empowerment indicators (decision-making power and disagreement to justification to wife-beating), a multinomial logistic regression was carried out.ResultsAmong currently married women, 48% experienced no barriers when accessing health care services, 21.9% had one barrier, and 30.1% had more than one barrier. After the exploratory factor analysis, scores were recoded into three levels. Women with low and middle empowerment had 1.5 odds (AOR 1.5, 95% CI: 1.2–1.8) and 1.5 odds (AOR 1.5, 95% CI: 1.3–1.9), respectively, to have barriers to accessing health care when compared to those with high empowerment for one barrier group. For the women who had more than one barrier, women with low empowerment were 1.4 times more likely (AOR 1.4, 95% CI: 1.1–1.7) to experience barriers in comparison to women with high empowerment. The barriers were seen to be reduced in the case of women who had a high level of education, had fewer children, came from rich households, and lived in urban areas.ConclusionWhen women are more empowered, they tend to face fewer barriers when accessing health care services. This finding could contribute to the policy formulation for reducing health inequity issues by increasing women’s empowerment.

Healthcare access barriers for FARC ex-combatants in Colombia: qualitative perspectives from healthcare providers and FARC health promoters

BackgroundFollowing the 2016 Peace Agreement with the Fuerzas Armadas Revolucionarias de Colombia (FARC), Colombia promised to reincorporate more than 13,000 guerrilla fighters into its healthcare system. Despite a subsidized healthcare insurance program and the establishment of 24 Espacios Territoriales de Capacitación y Reincorporación (ETCRs—Territorial Spaces for Training and Reintegration) to facilitate this transition, data has shown that FARC ex-combatants access care at disproportionately lower rates, and face barriers to healthcare services.MethodsSemi-structured interviews were conducted with FARC health promoters and healthcare providers working in ETCRs to determine healthcare access barriers for FARC ex-combatants. Analysis was completed with a qualitative team-based coding method and barriers were categorized according to Julio Frenk’s Domains of Healthcare Access framework.ResultsAmong 32 participants, 25 were healthcare providers and 7 self-identified as FARC health promoters. The sample was majority female (71.9%) and worked with the FARC for an average of 12 months in hospital, health center, medical brigade, and ETCR settings. Our sample had experiences with FARC across 16 ETCRs in 13 Departments of Colombia. Participants identified a total of 141 healthcare access barriers affecting FARC ex-combatants, which affected healthcare needs, desires, seeking, initiation and continuation. Significant barriers were related to a lack of resources in rural areas, limited knowledge of the Colombian health system, the health insurance program, perceived stigma, and transition process from the FARC health system.ConclusionsFARC ex-combatants face significant healthcare access barriers, some of which are unique from other low-resource populations in Colombia. Potential solutions to these barriers included health insurance provider partnerships with health centers close to ETCRs, and training and contracting FARC health promoters to be primary healthcare providers in ETCRs. Future studies are needed to quantify the healthcare barriers affecting FARC ex-combatants, in order to implement targeted interventions to improve healthcare access.