Application of the Andersen's health care utilization framework to secondary complications of spinal cord injury: a scoping review

Uses of Andersen health services utilization framework to determine healthcare utilization for mental health among migrants-a scoping review

Background

Migration is a worldwide occurrence that carries significant implications for healthcare systems, and it entails challenges to mental healthcare. The Andersen Behavioral Model is widely used by researchers to determine healthcare service utilization among many populations, including migrants. Our study aimed to explore the ways of using the Andersen Health System Utilization Framework in the literature to discover the utilization of mental healthcare by migrants.

Methods

This scoping review was based on Arksey and O'Malley's framework. A comprehensive search was performed across five electronic databases.

Results

A total of 12 articles from January 1992 to July 2023 identified various versions of the Andersen Behavioral Model to provide an overview of mental health services utilization among migrants. The analysis identified four significant trends in the literature. First, there is a predominant focus on individual characteristics over contextual factors. Second, researchers tend to integrate multiple versions of the Andersen Behavioral Model, and the most is the version from 1995. Third, additional factors specific to migrant populations are incorporated into the model, but the categorization is sometimes unclear. Finally, the majority of studies have used a quantitative approach and are based in North America, suggesting a focus on the significance of mental health in migrant communities in that context.

Conclusion

In summary, our scoping review calls for further research using the Andersen Behavioral Model to study mental healthcare utilization among migrants. Notable findings include the adaptation of the model to migrant populations, a focus on individual characteristics, a need for more diverse research methods, and the proposal of a new conceptual model to guide research and policy development in this field.

Factors enabling comorbidities and secondary conditions in older adults with spinal cord injury

OBJECTIVE

To examine the role of personal, social, and environmental factors predicting comorbidities and secondary conditions among older adults with spinal cord injury (SCI).

DESIGN

Cross-sectional study utilizing survey methods were used to collect the data analyzed with two distinct general linear models.

SETTING

Community-dwelling participants who resided in rural and urban areas.

PARTICIPANTS

One hundred and eighty-three (183) participants with SCI ages 45 and over at least five years post injury.

INTERVENTIONS

Not applicable.

MEASURES

Spinal Cord Injury Secondary Conditions Scale (SCI-SCS); Comorbidities Questionnaire; Spinal Cord Injury Functional Index Assistive Technology (SCI-FI/AT) Basic - Mobility; Spinal Cord Injury Quality of Life (SCI-QOL) Satisfaction with Social Roles and Activities Scale (SSRA); Cohen's Social Network-Social Integration Index, the Medical Outcomes Study (MOS) Social Support Emotional/Informational Support Scale, and the Facilitators and Barriers Survey for Mobility (FABS-Mv2). Questions were also asked from the Behavioral Risk Factor Surveillance System (BRFSS).

RESULTS

Common predictors of comorbidities and secondary conditions included age, basic mobility, primary health care payer and parking limitations. An interaction between parking and neurological classification was observed for comorbidities. Neurological classification and employment were significantly associated with comorbidities while for secondary conditions, sex, years since injury, education, satisfaction with social roles and the home environment were critical factors.

CONCLUSIONS

Our study shows the effects of demographic and injury factors, physical functioning, satisfaction with social roles, access to home environment adaptations and health resources in predicting comorbidities and secondary conditions among older adults with SCI.

Modernization of a Large Spinal Cord Injuries and Disorders Registry: The Veterans Administration Experience

Since the 1990s, Veterans Health Administration (VHA) has maintained a registry of Veterans with Spinal Cord Injuries and Disorders (SCI/Ds) to guide clinical care, policy, and research. Historically, methods for collecting and recording data for the VHA SCI/D Registry (VSR) have required significant time, cost, and staffing to maintain, were susceptible to missing data, and caused delays in aggregation and reporting. Each subsequent data collection method was aimed at improving these issues over the last several decades. This paper describes the development and validation of a case-finding and data-capture algorithm that uses primary clinical data, including diagnoses and utilization across 9 million VHA electronic medical records, to create a comprehensive registry of living and deceased Veterans seen for SCI/D services since 2012. A multi-step process was used to develop and validate a computer algorithm to create a comprehensive registry of Veterans with SCI/D whose records are maintained in the enterprise wide VHA Corporate Data Warehouse. Chart reviews and validity checks were used to validate the accuracy of cases that were identified using the new algorithm. An initial cohort of 28,202 living and deceased Veterans with SCI/D who were enrolled in VHA care from 10/1/2012 through 9/30/2017 was validated. Tables, reports, and charts using VSR data were developed to provide operational tools to study, predict, and improve targeted management and care for Veterans with SCI/Ds. The modernized VSR includes data on diagnoses, qualifying fiscal year, recent utilization, demographics, injury, and impairment for 38,022 Veterans as of 11/2/2022. This establishes the VSR as one of the largest ongoing longitudinal SCI/D datasets in North America and provides operational reports for VHA population health management and evidence-based rehabilitation. The VSR also comprises one of the only registries for individuals with non-traumatic SCI/Ds and holds potential to advance research and treatment for multiple sclerosis (MS), amyotrophic lateral sclerosis (ALS), and other motor neuron disorders with spinal cord involvement. Selected trends in VSR data indicate possible differences in the future lifelong care needs of Veterans with SCI/Ds. Future collaborative research using the VSR offers opportunities to contribute to knowledge and improve health care for people living with SCI/Ds.

Factors associated with telehealth use among adults in the United States: Findings from the 2020 National Health Interview Survey

INTRODUCTION

During the COVID-19 pandemic, health care shifted to virtual interactions with health professionals. The aim of this study was to examine the determinants of telehealth use in a nationally representative sample of the United States adult population.

METHODS

The study used data from the 2020 National Health Interview Survey of 17,582 respondents aged ≥18. Andersen's model of health services utilization was employed to examine predisposing, enabling, and needs factors associated with past-year telehealth use. Multivariable logistic regression was conducted to examine statistical associations.

RESULTS

32.5% of adults (n = 6402; mean age 51.6, SE = 0.4) reported telehealth use. Predisposing factors: Women and married/partnered adults and those with higher levels of education had greater odds of using telehealth. Adults living in Midwest and South and adults living in medium-small and non-metropolitan areas had decreased odds of using telehealth. Enabling factors: Income and having a usual source of care were positively associated with telehealth use. A negative association was found for those with no insurance and telehealth use, whereas a positive association was found for military insurance. Needs factors: Odds of using telehealth were increased for adults who had well-visits and ER visits in the past 12 months. Mental health services quadrupled the odds of telehealth use. Odds of using telehealth increased with each additional chronic disease, including COVID-19.

CONCLUSION

There are disparities in telehealth use according to sex, education, rurality, access to care, and health needs. Tackling these disparities is pivotal to ensure barriers to telehealth use are not exacerbated post-pandemic.

Rehabilitation processes, stress and depression in patients with spinal cord injury during the COVID-19 pandemic in Turkey: a telephone survey

Background/Aims

Spinal cord injury is a chronic disease that can develop various complications and multisystem dysfunctions. Patients with spinal cord injury need long-term follow up and rehabilitation. During the COVID-19 pandemic, people had to observe social distancing and stay at home. The aim of this study was to evaluate the effects of the COVID-19 pandemic on the rehabilitation and health status of patients with spinal cord injury and assesses their stress levels and depression status.

Methods

A telephone-based survey was conducted with patients followed up by a spinal cord injury outpatient clinic about rehabilitation processes and any health problems experienced. Stress levels were assessed using the Perceived Stress Scale, while depression was assessed using the Beck Depression Inventory. Demographic characteristics, American Spinal Injury Association Impairment Scale levels, Functional Ambulation Categories and Spinal Cord Independence Measure scores were retrieved from the patients' files.

Results

The study included 115 patients, none of whom had contracted COVID-19. Of these patients, 44.3% joined the rehabilitation programme before the pandemic, and 3.5% had been able to participate in the rehabilitation programme during the pandemic. An increase in spasticity was recorded in 43.5% of the respondents, an increase of neuropathic pain was recorded in 37.4% of patients and complaints of neurogenic bladder and neurogenic bowel increased by 26.1% and 16.5% respectively. In addition, 4.3% reported novel decubitus ulcers, while 5.2% reported having experienced autonomic dysreflexia episodes. The Perceived Stress Scale scores were 18.32 ± 5.91. No significant difference was detected between the Beck Depression Inventory scores taken at the time of the study and those recorded before the pandemic.

Conclusions

An insufficiency in the rehabilitation process was noted among patients with spinal cord injuries, accompanied by increased complications. New approaches need to be developed to ensure that the rehabilitation processes of patients with spinal cord injury are not interrupted during a pandemic, and that patients' mental health is not ignored.

Application of Andersen's behavioural model of health services use: a scoping review with a focus on qualitative health services research

INTRODUCTION

Qualitative methods have become integral in health services research, and Andersen's behavioural model of health services use (BMHSU) is one of the most commonly employed models of health service utilisation. The model focuses on three core factors to explain healthcare utilisation: predisposing, enabling and need factors. A recent overview of the application of the BMHSU is lacking, particularly regarding its application in qualitative research. Therefore, we provide (1) a descriptive overview of the application of the BMHSU in health services research in general and (2) a qualitative synthesis on the (un)suitability of the model in qualitative health services research.

METHODS

We searched five databases from March to April 2019, and in April 2020. For inclusion, each study had to focus on individuals ≥18 years of age and to cite the BMHSU, a modified version of the model, or the three core factors that constitute the model, regardless of study design, or publication type. We used MS Excel to perform descriptive statistics, and applied MAXQDA 2020 as part of a qualitative content analysis.

RESULTS

From a total of 6319 results, we identified 1879 publications dealing with the BMSHU. The main methodological approach was quantitative (89%). More than half of the studies are based on the BMHSU from 1995. 77 studies employed a qualitative design, the BMHSU was applied to justify the theoretical background (62%), structure the data collection (40%) and perform data coding (78%). Various publications highlight the usefulness of the BMHSU for qualitative data, while others criticise the model for several reasons (eg, its lack of cultural or psychosocial factors).

CONCLUSIONS

The application of different and older models of healthcare utilisation hinders comparative health services research. Future research should consider quantitative or qualitative study designs and account for the most current and comprehensive model of the BMHSU.

Characterization of Telehealth Use in Veterans With Spinal Cord Injuries and Disorders

BACKGROUND

Individuals with spinal cord injuries and disorders (SCI/D) require frequent interdisciplinary health care to address impairments in mobility, autonomic function, and secondary complications. Telehealth has the capacity to substantially transform health care delivery and improve care by increasing access and communication. However, relatively little is known about telehealth use in this specific population. Here we attempt to fill part of this gap.

OBJECTIVE

To investigate the frequency and characteristics associated with telehealth use in Veterans with SCI/D.

DESIGN

Cross-sectional, descriptive project.

SETTING

Veterans Health Administration (VHA) facilities.

PARTICIPANTS

A total of 15 028 Veterans living with SCI/D who received services from the VHA SCI/D System of Care.

INTERVENTION

Not applicable.

OUTCOME MEASURES

Frequency and characteristics associated with VHA telehealth utilization.

RESULTS

Of the 15 028 Veterans with SCI/D included in the evaluation, 17% used some form of telehealth in VHA Fiscal Year (FY)2017. Veterans older than 65 years of age had lower odds (odds ratio [OR] = 0.88, P < .05, confidence interval [CI] 0.80-0.98) of using telehealth. Being Caucasian (OR = 1.29, P < .01, CI 1.09-1.52), living in rural areas (OR = 1.16, P < .01, CI 1.05-1.28), living greater distances away from the VHA (P < .01 for all distances), and being in priority group 8, meaning that Veterans have higher copayment requirements (OR = 1.46, P < .001, CI 1.19-1.81), were all significantly associated with greater odds of telehealth use. The most frequent types of telehealth used were real-time clinical video and store-and-forward between a provider and patient within the same hub network.

CONCLUSION

There are opportunities to increase telehealth adoption in the SCI/D arena. The findings from this project highlight which Veterans are currently using telehealth services, as well as gaps regarding telehealth adoption in this population.

Health service use among adults with cerebral palsy: a mixed methods systematic review protocol

INTRODUCTION

Cerebral palsy (CP) is a neurodisability that primarily results in motor impairments and activity limitations, but is often associated with epilepsy and disturbances of sensation, perception, cognition, behaviour and speech. Most children with CP survive well into adulthood. Adults with CP experience increased risk of age-related chronic conditions such as arthritis, stroke, cardiorespiratory and mental health conditions in addition to the ongoing disabilities experienced from childhood. Therefore, adults with CP often require extensive health services. However, health service use among adults with CP has not been well documented. This mixed method review aims to identify, appraise and synthesise quantitative and qualitative literature examining health service use among adults with CP.

METHODS AND ANALYSIS

The mixed method systematic review will be conducted in accordance with the Joanna Briggs Institute (JBI) methodology. A systematic search of MEDLINE (Ovid), CINAHL, Embase, PsycINFO and Cochrane Library from inception to March 2020 will be conducted. Quantitative observational studies, qualitative studies and mixed method studies examining health service use among adults with CP (≥18 years) will be included. Outcomes of interest are the proportion of adults using health services frequency of use and experiences of health services from the perspectives of adults with CP, caregivers and health service providers. Two reviewers will independently screen titles, abstracts and full-texts, extract data and assess the quality of included studies using JBI instruments. Where possible a pooled analysis and aggregation of findings will be performed for quantitative and qualitative data, respectively, and Grading of Recommendations Assessment, Development and Evaluation (GRADE)/GRADE-CERQual (Confidence in Evidence from Reviews of Qualitative research) employed. Quantitative and qualitative findings will be integrated using a triangulation approach at the synthesis stage. A narrative synthesis will be carried out where this is not possible.

ETHICS AND DISSEMINATION

Ethical approval is not required for this review. The findings will be disseminated through a peer-reviewed journal and conferences.

PROSPERO REGISTRATION NUMBER

CRD42020155 380.

Profile of Long-Term Care Recipients Receiving Home and Community-Based Services and the Factors That Influence Utilization in Taiwan

In response to the irreversible aging trend, the Taiwan government has promoted the Long-Term Care (LTC) policy 1.0 launched in 2007 and the LTC policy 2.0 reform since 2016. This study aimed to explore the utilization of formal home and community-based care under LTC policy 1.0 to add scientific support for the on-going LTC policy 2.0 reform. Methods: By using Andersen and Aday’s behavioral model of healthcare utilization, the long-term care dataset was analyzed from 2013 to 2016. A total of 101,457 care recipients were identified after data cleaning. Results: The results revealed that about 40.7% of the care recipients stayed in the care system for more than two years. A common factor influencing the length of home and community-based services (HCBS) utilization period included need factors, where more dependent recipients leave the LTC system regardless of their socio-economic status. However, the utilization period of non-low-income households is significantly affected by the level of service resources. Conclusion: For long-term care needs, the phenomenon of a short utilization period was concerning. This study adds information which suggests policy should reconsider care capacity and quality, especially for moderate to severely dependent recipients. This will allow for better understanding to help maintain care recipients in their own communities to achieve the goal of having an aging in place policy.

What influences the use of professional home care for individuals with spinal cord injury? A cross-sectional study on family caregivers

STUDY DESIGN

Cross-sectional survey.

OBJECTIVE

The objective of this study is to identify what characteristics of the family caregivers influenced the use of professional home care for persons with SCI in Switzerland.

SETTING

Community setting, nationwide in Switzerland.

METHODS

Questionnaires were filled out by the adult family caregivers of persons with SCI. Influence of characteristics of the caregivers was analyzed with regression models, adjusting for the characteristics of the person with SCI. Logistic regression was used for whether professional home care was used. Poisson regression was applied for the absolute and relative amount of professional home care.

RESULTS

In total, 717 family caregivers participated in the study (31% response rate). Among the participants, 33% hired professional home care for 10 h per week on average. The level of dependency of the persons with SCI had a significant influence on the utilization of care. The availability and proximity of the primary family caregiver, namely being spouse and cohabiting, reduced the amount of services used, whereas caregivers who worked full time employed more services. Higher levels of education and income increased the use of professional home care. Compared with their reference groups, caregivers with older age and those with a migratory background used comparable or larger absolute amount of professional services, which, however, represented a smaller proportion of total hours of care.

CONCLUSIONS

Adequate support requires consideration of the characteristics of both the caregiver and of the person with SCI. The needs of family caregivers should also be assessed systematically in the needs assessment.

A narrative synthesis scoping review of life course domains within health service utilisation frameworks

Background: Current thinking in health recognises the influence of early life experiences (health and otherwise) on later life outcomes. The life course approach has been embedded in the work of the World Health Organisation since the Ageing and Health programme was established in 1995. Yet there has been limited debate on the relevancy of a life course lens to understanding health service utilisation. Aim: The aim of the review was twofold. Firstly, identify existing healthcare utilisation frameworks other than the dominant Andersen's behavioural model currently in use. Secondly, to identify if current frameworks incorporate the advocated life course perspective in understanding health service utilisation.     Methods: A scoping review of PubMed, Cinahl Plus, Emerald, PsycINFO, Web of Knowledge and Scopus was conducted. Data extraction used a framework approach with meta-synthesis guided by the four domains of the life course proposed by Elder (1979): human agency, location, temporality and relationships, and interdependencies. Results: A total of 551 papers were identified, with 70 unique frameworks (other than Andersen's Behavioural Model) meeting the inclusion criteria and included in the review. Conclusion: To date there has been limited explicit discussion of health service utilisation from a life course perspective. The current review highlights a range of frameworks that draw on aspects of the life course, but have been used with this perspective in mind. The life course approach highlights important gaps in understanding and assessing health service utilisation (HSU), such as utilisation over time. HSU is a complex phenomenon and applying a structured framework from a life course perspective would be of benefit to researchers, practitioners and policy makers.

Trends, Challenges, and Opportunities Regarding Research in Non-traumatic Spinal Cord Dysfunction

Background: Spinal cord dysfunction (SCDys) is caused by heterogeneous health conditions, and the incidence is increasing. Despite the growing interest in rehabilitation research for SCDys, research into SCDys faces many challenges. Objective: The objective of this project was to perform a clinical review of changes in SCDys research over the last 4 decades; identify challenges to conducting research in SCDys; and propose opportunities for improving research in SCDys. Methods: A triangulation approach was used for obtaining evidence: literature search (January 2017) using MEDLINE and Embase databases for publications in English (1974-2016) regarding SCDys; workshop discussions at the International Spinal Cord Society annual meeting, September 16, 2016, Vienna, Austria; and our collective expertise in SCDys clinical rehabilitation research. Results: There has been a substantial increase in publications on SCDys over the 4 decades, from 1,825 in 1974-1983 to 11,887 in the decade 2004-2013, along with an improvement in research methodology. Numerous challenges to research in SCDys rehabilitation were grouped into the following themes: (a) identification of cases; (b) study design and data collection; and (c) funding, preclinical, and international research. Opportunities for addressing these were identified. Conclusions: The increase in scientific publications on SCDys highlights the importance of this heterogeneous group among the research community. The overall lack of good quality epidemiological studies regarding incidence, prevalence, and survival in these patients serves as a benchmark for guiding improvements to inform evidence-based care and policy.

Frequency and predictors of health services use by Native Hawaiians and Pacific Islanders: evidence from the U.S. National Health Interview Survey

BACKGROUND

Native Hawaiians and Pacific Islanders (NHPIs) are one of the fasting growing racial groups in the United States (US). NHPIs have a significantly higher disease burden than the US population as a whole, yet they remain underrepresented in research. The purpose of this study is to examine factors associated with health care utilization among NHPIs.

METHODS

Drawing from the 2014 NHPI-National Health Interview Survey, we used stereotype logistic regressions to examine utilization of emergency department (ED) and outpatient services among 2172 individuals aged 18 and older.

RESULTS

NHPIs with chronic diseases were twice as likely to be multiple ED users and nearly four times as likely to be frequent-users of outpatient services. Social support played a protective role in preventing multiple use of ED. Having a usual source of care made it more than eight times as likely to be a frequent-user of outpatient services. Use of eHealth information increased the odds of using ED and outpatient services. Ability to afford health care increased the odds of using outpatient services. There was no association between health insurance coverage and use of ED and outpatient services among NHPIs.

CONCLUSIONS

This research provides the first available national estimates of health services use by NHPIs. Efforts to improve appropriate use of health services should consider leveraging the protective factors of social support to reduce the odds of frequent ED use, and having a usual source of care to increase use of outpatient services.

Reliability and validity of the Persian version of the spinal cord injury lifestyle scale and the health behavior questionnaire in persons with spinal cord injury

STUDY DESIGN

Cross-sectional psychometric study.

OBJECTIVE

To evaluate the reliability and validity of a spinal cord injury lifestyle scale (SCILS) and Health Behavior Questionnaire (HBQ) in the Persian language for persons with spinal cord injury (SCI).

SETTING

Participants were selected among those referred to health centers and the Brain and Spinal Cord Injury Research Center.

METHOD

In accordance with standard procedure for translation, two questionnaires, the SCILS and HBQ, were translated using a forward and backward translation approach by professional translators. Face validity of the questionnaires was assessed by ten persons with SCI and content validity was agreed upon by 12 professors from health care teaching universities. To test the final versions of both questionnaires, 97 persons with SCI were included using a consecutive sampling method. Other questionnaires were used to assess concurrent validity (secondary impairment checklist, as well as SCILS and HBQ) and convergent validity (impact of event scale revised, brief symptom inventory, beck depression inventory, and functional independence measure).

RESULTS

Internal consistency of SCILS and HBQ, assessed by Cronbach's alpha, was 0.75 for SCILS and 0.85 for HBQ. Test-retest reliability intraclass correlations were 0.86 and 0.92 for SCILS and HBQ, respectively. The number of current secondary impairments had a significant and negative correlation with SCILS (r = -0.22, P < 0.001), but it was not correlated with HBQ. SCILS had a significant and strong correlation with HBQ (r = 0.65, P < 0.001).

CONCLUSION

SCILS and HBQ can be used for measuring the health behavior of persons with SCI in Iran.

Individual and Regional Determinants for Physical Therapy Utilization in Germany: Multilevel Analysis of National Survey Data

BACKGROUND

Physical therapy is included in many clinical guidelines and is a commonly used health service. However, access to its benefits should not strongly depend on social or demographic factors.

OBJECTIVE

The present study used the Andersen model to explain to what extent physical therapy utilization in Germany depends on factors beyond medical need.

METHODS

The German Health Interview and Examination Survey for Adults (DEGS, 2008-2011; target population, 18-79 years) is part of the German health-monitoring system. Two-stage stratified cluster sampling resulted in a sample of 8152 participants. Data were matched with district-related information on social structures and service supply. Following Andersen's Behavioral Model of Health Services Use, this study identified predisposing, enabling, and need factors for physical therapy utilization using multilevel logistic regression analyses.

RESULTS

Physical therapy was used by 23.4% (95% CI: 22.0-24.8) of the German population within one year, with a higher proportion of females (26.8%; 95% CI: 25.1-28.6) than males (19.9%; 95% CI: 18.1-21.8) and an increase with age. Beyond medical need, physical therapy utilization depended on higher education, migrant background, nonsmoking (predisposing), social support, higher income, private health insurance, and gatekeeping service contact (enabling). Variation among districts partly reflected regional supply.

LIMITATIONS

Because the present study was cross-sectional, its findings provide representative information on physical therapy use but do not establish final causal links or identify whether utilization or supply in certain districts or population groups is adequate.

CONCLUSIONS

Whether certain regions are under- or overserved and whether further regulations are needed is of political interest. Physicians and therapists should develop strategies to improve both adherence of hard-to-reach groups and supply in low-supply regions.

Sociotechnical Perspective on Implementing Clinical Video Telehealth for Veterans with Spinal Cord Injuries and Disorders

BACKGROUND

Real-time videoconferencing technology such as clinical video telehealth (CVT) offers a means to reach patient populations who face limited access to healthcare. The Veterans Health Administration has invested in CVT to improve care access for U.S. military veterans with spinal cord injuries and disorders (SCI/D); however, no studies have assessed the factors that influence implementation of this technology in clinical practice for individuals with SCI/D.

INTRODUCTION

Guided by a sociotechnical perspective, the purpose of this study was to identify factors that influence implementation of CVT for veterans with SCI/D.

MATERIALS AND METHODS

We conducted semistructured telephone interviews with 40 healthcare providers who use CVT to deliver services to veterans with SCI/D.

RESULTS

Factors related to workflow and communication were widely reported as implementation barriers. Coordinating logistics for CVT appointments was challenging, and effective communication between CVT team members across facilities was considered crucial. Providers also cited factors related to technical infrastructure, people, and organizational features, including the need for appropriate equipment, space, personnel, and support for using CVT equipment.

DISCUSSION

The implementation of CVT in the care of veterans with SCI/D was influenced by an interrelated set of social and technical factors. Key among them were social factors related to people, workflow, and communication, given that CVT supports healthcare teams interacting remotely in real time.

CONCLUSIONS

CVT implementation requires teams working together to negotiate a complex, distributed process across multiple sites. Such complexity places a premium on teamwork and communication among healthcare teams before, during, and after a CVT encounter.

Identification of Barriers to Influenza Vaccination in Patients with Chronic Obstructive Pulmonary Disease: Analysis of the 2012 Behavioral Risk Factors Surveillance System

INTRODUCTION

Patients with chronic obstructive pulmonary disease (COPD) are at increased risk for influenza-related morbidity and mortality. Influenza vaccination is known to decrease influenza incidence, severity, hospitalizations, and mortality. Identification of barriers to influenza vaccination among patients with COPD may aid in efforts to increase vaccination rates. This study aims to identify predictors of influenza vaccination in COPD patients.

METHODS

This study used data from the 2012 Behavioral Risk Factor Surveillance System (BRFSS). Participants with self-reported COPD and receiving an influenza vaccination in the prior 12 months were identified. Independent predictors of the exposure were identified by estimating a parsimonious logistic regression model of influenza vaccination. All analyses were performed using weighted data.

RESULTS

The final study sample consisted of 36,811 COPD participants, with 48.5% of COPD patients reporting having been vaccinated and 51.5% reporting being unvaccinated. A total of 15 independent predictors of influenza vaccination in COPD patients were identified. Negative predictors included predisposing factors (younger age, male gender, household children, black or non-white/non-Hispanic/non-black race/ethnicity, lower education level, heavy alcohol use, current tobacco use) and enabling factors that reflect access to medical care (insurance status, ability to afford care, having a recent check-up). Positive predictors of influenza vaccination included need factors (chronic comorbidities), being a military veteran, or being a former smoker.

CONCLUSIONS

This analysis identifies multiple predictors of influenza vaccination in persons with COPD. Identification of at risk-groups provides the foundation for development of focused efforts to improve influenza vaccination rates in patients with COPD.

Determinants of postnatal service utilisation among mothers in rural settings of Malawi

The aim of this study was to determine significant predictors for the utilisation of postnatal service among mothers. A total of 295 postnatal mothers were enrolled in a cross-sectional study design undertaken in six health facilities of Lilongwe District using two-stage cluster sampling with a response rate of 100%. The data were collected by interview from December 2012 to January 2013 using a structured questionnaire. The result showed that over half of the mothers (56.6%) utilised postnatal service within 6 weeks after delivery. A stepwise multiple logistic regression was used to determine significant determinants of utilisation of postnatal service among mothers. After adjusting for confounding factors, utilisation of an alternative local source of care in home after delivery [adjusted odds ratio (aOR): 7.77, 95% CI: 4.14-14.58], women's perception on performance of health workforce during delivery and postnatal service (aOR: 6.56, 95% CI: 3.09-13.94), health education before hospital discharge of postnatal mothers (aOR: 4.08, 95% CI: 2.11-7.92), place of delivery (aOR: 4.32, 95% CI: 1.32-14.12), family income (aOR: 1.89, 95% CI: 1.03-3.46) and the occurrence of no complications during delivery (aOR: 1.90, 95% CI: 1.03-3.50) were significantly associated with the utilisation of postnatal service. Hence, this study suggests that improved health workforce performance coupled with effective health education may increase the utilisation of postnatal service. Furthermore, the utilisation of postnatal service may also be increased through reducing home deliveries, delivery complications and the use of alternative local care at home after delivery. Integration of postnatal service in outreach clinics might also assist through reducing the cost of accessing postnatal service among mothers.

Health care utilization in persons with traumatic spinal cord injury: the importance of multimorbidity and the impact on patient outcomes

BACKGROUND

Persons with spinal cord injury (SCI) living in the community have high health care utilization (HCU). To date, the interrelationships among multiple secondary health conditions (multimorbidity due to comorbidities and complications) that drive HCU and their impact on patient outcomes are unknown.

OBJECTIVE

To determine the association among multimorbidity, HCU, health status, and quality of life.

METHODS

Community-dwelling persons with traumatic SCI participated in an online/phone SCI Community Survey. Participants were grouped using the 7-item HCU questionnaire (group 1 did not receive needed care and/or rehospitalized; group 2 received needed care but rehospitalized; group 3 received needed care and not rehospitalized). Personal, injury, and environmental factors; multimorbidity (presence/absence of 30 comorbidities/ complications); health status (Short Form-12); and quality of life measures (Life Satisfaction-11 first question and single-item quality of life measure) were collected. Associations among these variables were assessed using multivariate analysis.

RESULTS

The 1,137 survey participants were divided into 3 groups: group 1 (n = 292), group 2 (n = 194), and group 3 (n = 650). Group 1 had the greatest number of secondary health conditions (15.14 ± 3.86) followed by group 2 (13.60 ± 4.00) and group 3 (12.00 ± 4.16) (P < .05). Multimorbidity and HCU were significant risk factors for having a lower SF-12 Mental (P < .001) and Physical Component Score (P < .001). They in turn were associated with participants reporting a lower quality of life (P < .001, for both questions).

CONCLUSIONS

Multimorbidity and HCU are interrelated and associated with lower health status, which in turn is associated with lower quality of life. Future work will include the development of a screening tool to identify persons with SCI at risk of inappropriate HCU (eg, rehospitalization, not able to access care), which should lead to better patient outcomes and cost savings.

Health care and HIV testing experiences among Black men in the South: implications for "Seek, Test, Treat, and Retain" HIV prevention strategies

Few studies have explored how overall general health care and HIV/STI testing experiences may influence receipt of "Seek, Test, Treat, and Retain" (STTR) HIV prevention approaches among Black men in the southern United States. Using in-depth qualitative interviews with 78 HIV-negative/unknown Black men in Georgia, we explored factors influencing their general health care and HIV/STI testing experiences. The Andersen behavioral model of health care utilization (Andersen model) offers a useful framework through which to examine the general health care experiences and HIV testing practices of Black men. It has four primary domains: Environment, Population characteristics, Health behavior, and Outcomes. Within the Andersen model framework, participants described four main themes that influenced HIV testing: access to insurance, patient-provider communication, quality of services, and personal belief systems. If STTR is to be successful among Black men, improving access and quality of general health care, integrating HIV testing into general health care, promoting health empowerment, and consumer satisfaction should be addressed.

Secondary health conditions and spinal cord injury: an uphill battle in the journey of care

PURPOSE

To understand the journey of care in the prevention and management of secondary health conditions (SHCs) following spinal cord injury (SCI).

METHOD

This was a case study design with 'Ontario' as the case. The Network Episode Model was used as the conceptual framework. Data sources included in depth interviews with persons with SCI, care providers, and policy and decision makers. Document analysis was also conducted on relevant materials and policies. Key informants were selected by purposeful sampling as well as snowball sampling to provide maximum variation. Data analysis was an iterative process and involved descriptive and interpretive analyses. A coding structure was developed based on the conceptual framework which allowed for free nodes when emerging ideas or themes were identified.

RESULTS

Twenty-eight individuals were interviewed (14 persons with SCI and 14 persons representing care providers, community advocacy organization representatives, system service delivery administrators and policy-makers). A major over-arching domain that emerged from the data was the concept of 'fighting'. Eleven themes were identified: at the micro-individual level: (i) social isolation and system abandonment, (ii) funding and equitable care, (iii) bounded freedom and self-management; at the meso care provider level: (iv) gender and caregiving strain, (v) help versus disempowerment, (vi) holistic care-thinking outside the box, (vii) poor communication and coordination of care; and at the macro health system level: (viii) fight for access and availability, (ix) models of care tensions, (x) private versus public tensions and (xi) rigid rules and policies.

CONCLUSIONS

Findings suggest that the journey is challenging and a persistent uphill struggle for persons with SCI, care providers, and community-based advocates. If we are to make significant gains in minimizing the incidence and severity of SHCs, we need to tailor efforts at the health system level.

IMPLICATIONS FOR REHABILITATION

• Secondary health conditions are problematic for individuals with a spinal cord injury (SCI). • This study aimed to understand the journey of care in the prevention and management of secondary health conditions (SHCs) following SCI. • Findings suggest that the journey is challenging and a persistent uphill struggle for persons with SCI, care providers, and community-based advocates. • All stakeholders involved recognized the disparities in access to care and resources that exist within the system. We recommend that if we are to make significant gains in minimizing the incidence and severity of SHCs, we need to tailor efforts at the health system level.