Navigating Health Care Systems Research Articles

Too long to wait: South Asian migrants\u2019 experiences of accessing health care in Australia

BackgroundMigrants settling in a new country experience multiple complexities in navigating health care systems and adapting to a new way of life in the host country. In South Asia, migrating to another country for better life opportunities has been an ongoing trend and migration to Australia has significantly increased in recent years. Lower utilisation of health services and higher risks of chronic diseases among South Asian migrants poses a continuing challenge for the Australian health care system and little is known about why this demographic group does not access health services at the same rate. This study aimed to explore factors influencing access to health care by South Asian migrants in Australia.MethodsUsing a mixed-method design, we conducted 62 online survey and 14 in-depth interviews with participants from four South Asian countries: Nepal, India, Bhutan, and Sri Lanka. Participants were recruited using a purposive snowball sampling approach following a standard ethical approval process. Survey data were analysed descriptively in SPSS and interview data were recorded, transcribed, and analysed thematically.ResultsSouth Asian migrants experienced various complexities while accessing health services in Australia. The findings of this study highlighted a number of negative factors influencing their experiences of accessing health care: long waiting times for public health care, the expense of private health care, and communication problems due to socio-cultural differences. South Asian migrants also expressed their concern for a greater investment of resources into public health care to enable them to access quality and affordable care in these settings.ConclusionsGiven limited evidence available to help understand factors leading to the lower utilisation of health care and higher risks of chronic diseases among South Asian migrants, this study plays an important role in highlighting social, cultural, financial, and institutional factors that are critical to designing appropriate health-care strategies. This study recommends incorporating a collaborative and culturally competent model of care to increase access to health care and thereby help reduce existing disparities in health outcomes among South Asian migrant populations.

Transgender People's Perceptions of Medical Treatment: Implications for Providers and Loved Ones

In this study, we examine qualitative data from 73 transgender adults. We present the information our participants shared about their experiences navigating health care systems (i.e., medical health, mental health, other providers). Four themes emerged. First, participants indicated that they wanted health care providers to be more aware of transgender-specific terminology, identities, and experiences. Second, participants were concerned that health care providers blame their medical transition for unrelated health concerns. Third, participants said they did not want health care providers to probe transgender patients about their transitions. Fourth, they reported that they wanted health care providers to treat transgender patients as individuals rather than a monolith. Our research has implications for mental health providers because they benefit from understanding the health care barriers experienced by their transgender patients, in mental health and other health realms. This will allow mental health providers to better support their patients as well as bolster support from loved ones.

Integrated care for children with medical complexity living in rural Australia – an evaluation of family experiences using the Paediatric Integrated Care Survey

1. Introduction: The number of children with medical complexity (CMC) residing in regional/rural Australia is growing, challenging the health system to provide equitable and accessible care. Families of CMC experience problems in accessing appropriate care locally; they have high out-of-pocket costs and family disruptions because of long travel distances to access care in metropolitan paediatric hospitals. 2. The Practice Change: The Murrumbidgee Local Health District (MLHD) in New South Wales (NSW), Australia, in collaboration with the Sydney Children’s Hospitals Network (SCHN) partnered with families and local services to co-design a Model of Care (MoC) to better meet the needs of CMC, their families and local services3. Aim and theory of change: To demonstrate changes in parent-reported experiences, we used the Paediatric Integrated Care Survey (PICS) in a longitudinal cohort design at baseline, and 6 months after enrolment in the MoC.4. Targeted population and stakeholders: To qualify for enrolment in the new MoC children had a diagnosed condition involving more than one organ system, were medically fragile or reliant on medical technology, or had used health services frequently in the last 12 months e.g. >6 emergency department presentations, >4 hospital admissions and >10 outpatient clinic visits. Stakeholders included families of CMC, healthcare providers and managers working in the MLHD and and at the SCHN.5. Timeline: The new MoC was implemented in 2018 and CMC have been systematically identified, and enrolled in the MoC. The PICS was administered at baseline and at 6 months.6. Highlights – innovation, impact and outcome: 41 CMC have been enrolled and 18 of the families completed the PICS at both time points. Difficulties navigating healthcare systems, fragmented care, poor communication, and limited care planning and goal setting were apparent at baseline. After accessing the MoC for at least 6 months (6-14 months) there was a 33% increase in written short term care goals (p=0.045). Care teams were 11% more likely to discuss healthcare decisions that impact the whole family (p=0.005) and intra-team communication improved for 5.5% of families (p=0.003). Interestingly, 22% of families were less comfortable letting team members know about concerns about their child’s healthcare (p=0.001). The care coordination team in the MoC reported valuing the PICS results as an assessment of need for integrated care.7. Comments on sustainability and 8. Transferability: The Moc has been embedded into the system in the MLHD, a rural area of NSW, Australia. The clinical teams working with families of CMC felt that the the PICS results informed their practice. The MoC, including assessments using the PICS has been adapted to another rural area - the Southern NSW LHD.9. Conclusions, 10. Discussion, and 11. Lessons learned: Using the PICS periodically during implementation of the new MoC provides feedback loops to inform future model adjustments. The PICS has highlighted the need for shared care plans and recognition of the impacts of caring for a CMC on family functioning. Qualitative research is needed to better provide context to the longitudinal PICS data.

Communication Among Southeast Asian Mothers and Daughters About Cervical Cancer Prevention.

Southeast Asian women have high rates of cervical cancer and yet are among the least likely to be screened. There is sparse literature on communication patterns among Southeast Asian women, specifically related to cervical cancer and Pap test uptake. Little is known about the influence of Southeast Asian mothers and daughters on each other's cervical cancer beliefs and screening behaviors. We examined the perceptions of and barriers to cervical cancer screening among Cambodian and Lao mothers and daughters and explored how they converse about women's health issues, specifically cervical cancer and Pap testing. We conducted in-depth interviews with Cambodian and Lao mother-daughter dyads, aged 18 years and older, living in a large Midwestern city between February and September of 2015. Descriptive statistics were calculated to summarize the sample demographic characteristics. Bivariate tests (contingency table analyses, independent t-tests, and Pearson correlations) were conducted to test for differences between the mothers and daughters in demographic characteristics and measures of health status and beliefs. Qualitative data were analyzed using content analysis. In-depth interviews were conducted with three Cambodian and eight Lao mother-daughter dyads. The daughters were significantly more acculturated to English, had greater education, and were mostly employed full time. The mothers and daughters evaluated their health status much the same, their medical mistrust equally, and all of the mothers and nine of the daughters were Buddhist. Themes in mother-daughter communication included what mothers and daughters do and do not talk about with regard to sexual health, refugee experiences, what hinders mother-daughter communication, and relationship dynamics. The mothers were embarrassed and uncomfortable discussing cervical cancer, Pap testing, and other women's health issues with their daughters. Although mothers did not influence women's health promotion or cervical cancer prevention with their daughters, daughters did influence their mothers' health and healthcare decisions. Daughters were critical in navigating healthcare systems, engaging with providers, and making medical decisions on behalf of their mothers. By leveraging the unique and dynamic intergenerational bond that mothers and daughters who identify as Southeast Asian have, we can develop strategies to influence the cultural dialogue related to cervical cancer and early detection.

Improving Spoken Language Interpreter Services for Birthing People

Health disparities for perinatal people in North Carolina (NC) with limited English proficiency (LEP) are widening, including decreased access to quality prenatal care, higher-risk deliveries, disproportionate obstetric trauma, and increased postpartum depression. Several obstacles exist related to utilization and availability of medical interpreters, and without swift policy action to address these barriers to linguistically accessible care, health disparities will continue to widen. The aim of this commentary is to assist NC in developing policy that increases health equity for perinatal people with LEP. Through utilization of a socioecologic framework and SWOT analysis, we proposed four different policies related to medical interpreter services. Proposed policies were: 1) to improve the quality of training for medical interpreters by requiring that all interpreters be board certified, 2) to provide Medicaid reimbursement to hospitals and providers for interpreter services, 3) to mandate culturally-sensitive curricula in medical schools, and 4) to allocate funding for language concordant statewide perinatal education that includes information about navigating healthcare systems with LEP, patients’ rights, and patient advocacy. Current policies are insufficient to address the widening health disparities that are occurring for perinatal people with LEP. The proposed policies are worthy of consideration for implementation to further address reducing health disparities for birthing people with LEP at patient, provider, and structural levels.

Healthcare Experiences of LGBTQ+ Elders: Two Focus Groups

LGBTQ+ elders experience significantly higher rates of disability, poor general health, and behavioral health problems than heterosexual and cisgender older adults; additionally, LGBTQ+ elders are less likely to seek medical attention or have a primary care provider than other older adults. In previous qualitative studies, LGBTQ+ elders have reported difficulties navigating healthcare systems due to provider incompetence in treating this population, financial barriers, systemic homophobia/transphobia, and high disease burdens. However, few qualitative studies have been conducted with this population from a nursing perspective, and little is known about the role of nurses in the health and wellness of LGBTQ+ elders. Nurses are uniquely positioned to help address both the physiological and psychosocial needs of older LGBTQ+ adults, and garnering an understanding of these needs directly from this community can help better direct future research. Accordingly, two focus groups were conducted with LGBTQ+ elders at different queer community centers in Philadelphia by a nurse scientist. This community engaged research aims to learn more about how nurses can serve this population through identifying their priorities. Through thematic analysis, it was found that LGBTQ+ elders reported being concerned about housing access, discrimination from healthcare providers, and challenges in accessing mental health care. Additionally, the researchers’ hypotheses were triangulated with the participants’ responses to demonstrate the utility of continued community engagement in addressing specific population needs.

"Health Is on the Back Burner:" Multilevel Barriers and Facilitators to Primary Care Among People Who Inject Drugs.

The estimated 2.2 million people who inject drugs (PWID) in the USA experience significant gaps in preventive healthcare and a high burden of infectious, psychiatric, and other chronic diseases. Many PWID rely on emergency medical services, which are costly and not designed to deliver preventive services, manage chronic conditions, or address social needs. The objective of this study was to explore barriers and facilitators to primary care utilization from the perspectives of PWID in New England, a region highly affected by the overdose crisis. Participants completed semi-structured qualitative interviews exploring substance use and healthcare utilization patterns. We recruited 78 PWID through community-based organizations (e.g., syringe service programs) in 16 urban and non-urban communities throughout Massachusetts and Rhode Island. Thematic analysis identified barriers and facilitators to primary care utilization at the individual, interpersonal, and systemic levels. Among 78 PWID, 48 described recent primary care experiences; 33 had positive experiences and 15 described negative experiences involving discrimination or mistrust. Individual-level barriers to primary care utilization included perceived lack of need and competing priorities (e.g., avoiding opioid withdrawal, securing shelter beds). Interpersonal-level barriers included stigma and perceived low quality of care for PWID. Systemic-level barriers included difficulty navigating healthcare systems, inadequate transportation, long wait times, and frequent provider turnover. Participants with positive primary care experiences explained how appointment reminders, flexible hours, addiction medicine-trained providers, case management services, and transportation support facilitated primary care utilization and satisfaction. Findings regarding the multilevel barriers and facilitators to accessing primary care among PWID identify potential targets for programmatic interventions to improve primary care utilization in this population. Based on these findings, we make recommendations for improving the engagement of PWID in primary care as a means to advance individual and public health outcomes.

A systematic review exploring palliative care for families who are forced migrants.

To explore the palliative care experiences of forced migrant children, families, and healthcare professionals (HCPs) highlighting successes, challenges, and associated practice implications. Systematic literature review. The following search engines were searched from 2008 - 2018: Allied and Complementary Medicine Database, Cumulative Index to Nursing and Allied Health, MEDLINE, Embase, ProQuest, Scopus, Psycinfo, and Web of Science. Extensive reference and citation checking were also conducted. Systematic review followed PRISMA guidelines with prepared PROSPERO registered protocol #CRD42019129200. English language qualitative, quantitative, or mixed methods studies were eligible for inclusion. Study quality was appraised using the Mixed Methods Appraisal Tool (MMAT). Eighteen studies (reported in 20 articles) met the final inclusion criteria. Most focused on challenges to care provision. Thematic analysis following methods proposed by Braun and Clarke was undertaken. Five themes were identified: (a) divergence of beliefs and expectations; (b) communication; (c) navigating healthcare systems; (d) burdens and coping strategies; and (e) training and knowledge. A compassionate, collaborative approach with mutual respect crossed themes and was linked to high-quality care. Forced migrant families have multiple needs including physical and emotional support and help in navigating complex systems. Professional interpreters can ease communication barriers when resourced appropriately. Individualized care is crucial to addressing the intricate mosaic of culture such families present. A cultural sensitivity/insensitivity framework is presented that may help guide future interactions and priorities for those working in children's palliative care. This systematic review explored the international experiences of palliative care for forced migrant families. The findings highlight the plight of families who experience multiple traumas and increased levels of grief and loss through their migration experiences and when caring for a child with a life-limiting condition. This research has potential to have an impact on professionals working with culturally diverse families in all palliative care settings.

Charting a course to support military families navigating service systems for children with Autism Spectrum Disorder: A qualitative study

Introduction: Most military families experience mandatory relocation, or posting, several times during their military career. For Canadian military families, who must access provincial or territorial health care systems, maintaining reasonable continuity of care is a persistent issue. Such challenges may be amplified when a child in a military family has special needs within the health and educational systems. The purpose of this qualitative study was to gain a better understanding of Canadian Armed Forces (CAF) families’ experiences in navigating health care systems on behalf of a child with Autism Spectrum Disorder (ASD), in the context of mandatory relocation, and to determine their recommendations for improved system navigation. Methods: Parents of children with ASD, where at least one parent serves in the CAF and had faced military-related relocation, were recruited. Semi-structured interviews were recorded, transcribed verbatim, and analyzed thematically. Results: A total of 13 participants represented 12 families and 15 children with ASD. Participants discussed two primary ways to support military families: (1) Improve communication between military-connected families with children with ASD, and (2) Improve transition coordination. Discussion: The recommendations made by military families echo those made in clinical professional association reports and recent Canadian research. International policy initiatives to offset the impacts of military family relocation may serve as examples to adapt to the provincial and territorial jurisdictions for both health and education in Canada.

0624 Voice of the Patient: A Patient-Centered Exploration of Factors Influencing Obstructive Sleep Apnea Care

Abstract Introduction Despite widely available efficacious treatments for obstructive sleep apnea (OSA), patients commonly report frustration in accessing and adhering to treatments. Sparse research has explored factors influencing OSA care from the patient perspective, which may limit provision of patient-centered care: care responsive to patient preferences, needs, and values. To this end, we conducted qualitative research to identify factors, voiced by patients, that influence OSA treatment initiation and adherence. Methods We performed semi-structured interviews with 15 patients previously diagnosed with OSA from Boston, MA and a national patient portal (MyApnea.Org). Patients were asked about barriers and facilitators to their diagnosis and treatment as well as about their preferences and values that informed their treatment decisions. Interviews were audio-recorded and transcribed. A qualitative content analysis was performed to identify themes. After developing a codebook, interviews were coded. Codes were then audited and finalized by study team consensus. Results Our sample was aged 25-74 years; 71% identified as female. Among participants, 57.1% identified as White, 14.3% Black, 14.3% Asian, and 14.3% Other. Major themes were broadly classified as (1) facilitators (provision of useful information on treatment options, participation in shared decision-making, continued clinician support); (2) barriers (inconvenience of treatment, difficulty of habit formation, treatment side effects, competing comorbid conditions); (3) motivators (value of improving chronic health, family support, positive treatment effects); (4) contextual factors (insufficient knowledge/awareness of OSA, navigating healthcare systems, access to informational resources). Awareness of OSA symptoms and treatments, and ongoing support were cited as the most common factors influencing the patient experience. Conclusion This formative research highlights that diverse factors impact the OSA evaluation and treatment patient experience. Further research should test interventions that promote effective patient-centered care for OSA, such as shared decision-making tools. Support Brigham and Women’s Hospital Research Institute Patient-Centered Comparative Effectiveness Research Center Grant

Health-care Workforce Training to Effectively Support Family Caregivers of Seniors in Care.

IntroductionFamily caregivers (FCGs) play an integral, yet often invisible, role in the Canadian health-care system. As the population ages, their presence will become even more essential as they help balance demands on the system and enable community-dwelling seniors to remain so for as long as possible. To preserve their own well-being and capacity to provide ongoing care, FCGs require support to the meet the challenges of their daily caregiving responsibilities. Supporting FCGs results in better care provision to community-dwelling seniors receiving health-care services, as well as enhancing the quality of life for FCGs. Although FCGs rely upon health-care professionals (HCPs) to provide them with support and services, there is a paucity of research pertaining to the type of health workforce training (HWFT) that HCPs should receive to address FCG needs. Programs that train HCPs to engage with, empower, and support FCGs are required.ObjectiveTo describe and discuss key findings of a caregiver symposium focused on determining components of HWFT that might better enable HCPs to support FCGs.MethodsA one-day symposium was held on February 22, 2018 in Edmonton, Alberta, to gather the perspectives of FCGs, HCPs, and stakeholders. Attendees participated in a series of working groups to discuss barriers, facilitators, and recommendations related to HWFT. Proceedings and working group discussions were transcribed, and a qualitative thematic analysis was conducted to identify key themes.ResultsParticipants identified the following topic areas as being essential to training HCPs in the provision of support for FCGs: understanding the FCG role, communicating with FCGs, partnering with FCGs, fostering FCG resilience, navigating healthcare systems and accessing resources, and enhancing the culture and context of care.ConclusionsFCGs require more support than is currently being provided by HCPs. Training programs need to specifically address topics identified by participants. These findings will be used to develop HWFT for HCPs.

Queering Whole Person Care

This workshop is the product of a research study exploring the strategies that queer people develop to navigate hegemonic, heteropatriarchal health care systems, and ways that nurse education can incorporate a narrative-based, whole person care approach to understanding and supporting the needs of queer patients. This mixed-methods study included interviews with queer people, nurse educators and practicing nurses; textual analysis of queer health narratives; close reading of queer, feminist and cultural theory; and autoethnography.Some of the questions that we will explore are: How do queers use personal narratives to help navigate health care systems not designed to see/meet their needs? How do queers challenge dominant power structures in medicine? What does whole person care look like in a queer context? What would nurses like to see included in nursing education, and what do queers want health providers to know? What are the key pedagogical challenges in attempting such communication?The stories that queer people carry with them to medical encounters are a rich and underutilized resource for health care providers, and a tool for patients trying to manage serious or chronic illness. We will explore methods for including storytelling in nursing education as well as patient care, and participants will engage in a narrative medicine/autoethnographic exercise.We hope participants will leave our workshop with a better understanding of queer peoples' experiences of health care, and ways that queers and nurses can work together for better health outcomes.

Navigating health care systems for military-connected children with autism spectrum disorder: A qualitative study of military families experiencing mandatory relocation.

Most military families experience mandatory relocation, or posting, several times during the military career. For Canadian military families who must access provincial or territorial health care systems, maintaining reasonable continuity of care is a persistent issue. Such challenges may be amplified when a child in a military family has special needs within the health and educational systems. The purpose of this qualitative study was to gain a better understanding of Canadian Armed Forces families' experiences in navigating health care systems on behalf of a child with autism spectrum disorder (ASD) in the context of mandatory relocation. Parents of children with ASD, where at least one parent serves in the Canadian Armed Forces and had faced military-related relocation, were recruited. Semi-structured interviews were recorded, transcribed verbatim, and analyzed thematically. Twelve participants represented 12 families and 15 children with ASD. Participants discussed two primary themes. (1) High mobility inherent in the military lifestyle can create disruptions and discontinuities to service, including delays in diagnosis or intervention, losses and gains in available services determined by the direction of posting, and the need to start health care access processes over again when relocating. (2) Navigating health systems for children with ASD creates personal stress and frustration related to relocating, and has career implications for both parents. Military-related relocation can create significant disruption in access to health and educational services for Canadian military families who have a child with ASD, and take a personal toll on these families.

Health literacy, sociodemographic factors, and cognitive training in the active study of older adults.

Health literacy is critical for understanding information from health-care providers and correct use of medications and includes the capacity to filter other information in navigating health care systems. Older adults with low health literacy exhibit more chronic health conditions, worse physical functioning, and poorer mental health. This study examined the relationship between sociodemographic variables and health literacy, and the impact of cognitive training on change in health literacy over 10years in older adults. Participants (N=2,802) aged 65years and older completed assessments, including reading and numeracy health literacy items, as part of the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) study. We evaluated baseline sociodemographic variables and change in health literacy over a 10-year period in individuals exposed to cognitive training in reasoning, processing speed, memory, or a no-contact control condition. Age, sex, race, education level, and general cognitive functioning at baseline were all associated with baseline health literacy in older adults. Predictors of change in health literacy over the 10-year follow-up were age, race, education level, general cognitive functioning, and neighborhood income; disparities in health literacy because of race attenuated over time, while the effect of age increased over time. Health literacy was generally stable across the ACTIVE intervention groups over 10years. The present study showed important disparities in health literacy level and change over 10years. Cognitive training did not significantly impact health literacy, suggesting that alternative approaches are needed to reduce the disparities.

Establishing a Childhood Cancer Survivorship Program in Rwanda

Background: Over 80% of children diagnosed with cancer survive in high-income countries (HICs). While the survival rate remains poor in low- and middle-income countries (LMICs) such as Rwanda, a growing number of children with cancer are surviving to adulthood. These children and young adults will face an increased risk of secondary cancers and late complications from their curative treatment. Cancer centers in HICs have established Long Term Survivorship (LTS) programs to cater for childhood cancer survivors and to capture these complications and/or recurrences at an early stage. They also address the more complex psychological and social aspects of surviving cancer in childhood. Aims: To develop an LTS program in Rwanda, initial training will take place in Botswana where a pediatric hematology-oncology (PHO) program was established at the national referral hospital, Princess Marina Hospital (PMH), in 2007. This training program will allow successful methods and lessons learned from the development of an LTS program in Botswana to establish a similar program in Rwanda with ongoing bidirectional collaboration. Methods: The Texas Children's Cancer and Hematology Centers (TXCH) Global Hematology-Oncology Pediatric Excellence (HOPE) program in Botswana is the only provider of PHO care in the country, provided at PMH, through a partnership with the Botswana government. The program has over 130 childhood cancer survivors in active follow-up. A one-month bench-marking visit will be conducted. During this period, Dr. Rubagumya will spend time with the medical director of the program learning how the LTS program was established and current operations. He will spend time with clinicians during consultations to understand the scope of tests requested, frequently asked questions across all parties: clinicians, survivors and/or caretakers and use of technology to aid in the management of LTS patients. Focused interviews of clinicians, patients, caregiver and administration will be conducted to further understand the challenges of the pediatric cancer survivors and the development of an LTS program in an LMIC face. Results: After this month visit, critical areas of knowledge transfer will include: how to set up a childhood cancer survivorship programs; methods for sustainable operation of a childhood cancer LTS program, and how to help childhood cancer survivors navigate health care systems. A similar model will be established in Rwanda. Long-term mentorship with Botswana colleagues will help to build Rwanda's first LTS. Conclusion: Survivors involved in dedicated LTS follow-up care have better health outcomes. This indicates the need for life long survivorship care. There is a dearth of data on how to establish and operate a childhood cancer LTS program in LMIC settings. Lessons learned through this program will guide us on how to set up such program in Rwanda.

Utilization of Patient Navigators in an Urban Academic Pediatric Primary Care Practice.

Navigating health care systems can be a challenge for families. A retrospective descriptive cohort analysis was conducted assessing referrals to patient navigators (PNs) in one urban academic pediatric primary care practice. PNs tracked referral processes and a subset of PN referrals was assessed for markers of successful referrals. The most common reasons for referral were assistance overcoming barriers to care (46%), developmental concerns (38%), and adherence/care coordination concerns (14%). Significant predictors of referral were younger age, medical complexity, public insurance, male sex, and higher rates of no-show to visits in primary or subspecialist care. The majority of referrals were resolved. The referrals for process-oriented needs were significantly more successful than those for other concerns. PNs were more effective for discrete process tasks than for those that required behavior change by patients or families. Future directions include analysis of cost effectiveness of the PN program and analysis of parent and primary care provider experience.

The impact of health and health insurance literacy on access to care for Hispanic/Latino communities.

The aim of this study was to assess the impact of health literacy (HL) and health insurance literacy (HIL) on health insurance status and access to health care services for Spanish-speaking communities living in Massachusetts. A total of 139 surveys (descriptive, knowledge-based HIL questions, and Short Assessment of Health Literacy in Spanish) and 30 semi-structured interviews were collected and analyzed using chi-square, Mann-Whitney U test, and logistic regression analysis. The majority of participants had inadequate HL (56%) and HIL (93%). There were differences in HL scores (t=4.1; p<.0001) between the insured (M=12.3, SD=5.7) and uninsured (M=7.9, SD=6.7) and differences (t=1.9; p=.05) between those with adequate HIL (M=14.3, SD=4.3) and inadequate HIL (M=10.2, SD=6.6). Participants who were uninsured (MW U=37.6; p<.0001) and who had inadequate HL (MW U=5.2; p=.02) were more likely to have never accessed health care in the U.S. Participants who had never accessed health care were 93% less likely to be insured and those with adequate HL were three times more likely to be insured. Health literacy and HIL are closely associated with insurance status and access to health care for Spanish-speaking communities, indicating the need for further research and enhanced public health efforts to improve knowledge and awareness around navigating health care systems.

Exploring communication during the journey from noticing bodily changes to a diagnosis of endometrial cancer.

To understand women's perspectives about the trajectory from first bodily changes to diagnosis. With endometrial cancer, as with all gynaecological cancers, early diagnosis is key to successful outcomes. However, women do not always seek clinical advice early. Previously, this gap has been referred to as a "delay," blamed on fear or refusal to acknowledge symptoms. A qualitative research project which involved face-to-face interviews with 16 women who had presented with symptoms of endometrial cancer. The paucity of research in the trajectory of women who experience a diagnosis of endometrial cancer required an exploratory overview of the data. Accordingly, an inductive thematic analysis was conducted using the framework of Braun and Clarke (Qualitative Research in Psychology, 3, 2006, 77). Women and health professionals both resorted to satisficing, using heuristics to make decisions about the importance of symptoms depending on their severity and duration. Most women initially determined that the bodily changes were within the realms of normal. Time to diagnosis was also affected by the following: women's long-standing assumptions; communication with health professionals; liminality-women oscillating between their self-assessment that these changes were something significant or nothing important; and gaps in health literacy. The journey from noticing bodily changes to diagnosis was a nonlinear trajectory. Women worked to make sense of what was happening to them, informed by their sociocultural environment. In particular, confusion about the purpose of cervical screening led a number of participants who had regular smears to assume they were "safe" from cancer worries. Women and some health professionals may be unfamiliar with symptoms potentially indicative of endometrial cancer. There may be structural and communication barriers for women navigating healthcare systems. It is vital that nurses take time both to listen to women and to provide them with resources to enhance their health literacy.

Increasing Breast Cancer Screening in Russian Immigrant Women: Identifying Barriers and Providing On-Site Mammography.

Background: There has been a significant decline in the use of mammography in the Russian immigrant population. Local Problem: Structural barriers to mammography include lack of or insufficient health insurance and distance to medical facilities. Organizational barriers include difficulty communicating with medical staff and navigating health care systems. The strongest mammography intervention is access. Methods: A Breast Health Tea event, small group discussions, and an on-site mammography event were held within this community to provide education about breast cancer and provide on-site screening mammography. Results: Twenty-seven women received the education and returned the questionnaires. Of these 27, 19 had mammograms. Of the 19, 16 had normal/benign results. Three required follow-up. Of the 3, 1 was positive for breast cancer, 1 was benign, and 1 went elsewhere. Conclusions: Providing access to on-site mammography has been shown to be an effective tool to reach communities that otherwise would not have access to these screenings. Advanced practice registered nurses can partner with public and private organizations and remove barriers to access for breast cancer screening in immigrant communities.

Stroke, multimorbidity and polypharmacy in a nationally representative sample of 1,424,378 patients in Scotland: implications for treatment burden.

BackgroundThe prevalence of multimorbidity (the presence of two or more long-term conditions) is rising internationally. Multimorbidity affects patients by increasing their burden of symptoms, but is also likely to increase the self-care demands, or treatment burden, that they experience. Treatment burden refers to the effort expended in operationalising treatments, navigating healthcare systems and managing relations with healthcare providers. This is an important problem for people with chronic illness such as stroke. Polypharmacy is an important marker of both multimorbidity and burden of treatment. In this study, we examined the prevalence of multimorbidity and polypharmacy in a large, nationally representative population of primary care patients with and without stroke, adjusting for age, sex and deprivation.MethodsA cross-sectional study of 1,424,378 participants aged 18 years and over, from 314 primary care practices in Scotland that were known to be demographically representative of the Scottish adult population. Data included information on the presence of stroke and another 39 long-term conditions, plus prescriptions for regular medications.ResultsIn total, 35,690 people (2.5%) had a diagnosis of stroke. Of the 39 comorbidities examined, 35 were significantly more common in people with stroke. Of the people with a stroke, the proportion that had one or more additional morbidities present (94.2%) was almost twice that in the control group (48%) (odds ratio (OR) adjusted for age, sex and socioeconomic deprivation 5.18; 95% confidence interval (CI) 4.95 to 5.43). In the stroke group, 12.6% had a record of 11 or more repeat prescriptions compared with only 1.5% of the control group (OR adjusted for age, sex, deprivation and morbidity count 15.84; 95% CI 14.86 to 16.88). Limitations include the use of data collected for clinical rather than research purposes, a lack of consensus in the literature on the definition of certain long-term conditions, and the absence of statistical weighting in the measurement of multimorbidity, although the latter was deemed suitable for descriptive analyses.ConclusionsMultimorbidity and polypharmacy were strikingly more common in those with a diagnosis of stroke compared with those without. This has important implications for clinical guidelines and the design of health services.Electronic supplementary materialThe online version of this article (doi:10.1186/s12916-014-0151-0) contains supplementary material, which is available to authorized users.