RESUMO
We conducted a study in early 2014 to document how the initial implementation of the Affordable Care Act (ACA) affected health care provision to different categories of immigrants from the perspective of health care providers in New Mexico. Though ACA navigators led enrollment, a range of providers nevertheless became involved by necessity, expressing concern about how immigrants were faring in the newly configured health care environment and taking on advocacy roles. Providers described interpreting shifting eligibility and coverage, attending to vulnerable under/uninsured patients, and negotiating new bureaucratic barriers for insured patients. Findings suggest that, like past efforts, this recent reform to the fragmented health care system has perpetuated a condition in which safety-net clinics and providers are left to buffer a widening gap for immigrant patients. With possible changes to the ACA ahead, safety-net providers' critical buffering roles will likely become more crucial, underscoring the necessity of examining their experiences with past reforms.
Assuntos
Emigrantes e Imigrantes , Acessibilidade aos Serviços de Saúde , Patient Protection and Affordable Care Act , Provedores de Redes de Segurança/etnologia , Adulto , Antropologia Médica , Criança , Feminino , Pessoal de Saúde , Humanos , Masculino , New Mexico/etnologiaRESUMO
In the new Affordable Care Act (ACA) health care environment, safety-net institutions continue to serve as important sources of culturally appropriate care for different groups of immigrant patients. This article reports on a qualitative study examining the early ACA enrollment experiences of a range of health care providers (n = 29) in six immigrant-serving safety-net clinics in New Mexico. The six clinics configured their ACA enrollment strategies differently with regard to operations, staffing, and outreach. Providers reported a generally chaotic rollout overall and expressed frustration with strategies that did not accommodate patients, provided little training for providers, and engaged in minimal outreach. Conversely, providers lauded strategies that flexibly met patient needs, leveraged trust through strategic use of staff, and prioritized outreach. Findings underscore the importance of using and funding concerted strategies for future enrollment of immigrant patients, such as featuring community health workers and leveraging trust for outreach.
Assuntos
Emigrantes e Imigrantes , Pessoal de Saúde/organização & administração , Pessoas sem Cobertura de Seguro de Saúde/etnologia , Patient Protection and Affordable Care Act/organização & administração , Provedores de Redes de Segurança/organização & administração , Atitude do Pessoal de Saúde , Humanos , New Mexico , Estados UnidosRESUMO
INTRODUCTION: National guidelines call for annual lung cancer screening for high-risk smokers using low-dose computed tomography (LDCT). The objective of our study was to characterize patient knowledge and attitudes about lung cancer screening, smoking cessation, and shared decision making by patient and health care provider. METHODS: We conducted semistructured qualitative interviews with patients with histories of heavy smoking who received care at a Federally Qualified Health Center (FQHC Clinic) and at a comprehensive cancer center-affiliated chest clinic (Chest Clinic) in Albuquerque, New Mexico. The interviews, conducted from February through September 2014, focused on perceptions about health screening, knowledge and attitudes about LDCT screening, and preferences regarding decision aids. We used a systematic iterative analytic process to identify preliminary and emergent themes and to create a coding structure. RESULTS: We reached thematic saturation after 22 interviews (10 at the FQHC Clinic, 12 at the Chest Clinic). Most patients were unaware of LDCT screening for lung cancer but were receptive to the test. Some smokers said they would consider quitting smoking if their screening result were positive. Concerns regarding screening were cost, radiation exposure, and transportation issues. To support decision making, most patients said they preferred one-on-one discussions with a provider. They also valued decision support tools (print materials, videos), but raised concerns about readability and Internet access. CONCLUSION: Implementing lung cancer screening in sociodemographically diverse populations poses significant challenges. The value of tobacco cessation counseling cannot be overemphasized. Effective interventions for shared decision making to undergo lung cancer screening will need the active engagement of health care providers and will require the use of accessible decision aids designed for people with low health literacy.
Assuntos
Conhecimentos, Atitudes e Prática em Saúde , Neoplasias Pulmonares/diagnóstico por imagem , Programas de Rastreamento/métodos , Fumar/terapia , Idoso , Detecção Precoce de Câncer/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , New Mexico , Fatores de Risco , Fumar/efeitos adversos , Abandono do Hábito de Fumar , Tomografia Computadorizada por Raios XRESUMO
INTRODUCTION: On the basis of results from the National Lung Screening Trial (NLST), national guidelines now recommend using low-dose computed tomography (LDCT) to screen high-risk smokers for lung cancer. Our study objective was to characterize the knowledge, attitudes, and beliefs of primary care providers about implementing LDCT screening. METHODS: We conducted semistructured interviews with primary care providers practicing in New Mexico clinics for underserved minority populations. The interviews, conducted from February through September 2014, focused on providers' tobacco cessation efforts, lung cancer screening practices, perceptions of NLST and screening guidelines, and attitudes about informed decision making for cancer screening. Investigators iteratively reviewed transcripts to create a coding structure. RESULTS: We reached thematic saturation after interviewing 10 providers practicing in 6 urban and 4 rural settings; 8 practiced at federally qualified health centers. All 10 providers promoted smoking cessation, some screened with chest x-rays, and none screened with LDCT. Not all were aware of NLST results or current guideline recommendations. Providers viewed study results skeptically, particularly the 95% false-positive rate, the need to screen 320 patients to prevent 1 lung cancer death, and the small proportion of minority participants. Providers were uncertain whether New Mexico had the necessary infrastructure to support high-quality screening, and worried about access barriers and financial burdens for rural, underinsured populations. Providers noted the complexity of discussing benefits and harms of screening and surveillance with their patient population. CONCLUSION: Providers have several concerns about the feasibility and appropriateness of implementing LDCT screening. Effective lung cancer screening programs will need to educate providers and patients to support informed decision making and to ensure that high-quality screening can be efficiently delivered in community practice.
Assuntos
Conhecimentos, Atitudes e Prática em Saúde , Neoplasias Pulmonares/diagnóstico por imagem , Programas de Rastreamento/métodos , Médicos de Atenção Primária/psicologia , Tomografia Computadorizada por Raios X/métodos , Aconselhamento Diretivo/estatística & dados numéricos , Detecção Precoce de Câncer/métodos , Detecção Precoce de Câncer/psicologia , Feminino , Fidelidade a Diretrizes/normas , Implementação de Plano de Saúde , Humanos , Entrevistas como Assunto , Neoplasias Pulmonares/prevenção & controle , Masculino , Programas de Rastreamento/normas , Área Carente de Assistência Médica , New Mexico , Assistentes Médicos/psicologia , Serviços Preventivos de Saúde/estatística & dados numéricos , Relações Profissional-Paciente , Pesquisa Qualitativa , Doses de Radiação , Fatores de Risco , Fumar/efeitos adversos , Abandono do Hábito de Fumar/métodosRESUMO
QUESTIONS: What information resources are available to health care practitioners not affiliated with the University of New Mexico? How satisfied are they with those resources? SETTING: The state is rural and medically underserved. METHODS: The authors interviewed practitioners, using a nine-item guide. Interview transcripts were coded using QSR NVivo 9 software. MAIN RESULTS: Fifty-one practitioners were interviewed. Most use online information resources. Many have access to a point-of-care resource within an electronic health records system. They often expressed dissatisfaction with available patient education resources. CONCLUSION: New Mexico practitioners routinely use electronic information resources but indicate they need better patient information.
Assuntos
Registros Eletrônicos de Saúde/estatística & dados numéricos , Médicos de Atenção Primária , Sistemas Automatizados de Assistência Junto ao Leito/organização & administração , Padrões de Prática Médica/organização & administração , População Rural/estatística & dados numéricos , Atitude do Pessoal de Saúde , Difusão de Inovações , Eficiência Organizacional , Humanos , New MexicoRESUMO
OBJECTIVE: Human papillomavirus (HPV) vaccination rates in the United States have been lower than anticipated since the vaccine became widely available globally in 2006. Of particular concern are data that suggest disparities in vaccine receipt among US ethnic minority and health disparity populations such as Hispanics, who are disproportionately affected by cervical cancer. Given these trends, it is important to examine actual vaccination decision-making processes among clinicians, parents, and adolescents to identify strategies to enhance uptake. DESIGN: We conducted a mixed-method study examining HPV vaccine decision-making, utilizing both structured questionnaires of primarily Hispanic mothers and daughters (aged 12-18) and semi-structured interviews with mothers, daughters, and health-care clinicians to more deeply investigate decision-making dynamics. Quantitative analysis was used for descriptive purposes, while qualitative analysis featured an iterative process to examine factors related to decision-making surrounding the HPV vaccine. The study was conducted in two primary care clinics serving predominantly Hispanic patients in an urban New Mexico setting through Research Involving Outpatient Setting Network (RIOS Net), a primary care practice-based research network. RESULTS: We administered 22 questionnaires and conducted 30 interviews. We identified three aspects of vaccine delivery that were similar across clinics: availability/supply of the vaccine, favorable clinician attitudes toward the vaccine, and clinicians' competing demands. We also identified three decision-making stages (pre-encounter, encounter, and post-encounter), though we found distinct differences in decision-making processes at the two sites. We describe the differences between an encounter-based and a process-based model of decision-making, and the ways in which explanatory factors might influence the decision-making process. CONCLUSION: Our findings suggest that factors other than race and ethnicity, such as education, socioeconomic status, and health-care access, play an important role in HPV vaccination decisions. Further research to elucidate the specific informational needs and communication strategies associated with these factors will be needed to enhance vaccine uptake.
Assuntos
Atitude do Pessoal de Saúde , Hispânico ou Latino/psicologia , Mães/psicologia , Vacinas contra Papillomavirus/administração & dosagem , Aceitação pelo Paciente de Cuidados de Saúde/etnologia , Adolescente , Adulto , Criança , Tomada de Decisões , Feminino , Acessibilidade aos Serviços de Saúde , Humanos , Entrevistas como Assunto , Pessoa de Meia-Idade , Modelos Psicológicos , New Mexico , Aceitação pelo Paciente de Cuidados de Saúde/psicologia , Pesquisa Qualitativa , Classe Social , Inquéritos e QuestionáriosRESUMO
Although national colorectal cancer (CRC) incidence rates have steadily decreased, the rate for New Mexico Hispanics has been increasing, and screening rates are low. We conducted an exploratory qualitative study to determine barriers to CRC screening for New Mexico Hispanics. We found that machismo served as a dynamic influence on men's health-seeking behaviors; however, it was conceptualized differently by two distinct Hispanic subpopulations, and therefore appeared to play a different role in shaping their screening attitudes and behaviors. Machismo emerged as more of an influence for Mexican men, who expressed concern over colonoscopies being potentially transformative and/or stigmatizing, but was not as salient for Hispanos, who viewed the colonoscopy as "strictly medical," and were more concerned with discomfort and pain. Findings from the study highlight the importance of identifying varying characteristics among subpopulations to better understand screening barriers and provide optimal CRC screening counseling in primary care settings.