Erectile dysfunction prevalence in the United States: report from the 2021 National Survey of Sexual Wellbeing

BACKGROUND

There has been a great deal of public speculation regarding a surge in erectile dysfunction (ED) in younger men despite data consistently indicating that the ED prevalence rates increase with age.

AIM

In this study we sought to assess the prevalence and risk of experiencing ED in a nationally representative sample of men in the United States across various social groups, describe comorbidities, and examine barriers to treatment.

METHODS

Data from the 2021 National Survey of Sexual Wellbeing were analyzed by utilizing the Ipsos KnowledgePanel®, a probability-based online panel, for the purpose of obtaining US nationally representative data of adults aged 18 years and older. The analytic sample consisted of 1822 cisgender men ranging in age from 18 to 87 years, with a mean age of 47.5 years.

OUTCOMES

Study outcomes were ED as measured by the 5-item version of the International Index of Erectile Function (IIEF-5), as well as self-reported diagnosis by a medical professional, comorbidities with other health issues, medications taken for ED, and barriers to treatment.

RESULTS

The ED prevalence rate based on IIEF-5 scores was 24.2%. Prevalence increased with age: 52.2% of the 75+ age group, and 48.0% of the 65-74 age group meeting diagnostic criteria for ED. Diagnostic criteria were met for more participants in the 18-24 age group (17.9%) than the 25-34 (13.3%) or 35-44 (12.7%) age groups, but less than the 45-54 (25.3%) or 55-64 (33.9%) age groups. Only 7.7% (n = 141) of the sample reported having been diagnosed by a provider (n = 4 in 25-34, n = 6 in 35-44, n = 13 in 45-54, n = 39 in 55-64, n = 44 in 65-74, and n = 34 in ≥75-year olds), indicating a gap in access to treatment. The most common reason selected for not accessing care for ED concerns was a lack of need to see a provider in the past year.

CLINICAL IMPLICATIONS

The discrepancy between ED self-report and medical diagnosis is critical, given that ED can be an indication of underlying health risks.

STRENGTHS AND LIMITATIONS

This study is the first nationally representative update to information regarding the prevalence of ED in almost 2 decades. Standard administration of the IIEF-5 is limited to participants who have had sex in the last 6 months, so these rates do not include those men with ED who have been avoiding penetrative sex for a significant time.

CONCLUSION

The results indicate that ED prevalence and severity remain highest in older age groups and that most individuals who meet criteria for ED have not sought medical care related to this concern.

Access to primary healthcare services for adults with disabilities in Latin America and the Caribbean: a review and meta-synthesis of qualitative studies

PURPOSE

This review and meta-synthesis of qualitative studies aims to provide an overview of qualitative evidence on primary healthcare access of people with disability in Latin America and the Caribbean, as well as to identify barriers that exist in this region.

METHODS

Six databases were searched for studies from 2000 to 2022. 34 qualitative studies were identified.

RESULTS

Barriers exist on both demand and supply sides. The thematic synthesis process generated three broad overarching analytical themes, which authors have related to Levesque et al.'s aspects of "ability to perceive," "availability, accommodation and ability to reach" and "appropriateness and ability to engage." Access to information and health literacy are compromised due to a lack of tailored health education materials. Barriers in the urban environment, including inadequate transportation, and insufficient healthcare facility accessibility create challenges for people with disabilities to reach healthcare facilities independently. Attitudinal barriers contribute to suboptimal care experiences.

CONCLUSION

People with disabilities face several barriers in accessing healthcare. Lack of healthcare provider training, inappropriate urban infrastructure, lack of accessible transport and inaccessibility in healthcare centers are barriers that need to be addressed. With these actions, people with disabilities will be closer to having their rights met.

To confirm your appointment, please press one: Examining demographic and health system interface factors that predict missed appointments in a pediatric outpatient neuropsychology clinic

Objective: Missed patient appointments have a substantial negative impact on patient care, child health and well-being, and clinic functioning. This study aims to identify health system interface and child/family demographic characteristics as potential predictors of appointment attendance in a pediatric outpatient neuropsychology clinic. Method: Pediatric patients (N = 6,976 across 13,362 scheduled appointments) who attended versus missed scheduled appointments at a large, urban assessment clinic were compared on a broad array of factors extracted from the medical record, and the cumulative impact of significant risk factors was examined. Results: In the final multivariate logistic regression model, health system interface factors that significantly predicted more missed appointments included a higher percentage of previous missed appointments within the broader medical center, missing pre-visit intake paperwork, assessment/testing appointment type, and visit timing relative to the COVID-19 pandemic (i.e. more missed appointments prior to the pandemic). Demographic characteristics that significantly predicted more missed appointments in the final model included Medicaid (medical assistance) insurance and greater neighborhood disadvantage per the Area Deprivation Index (ADI). Waitlist length, referral source, season, format (telehealth vs. in-person), need for interpreter, language, and age were not predictive of appointment attendance. Taken together, 7.75% of patients with zero risk factors missed their appointment, while 22.30% of patients with five risk factors missed their appointment. Conclusions: Pediatric neuropsychology clinics have a unique array of factors that impact successful attendance, and identification of these factors can help inform policies, clinic procedures, and strategies to decrease barriers, and thus increase appointment attendance, in similar settings.

Examining the Effectiveness of Financial Protection Schemes in Reducing Health Inequality

Health protection schemes such as health insurance and financial assistance provide immense help and support to access health care services, especially to the poor and marginalized section of society. India is witness to low health-related expenditure, and the society's socioeconomic and demographic structure further drops health care access to the new bottom. Consequently, inequality in health care access is highly observed across many socioeconomic attributes. The condition of Bihar, the poorest state of India, is more alarming. The analysis suggests that financial support in terms of universal health insurance coverage considerably reduces out-of-pocket expenditure and thus health inequality. Further, the low health insurance coverage is not solely due to a lack of institutional commitment and implementation process; the cognitive behavior and attitude of people are equally responsible for low health care access. An intensive awareness program to show the benefit of the health insurance scheme and sensitization of people against the social stigma is important to provide better health care access and reduce health inequality.

Cardiovascular health and risk factors in African refugees and immigrants in the United States: a narrative review

OBJECTIVES

Refugees and immigrants often experience challenges pre- and post-settlement that expose them to risk factors of cardiovascular disease (CVD). Literature on CVD among the growing population of African refugees and immigrants in the United States (US) is scant. This narrative review aimed to evaluate existing studies reporting on CVD and its risk factors among African refugees and immigrants in the US, and to recognize limitations in the current research, policy, and healthcare for adequate CVD-related care for African refugees and immigrants.

DESIGN

Articles on African refugee and/or immigrant health were searched on PubMed using multiple key search terms. Studies conducted between 1995 and 2020 and reporting on CVD-related measures in individuals from African countries of origin were included. Six articles were found discussing refugee health only and seven articles discussed refugee and immigrant health together.

RESULTS

Overall, the studies showed the varying prevalence of CVD risk factors, mostly depending on the country of origin. Worsening cardiometabolic health with longer residency in the US was generally reported. Refugee-only studies relied mostly on medical records data, while refugee and immigrant studies used both medical records and primary data collection. Limitations in data pertain to the geographical representation of both African countries (predominantly from Somalia despite migrants arriving from diverse African countries) and of regions of settling in the US (predominantly the north/northeast), scarce longitudinal studies, and lack of distinction between refugees and immigrants. Multiple social and structural barriers to cardiovascular health were identified, mostly related to cultural and linguistic challenges and to inadequate or complex health insurance and healthcare systems.

CONCLUSION

The cardiovascular health of African refugees and immigrants remains understudied and underserved. Further research and interventions to alleviate barriers and improve cardiovascular health in African refugees and immigrants in the US should be developed using culturally appropriate, accessible, flexible, and multifaceted strategies.

Exploring the linkage between family financial struggle and children's bullying victimization: Implications for nursing and psychotherapeutic practices

PURPOSE

A few studies have found that children whose families are economically disadvantaged and financially struggling are at an elevated risk of victimization by their peers. However, extant research is largely descriptive. To address this gap, this study empirically tested the proposed pathways from family financial struggle to children's bullying victimization, including the role of barriers to healthcare access in this association using a nationally representative sample.

DESIGN AND METHODS

The study utilizes the 2016 National Survey of Children's Health, a survey of a cross-sectional, weighted probability sample of US children (ages 0-17 years) living in 50 states and the District of Columbia, and their caregivers. The sample used for the current study included 14,374 racially and ethnically diverse caregivers of children, aged 6-11 years.

RESULTS

Positive significant associations between family financial struggle and children's bullying victimization, and between financial struggle and barriers to healthcare access were found. Barriers to healthcare access mediated the association between family financial struggle and bullying victimization.

PRACTICE IMPLICATIONS

Given the documented effects of bullying victimization on children, findings point to the importance of developing psychotherapeutic practices that are appropriate for children who are flagged as "high-risk."

Doctor-perceived-barriers to telephone clinics at KwaZulu-Natal hospitals during the COVID-19 pandemic

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has led to an unprecedented international emergency, resulting in a need to adapt the existing healthcare systems, in order to enable ongoing patient care despite the current disruptions. Telemedicine may be a viable option to continue hospital workflow, however there are barriers to its implementation. We set out to establish what barriers might exist and to assess the viability of teleclinics within the province KwaZulu-Natal (KZN), as perceived by doctors.

METHODS

This was a quantitative, observational, survey-based study targeted at medical doctors working in both the public as well as the private healthcare sector in University of KwaZulu-Natal (UKZN).

RESULTS

One hundred and forty-seven (147) responses were included. The majority (86%) of respondents felt that telemedicine could provide a useful means to continuing hospital workflow, however, only 47% believed that it was a viable option for their unit. The major barrier identified was a feeling that doctors would-be at-increased medico-legal risk. Only 38.4% of doctors were familiar with the Health Professions Council of South Africa (HPCSA) guidelines on telemedicine usage. Other major barriers included: doctors feeling uncomfortable with not seeing a patient in person or not being able to perform a thorough physical examination. Other reasons identified as potential barriers were doctors foreseeing difficulty in accessing patient medical records and the absence of available systems to order investigations without the patient being physically present.

CONCLUSION

Telemedicine is currently not widely utilised in KZN; although most doctors were of the opinion that it could be a useful tool in order to continue the workflow during the pandemic. The major barrier identified were issues surrounding medico-legal coverage.

How to improve healthcare for autistic people: A qualitative study of the views of autistic people and clinicians

LAY ABSTRACT

Research has shown that on average, autistic people are more likely to die earlier than non-autistic people, and barriers can stop autistic people accessing healthcare. We carried out a study where we interviewed healthcare professionals (including doctors and nurses), and held discussion groups of autistic people. Our results highlighted several key points: seeing the same professional is important for autistic people and clinicians; both clinicians and autistic people think making adjustments to healthcare is important (and often possible); autistic people process information in a different way and so may need extra support in appointments; and that clinicians are often constrained by time pressures or targets.

Case Study Comparison: Limitations in Telehealth Relating to Poverty and Family Support

Telehealth appointments have grown in popularity due to the COVID-19 global pandemic. Three cases presented in this article show several different perspectives where telehealth was utilized. For the first patient, appointments were successfully completed via telehealth; however, the patient's family opted to continue with an unsecure internet connection at a local laundromat. For the second patient, a stable internet connection could not be obtained in his home, thus making telehealth appointments unavailable. The caregiver of this patient ended up driving to the clinic to have adjustments made in person. For the third patient, telehealth appointments were unavailable due to unstable internet connections as well as difficulty setting up video interpreting services. These cases highlight the idea that telehealth can be incredibly beneficial, when used correctly. For some, the option to attend appointments virtually gives them access to specialists that otherwise may not be available. For other patients, aspects such as access to smart devices and steady internet access must be considered to ensure a successful connection. The hope is that this article sheds light on some of the potential setbacks that can come from the use of telehealth appointments in a practice and provides discussion regarding for whom telehealth may be appropriate, even in pediatric patients. After reading this article, readers should be able to discuss ways in which there could be solutions for these barriers that may prevent some patients from utilizing these types of virtual appointments.

Barriers to accessing primary healthcare services for people with disabilities in low and middle-income countries, a Meta-synthesis of qualitative studies

METHODS

Six electronic databases were searched for relevant studies from 2000 to 2019. Forty-one eligible studies were identified.

RESULTS

Findings suggest that the people with disabilities' choice to seek healthcare services or not, as well as the quality of intervention provided by primary healthcare providers, are influenced by three types of barriers: cultural beliefs or attitudinal barriers, informational barriers, and practical or logistical barriers.

CONCLUSION

In order to achieve full health coverage at acceptable quality for people with disabilities, it is necessary not only to consider the different barriers, but also their combined effect on people with disabilities and their households. It is only then that more nuanced and effective interventions to improve access to primary healthcare, systematically addressing barriers, can be designed and implemented.IMPLICATIONS FOR REHABILITATIONPeople with disabilities in both high income and low- and middle-income country settings are more likely to experience poorer general health than people without disabilities.Barriers to accessing primary healthcare services for people with disabilities result from a complex and dynamic interacting system between attitudinal and belief system barriers, informational barriers, and practical and logistical barriers.Given primary healthcare is often the initial point of contact for referral to specialty care and rehabilitation services, it is crucial for people with disabilities to access primary healthcare services in order to get appropriate referrals for such services, specifically rehabilitation as appropriate.To achieve full health coverage at acceptable quality for people with disabilities, starting with primary healthcare, it is necessary for healthcare stakeholders, including rehabilitation professionals, to consider the combined and cumulative effects of the various barriers to healthcare on people with disabilities and their families and develop an understanding of how healthcare decisions are made by people with disabilities at the personal and the household level.

Diabetes in Appalachia: providers' perspectives

BACKGROUND

Southeastern Appalachian Ohio has more than double the national average of diabetes and a critical shortage of healthcare providers. Paradoxically, there is limited research focused on primary care providers' experiences treating people with diabetes in this region. This study explored providers' perceived barriers to and facilitators for treating patients with diabetes in southeastern Appalachian Ohio.

METHODS

We conducted in-depth interviews with healthcare providers who treat people with diabetes in rural southeastern Ohio. Interviews were transcribed, coded, and analyzed via content and thematic analyses using NVivo 12 software (QSR International, Chadstone, VIC, Australia).

RESULTS

Qualitative analysis revealed four themes: (1) patients' diabetes fatalism and helplessness: providers recounted story after story of patients believing that their diabetes was inevitable and that they were helpless to prevent or delay diabetes complications. (2) Comorbid psychosocial issues: providers described high rates of depression, anxiety, incest, abuse, and post-traumatic stress disorder among people with diabetes in this region. (3) Inter-connected social determinants interfering with diabetes care: providers identified major barriers including lack of access to providers, lack of access to transportation, food insecurity, housing insecurity, and financial insecurity. (4) Providers' cultural understanding and recommendations: providers emphasized the importance of understanding of the values central to Appalachian culture and gave culturally attuned clinical suggestions for how to use these values when working with this population.

CONCLUSIONS

Evidence-based interventions tailored to Appalachian culture and training designed to increase the cultural competency and cultural humility of primary care providers may be effective approaches to reduce barriers to diabetes care in Appalachian Ohio.

Developing Trans-Affirming Health Services in an Underserved Area: An Intersectional Approach

Purpose: Gender-nonconforming patients are at higher risk for medical problems that require prompt medical and mental health intervention. Barriers to healthcare for transgender individuals have been well characterized in the literature, but not in low resource settings. The purpose of this paper is to present the barriers encountered when bringing healthcare to transgender children, adolescents, and adults in a medically underserved, predominantly Hispanic area of the United States. Methods: In this medically underserved area on the U.S.-Mexico border, there is a severe shortage of medical expertise for transgender individuals at both the primary- and specialty-care levels. Further, given the mainly Hispanic population, there is an additional culturally based barrier to obtaining medical care for transgender patients. Results: It is important for academic centers in these regions to collaborate to overcome these barriers through a multidisciplinary approach that includes providing education for medical students and physicians in training and identifying medical providers who are able and willing to provide transgender-competent care adapted to local culture and gender norms. Conclusion: In this manuscript, we will describe the efforts of various groups to address the needs of the transgender community in the region.

Early Marriage and Barriers to Contraception among Syrian Refugee Women in Lebanon: A Qualitative Study

The Syrian conflict has displaced five million individuals outside their country with Lebanon hosting the largest numbers per capita. Around 24% of Syrian refugees fleeing to Lebanon are women of reproductive age (15–49). Yet, a better understanding of the sexual and reproductive health needs of Syrian refugee women in Lebanon is required to improve provided services. Eleven focus group discussions were conducted in four regions of Lebanon with 108 Syrian refugee women of reproductive age. Thematic analysis was used to examine the data. Interviewed women were mainly adults. They believed that, in Lebanon, they were subjected to early marriage compared to the norm in Syria due to their financial situation and uncertainty. Cost was reported as the main barrier to use contraception in Lebanon but some Syrian refugee women were not aware of free services covering sexual and reproductive health. In general, marriage, pregnancy, and family planning behavior of Syrian refugee women in Lebanon slightly differed from those in Syria pre-conflict in terms of age of marriage, conception subsequent to marriage, and contraception method. Hence, interventions to increase awareness of subsidized sexual and reproductive health services, including free contraceptives at primary health care centers, and those targeting protection from early marriage of Syrian refugee women in Lebanon are strongly recommended.

Prevalence and Barriers to Lung Cancer Screening in Karachi, Pakistan: A Cross-Sectional Survey of Smokers and Physicians

Background

Early detection of lung cancer using low-dose computed tomography (LDCT) can potentially reduce morbidity and mortality. However, LDCT for lung cancer screening, especially in low income countries, has been underutilized. The objective of this study was to evaluate the prevalence and the potential personal, social, and economic barriers of lung cancer screening using LDCT.

Methods

A total sample of 156 smokers and 200 general physicians was collected during December 2016-February 2017 from community settings in Karachi, Pakistan. Two separate questionnaires were constructed to characterize participants’ knowledge, attitudes, and practices regarding lung cancer screening. Screening-eligible smokers and physicians were asked to identify patient barriers to screening and were asked their opinion regarding most effective approach for increasing awareness of screening guidelines.

Results

The majority of smokers' (n=91, 58.3%) and physicians' (n=131, 65.7%) beliefs about the US Preventive Services Task Force (USPSTF) eligibility criteria were inconsistent with the actual recommendations. Major barriers to screening included financial cost, lack of patient counseling and health anxiety related to screening. Over two-thirds (n=105, 67.3%) of smokers were receptive to further information about LDCT screening, and half (n=78, 50.0%) favored one-on-one counseling by their physician, compared to other media. Only one-third (n=65, 33.3%) of physicians reported use of LDCT screening, although 54.5% (n=108) felt that screening implementation would be very effective in their practice.

Conclusion

LDCT screening is currently an uncommon practice in Pakistan. Financial cost, inadequate doctor-patient communication, and lack of awareness of guidelines among both patients and physicians are the major barriers in the utilization of LDCT screening.

Medical Care in a Free Clinic: A Comprehensive Evaluation of Patient Experience, Incentives, and Barriers to Optimal Medical Care with Consideration of a Facility Fee

Free and charitable clinics are important contributors to the health of the United States population. Recently, funding for these clinics has been declining, and it is, therefore, useful to identify what qualities patients value the most in clinics in an effort to allocate funding wisely. In order to identify targets and incentives for improvement of patients’ health, we performed a comprehensive analysis of patients’ experience at a free clinic by analyzing a patient survey (N=94). The survey also assessed patient opinions of a small facility fee, which could be used to offset the decrease in funds. Interestingly, our patients believed it is appropriate to be charged a facility fee (78%) because it increases involvement in their care (r = 0.69, p < 0.001) and self-respect (r = 0.66, p < 0.001). Incentives to medical care include continuity of care, faith-based care, having a patient medical provider partnership, and charging a facility fee. Barriers include affordable housing, transportation, medication, and accessible information. In order to improve medical care in the uninsured population, our study suggested that we need to: 1) offer continuity of medical care; 2) offer affordable preventive health screenings; 3) support affordable transportation, housing, and medications; and 4) consider including a facility fee.

Barriers to biomedical care and use of traditional medicines for treatment of cervical cancer: an exploratory qualitative study in northern Uganda

Use of traditional medicines for treatment of cancers has increased worldwide. We used a qualitative approach to explore barriers to biomedical care and reasons for use of traditional medicines for the treatment of cervical cancer in Gulu, northern Uganda. We carried out 24 focus group discussions involving men and women aged 18-59 years. We employed content analyses technique in data analysis. Traditional medicines were used mainly due to barriers to biomedical care for cervical cancer. The barriers included health system factors, for example long distances to health facilities and unavailability of medicines; health workers' factors, for example negative attitudes towards patients and demands for bribes; individual patient's factors, for example inability to pay for medical care; and socio-cultural beliefs about superiority of traditional medicines and perceived greater privacy in accessing traditional healers. Barriers to biomedical care and community beliefs in the effectiveness of traditional medicines encourage use of traditional medicines for treatment of cervical cancer but might hinder help-seeking at biomedical facilities. There is need for targeted culturally sensitive awareness campaign to promote effectiveness of modern medicine and to encourage cautious use of traditional medicines in the treatment of cervical cancer.

Identifying barriers to healthcare to reduce health disparity in Zuni Indians using focus group conducted by community health workers

The Zuni Pueblo is home to an economically disadvantaged population, which faces a public health challenge from the interrelated epidemics of obesity, diabetes and kidney disease. Efforts to decrease the impact of these epidemics have been complicated by historical, economic and cultural barriers, which may limit healthcare utilization. The NIH supported Zuni Health Initiative (ZHI) conducted a study to identify barriers to healthcare in the Zuni Pueblo. Community health representatives (CHRs) led 14 one-hour focus group sessions at which a total of 112 people participated posed unique questions that took into account the Zuni culture to elicit information on perceived barriers to healthcare. Audiotapes were translated and transcribed by bilingual ZHI staff. We reduced the text to thematic categories, constructed a coding dictionary and inserted the text into NVivo 9 program. We identified nine themes emerged regarding the barriers experienced in receiving healthcare and adhering to medical advice. These included distance; transportation; embarrassment; relating to healthcare professionals; navigating the medical system; awareness of available resources; waiting times; adhering to medication; and incentives in health promotion. In conclusion the implementation of culturally appropriate community-based health promotion programs and preventive screening techniques will improve access to healthcare and diminish health disparities.

Fear, fatalism and breast cancer screening in low-income African-American women: the role of clinicians and the health care system

BACKGROUND

African-American women have the highest breast cancer death rates of all racial/ethnic groups in the US. Reasons for these disparities are multi-factorial, but include lower mammogram utilization among this population. Cultural attitudes and beliefs, such as fear and fatalism, have not been fully explored as potential barriers to mammography among African-American women.

OBJECTIVE

To explore the reasons for fear associated with breast cancer screening among low-income African-American women.

METHODS

We conducted four focus groups (n = 29) among a sample of African-American women at an urban academic medical center. We used trained race-concordant interviewers with experience discussing preventive health behaviors. Each interview/focus group was audio-taped, transcribed verbatim and imported into Atlas.ti software. Coding was conducted using an iterative process, and each transcription was independently coded by members of the research team.

MAIN RESULTS

Several major themes arose in our exploration of fear and other psychosocial barriers to mammogram utilization, including negative health care experiences, fear of the health care system, denial and repression, psychosocial issues, delays in seeking health care, poor health outcomes and fatalism. We constructed a conceptual model for understanding these themes.

CONCLUSIONS

Fear of breast cancer screening among low-income African-American women is multi-faceted, and reflects shared experiences within the health care system as well as the psychosocial context in which women live. This study identifies a prominent role for clinicians, particularly primary care physicians, and the health care system to address these barriers to mammogram utilization within this population.