Data were extracted from the 36 papers and first described according to general study characteristics (e.g. primary author, year of publication, context of the study), participants (age, gender and socio- demographic data), study aim, study design and find- ings (see Table 3). The conceptual framework outlined in Fig. 1 was then applied to identify the workforce, leadership and governance strategies described in the studies that had impacted on universal health access for vulnerablepopulations. A content analysis of the extracted text relating to each identified workforce, leadership and governance strategy was performed. This involved coding text according to emergent de- scriptions and then labelling and grouping them ac- cording to key HRH performance areas relating to policy, management, collaboration and education and training. Tables and concept maps were used to plot patterns and relationships across the categories and robustness assessed through critical reflection and discussion among the three authors.
Our findings can also be placed in the context of a long history of participatory action research in health. Partici- patory action research emphasizes the importance of in- volving communities in the research process, aims to avoid power imbalances and build trust, and prioritizes working with a community to effect change [21, 22]. These three principles can be seen in our findings. All de- velopers we interviewed emphasized the importance of working with research end users, but those who involved members of vulnerablepopulations spoke specifically about involving communities. The second principle is reflected in themes we identified around researchers going to the community, paying close attention to issues of stigma and building relationships of trust. However, our comparison with this principle is challenged by the fact that we were unable to interview any of the patients who had been involved in these projects. This may be a func- tion of the overall research enterprise and the way ethical oversight works within it, as well as our decision to approach teams by way of published articles. Had we sought out projects by directly contacting community- based organizations, we might have had different results. The third principle of participatory action research,
Impacted by forces of oppression, such as racism, colo- nialism, sexism, and/or classism, structurally vulnerablepopulations experience disproportionate rates of negative health outcomes, including, a heightened risk of poorer mental health, problematic substance use, as well as pre- mature chronic morbidity and earlier death expectancy when compared to the average population [19–24]. Such negative health outcomes are the manifestation of various structural and systemic processes that produce violence, trauma, and harm [25, 26]. These processes constrain peo- ples’ agency and opportunities to achieve and maintain adequate health and access needed health care . Al- though the level of systemic suffering and negative health and life expectancy outcomes of structurally vulnerablepopulations denote an increased need for care, barriers ex- perienced in accessing such care are likely the highest , particularly at EOL. Existing disparities in access to palliative care emerge partly from deep-rooted assump- tions regarding who needs such services . The major- ity of those accessing palliative care tend to share similar socio-demographic and economic profiles (e.g., are diag- nosed with diseases such as cancer, with more predictable trajectories, come from dominant social groups, have strong family and community connections, and are stably housed [16, 29, 30]. However, many dying people fall out- side this demographic – those who are experiencing homelessness or unstable housing, poverty, mental illness and substance use, and stigmatized diseases such as HIV/ AIDS and Hepatitis C. Their experiences remain largely unnoticed and their needs neglected .
Several types of interventions, including small media, patient and provider reminders, and possibly financial incentives are effective in increasing screening, and some of these interventions have been tested in vulnerablepopulations . However, these effective interventions have not been widely disseminated . Reasons for fail- ure of dissemination may include intervention com- plexity, costs of intervention, challenges in scaling, or difficulty in choosing among potentially effective inter- ventions. Policy makers and payers may need to decide among potential options for programs to increase CRC screening among vulnerablepopulations, including the option of maintaining the status quo.
enormous financial and health implications. Our study was specifically designed to examine this fundamental and important question, by creating a realistic (though hypo- thetical and simplified), exchange environment. We are concerned with health insurance literacy, given its key role in understanding health insurance information [8, 10, 11, 33–35]. For tobacco users, having low HIL may have long-term implications, because it suggests they are more likely to have difficulty anticipating their health care needs and selecting a health insurance plan that provides them with adequate risk protection. The ACA is expanding coverage to four million tobacco users, many of whom were previously uninsured [2, 3]. An unsubsidized sur- charge of up to 50% on premiums was placed on tobacco users to internalize the voluntary risk-taking behavior that resulted in increased healthcare costs, increased consump- tion of health services, and, consequently, increased pre- miums [4, 36]. By construction, this surcharge raises the premium prices tobacco users face, having an unintended consequence of deterring them from purchasing insur- ance. Thus, the tobacco use surcharge could, paradoxic- ally, impede health insurance uptake for vulnerablepopulations ultimately reducing opportunities for tobacco users to access much-needed health services, including to- bacco cessation programs.
In addition to the numerous strategies outlined above, we examined the influence of unconditional incentives on the response rate. Based on a predictive model devel- oped by Edwards et al. where the odds of response increased significantly for each $0.01 increase in incen- tive value up until $5,  we chose to use prepaid incen- tives valued at $5. An increase in response rate, cooperation rate and less conservative cooperation rate of 7.4%, 8.2% and 6.4% respectively were observed in the incentive versus non-incentive group; however, these dif- ferences were accompanied by wide CIs, which did not completely exclude very small or even negative values. A larger sample size may have provided smaller CIs mak- ing our conclusion more definitive. It was hoped that an increase in response of 15% would be achieved with incentives and although a difference of 15% can be seen in the upper confidence limits of all three response pro- portions, the width of these CIs makes it unlikely that the true difference is actually this large. Nevertheless, our results suggest that an unconditional incentive likely increases the response rate in our targeted population. Although others have demonstrated the positive effect of incentives on response rates, [6,7,9-11,16,27] ours was the first to examine unconditional incentives in these vulnerablepopulations for a telephone survey.
antidepressant prescription fills after Part D. This suggests that once they surmounted initial barriers to access (such as clinician prescribing and coverage restrictions), they received prescription drug treatment for a longer period after Part D. Among nonelderly disabled beneficiaries, our findings were similar. We did not observe any change in terms of the prevalence of treatment initiation among the disabled, but there was a significant increase in treatment intensity for those who were treated. These main findings raise several questions about the effectiveness of Part D in increasing access to medications for vulnerablepopulations. It is possible special protections around antidepressants under Part D were insufficient to ensure access to this drug class, and Part D plans erected excessively high barriers to treatment.
While only one ‘dimension-outcome’ pattern was found in this review, the limited number of included studies on patients in situation of vulnerability and the theory-driven approach may have precluded finding others. For example, we found few studies on the three outcomes of interest outside the formal integration of services and case management. This might reflect the fact that few inno- vations have been evaluated or published yet. For in- stance, several organizational innovations have been put in place in OECD countries to improve access to primary care (i.e., advanced access) . Although nu- merous articles describe primary care organizational innovations for vulnerablepopulations, few report on the evaluation of these innovations. While three main databases were searched, subsequent systematic review may include an exhaustive search of evidence in Table 3 Pattern dimension-outcome
A key limitation of this study is that we did not inter- view the women who enrolled into the medical record review study. Understanding the enrollment process from the patients’ perspectives could add important in- formation on effective strategies in the recruitment of minority and low-income populations. However, we were able to obtain proxy information on women who were unlikely to consent to research. Another limitation of the study is that the staff experiences were limited to the recruitment and enrollment of female patients of low socioeconomic status in CHCs in a specific geo- graphic area. Further research using other demographic groups is warranted to identify whether these themes are universal or specific to vulnerablepopulations.
This study was completed as part of the collaborative research being conducted by the National Institutes of Health (NIH) and Food and Drug Administration (FDA) Tobacco Centers of Regulatory Science (TCORS) VulnerablePopulations Workgroup. The review reported in this publication was supported by grant numbers P50CA180905 and U54CA180905 from the National Cancer Institute (NCI) and the FDA Center for Tobacco Products (CTP) for Cruz, Unger, Lienemann, Baezconde-Garbanati and Soto; grant number T32CA009492-29 from NCI for Lienemann; grant number U54CA189222 under a subcontract to Westat from NCI, FDA and the Center for Evaluation and Coordination of Training and Research (CECTR) in Tobacco Regulatory Science for Rose; grant number P50 CA180907 from the NCI and FDA CTP for Byron and Huang and the National Research Service Award T32 DA007097 from the National Institute on Drug Abuse for Carroll. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the FDA.
Methods: We distributed a brief online survey to an international audience of PHC researchers, practitioners, policy makers and stakeholders using a combined email and social media approach. Respondents were invited to describe a program, service, approach or model of care that they considered innovative in helping vulnerablepopulations to get access to PHC. We used descriptive statistics to characterise the innovations and conducted a qualitative framework analysis to further examine the text describing each innovation. Results: Seven hundred forty-four responses were recorded over a 6-week period. 240 unique examples of innovations originating from 14 countries were described, the majority from Canada and Australia. Most interventions targeted a diversity of population groups, were government funded and delivered in a community health, General Practice or outreach clinic setting. Interventions were mainly focused on the health sector and directed at organisational and/or system level determinants of access (supply-side). Few innovations were developed to enhance patients ’ or populations ’ abilities to access services (demand-side), and rarely did initiatives target both supply- and demand-side determinants of access.
The video game industry has blossomed from a niche hobby into a mainstream cultural industry, outpacing global box office sales in annual revenue. Yet the price of a video game has barely increased since the industry’s inception, and the current standard price point of sixty dollars has survived for over a decade. Competitive market forces drive companies to invest ever more time and money into creating increasingly complex software in order to remain on the cutting edge of graphics and design, while simultaneously increasing revenue. Thus, video game developers and publishers have developed a multitude of alternative money- making services to provide revenue beyond the initial sale of a game. Of these, the one technique that has garnered the most attention, and the most legislative scrutiny, is the “loot box.” Through this system, players are allowed to pay a sum of real-world currency in exchange for receiving one or more random in-game items. This technique simulates gambling practices yet escapes current gambling oversight, leaving games containing this technique available to anyone. This includes vulnerablepopulations that do not have the capacity for rational spending, such as minors and
ABSTRACT: The presence of cutaneous nodules is reported in vulnerablepopulations of Irra - waddy dolphins Orcaella brevirostris from Malaysia (Kuching, Bintulu-Similajau, Kinabatangan- Segama and Penang Island), India (Chilika Lagoon) and Bangladesh (Sundarbans). Approxi- mately 5700 images taken for photo-identification studies in 2004 to 2013 were examined for skin disorders. Nodules were detected in 6 populations. They appeared as circumscribed elevations of the skin and varied in size from 2 to > 30 mm, were sparse or numerous and occurred on all visible body areas. In 8 photo-identified (PI) dolphins from India and Malaysia, the lesions remained sta- ble (N = 2) or progressed (N = 6) over months but did not regress. The 2 most severely affected individuals were seen in Kuching and the Chilika Lagoon. Their fate is unknown. Cutaneous nod- ules were sampled in a female that died in a gillnet in Kuching in 2012. Histologically, the lesions consisted of thick collagen bundles covered by a moderately hyperplasic epithelium and were diagnosed as fibropapillomas. Whether the nodules observed in the other O. brevirostris were also fibropapillomas remains to be investigated. Disease prevalence ranged from 2.2% (N = 46; Bin- tulu-Similajau) to 13.9% (N = 72; Chilika) in 4 populations from Malaysia and India. It was not sig- nificantly different in 3 study areas in eastern Malaysia. In Chilika, prevalence was significantly higher (p = 0.00078) in 2009 to 2011 (13.9%) than in 2004 to 2006 (2.8%) in 72 PI dolphins. The emergence of a novel disease in vulnerable O. brevirostris populations is of concern.
Probabilistic data linkage does not require perfect match- ing for a link between two datasets to be established. Rather, record pairs are created by matching exactly on se- lected variables (if desired) and allowing remaining vari- ables to vary. One aspect of data linkage that is often not considered when matching data from the general popula- tion, but which may be particularly relevant for vulnerablepopulations such as people with a history of incarceration, is the use of aliases - defined herein as any record for an individual in which demographic variables differ from ‘ birth ’ or ‘ legal ’ records verified with documentation.
Each of the other project teams had at least one repre- sentative on the GVP team, and several GVP team mem- bers were leads of their project teams. GVP members were also selected from among OPEN members based on their interest and previous experience with research related to sex and gender and social inequality. The GVP team had two co-leads; one was a non-pharmacist social scientist with expertise in health inequities and health research in vulnerablepopulations, and the other was one of the pharmacist co-leads of the OPEN programme, included to signal the importance of GVP activities within the OPEN research programme and to coordinate activities across project teams. A part-time non-pharmacist research coordinator with graduate training in social science research was hired to keep track of GVP sub-projects and budgets, schedule meet- ings, coordinate communication, and assist with re- search and writing.
The study uses the Nationwide Readmissions Database (NRD) for 2010–2014 covering the period before and after the launch of the HRRP. This is a large dataset that in- cludes all discharges from community hospitals in 27 states, excluding rehabilitation or long-term acute care hospitals. The annual NRD data has 14 to 17 million discharges. The large sample allows us to conduct an in- depth analysis of the impact of HRRP on the patient and hospital subgroups. As mentioned, some studies  are concerned with the effect of the HRRP on some types of vulnerablepopulations but assess the impact using data from before the launch of the HRRP. Other studies [7, 14] are more recent but focus on smaller state-level data sets. Our choice of study period and national level data over- comes these two limitations. Similarly to studies [7, 14], we defined the two years before the launch of the HRRP (2010–2011) as the ‘pre-HRRP’ period and the three years after the launch of the HRRP (2012–2014) as the ‘post- HRRP’ period, during which time HRRP targeted three conditions among Medicare patients (AMI, HF and PN). A limitation of NRD is that its hospital identifiers cannot be linked across years or linked to other databases. A new set of unique IDs is created each year in NRD.
vulnerable individuals in society is identified as a way to gain the most benefit. The most vulnerable and excluded populations, who experience higher levels of social and health inequalities include people with experiences of drug use, imprisonment, homelessness and sex work (Luchenski et al 2018). There is also significant evidence detailing the health needs and inequalities associated with Gypsy and Traveller communities. The 2011 Census included Gypsies and Travellers as an ethnic category for the first time and found that Gypsy and Irish Travellers across England and Wales had the lowest proportion of people who rated their general health as good: only 70% compared to 81% of the general population (ONS 2014). All of these vulnerablepopulations have common adverse life experiences and risk factors which lead to poorer health, multiple morbidity and early morbidity (Aldridge et al 2017). An overview of the health needs of these vulnerablepopulations is illustrated in table 1.2. Table 1.2 Health Needs of VulnerablePopulations
easier to secure support for the study and the data. So the researcher must remain clear about why this popu- lation is needed to investigate this specific research question. This clarity will serve the researcher well es- pecially during the IRB approval process. One colleague even suggested securing a public dataset given the lengthy approval process. However, the author was clear about the focus on youth on probation, and the special focus on girls. Specifically, research on female offenders has been overshadowed by research on male offenders even though girls are the fastest growing group of of- fenders (American Bar Association [ABA] National Bar Association [NBA], 2001). This is the case even though most adolescent female offenders are not arrested and/ or detained because of violent offenses (Chesney-Lind, and Jones 2010). Also, girls have been recipients of a special and discriminatory form of justice since the incep- tion of a separate system of justice for youth (Chesney- Lind 1973; Schlossman, and Wallach 1987). “With some exceptions, extensive recent scholarship focusing on gen- der and crime has tended to concentrate on women, not on girls” (Zahn et al. 2009). Consequently, there has been a growing recognition that a significant number of young women and girls engage in aggressive and antisocial be- haviors including traditionally male anti-social behaviors like truancy, delinquency and substance abuse (Kann et al. 1997; Poe-Yamagata and Butts 1996; Schaffner 1998). Scholars have begun to note that girls have negative inter- personal relationships (Ehrensaft 2005), histories of abuse, mental disorders, and trauma (Teplin et al. 2002). Re- search that highlights the needs of vulnerablepopulations and directly relates to the problem of juvenile recidivism could further efforts to reduce the risk of recidivism by addressing their underlying needs (Farrell et al. 2011). Consequently, the selection of this vulnerable popula- tion was prudent and directly related to the problem of juvenile delinquency.
The tension is clear. To provide a comprehensive review of the proposed research, the informed consent document and process are often lengthy, complex, and burdensome. 2 Consequently, research participants who sign or verbalize consent often do so without truly understanding the form that they are being asked to sign. In a recent systematic review, participants in one-third of trials assessed did not have adequate understanding in the areas of risks, beneﬁts, randomization, study aims, withdrawal, and voluntarism. 3 There are no clear standards for “how much ” understanding is adequate. Furthermore, we know that lower education levels, lower literacy, and a participant ’ s primary language are all associated with poor comprehension of the informed consent process. 4 These issues are particularly important when studies are being done in children, adding an additional dimension to vulnerablepopulations. Our approach was developed as a part of an ongoing randomized controlled trial (RCT) designed to prevent childhood obesity. As a part of the Growing Right Onto Wellness Trial (GROW; clinicaltrials.gov, NCT01316653), 5 839 mother-child pairs consented to participate in this 3-year family-centered, community-based behavioral RCT. All 839 participants were from low-income, underserved populations at highest risk for obesity, and all children were between 3 and 5 years old. The institutional review board at Vanderbilt University Medical Center approved the trial.
Hegele and collaborators first showed that different atherosclerosis phenotypes associate with different risk factors in a closed aboriginal population . In their analysis of a subject population distinct from the two cohorts studied here, ultrasound phenotype correlations were similar to those found in our analysis of middle-aged diabetics and elderly with carotid stenosis; IMT was found to be associated with age and hypertension, and TPV with age and the presence of diabetes. Different associations between phenotypes with PPARG genotypes and PCK1 variants were also identified [17-20] and TPV in particular was increased over a seven year period for type 2 diabetic subpopulation of the cohort . Our analysis of two addi- tional vulnerablepopulations extends these landmark findings and further suggests that IMT and TPV may rep- resent different stages of atherosclerosis and may also reflect different biological and genetic contributions to, or attributes of, the atherosclerotic process. The fact that in both populations, 2-dimensional and 3-dimensional ultrasound phenotypes associate significantly with plaque ulcerations also suggests these are related to plaque vul- nerability in both middle-aged diabetics and elderly sub- jects with carotid stenosis.