Elevated asthma morbidity in Puerto Rican children: a review of possible risk and prognostic factors

Latino children represent a significant proportion of all US children, and asthma is the most common chronic illness affecting them. Previous research has revealed surprising differences in health among Latino children with asthma of varying countries of family origin. For instance, Puerto Rican children have a higher prevalence of asthma than Mexican American or Cuban American children. In addition, there are important differences in family structure and socioeconomic status among these Latino populations: Cuban Americans have higher levels of education and family income than Mexican-Americans and Puerto Ricans; mainland Puerto Rican children have the highest proportion of households led by a single mother. Our review of past research documents differences in asthma outcomes among Latino children and identifies the possible genetic, environmental, and health care factors associated with these differences. Based on this review, we propose research studies designed to differentiate between mutable and immutable risk and prognostic factors. We also propose that the sociocultural milieus of Latino subgroups of different ethnic and geographic origin are associated with varying patterns of risk factors that in turn lead to different morbidity patterns. Our analysis provides a blue-print for future research, policy development, and the evaluation of multifactorial interventions involving the collaboration of multiple social sectors, such as health care, public health, education, and public and private agencies.     

Poverty,prenatal care,and infant health in Puerto Rico

Using data from a survey administered to a representative sample of mothers who gave birth in Puerto Rico in 1994-95, we investigate whether prenatal care and infant health outcomes are associated with family poverty and neighborhood poverty. The results show that infant health outcomes are unrelated to both family poverty and neighborhood poverty, despite the association of family poverty with the adequacy of prenatal care and the content of prenatal care. However, the poverty paradigm does receive some support using measures of participation in government programs that serve the low-income population. Women who rely on the government to fund their medical care are more likely than women who rely on private health insurance to have an infant death. They are also less likely to receive the highest levels of prenatal care. Nonetheless, targeted government programs can have an ameliorative impact. The analysis shows that participants in the Women, Infants, and Children (WIC) program are more likely than non-participants to receive superior levels of prenatal care and are less likely to have negative infant health outcomes.     

Observational Study Assessing Demographic,Economic and Clinical Factors Associated with Access and Utilization of Health Care Services of Patients with Multiple Sclerosis under Treatment with Interferon Beta-1b (EXTAVIA)

Multiple sclerosis (MS) results in an extensive use of the health care system, even within the first years of diagnosis. The effectiveness and accessibility of the health care system may affect patients'' quality of life. The aim of the present study was to evaluate the health care resource use of MS patients under interferon beta-1b (EXTAVIA) treatment in Greece, the demographic or clinical factors that may affect this use and also patient satisfaction with the health care system. Structured interviews were conducted for data collection. In total, 204 patients (74.02% females, mean age (SD) 43.58 (11.42) years) were enrolled in the study. Analysis of the reported data revealed that during the previous year patients made extensive use of health services in particular neurologists (71.08% visited neurologists in public hospitals, 66.67% in private offices and 48.53% in insurance institutes) and physiotherapists. However, the majority of the patients (52.45%) chose as their treating doctor private practice neurologists, which may reflect accessibility barriers or low quality health services in the public health system. Patients seemed to be generally satisfied with the received health care, support and information on MS (84.81% were satisfied from the information provided to them). Patients'' health status (as denoted by disease duration, disability status and hospitalization needs) and insurance institute were found to influence their visits to neurologists. Good adherence (up to 70.1%) to the study medication was reported. Patients'' feedback on currently provided health services could direct these services towards the patients'' expectations.     

Fatal hyperthermia associated with cocaine use.

Health insurance in the United States is failing patients and physicians alike. In this country 37 million uninsured face economic barriers to care, and the health of many suffers as a result. The "corporatization" of medical care threatens professional values with an unprecedented administrative and commercial intrusion into the daily practice of medicine. Competitive strategies have also failed their most ostensible goal--cost control. In contrast, Canada offers a model of a national health insurance plan that provides universal and comprehensive coverage, succeeds at restraining health care inflation, and does little to abrogate the clinical autonomy of physicians in private practice. I propose that American physicians relent in their historical opposition to national health insurance and participate in the development of a universal, public insurance plan responsive to the needs of both patients and physicians.     

NHS waiting list have been a boon for private medicine in the UK.

Health care: public, private or both? In Great Britain, about 13% of the population is covered by private health insurance, and everyone else is served by the public health care system known as the National Health Service, or NHS. Caroline Richmond, who examined the impact of private medical practice in Britain, says people become private patients for one compelling reason: to avoid the NHS''s notoriously long waiting lists for surgery. According to Professor Alan Maynard, a health care researcher, the mainstays of the private sector are the "three h''s" --hips, hernias and hemorrhoids-- along with some elective surgery, particularly in gynecology and opthalmology. Another small sector focuses on fertility regulation and cosmetic surgery. Although the levels are not monitored closely, physician consultants are not permitted to earn more than 10% of their income from private practice.     

Comparisons for Body Mass Index and Body Fat Percent Among Puerto Ricans,Blacks, Whites and Asians Living in the New York City Area

The latest data (NHANES III) from the National Center for Health Statistics (NCHS) show that the black population has the highest proportion of overweight among all adult populations in the United States. The present study compared the body mass index (BMI) and body fat percent from dual-photon absorptiometry in 1,324 healthy adults aged 18 to 107 years recruited from four ethnic groups in the New York City area; 523 whites, 280 blacks, 267 Asians and 254 Puerto Ricans. Puerto Ricans had the largest BMI and the largest percent of subjects with body weight more than 120% of their ideal weight, and the largest fat percent of the four ethnic groups: 76% of Puerto Rican males had fat percent above the median value for white males (fat percent = 19.6%) and 95% of Puerto Rican females had fat percent above the median for white females (fat percent = 30.8%). Asians had the smallest BMI, but 63% of them had fat percent above the median values for whites in each gender. Puerto Ricans also had the largest waist-to-hip ratios among the four ethnic groups. In blacks, the percent of subjects with fat percent larger than the median for whites was slightly smaller than that for Puerto Ricans, 64% and 82% of males and females respectively. These results differ from the latest NCHS data and show that Puerto Ricans in this sample are heavier and fatter than blacks.     

Preventive health care of Indian preschoolers in the Sioux Lookout Zone,northwestern Ontario.

The provision of preventive health care to native children in the Sioux Lookout Zone of northwestern Ontario was assessed by reviewing the medical charts of 568 randomly selected preschoolers in 1980. Data were collected on the method of infant feeding; immunization status, vaccination and testing for tuberculosis; development, vision and hearing screening; monitoring of growth; and nutritional status and vitamin supplementation. Most of the children had been breast-fed and had received primary diphtheria-pertussis-tetanus-polio immunization as well as measles-mumps-rubella and bacille Calmette-Guérin vaccination. However, less than 30% had undergone developmental screening, and only 10% and 8% respectively had had their vision and hearing screened. Growth monitoring was adequate in the first year of life but not thereafter. Only about 55% of the children had ever had a hemoglobin level determined. More emphasis on health promotion is needed if native children are to receive adequate preventive health care.     

A Social-Ecological View of Barriers and Facilitators for HIV Treatment Adherence: Interviews with Puerto Rican HIV Patients

Purpose

To identify perceived barriers and facilitators for HAART adherence among people living with HIV/AIDS in Southern Puerto Rico using a Social Ecological framework.

Patients and Methods

Individual in-depths interviews were conducted with 12 HIV patients with a history of HAART non-adherence. Interviews were audio-taped and transcribed. Content analysis was performed for each transcribed interview by three independent coders using a codebook. Using Atlas TI, super-codes and families were generated to facilitate the categorization tree as well as grounded analyses and density estimates

Results

Most participants reported a monthly income of $500 or less (n = 7), a high school education level (n = 7), being unemployed (n = 9) and being recipients of government health insurance (n = 11). Three out of six women reported living alone with their children and most men informed living with their parents or other relatives (n = 4). For the grounded analyses, the top four sub-categories linked to high number of quotations were mental health barriers (G = 32) followed by treatment regimen (G = 28), health system (G = 24) and interpersonal relations (G = 16). The top four sub-categories linked to high number of codes are treatment regimen (D = 4), health status perception (D = 3), interpersonal relations (D = 3) and health system (D = 3).

Conclusion

The results of this study suggest the interconnection of HIV treatment adherence barriers at various system levels. Future studies on HIV treatment barriers should explore these interactions and investigate the possible synergistic effect on non-adherent behavior     

Breast,cervical, and colorectal cancer screening test use in the US territories of Guam,Puerto Rico,and the US Virgin Islands

BackgroundThe United States Preventive Services Task Force (USPSTF) recommends breast, cervical, and colorectal cancer screening among eligible adults, but information on screening use in the US territories is limited.MethodsTo estimate the proportion of adults up-to-date with breast, cervical, and colorectal cancer screening based on USPSTF recommendations, we analyzed Behavioral Risk Factor Surveillance System data from 2016, 2018, and 2020 for the 50 US states and DC (US) and US territories of Guam and Puerto Rico and from 2016 for the US Virgin Islands. Age-standardized weighted proportions for up-to-date cancer screening were examined overall and by select characteristics for each jurisdiction.ResultsOverall, 67.2% (95% CI: 60.6–73.3) of women aged 50–74 years in the US Virgin Islands, 74.8% (70.9–78.3) in Guam, 83.4% (81.7–84.9) in Puerto Rico, and 78.3% (77.9–78.6) in the US were up-to-date with breast cancer screening. For cervical cancer screening, 71.1% (67.6–74.3) of women aged 21–65 years in Guam, 81.3% (74.6–86.5) in the US Virgin Islands, 83.0% (81.7–84.3) in Puerto Rico, and 84.5% (84.3–84.8) in the US were up-to-date. For colorectal cancer screening, 45.2% (40.0–50.5) of adults aged 50–75 years in the US Virgin Islands, 47.3% (43.6–51.0) in Guam, 61.2% (59.5–62.8) in Puerto Rico, and 69.0% (68.7–69.3) in the US were up-to-date. Adults without health care coverage reported low test use for all three cancers in all jurisdictions. In most jurisdictions, test use was lower among adults with less than a high school degree and an annual household income of < $25,000.ConclusionCancer screening test use varied between the US territories, highlighting the importance of understanding and addressing territory-specific barriers. Test use was lower among groups without health care coverage and with lower income and education levels, suggesting the need for targeted evidence-based interventions.     

Relation between private health insurance and high rates of caesarean section in Chile: qualitative and quantitative study

ObjectivesTo explore the circumstances and factors that explain the association between private health insurance cover and a high rate of caesarean sections in Chile.DesignQualitative analysis of audiotaped in-depth interviews with obstetricians and pregnant women; quantitative analysis of data from face to face semistructured interview survey conducted postnatally (with women who had given birth in the previous 24-72 hours), and of a review of medical notes at a public hospital, a university hospital, and a private clinic.SettingSantiago, Chile.ParticipantsQualitative arm: 22 obstetricians, 21 pregnant women; quantitative arm: 540 postnatal women.ResultsPrivate health insurance cover requires the primary maternity care provider to be an obstetrician. In the postnatal survey, women with private obstetricians showed consistently higher rates of caesarean section (range 57-83%) than those cared for by midwives or doctors on duty in public or university hospitals (range 27-28%). Only a minority of women receiving private care reported that they had wanted this method of delivery (range 6-32%). With the diversification in the healthcare market, most obstetricians now have demanding peripatetic work schedules. Private maternity patients are a lucrative source of income. The obstetrician is committed to attend these private births in person, and the “programming” (or scheduling) of births is a common time management strategy. The rate of elective caesarean sections was 30-68% in women with private obstetricians and 12-14% in women not attended by private obstetricians.ConclusionsPolicies on healthcare financing can influence maternity care management and outcomes in unforeseen ways. The prevailing business ethos in health care encourages such pragmatism among those doctors who do not have a moral objection to non-medical caesarean section.     

Health Care Utilization and Symptom Severity in Ghanaian Children – a Cross-Sectional Study

The aim of this study was to identify factors influencing health care utilization behavior for children with mild or severe disease symptoms in rural Ghana. Between March and September 2008 a cross-sectional health care utilization survey was conducted and 8,715 caregivers were interviewed regarding their intended behavior in case their children had mild or severe fever or diarrhea. To show associations between hospital attendance and further independent factors (e.g. travel distance or socio-economic status) prevalence ratios were calculated for the four disease symptoms. A Poisson regression model was used to control for potential confounding. Frequency of hospital attendance decreased constantly with increasing distance to the health facility. Being enrolled in the national health insurance scheme increased the intention to attend a hospital. The effect of the other factors diminished in the Poisson regression if modeled together with travel distance. The observed associations weakened with increasing severity of symptoms, which indicates that barriers to visit a hospital are less important if children experience a more serious illness. As shown in other studies, travel distance to a health care provider had the strongest effect on health care utilization. Studies to identify local barriers to access health care services are important to inform health policy making as they identify deprived populations with low access to health services and to early treatment.     

From Puerto Rican to pan-ethnic in New York city

Abstract

The increasing diversity of the US population has stimulated interest in racial identification, which is complex for phenotypically heterogeneous groups such as Puerto Ricans. We overcome several limitations of the empirical literature on racial identification among Puerto Ricans with a study that is grounded in the experience of Puerto Rican women in New York City. Our analysis focuses on two questions: How do Puerto Rican women in New York identify themselves racially? What are the sources of racial identification? The results indicate that most Puerto Rican women in New York conflate race and ethnicity by designating their race as either ‘Puerto Rican’ or ‘Hispanic’. Moreover, the decision to ‘become’ pan-ethnic has complex roots. In particular, the effect of skin tone on pan-ethnic identification is conditioned by socioeconomic and neighbourhood characteristics.     

Association of race and health insurance in treatment disparities of colon cancer: A retrospective analysis utilizing a national population database in the United States

BackgroundBoth health insurance status and race independently impact colon cancer (CC) care delivery and outcomes. The relative importance of these factors in explaining racial and insurance disparities is less clear, however. This study aimed to determine the association and interaction of race and insurance with CC treatment disparities.Study settingRetrospective cohort review of a prospective hospital-based database.Methods and findingsIn this cross-sectional study, patients diagnosed with stage I to III CC in the United States were identified from the National Cancer Database (NCDB; 2006 to 2016). Multivariable regression with generalized estimating equations (GEEs) were performed to evaluate the association of insurance and race/ethnicity with odds of receipt of surgery (stage I to III) and adjuvant chemotherapy (stage III), with an additional 2-way interaction term to evaluate for effect modification. Confounders included sex, age, median income, rurality, comorbidity, and nodes and margin status for the model for chemotherapy. Of 353,998 patients included, 73.8% (n = 261,349) were non-Hispanic White (NHW) and 11.7% (n = 41,511) were non-Hispanic Black (NHB). NHB patients were less likely to undergo resection [odds ratio (OR) 0.66, 95% confidence interval [CI] 0.61 to 0.72, p < 0.001] or to receive adjuvant chemotherapy [OR 0.83, 95% CI 0.78 to 0.87, p < 0.001] compared to NHW patients. NHB patients with private or Medicare insurance were less likely to undergo resection [OR 0.76, 95% CI 0.63 to 0.91, p = 0.004 (private insurance); OR 0.59, 95% CI 0.53 to 0.66, p < 0.001 (Medicare)] and to receive adjuvant chemotherapy [0.77, 95% CI 0.68 to 0.87, p < 0.001 (private insurance); OR 0.86, 95% CI 0.80 to 0.91, p < 0.001 (Medicare)] compared to similarly insured NHW patients. Although Hispanic patients with private and Medicare insurance were also less likely to undergo surgical resection, this was not the case with adjuvant chemotherapy. This study is mainly limited by the retrospective nature and by the variables provided in the dataset; granular details such as continuity or disruption of insurance coverage or specific chemotherapy agents or dosing cannot be assessed within NCDB.ConclusionsThis study suggests that racial disparities in receipt of treatment for CC persist even among patients with similar health insurance coverage and that different disparities exist for different racial/ethnic groups. Changes in health policy must therefore recognize that provision of insurance alone may not eliminate cancer treatment racial disparities.

Scarlett Hao and colleagues utilize a national population database to investigate the association of race and health insurance in treatment disparities of colon cancer in US.     

Costs and coverage. Pressures toward health care reform.

Signs of discontent with the health care system are growing. Calls for health care reform are largely motivated by the continued increase in health care costs and the large number of people without adequate health insurance. For the past 20 years, health care spending has risen at rates higher than the gross national product. As many as 35 million people are without health insurance. As proposals for health care reform are developed, it is useful to understand the roots of the cost problem. Causes of spiraling health care costs include "market failure" in the health care market, expansion in technology, excessive administrative costs, unnecessary care and defensive medicine, increased patient complexity, excess capacity within the health care system, and low productivity. Attempts to control costs, by the federal government for the Medicare program and then by the private sector, have to date been mostly unsuccessful. New proposals for health care reform are proliferating, and important changes in the health care system are likely.     

The health of Indians in Canadian cities: a challenge to the health care system

It is well known that Canadian native people living on reserves have high morbidity and mortality rates, but less is known about the health of those who migrated to urban centres. Several studies have shown that these people have high rates of mental health problems, specific diseases, injuries, infant death and hospital admission. In addition, there is evidence that cultural differences create barriers to their use of health care facilities. The low socioeconomic status, cultural differences and discrimination that they find in cities are identified as the primary blocks to good health and adequate health care. More epidemiologic studies need to be done to identify health problems, needs and barriers to health care. Federal, provincial and civic governments along with the appropriate departments of faculties of medicine should begin working with native organizations to improve the health of native people living in Canada''s cities.     

The benefits of privatization.

The promise of a universal, comprehensive, publicly funded system of medical care that was the foundation of the Medical Care Act passed in 1966 is no longer possible. Massive government debt, increasing health care costs, a growing and aging population and advances in technology have challenged the system, which can no longer meet the expectations of the public or of the health care professions. A parallel, private system, funded by a not-for-profit, regulated system of insurance coverage affordable for all wage-earners, would relieve the overstressed public system without decreasing the quality of care in that system. Critics of a parallel, private system, who base their arguments on the politics of fear and envy, charge that such a private system would "Americanize" Canadian health care and that the wealthy would be able to buy better, faster care than the rest of the population. But this has not happened in the parallel public and private health care systems in other Western countries or in the public and private education system in Canada. Wealthy Canadians can already buy medical care in the United States, where they spend $1 billion each year, an amount that represents a loss to Canada of 10,000 health care jobs. Parallel-system schemes in other countries have proven that people are driven to a private system by dissatisfaction with the quality of service, which is already suffering in Canada. Denial of choice is unacceptable to many people, particularly since the terms and conditions under which Canadians originally decided to forgo choice in medical care no longer apply.