August 2012 issue
For access to the articles listed below, click here.
As we move closer to the U.S. presidential election of 2012, and work in light of the June U.S. Supreme Court decision regarding the Patient Protection and Affordable Care Act (ACA) of 2010, an army of dedicated scholars and clinicians continues its assault on inequities in health, the massive and complex set of imbalances that make this journal necessary and important. In this issue, we present work on four themes (although they are organized only in terms of article type rather than separated into separate sections as in previous issues):
• Theme 1—Cross-Cultural and International Care
• Theme 2—The Safety Net
• Theme 3—Epidemiology, Measurement, and Other Public Health Topics
• Theme 4—Health Policy
THEME 1—CROSS-CULTURAL AND INTERNATIONAL CARE
Six articles fit into the area of cross-cultural and international care. A Report from the Field by Weissman and colleagues describes the two-sided success of free, student-run health initiatives, which provide much needed medical care and teach students about cross-cultural caregiving and systems-based medical practice. In a Commentary, Fernando DeMaio argues for three research priorities on concerning immigrants to Canada: incorporating context into data collected, conducting comparative international studies, and refining the constructions of race and ethnicity to reflect recent developments in social theory.
In another Commentary, Perry Payne calls the question of whether the U.S. Federal government is correct in saying there are mandates to follow National Standards for Culturally and Linguistically Appropriate Services, given that they are often not followed and have even been referred to as voluntary by government officials. Having sketched out the actual state of affairs, Payne goes on to explain why such standards are indeed important, specifically for populations with limited English proficiency. In a related Brief Communication, Shippee and colleagues analyze data from nearly 2,500 Hispanic/Latino, Hmong, and Somali enrollees of public health insurance programs in Minnesota. Unsurprisingly, the Hmong and Somali people experienced much more unmet need for interpreter services than the Latinos.
Chisholm-Staker and colleagues take on the grave issue of human trafficking (or, slavery) in their report on training of emergency room (ER) providers about how to look for and probe patients who may be living as slaves. The ER, the authors convincingly argue, may be one of the few places where care providers and victims of human trafficking come face to face, and thus offers an important opportunity for righting a fundamental wrong.
Njuguna and colleagues from Kenya assessed malaria curative services in Ijara District (in the Northeast of Kenya). They report that all the facilities they studied had the recommended drugs, but only 90% had injectable quinine, and that all facilities lacked rapid diagnostic tests and several other critical components of the malaria-fighting toolkit.
THEME 2—THE SAFETY NET
The core of this issue consists of papers about the so-called safety net, the generally uncoordinated panoply of caregivers, sites of care, and sources of financing to which people who lack private medical resources turn for preventive, maintenance, illness-induced, and catastrophic care. While this journal could hardly function without the term safety net, readers should always read it skeptically: saying there is a safety net counter-factually implies that the net (1) catches everyone who falls ill, and (2) prevents those it does catch from suffering due to their lack of other resources. It does neither. Having said that, however, the safety net does a lot of good in the U.S., and readers of this issue will learn much about its strengths and some of its weaknesses.
Masi’s Commentary on Promise Neighborhoods directs our attention to a the U.S. Department of Education’s program to provide coordinated services for children living in poverty, modeling the program after Geoffrey Canada’s ambitious Harlem Children’s Zone. Masi presents the case based on rapidly accumulating evidence that children experience health benefits when immersed in highly nurturing educational environments. Anderson and Olayiwola’s Commentary concerns patient-centered medical homes and the pressing need to strengthen the federal community health center program (as the ACA proposes to do).
Coordination of primary care and specialty care services is one of the next big challenges that safety-net providers are facing, and in their Brief Communication Lauren Block and colleagues report on The Access Partnership’s record of success in getting uninsured patients to the specialists they needed to see.
A group of empirical papers concern community health centers (CHCs). Ramirez-Zohfeld and colleagues explore the potential—given the limited resources of the mechanisms of CHCs—for outreach to diabetes patients who have fallen out of care; Richard Roetzheim and colleagues study the timeliness of diagnostic evaluation of abnormal cancer screening text results at CHCs; Fernandes and colleagues assess the efficacy of community health workers at a Hawaiian CHC in educating heart patients about their condition so that their clinical outcomes improve over time.
Lopez-Class and colleagues study colorectal cancer screening at seven CHCs and other safety-net clinics in the Washington, D.C. area, providing a transition to the articles in safety-net settings other than CHCs (as some of the clinics in the Lopez-Class study are free clinics). Nuss et al. look at the improvement of colon cancer treatment at safety-net hospitals in terms of a social-ecological model; Sheu et al. report on how student-run free clinics affect the health professions students who work in them; Hwang and colleagues report that the use of free clinics decreases the likelihood that an individual will use and emergency room for primary care, and conclude that this provides strong support for expanding the primary care workforce as the Medicaid population expands.
Further outside the circle of prototypical safety-net settings are Head Start classrooms, churches, and homes, but constructive public health endeavors spring up in those locations, too. Kranz and colleagues compare oral health practices at two types of Head Start programs, providing useful information for others who might want to intervene in the growing problem of early pediatric oral health disorder. Pichon and colleagues study the outcomes of African American faith leaders’ training to deliver a faith-based HIV prevention curriculum to young people and adults in their congregations. Okamoto et al. report on the drug-resistance strategies endorsed by Hawaiian community leaders for rural Hawaiian youth.
THEME 3—EPIDEMIOLOGY, MEASUREMENT, AND OTHER PUBLIC HEALTH TOPICS
Another major theme of this issue are the core public health topics of epidemiology and measurement, as well as four qualitative explorations of the experiences of particular populations in the health system. Juarez and colleagues quantitatively assess the prevalence and heart disease and its risk factors in Hawaii, comparing Asians, Pacific Islanders, and Whites: Native Hawaiians and Filipinos had the highest incidences of hypertension and diabetes; Asians had the highest rates of hyperlipidemia; although Whites had fewer known risk factors than the others, they faced the same overall risk of heart disease. The prevalence curves for the different groups begin to diverge at about age 30. Hanson and Olson report on a longitudinal study over 13 states of food insecurity in low-income rural families with children. Both enduring chronic health conditions and risk for depression predicted lasting food insecurity, while education beyond high school was protective against it. Ziller and colleagues also focus on rural populations, examining the perennial issues of health care access and use, in their case among uninsured residents of rural areas in comparison with uninsured urban dwellers: the rural uninsured are more likely to have a usual source of care and to use it than are their urban counterparts. Wen and colleagues investigated what predicts smoking cessation among low-income pregnant women, finding that factors such as more cigarettes smoked per day, lower education, higher self-efficacy for quitting on one’s own, and more children at home each correlated with a failure to complete cessation programs at different stages of the pregnancy.
Spiers and colleagues remind readers of the persistence of low health literacy as a barrier to optimal health by reporting on a study of over 154 adults eligible for the federal Supplemental Nutrition Assistance Program (the core of which is Food Stamps): health literacy was very low in the population sampled, and the lower it was the more likely the respondent was to eat unhealthy food (such as fried chicken) and not to eat healthy food (such as the peels of fruit). Bauer and colleagues retrospectively examine several years worth of data from a San Francisco medical respite program for homeless patients discharged from the hospital. Over two-thirds of patients stayed the recommended length of time, but those who left early were more likely to be re-admitted within 90 days. Frech and colleagues at the University of Utah studied over 8,000 American Indians and Alaska Natives (AIAN) for risk of osteoporosis and the prevalence of fracture; they report a high prevalence of multiple risk factors for osteoporosis in AIAN and call for attention to the problem. Edwards and colleagues, also at the University of Utah, provide a report on their study of construct validity of the Short-Form 12 (SF-12) Health Survey Instrument and the Mental Component Summary of the SF-12 (MCS-12) in a cohort of AIAN people, which produced positive results.
The four qualitative papers that fit into the core public health theme are Siegel and colleagues’ study of types of dental fear among African American adults in Harlem; Sansgiry et al.’s study of over-the-counter drug purchases by blind consumers; Zaller et al.’s study of the interactions between purchasers and pharmacists in the course of the sale of clean syringes; and Cassady et al.’s study of the H1N1 epidemic among Latino populations whom they deem hard to reach.
THEME 4—HEALTH POLICY
Finally, two papers and in this issue bear directly on financing of health care and thus fall squarely into the health policy section. Fonk and colleagues look at the effect of advance directives on end-of-life costs, perhaps surprisingly finding no relationship once patient health is controlled for. Prather and colleagues at the CDC investigated using microenterprise as a means of simultaneously addressing poverty and HIV by conducting focus groups with young African American women and community leaders in two southern states, and report on their interesting findings here. Finally, the ACU Column in this issue directs all of our attention to the next kind of application that may be on all of our phones: a mobile health app!
In the coming months, readers will have the opportunity to order two new books that we hope will prove valuable: Will Anybody Help? Is a collection of articles concerning the free clinics and student-run clinics in a wide array of localities across the United States, with a preface by Dr. Charles Mouton, Dean of the Meharry Medical College School of Medicine (Virginia M. Brennan, ed.). Obesity Interventions among Underserved U.S. Populations: Evidence and Directions is a collection of peer-reviewed new work sponsored by the Aetna Foundation and edited by Drs. Virginia Brennan, Shiriki Kumanyika, and Ruth Zambrana. Both will be available soon from Johns Hopkins University Press and we hope you will seek them out.
Virginia M. Brennan, PhD, MA
Associate Professor, Meharry Medical College