Underserved Populations

members of the initial steering committee identified two broad categories of perceived need: (i) lack of access to care for underserved populations; and (ii) barriers to care of underserved populations. Additional subcategories were then identified under each category. The demographics of the focus group participants were representative of underserved populations in the community. Based on the initial review by the task force committee of health statistics from the Virginia Department of Health and anecdotal provider information, six distinct populations were targeted for the focus group sessions which were representative of underserved populations within the county: low-income children and families, low-income elderly recipients, low-income residents living in substandard housing, graduate and medical students and their families, and low-income pregnant women. One focus group for each population was conducted. A description of each focus group’s composition and location is provided (Table 1).

promotion program to address the diverse needs of underserved populations in community-based settings. The combination of racial and ethnic disparities coupled with aspects of environmental, physical, social, and spiritual contexts have contributed to negative health behaviors (Yeary et al., 2011). Multiple organizations have taken up the charge of addressing the health and well-being of the population in an effort to control health care costs as well as to contribute to a healthier and more productive society. A primary goal of the CDC’s National Center for Chronic Disease Control and Health Promotion (NCCDCHP) is to address issues of health disparities and thereby promote optimal health for all Americans (2009).

In general, the demographic profiles of the medical students from these schools were more representative of the population of the country than those from other medical schools, although comparison data are limited. For example, at WSU, the proportion of students who self-report as coming from underserved populations (mostly black South Africans) was extremely high at 90.2%; an over-representation compared with the national population proportion of 79.2%, but in line with the population of Eastern Cape Province. 23 Likewise, the population of students that self-identify as Indigenous at JCU (1.9%) was much closer to (and exceeds) national population demographics. Student self-described socio-economic status (as measured through reported family income in previous 12 months) was relatively widely distributed, and in fact, those schools with an explicit quota system for students from low-socioeconomic status had an over-

Abstract: This review of contingency management (CM; the behavior-modification method of providing reinforcement in exchange for objective evidence of a desired behavior) for the treatment of substance-use disorders (SUDs) begins by describing the origins of CM and how it has come to be most commonly used during the treatment of SUDs. Our core objective is to review, describe, and discuss three ongoing critical advancements in CM. We review key emerging areas wherein CM will likely have an impact. In total, we qualitatively reviewed 31 studies in a systematic fashion after searching PubMed and Google Scholar. We then describe and highlight CM investigations across three broad themes: adapting CM for underserved populations, CM with experimental technologies, and optimizing CM for personalized inter- ventions. Technological innovations that allow for mobile delivery of reinforcers in exchange for objective evidence of a desired behavior will likely expand the possible applications of CM throughout the SUD-treatment domain and into therapeutically related areas (eg, serious mental illness). When this mobile technology is coupled with new, easy-to-utilize biomarkers, the adaptation for individual goal setting and delivery of CM-based SUD treatment in hard-to- reach places (eg, rural locations) can have a sustained impact on communities most affected by these disorders. In conclusion, there is still much to be done, not only technologically but also in convincing policy makers to adopt this well-established, cost-effective, and evidence-based method of behavior modification.

The Mobile Health Program has allowed the students to better understand the need for community and public health. If this program is thoroughly explored, developed and well-funded, it can be incorporated into the curriculum of universities and this could greatly improve the capacity of such universities to train more nurses on yearly basis. Additionally, having the undergraduate students work alongside the Family Nurse Practitioners (FNP) can eventually inspire many undergraduates to become a Family Nurse Practitioners. This, in turn, can help to meet the need for primary health care providers in underserved areas. Finally, the Mobile Health Program provided a unique opportunity for inter-professional collaboration among the various health care services departments, within the College of Health and Human Services. This is definitely a golden opportunity to bring the best minds together from various fields, with the goal of meeting the needs of underserved populations.

Sites in diverse underserved communities provide a venue for clinical dental experiences in settings where students can observe and learn about different patient groups and varied practice patterns. Placement in publicly owned facilities ensures that dental students are experiencing delivery systems that will not use their labor for personal profit and allows students to address oral health in an underserved setting (Strauss, Stein, Edwards, & Nies, 2010). Recent studies of the broader impact of community-based dental education for dental students suggest a promising and complex picture in terms of students’ attitudes and plans for caring for the underserved. The students’ perceptions and their preparation for extramural rotations were positively associated with their plans to provide at least 25% of their care to underserved patients (Strauss et al., 2010). The authors concluded that community-based dental education as a preventative measure has substantial potential for affecting the values and behaviors for dental students. Also, including dental students in communities is relative to health care access for underserved populations and for attracting a more diverse array of students to dental education.

The second component in the conceptual framework is patient-centered communication (PCC) [36,37]. Patient-centered communication directly addresses barriers in counseling for underserved populations that may not be adequately captured in the 5As alone. Understanding patients’ social context might help narrow the gap in the social distance between patient and physician. For example, miscommunication can occur if clinicians give advice without understanding the patient’s life situation, without encouraging the patient to ask questions and take an active role, and without reinforcing the patient’s learning during the office visit by summarizing, checking, and verifying mutual under- standing [38]. PCC improves trust,[16] motivation, ad- herence and control of some chronic illness [17,18] however its application to physical activity counseling is less well understood. PCC consists of several constructs; [39-44] for this project, we focus on the constructs over- lapping with SDT of (1) autonomy support, defined as activating and involving patients in choices about their care [45] such that they feel supported and empowered, [46] and (2) understanding patients’ social context.

One of the limitations of this study is that it includes only patients from one CHC system in Indianapolis. However, this CHC system involves multiple geographic sites and is very diverse from the patient characteristics perspective. Another limitation of this study is that the dataset used in this study did not have information on the clinical, physical and functional status of patients (e.g., diabetes, depression, congestive heart failure, etc.). These attributes can be significant predictors of the no-show. However, visit type variable in our dataset did relate to a patient’s clinical characteristics. Findings of this study are drawn from FQHC clinics providing primary care to underserved populations. Whether these results are generalizable to other patient populations will need to be addressed in other studies. Another limitation of this study is that the dataset did not include information about new patients who no-showed in their first appointments; however, sufficient number of observations did not significantly impact the outcomes of this study.

The second challenge school personnel must consider is with regard to students who speak languages other than English. Gandara (1999) found academic barriers to non-English speaking students’ college choice processes, noting that literacy in both English and Spanish actually played a constructive role in the process. Yet, policies in many schools mandate English as a Second Language (ESL) or English Language Learner (ELL) courses for non-English speaking students (Gonzales, Stoner, & Jovel, 2003) and do not encourage or teach literacy in students’ native languages. These policies, whose goal is to minimize educational inequities of students who speak languages other than English, may actually “hinder their progress toward postsecondary education” (Bergerson, 2009, p. 45). Examined through a community cultural wealth lens (Yosso, 2005), the second language capabilities of students from historically underserved populations and their parents is a form of cultural capital that has been overlooked and considered to be a deficit, instead of an asset. Yosso (2005) highlighted the language capabilities of students from historically underserved populations and cited three decades of research underscoring “the value of bilingual education and emphasizes the connections between radicalized cultural history and language” (p. 78).

The problems that hinder educational access and hamper classroom performance are multidimensional and include extra-classroom factors (poor health and nutrition, poverty, social stigma, discrimination) and classroom factors (language barriers, cultural norms, relevance of curricula, learning and physical disabilities). Building inclusive learning environments is essential to overcoming the classroom-based factors and should be developed with an appreciation of the barriers confronting the child outside the classroom. For example, inclusive classrooms comprise not only skilled teachers and appropriate pedagogy and materials but also some teachers (professionals or volunteers) who can communicate with children in their language and understand their cultural mores. Building inclusive learning environments requires holistic programming that recognizes that the learning environment of children, especially the underserved, is multidimensional. Projects that focus on only one aspect of a child’s learning environment to the exclusion of others often have muted impacts. A well-trained teacher, for example, will still have a limited impact on learning if children come to school hungry or if parents do not provide support for homework at home. One approach that has applied a holistic approach to educational development is the child friendly school (CFS) programming model. CFS has become the main model through which UNICEF promotes quality education worldwide, and it has proved to be very effective in promoting learning, including among educationally marginalized children. UNICEF defines the CFS model as one that “promotes healthy and protective environments for learning and strives to provide quality basic education” (UNICEF, 2006). CFS is an important feature of the IBEC project.

Federally Qualified Health Centers (FQHCs) are community based centers created to provide comprehensive primary and preventive care to individuals unable to access care in the commercial medical system (e.g. related to poverty, and/or race-ethnicity). The Affordable Care Act (ACA) proposes offering Medicaid coverage to many such individuals, thus, FQHCs should receive many new Medicaid enrollees. The ACA has triggered a number of new ideas to improve affordability, health status and patient experience, commonly known as the “triple aim.” These initiatives include quality incentive programs, payment reform, and the promotion of medical homes and accountable care organizations (ACOs). These are in addition to earlier efforts to facilitate market reform, such as incentives to develop information and communication tools, such as interoperable electronic health records (EHRs) (Doebbeling, Chou & Tierney, 2006). The goals of the “triple aim” cannot be met unless there is greater access to primary and preventive care. Since limited access to poor and minority populations exists today, the FQHC system could easily become overwhelmed with demand. Innovative models are essential to ensure access to needed care.

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The most often mentioned barriers to good oral health mentioned in participant groups was access – including lack of insurance and high cost of services. Other fre- quently mentioned barriers were language, legal status, social/economic status, and fear and trust. The examin- ation of the figure drawings and the identification of their emerging themes provided crucial insights towards understanding the significant impact of oral health. As the drawings poignantly revealed, many Latinx individ- uals experience diminished self-esteem and negative self-image as well as often endure emotional and phys- ical pain. Overall, our positive findings for knowledge gain, and the high-levels of participant engagement in the group activities and drawings, support the idea that migrant populations may be better reached by education programs led by community health workers and promo- toras de salud, especially those programs using an inter- active approach [7].

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edge and new approaches to the health problems of mothers and children, including children with special health care needs, which can be applied in the health care delivery system;.. MCH [r]

It was concluded in Oslo that the burden of NTDs and EIDs disproportionally affect the most neglected and underserved populations, in LMICs. They are diseases of poverty, neglected people, neglected research and develop- ment, knowledge, data and access to diagnostic, treatment and prevention mechanisms. Furthermore, this neglect takes place at the local, national and global level. Strength- ening health systems, community ownership of disease sur- veillance and programmes as well as different and/or novel approaches to dealing with and preventing NTDs and EIDs simultaneously i.e. addressing living conditions, behaviour change and disease education, are required to combat the current and future challenges. Reciprocally, integrating programmes into health systems that effectively com- bat NTDs and prevent the spread of EIDs has the po- tential to accelerate progress towards Universal Health Coverage while advancing the broader SDGs for 2030. Finally, it was considered imperative to also address the zoonotic roots of NTDs and EIDs, the majority of which are not prioritised and targeted by pharmaceutical companies and governments. Address- ing zoonotic diseases by taking a One Health ap- proach is a great opportunity to tackle NTDs and EIDs in a holistic and multidisciplinary way [42, 53]. This has now also been taken up by a Lancet One Health Commission of which some of the authors of the current paper are part and that will hold its first meeting again in Oslo at the beginning of May 2019.

undertaken. A 45-item survey instrument, including health-related questions on tobacco exposure, workplace safety practices, musculoskeletal disorders and health symptoms, was programmed onto Apple iPod Touch ® devices. Language sensitive (English and Spanish) recruitment scripts, verbal consent forms, and survey questions were all preloaded onto the handheld devices. The experience (time to survey administration and capital cost) of the handheld administration method was recorded and compared to approaches available in the extant literature. Results: Construction workers were very receptive to the recruitment, interview and assessment processes conducted through the handheld devices. Some workers even welcomed the opportunity to complete the questionnaire themselves using the touch screen handheld device. A list of advantages and disadvantages emerged from this experience that may be useful in the rapid health assessment of underserved populations working in a variety of environmental and occupational health settings.

Environmental injustice is driven by privilege, power– par- ticularly structural and environmental racism which are embedded in our regulatory schema, zoning, planning and community development processes [1,2]. Additionally, un- healthy geographies that concentrate environmental, so- cial, and health risks in urban and rural areas are produced and are known as ‘riskscapes’ [3,4]. The original Toxic Waste and Race in America report published in 1987, was the first report to demonstrate that many eco- nomically underserved populations and people of color communities are disproportionately impacted by locally unwanted land uses (LULUs) [5]. Since the 1987 report and the recent twenty-year anniversary report [5], re- searchers have shown that these disparities persist, with low-income persons and populations of color continuing to live in communities with a differential burden of LULUs including toxic release inventory (TRI) facilities [6-18], landfills [5], incinerators [5], hazardous waste sites [5,18], sewer and water infrastructure including sewer and water treatment plants [7,8,19,20], coal-fired plants [5], industrial animal operations [21,22], and Superfund sites [23-25]. This disproportionate burden can lead to increased expos- ure to harmful environmental conditions and chemical, physical, and biological agents for impacted communities [1,2,26-28].

States of fragility and insecurity often give rise to urgent health needs that need to be met quickly and effectively, particularly for women and adolescents. Vouchers are a demand-side financing mechanism which can be used to address some of the health challenges faced by women under these circumstances. A number of organisations have begun to use vouchers to enable access to reproductive, maternal and newborn care services in conflict-affected countries such as Yemen, Syria and Central African Republic. Vouchers allow health programme implementers to use targeted subsidies to reduce financial and other barriers to accessing care, increasing and catalysing the uptake of specific health services among vulnerable and underserved populations. These subsidies are passed onto public and private providers in the form of service reimbursements and are often used to enhance capacity to meet increased demand for services, as well as to invest in quality improvements.