The unique characteristic of BETTER is the comprehen- sive approach used to address a wide variety of maneu- vers related to a patient’s health, such as blood results, diet, physical activity, mental health, in a one-hour pre- vention visit with a PP [6, 7]. While this qualitative study suggests that the implementation of BETTER 2 was val- ued as an opportunity to address patients’ complex and multi-faceted health care needs from a CDPS perspec- tive, it also revealed important barriers related to imple- menting comprehensive preventive activities. Our results identified a disconnect between perceptions of physi- cians regarding the BETTER 2 program and those of other primarycare providers and patients. This reflects the long-standing recognition that physicians and pa- tients often have different positions and perspectives of illness and care . For instance, patients appreciated the individualized prevention visits with PPs and de- scribed them as motivating, non-judgmental, and sup- portive. Some physicians, on the other hand, emphasized pride in being able to provide CDPS as part of their regular practice, and expressed a preference to provide those services themselves.
There are many members of the LGBTcommunity who refuse to seek medical care because they are fearful of being discriminated against by healthcare providers. However, for the ones who do seek help, it can become quite difficult to gain access. Rural populations in general struggle when it comes to getting access to healthcare whether it be because of the geography, lack of transportation, lack of finances or insurance, or provider shortages (Whitehead, Shaver, & Stephenson, 2016). It may be even more difficult for those who identify as a member of the LGBTcommunity to access care. According to Whitehead et al. (2016), previous studies have shown that rural LGBT people are possibly less likely to access primarycare, may experience more judgment, or may come out less often to their providers. Prior studies have not investigated the interactions between each of these factors that contribute to health care disparities. There is limited research available regarding the health of the LGBTcommunity overall, and rural areas have less access to research versus an urban area. In fact, according to Whitehead et al. (2016) “[the] majority of studies of LGBT populations have been conducted in urban centers due to ease of access to high concentrations of LGBT people in social spaces catering to this community” (p. 3). This lack of data is a national and community problem because informative research for the care of LGBT people is not being adequately or accurately prepared.
groups because many of them have received little education, which considerably heightens the rela- tive risk of dementia. 5 Recent research suggests that dementia might be up to three to four times more prevalent in the majority of non-Western immigrant groups when compared with the native Dutch population. 4 GPs, together with other communitycare services, play a central role in detect- ing and diagnosing dementia, and organising medical care to patients with mild cognitive impairment or dementia. GPs increasingly have to care for patients with a non-Western immigration background who have dementia. In the Netherlands, the four biggest cities — Amsterdam, Rotter- dam, The Hague, and, to a lesser degree, Utrecht — have a large proportion of older non-Western immigrants. Providing tailored primarycare is challenging and often hampered by linguistic, cultural, and diagnostic barriers. 6 Diagnosing dementia is difficult because of the high proportion of low literacy and the low cultural validity of assessment tools. 6–9 Dementia is still a taboo subject
barriers that their patients face in maintaining a healthy weight. Clinicians acknowledged that they have print materials to assist them in providing nutrition counsel- ing to patients, but noted that these materials are com- plex and time-consuming to explain to patients, particularly to those with limited literacy levels and edu- cational attainment. Additionally, clinicians pointed out that these materials may not provide the information pa- tients need to make health-promoting changes to their diets. As an alternative to the traditional nutrition edu- cation materials focused on serving sizes, calorie count- ing, macronutrient intake, and diabetic exchanges, participants in this study reported that they would prefer materials that rely less on text and more on graphics, focus on specific behavior change recommendations, in- clude simple advice to make healthier food choices, and list foods to eat more of or to avoid. In a prior analysis from this study, we found that many CHC clinicians re- ported that they have begun to develop their own tools, handouts and resources to give patients during clinical encounters . Future avenues for research may in- clude developing and evaluating materials for clinicians to use during weight counseling encounters that are better suited to meeting the needs of CHC patients.
New models of care for management of chronic liver disease as a whole are essential and timely. In contrast to other countries in Western Europe, rates of liver disease are increasing in the UK; over 600 000 people are known to have liver disease with 10% of these having cirrhosis and liver disease mortality has increased by 400% over the last 40 years. 12 The Lancet Commission on Liver Disease has highlighted the numerous challenges currently faced by the National Health Service (NHS) and by patients including inequalities in service provision (the so-called ‘postcode lottery’). The Commission’s recommendations included the need to improve access to specialist care and services for those most in need as well as increasing involvement from primarycare and community services. 12
The authors of most of the articles were based in the United States (n = 29), discussed broad health care innovations (n = 32), and used solely qualitative research methods (n = 35). Twenty articles about implementing clinical practice guidelines were also found, even though the search was intended to focus on articles about implementing quality indicators and clinical prac- tice guidelines was not a search term. There were only 5 empirical studies of the specific process of implementing quality indicators. The settings of 4 of these studies were clearly primarycare, yet the indicators were not mental health–related, and 1 study implemented mental health quality indicators in a community-based mental health clinic. The fifth study was retained, even though the clinic might have offered both primary and sec- ondary care, because we wanted to glean information about implementing mental health–specific indica- tors. The 5 articles included 1 quasi-experimental study, 1 case study, 1 retrospective audit, and 2 qualitative studies published between 2000 and 2004. Table 3 lists facilitators and barriers to implementing quality indi- cators, as listed in these specific articles, and Table 4 presents facilitators in the form of a checklist for readi- ness to implement clinical practice guidelines and other health care innovations.
In 1980, Steve Endean founded the Human Rights Campaign (HRC) Foundation, which was established to be a gay and lesbian political action committee. The first of its kind, the HRC has since expanded from lobbying for gay civil rights legislation to become one of the largest civil rights organizations fighting to achieve equality for lesbian, gay, bisexual, transgender, and queer (LGBTQ) Americans nationwide (Human Rights Campaign, 2016). Its mission is to create a world in which all LGBTQ persons are accepted fully as members of society in all settings: home, workplace, and the community (Human Rights Campaign, 2016). To do so, the HRC has identified educating the American public about LGBTQ issues and encouraging the adoption of LGBTQ-inclusive policies and practices as its key goals (Human Rights Campaign, 2016). Recently, it has partnered with the National LGBT Health Education Center, which aims to increase health providers’ understanding of LGBTQ patient health by creating patient-centered care trainings. The foundation has made tremendous efforts towards building support for LGBTQ persons that include both their families and social networks from every aspect of their life. In doing so, HRC hopes to positively impact acceptance of the LGBTQ community in the United States and globally.
The recently published NHS Long Term Plan identifies primary health care, including GPs as the first point of contact, as key to supporting improvements in mental health outcomes for autistic people. Despite evidence of the increased risk of mental health problems among autistic adults, particularly those without a learning disability, relatively little is known about how these are experienced and understood by autistic people, and the implication this may have on GP support provision. Based in the context of wider evidence that young people face barriers or are disinclined to seek help for mental health problems, this study explored autistic young adults’ attitudes to managing and seeking help for mental health. It identified a number of unique barriers to help seeking for mental health difficulties, of which GPs need to be aware, and identified the need for GPs to feel confident raising mental health issues with autistic young adult patients.
Consumers initiated the challenge to professionally controlled rehabilitation in North America and other developed nations, which led to the emergence of the Independent Living (IL) movement. In this barriers to access and equality in service provision were principally identified as environmental and attitudinal with particular concern that the professional-client relationship facilitated dependency-inducing features in the person with a disability. In the USA and Canada IL centres developed providing peer counselling, consumer-based research, advocacy and self-help (Lysack and Kaufert 1994). There has perhaps been greater progress with social welfare issues than with rehabilitation in this approach. This might in part be related to the way in which independent living centres (ILCs) were set up by professionals, as opposed to centres for independent living (CILs) which were set up and staffed by disabled people (Oliver 1999).
It is noteworthy that despite the many challenges faced by the health sector in Malawi, the authorities remain committed to improving accessibility to community health services. There are ongoing community-based health initiatives actively engaging communities them- selves . There is also a network of volunteers and community health workers who are actively involved in the delivery of various health services at community level. However increasing community participation is likely to bring specific programme benefits, as shown with CDI [13,14]. Here we show that both providers and beneficiaries in the two study districts perceived com- munity participation as vital for the strengthening of PHC. It is desirable that the interventions are defined on the basis of existing supportive capacity and engagement of the health system, its partners, and the communities themselves to increase the sense of ownership and to minimise conflicts or duplication of efforts . This study shows that perspectives of stakeholders on the specific PHC interventions to be prioritized were similar. Thus, the minimum conditions for the early involvement of all stakeholders, including community members, in the planning phase of interventions are met. Stakeholders interviewed expressed their desire for the implementation of interventions such as provision of ITN to children under the age of five and ante-natal mothers, home case management of malaria, management of diarrhoeal dis- eases, treatment of schistosomiasis, HIV testing and coun- selling (HTC), prevention of mother to child transmission (PMTCT) of HIV services and provision of food supple- ments to malnourished children and mothers implemen- ted at the community level. However, considering the limitations in available resources, competencies as well as
It may be useful for FQHCs to maintain an archive of insti- tutional knowledge about specialty access strategies that have proven effective within each community. This information may be especially useful to FQHCs that hire clinicians through loan repayment programs, where clinician turnover is often high. In the clinics that were the focus of this study, two of the three key informant physicians left the FQHC after 3-year loan repayment periods. It will be advantageous for more experi- enced and assertive clinicians to assist new clinicians with specialty access issues. Experienced clinicians can provide guidance in analyzing the access situation in their community, in identifying leaders in the medical community, in making full use of available resources for uninsured patients, and in developing effective strategies to improve access.
To overcome barriers to better dia- betes outcomes, new approaches must be explored when introducing thera- pies into practice. Diabetes educators (DEs) can play a pivotal role in edu- cating and supporting both patients and providers in the adoption and delivery of therapies. Although pre- vious studies have identified barriers to diabetes care, no recent studies have explored insights that offer the potential to directly inform the practice of diabetes education and advancement of diabetes therapies in primarycare. Based on provider interviews and patient focus group findings from the first phase of this study (11), the objectives of the sub- sequent phases (reported here) were 1) to develop and assess the usefulness of an educational program on ther- apy intensification delivered by DEs
Background and Objectives: The aim of this study was to explore the relationship between barriers to care with parents’ perceptions of primarycare and quality of life in children with thalassemia major in Kerman, Iran. Methods: A cross-sectional study was conducted in 2015. The sample included 150 children aged 6 to 15 years with thalassemia major and one of their parents. Data were collected using 3 standardized questionnaires: barriers to care questionnaire (BCQ), parents’ perceptions of primarycare (P3C), and the pediatric health related quality of life (PedsQL). To determine the association between demographic characteristics and barriers to care t test and ANOVA were used. Correlation coefficient was used to determine the relationship between barriers to care and parents perceptions of primarycare and health-related quality of life.
Given the multifaceted nature of the barriers and enablers identified, it is likely that to achieve higher engagement in ACP, strategies will be needed at multiple levels that target the public at large, patients (and families), clini- cians in family practice, and the health care system. With knowledge of the barriers and enablers that are specific to primarycare, targeted strategies to integrate ACP into routine primarycare can be developed to achieve the positive outcomes of meaningful engagement in ACP. Dr Howard is Assistant Professor in the Department of Family Medicine at McMaster University in Hamilton, Ont. Dr Bernard is Assistant Clinical Professor in the Department of Family Medicine at McMaster University and Associate Program Director, Curriculum and Remediation in the Department of Family and Community Medicine at the University of Toronto in Ontario. Dr Klein is Associate Professor in the Department of Family Medicine at the University of Alberta in Edmonton. Ms Elston is a researcher in the Department of Family Medicine at McMaster University. Dr Tan is Associate Professor in the Department of Family Medicine at the University of Calgary in Alberta. Dr Slaven is Assistant Clinical Professor in the Division of Palliative Care at McMaster University. Dr Barwich is Clinical Associate Professor in the Division of Palliative Care in the Department of Medicine at the University of British Columbia in Vancouver. Dr You is Associate Professor in the Department of Health Research Methods, Evidence and Impact and the Department of Medicine at McMaster University. Dr Heyland is Professor in the Department of Critical Care Medicine and the Department Public Health Sciences at Queen’s University in Kingston, Ont, and Director of the Clinical Evaluation Research Unit at Kingston General Hospital.
suggested several useful strategies for eliminating dis- parities in asthma care that are also applicable to modifying barriers to care. At the structural level, the authors suggested creating programs to increase work- force diversity, creating standards for culturally and linguistically appropriate services, requiring health care systems to collect and to analyze data according to race/ethnicity, ensuring that health care financing does not lead to fragmentation of care, and supporting community health centers. To change processes of care at the health care system level, the authors sug- gested improved adherence to standards of care, qual- ity improvement interventions, and ensuring the availability of professional interpreter services. At the interpersonal level, they suggested efforts to reduce stereotyping and to improve patient education and patient empowerment. Practitioners should anticipate and be prepared to address the fact that barriers to optimal care exist even within the examination room. Policymakers seeking to improve primarycare should develop and evaluate programs and policies that ad- dress multiple types of barriers to care, beyond a nar- row focus on insurance status. Additional research is clearly necessary, to establish temporal order and cau- sality and to determine better ways to reduce barriers to care and to help families overcome these barriers to care.
The Partnership for Health Equity (PHE) is an innovative collaboration which engages medical educators, researchers, clinicians and health service planners from across Ireland in collaboration to work on projects seeking to improve healthcare for marginalised groups. The current partners are the University of Limerick Graduate Entry Medical School, the North Dublin City General Practice Training programme and the Health Service Executive (HSE) Social Inclusion Division. The aim of the partnership is to improve healthcare for marginalised groups by conducting relevant research, by educating future healthcare professionals and by directly providing primarycare to marginalised groups. A key feature of the PHE is that research is planned with all partners and research findings are used to inform the development of services, with a focus on priorities for action by the HSE – thereby making real differences in the day-to-day health- care experiences of patients from marginalised groups across the country. Limerick City was recognised as the most deprived local authority area in the country in 2014, with 28% unemployment and above average rates for all major causes of mortality (cardiovascular and respiratory disease, cancer, injury) . Groups identified as ‘ marginalised ’ by the PHE in this setting included migrants, homeless, Irish Travellers, young mothers living in deprived areas, sex workers and drug users. The PrimaryCare Team of interest was being established by the HSE and local general practitioners (GPs) in a one of the most deprived areas in the city, with a number of homeless hostels and a high migrant population. The PCT was to consist primarily of a physiotherapist, an occupational therapist, public health nurse (PHN), GPs and allied health professionals.
Research points to common prejudices and false assumptions about the LGBTcommunity that often act as barriers to quality healthcare. The attitudes of nurses and the impact of those attitudes are very relevant to the issue of LGBT healthcare (Strong & Folse, 2015; Smith & Matthew, 2008). Societal stigma, including avoidance of disclosing one’s sexual minority status, threats or acts of violence, avoidance of health care providers, and risk of pregnancy among LGBT teens needs to be identified and discussed (Brennan et al., 2012). LGBT health- care topics must be brought to the forefront and discussed. Other challenges to be addressed include the integration of spiritual and religious beliefs, self-awareness, and the fact that until recently LGBT issues have not really been ap- proached in nursing education (Brennan et al., 2012; Carabez et al., 2015). Nursing research has inadequately addressed the health needs of the LGBT population. Between 2005 and 2009, the top 10 nursing journals published only eight articles that focused on LGBT health issues of almost 5,000 total articles (Strong & Folse, 2015). This study aimed to address the discourse of nursing programs preparing students for provision of culturally competent care for all in- dividuals, including the LBGT community.
Efforts to meet these requirements and to fill the need identified in the community for improved behavioral health access added to the weight of support for this project. Specifically, the primarycare office manager and clinical staff, medical care system administrative staff, the community health team, and behavioral health services were in support of this project. The quality improvement team had measures in place to track data. They met monthly to discuss progress on compliance with the VB objectives, and brainstorm when barriers arose, adding increased support of this PHQ-9 project. The incentives that are available when requirements addressed in the VB are met were also a significant facilitator of this project. The intention of the VB is that a broad range of health and human services will be offered in a seamless fashion through coordination by health systems to meet the needs of patients and their families (Vermont Agency of Human Services, 2010). The VB (2010) offers enhanced payments to NCQA
In 2011 Alissa Hernandez proposed to her girlfriend two days after the New York state legislature passed a bill legalizing same-sex marriage and Governor Cuomo signed it into law. Active duty military marched in San Diego's parade two months before the federal government officially ended the “Don' Ask, Don't Tell” policy that prohibited gays and lesbians from serving openly in the military 1 . Despite these legal gains, same- sex marriage and gays in the military remain hotly contested political and cultural issues (the former much more than the latter). These two scenes illustrate much of what Pride is about. Externally, it is a public demonstration to contest the cultural marginalization of LGBT people. Through their acts, Hernandez, San Diego military, and the crowds that supported them took a stance for visibility and celebration of queer sexuality in contrast to cultural messages to silence and condemn it. Internally, Pride is a grand celebration for the LGBTcommunity in which all who count themselves members or supporters gather to honor their achievements and support one another in difficult times.