Medical Mistrust and Adherence to Care Among a Heterogeneous Cohort of Women Living with HIV, Followed in a Large, U.S. Safety Net Clinic.
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ABSTRACT:
SUBMITTER: Duthely LM
PROVIDER: S-EPMC8665805 | biostudies-literature | 2021
REPOSITORIES: biostudies-literature
Publications
Medical Mistrust and Adherence to Care Among a Heterogeneous Cohort of Women Living with HIV, Followed in a Large, U.S. Safety Net Clinic.
Duthely Lunthita M LM Sanchez-Covarrubias Alex P AP Prabhakar Varsha V Brown Megan R MR Thomas Tanya E S TES Montgomerie Emily K EK Potter JoNell E JE
Health equity 20210924 1
<b>Purpose:</b> To explore the relationship between medical mistrust, as measured by the Group-Based Medical Mistrust (GBMM) scale, and HIV care adherence among a cohort of minority women receiving care in a U.S. safety net clinic. <b>Methods:</b> English-, Spanish-, and Haitian Creole (Creole)-speaking patients with a recent history of nonadherence to care were surveyed. <b>Results:</b> English speakers endorsed the highest level of mistrust, followed by Spanish speakers and Creole speakers. Cr ...[more]
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| S-EPMC4254756 | biostudies-literature
Project description:IntroductionHIV pre-exposure prophylaxis (PrEP) is an effective HIV prevention method for women experiencing intimate partner violence (IPV). This study aimed to examine (1) relationships between physical, sexual, and psychological IPV and women's PrEP communication with a health care provider and domestic violence advocate; and (2) how IPV-specific medical mistrust modifies the association between IPV and PrEP communication.MethodsData were from 2 studies conducted in Connecticut and Baltimore, MD on adult women experiencing IPV (N = 272). Logistic regressions examined associations between IPV, PrEP communication, and IPV-specific medical mistrust.ResultsThe average age was 25.7. The most common identity was non-Hispanic black (37.1%), followed by non-Hispanic white (33.8%), Hispanic (20.6%), and non-Hispanic another racial group (8.5%). Higher severity of psychological IPV was associated with more embarrassment to initiate a PrEP discussion with a health care provider (P = 0.009) or domestic violence advocate (P = 0.026). However, women with more severe psychological IPV were more willing to accept a PrEP recommendation from a health care provider (P = 0.033) or domestic violence advocate (P = 0.044). IPV-specific medical mistrust modified the association between physical IPV and willingness to accept a PrEP recommendation by a domestic violence advocate, such that women with physical IPV were significantly less likely to accept a PrEP recommendation by a domestic violence advocate, but only for women with high IPV-specific medical mistrust (P = 0.021).ConclusionsPrEP initiation among women experiencing IPV may be strengthened by addressing and dismantling systems that perpetuate IPV-specific medical mistrust and stigma against IPV survivors.
| S-EPMC9203922 | biostudies-literature
Project description:ImportanceNational patterns of low-value and high-value care delivered to patients without insurance or with Medicaid could inform public policy but have not been previously examined.ObjectiveTo measure rates of low-value care and high-value care received by patients without insurance or with Medicaid, compared with privately insured patients, and provided by safety-net physicians vs non-safety-net physicians.Design, setting, and participantsThis multiyear cross-sectional observational study included all patients ages 18 to 64 years from the National Ambulatory Medical Care Survey (2005-2013) and the National Hospital Ambulatory Medical Care Survey (2005-2011) eligible for any of the 21 previously defined low-value or high-value care measures. All measures were analyzed with multivariable logistic regression and adjusted for patient and physician characteristics.ExposuresComparison of patients by insurance status (uninsured/Medicaid vs privately insured) and safety-net physicians (seeing >25% uninsured/Medicaid patients) vs non-safety-net physicians (seeing 1%-10%).Main outcomes and measuresDelivery of 9 low-value or 12 high-value care measures, based on previous research definitions, and composite measures for any high-value or low-value care delivery during an office visit.ResultsOverall, 193 062 office visits were eligible for at least 1 measure. Mean (95% CI) age for privately insured patients (n = 94 707) was 44.7 (44.5-44.9) years; patients on Medicaid (n = 45 123), 39.8 (39.3-40.3) years; and uninsured patients (n = 19 530), 41.9 (41.5-42.4) years. Overall, low-value and high-value care was delivered in 19.4% (95% CI, 18.5%-20.2%) and 33.4% (95% CI, 32.4%-34.3%) of eligible encounters, respectively. Rates of low-value and high-value care delivery were similar across insurance types for the majority of services examined. Among Medicaid patients, adjusted rates of use were no different for 6 of 9 low-value and 9 of 12 high-value services compared with privately insured beneficiaries, whereas among the uninsured, rates were no different for 7 of 9 low-value and 9 of 12 high-value services. Safety-net physicians provided similar care compared with non-safety-net physicians, with no difference for 8 out of 9 low-value and for all 12 high-value services.Conclusions and relevanceOveruse of low-value care is common among patients without insurance or with Medicaid. Rates of low-value and high-value care were similar among physicians serving vulnerable patients and other physicians. Overuse of low-value care is a potentially important focus for state Medicaid programs and safety-net institutions to pursue cost savings and improved quality of health care delivery.
| S-EPMC5540058 | biostudies-literature
Project description:BackgroundMedical mistrust, a result of systemic racism, is prevalent among Black Americans and may play a role in COVID-19 inequities. In a convenience sample of HIV-positive Black Americans, we examined associations of COVID-19-related medical mistrust with COVID-19 vaccine and COVID-19 treatment hesitancy and negative impacts of COVID-19 on antiretroviral therapy (ART) adherence.MethodsParticipants were 101 HIV-positive Black Americans (age: M = 50.3 years; SD = 11.5; 86% cisgender men; 77% sexual minority) enrolled in a randomized controlled trial of a community-based ART adherence intervention in Los Angeles County, CA. From May to July 2020, participants completed telephone interviews on negative COVID-19 impacts, general COVID-19 mistrust (eg, about the government withholding information), COVID-19 vaccine and treatment hesitancy, and trust in COVID-19 information sources. Adherence was monitored electronically with the Medication Event Monitoring System.ResultsNearly all participants (97%) endorsed at least one general COVID-19 mistrust belief, and more than half endorsed at least one COVID-19 vaccine or treatment hesitancy belief. Social service and health care providers were the most trusted sources. Greater COVID-19 mistrust was related to greater vaccine and treatment hesitancy [b (SE) = 0.85 (0.14), P < 0.0001 and b (SE) = 0.88 (0.14), P < 0.0001, respectively]. Participants experiencing more negative COVID-19 impacts showed lower ART adherence, assessed among a subset of 49 participants [b (SE) = -5.19 (2.08), P = 0.02].DiscussionTo prevent widening health inequities, health care providers should engage with communities to tailor strategies to overcome mistrust and deliver evidence-based information, to encourage COVID-19 vaccine and treatment uptake.
| S-EPMC7808278 | biostudies-literature
Project description:BackgroundMailed fecal immunochemical testing (FIT) can increase colorectal cancer (CRC) screening rates, including for vulnerable patients, but its cost-effectiveness is unclear.ObjectiveWe sought to examine the effectiveness and cost-effectiveness of the initial cycle of our mailed FIT program from November 2017 to July 2019 in a federally qualified health center (FQHC) system in Central Texas.DesignSingle group intervention and economic analysis PARTICIPANTS: Eligible patients were those ages 50-75 who had been seen recently in a system practice and were not up to date with screening.InterventionThe program mailing packet included an introductory letter in plain language, the FIT itself, easy to read instructions, and a postage-paid lab mailer, supplemented with written and text messaging reminders.Main measuresWe measured effectiveness based on completion of mailed FIT and cost-effectiveness in terms of cost per person screened. Costs were measured using detailed micro-costing techniques from the perspective of a third-party payer and expressed in 2019 US dollars. Direct costs were based on material supply costs and detailed observations of labor required, valued at the wage rate.Key resultsOf the 22,838 eligible patients who received program materials, mean age was 59.0, 51.5% were female, and 43.9% were Latino. FIT were successfully completed by 19.2% (4395/22,838) patients at an average direct cost of $5275.70 per 500-patient mailing. Assuming completed tests from the mailed intervention represent incremental screening, the direct cost per patient screened, compared with no intervention, was $54.83. Incorporating start-up and indirect costs increases total costs to $7014.45 and cost per patient screened to $72.90. Alternately, assuming 2.5% and 5% screening without the intervention increased the direct (total) cost per patient screened to $60.03 ($80.80) and $67.05 ($91.47), respectively.ConclusionsMailed FIT is an effective and cost-effective population health strategy for CRC screening in vulnerable patients.
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Project description:BackgroundExisting tools to measure patient-centered medical home (PCMH) adoption are not designed for research evaluation in safety-net clinics.ObjectiveDevelop a scale to measure PCMH adoption in safety-net clinics.Research designCross-sectional survey.SubjectsSixty-five clinics in five states.Main measuresFifty-two-item Safety Net Medical Home Scale (SNMHS). The total score ranges from 0 (worst) to 100 (best) and is an average of multiple subscales (0-100): Access and Communication, Patient Tracking and Registry, Care Management, Test and Referral Tracking, Quality Improvement, and External Coordination. The scale was tested for internal consistency reliability and tested for convergent validity using The Assessment of Chronic Illness Care (ACIC) and the Patient-Centered Medical Home Assessment (PCMH-A). The scale was applied to centers in the sample. In addition, linear regression models were used to measure the association between clinic characteristics and medical home adoption.ResultsThe SNMHS had high internal consistency reliability (Cronbach's alpha = 0.84). The SNMHS score correlated moderately with the ACIC score (r = 0.64, p < 0.0001) and the PCMH-A (r = 0.56, p < 0.001). The mean SNMHS score was 61 ± SD 13. Among the subscales, External Coordination (66 ± 16) and Access and Communication (65 ± 14) had the highest mean scores, while Quality Improvement (55 ± 17) and Care Management (55 ± 16) had lower mean scores. Clinic characteristics positively associated with total SNMHS score were having more providers (β 15.8 95% CI 8.1-23.4 >8 provider FTEs compared to <4 FTEs) and participation in financial incentive programs (β 8.4 95% 1.6-15.3).ConclusionThe SNMHS demonstrated reliability and convergent validity for measuring PCMH adoption in safety-net clinics. Some clinics have significant PCMH adoption. However, room for improvement exists in most domains, especially for clinics with fewer providers.
| S-EPMC3235610 | biostudies-literature
Project description:ObjectivesObesity adversely inhibits antibody response to vaccination. Three doses of HPV4 may or may not provide adequate long term protection against HPV 16/18 in obese females. The aim of this study was to determine whether adherence to HPV4 vaccination in a safety net population was reduced with increasing body mass index (BMI).MethodsWe designed a historical prospective study evaluating the number and dates of HPV4 dosing that occurred from July 1, 2006 through October 1, 2009 by the demographic characteristics of the 10-26 year old recipient females. The defined dosing intervals were adapted from the literature and obesity categories were defined by the WHO.Results1240 females with BMI measurements received at least one dose of HPV4; 38% were obese (class I, II and III) and 25% were overweight. Females with normal BMI received on-time triplet dosing significantly more often than did the obese class II and III females (30% vs. 18%, p<0.001). Obese class II/III females have a significant 45% less chance of completing the on-time triplet HPV4 series than normal women (OR = 0.55, 95% CI: 0.37, 0.83). Pregnancy history has a significant influence on BMI and HPV4 dosing compliance in this safety net population where 71% had been gravid. Hispanic females were less likely to complete HPV4 dosing regardless of BMI (aOR = 0.39, 95% CI: 0.16, 0.95).ConclusionsObesity, as well as gravidity and Hispanic race, are risk factors for lack of HPV4 vaccine adherence among young females in a safety net population.
| S-EPMC4116139 | biostudies-literature
Project description:IntroductionSafety-net sexually transmitted disease services can prevent transmission of sexually transmitted disease. This study assesses the availability of safety-net sexually transmitted disease clinical services across the U.S.MethodsA 2018 survey of U.S. local health departments examined the availability of safety-net providers and the availability of specific sexually transmitted disease clinical services, including point-of-care testing and treatment. In 2019, Rao-Scott chi-square tests were used to compare service availability by clinic type (sexually transmitted disease clinic versus other clinics).ResultsA total of 326 local health departments completed the survey (49% response rate). Of respondents, 64.4% reported that a clinic in their jurisdiction provided safety-net sexually transmitted disease services. Having a safety-net clinic that provided sexually transmitted disease services was more common in medium and large jurisdictions. Sexually transmitted disease clinics were the primary provider in 40.5% of jurisdictions. A wide range of specific sexually transmitted disease services was offered at the primary safety-net clinic for sexually transmitted diseases. Most clinics offered human papillomavirus vaccination and appropriate point-of-care treatment for gonorrhea and syphilis. Fewer than one-quarter of clinics offered point-of-care rapid plasma reagin or darkfield microscopy syphilis testing. Compared with other clinics, services more commonly offered at sexually transmitted disease clinics included same-day services, hepatitis B vaccination, rapid plasma reagin testing (syphilis), any point-of-care testing for gonorrhea, point-of-care trichomonas testing, and extragenital chlamydia or gonorrhea testing.ConclusionsOne-third of local health departments reported no safety-net sexually transmitted disease services or were not aware of the services, and availability of specific services varied. Without an expansion of resources, local health departments might explore collaborations with healthcare systems and innovations in testing to expand sexually transmitted disease services.
| S-EPMC10088361 | biostudies-literature
Project description:COVID-19 has stretched the U.S. social safety net and prompted federal legislation designed to ameliorate the pandemic's health and economic impacts. We surveyed a nationally representative cohort of 1222 U.S. adults in April 2020 and November 2020 to evaluate changes in public opinion about 11 social safety net policies and the role of government over the course of the pandemic. A majority of U.S. adults supported six policies at both time points, including policies guaranteeing two weeks of paid sick leave; enacting universal health insurance; increasing the federal minimum wage; and increasing government spending on construction projects, business tax credits, and employment education and training. From April to November 2020, public support was stable for nine of the 11 policies but declined nearly 10 percentage points for policies guaranteeing two weeks paid sick leave (from 76% support in April 2020 to 67% support in November 2020) and extending unemployment insurance benefits (51% to 42%). Declines in support for these two policies were concentrated among those with higher incomes, more education, in better health status, the employed, and those with health insurance. The share of respondents believing in a strong role of government also declined from 33% in April to 26% in November 2020 (p > 0.05). Despite these shifts, we observed consistent majority support for several policies enacted during the pandemic, including guaranteeing paid sick leave and business tax credits, as well as employment-related policies.
| S-EPMC8620405 | biostudies-literature
Project description:IntroductionUsing plan-do-study-act cycles, our team aimed to increase mean provider adherence to the Lead Exposure Protocol at the Boston Medical Center Pediatric Primary Care Clinic from 16% (baseline global mean provider adherence) to 80% from April 1, 2021, to February 1, 2023, thereby curbing the secondary effects of lead exposure.MethodsOur team performed a chart review of patients 6 months to 5 years of age with blood lead levels (BLLs) ≥2 µg/dL (n = 853) to track provider adherence to Boston Medical Center's Lead Exposure Protocol. We created p charts to track the efficacy of interventions to improve adherence. Interventions included (1) electronic medical record SmartPhrases, (2) provider education, (3) provider feedback, (4) implementation of a follow-up nursing workflow, and (5) simplification of nursing workflow.ResultsFor BLL 2-4 µg/dL (n = 783), a centerline shift in provider adherence was observed, with >8 points above the preintervention mean after intervention (2) and an increase in mean adherence from 14.1% to 50%. For BLL 5-9 µg/dL (n = 58), no centerline shift was observed, with only 6 points above the upper control limit after intervention (4). The 2-4 µg/dL range changes indicate special cause variance and system change. Global mean provider adherence increased by 3.3 times to 53%.ConclusionsSimple, low-cost process changes improved adherence to complex guidelines for managing lead-exposed children in the primary care setting. Similar interventions could be implemented on a broader scale to standardize the management of other routine pediatric screens.
| S-EPMC11798393 | biostudies-literature