The psychological impact of rape victims.

This review article examines rape victims' experiences seeking postassault assistance from the legal, medical, and mental health systems and how those interactions impact their psychological well-being. This literature suggests that although some rape victims have positive, helpful experiences with social system personnel, for many victims, postassault help seeking becomes a "second rape," a secondary victimization to the initial trauma. Most reported rapes are not prosecuted, victims treated in hospital emergency departments do not receive comprehensive medical care, and many victims do not have access to quality mental health services. In response to growing concerns about the community response to rape, new interventions and programs have emerged that seek to improve services and prevent secondary victimization. The contributions of rape crisis centers, restorative justice programs, and sexual assault nurse examiner programs are examined. Strategies for creating more visible and impactful roles for psychologists and allied professionals are also discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Integrating health care: The clear advantage for underserved diverse populations.

Integrating health care into primary and specialty physician practices and clinics has potential benefits for women; racial/ethnic minorities; and lesbian, gay, bisexual, transgendered populations, thus making a major contribution to the health disparities in America. Mounting evidence suggests that physical illnesses are accompanied and exacerbated by emotional, social, and cultural factors. Many of the chronic diseases, cardiovascular disease, HIV-AIDS, diabetes, and some cancers can be prevented and altered by behavioral changes and are thus considered behavioral diseases. In addition, nonadherence to medication is a significant factor in less-than-optimal treatment of any illness. Thus, medical treatment without coordinated attempts to also treat the behavioral and social factors compromises its effectiveness. Treatment is often complicated by the lack of timely diagnoses of issues such as domestic violence, substance abuse, and eating disorders. Furthermore, helping patients negotiate medical visits, treatment options, and disease prevention and management can be effectively addressed within an integrated primary care system of health delivery with better outcomes for minorities. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Why are sicker patients less satisfied with their medical care? Tests of two explanatory models.

Two explanations were tested for why patients who are less healthy tend to be less satisfied with their medical care than healthier patients. The explanations were (a) that poor health produces dissatisfaction directly and (b) that poor health produces dissatisfaction through the mediating effect of physicians' behavior. Two studies are presented that measured patients' health status, patients' satisfaction with care, and their physicians' communication as reported on audiotape. In Study 1, 114 patients had first visits with rheumatologists; in Study 2, 649 patients had continuing-care visits with physicians in internal and family medicine. Causal modeling revealed that the first study supported the direct explanation. The second study also supported the direct explanation, as well as the mediation explanation with respect to the physician's use of social conversation. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

How psychology can improve effectiveness and reduce costs of health services.

Contends that psychology can be used to prevent heart disease, cancer, accidents and violence, and respiratory disease through programs such as those designed to eliminate smoking, control obesity, reduce stress, and intervene when multiple risk factors are present. Psychological techniques—as useful and cost-saving companions to traditional medical treatments—can increase checkup visits and participation in health screening, improve adherence to medication schedules, aid recovery from surgery, and facilitate outpatient medical service delivery. Since 40–60% of physician visits are for nonmedical reasons that are psychological and behavioral in nature, psychologists can reduce medical care overutilization and unnecessary medical expenditures by offering less costly and more appropriate alternatives. Psychological interventions for health disorders include treatment for pain, asthma attacks not responsive to medical treatment, heart rate variability, gastrointestinal problems, skin disorders, and self-destructive behaviors. It is concluded that psychological procedures offer a means of reducing health care expenditures reliably. (4 p ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The homeless and the health system: profile of the homeless patient

The homeless population is mobile and does not use ambulatory health care services. Thus the major contact between the homeless and the medical establishment occurs primarily when they are treated for acute symptoms in hospital. We describe the clinical and sociodemographic profile of the homeless who require hospital services. The research population included 50 homeless treated in the emergency room and various departments of our medical center between October 1994 and August 1995. Social workers used a questionnaire relating to clinical, sociodemographic and social factors. Most patients were men, 76% under the age of 50. The most common diagnosis was alcoholism; other diagnoses included back, limb and joint injuries, infections, skin diseases, and general exhaustion. There were subgroups with differing needs within this homeless population for which appropriate rehabilitation programs are proposed.     

Mental disorders and access to medical care in the United States

OBJECTIVE: The authors examined the barriers to receipt of medical services among people reporting mental disorders in a representative sample of U.S. adults. METHOD: The sample was drawn from adults who responded to the 1994 National Health Interview Survey (N=77,183). The authors studied the association between report of a mental disorder and 1) access to health insurance and a primary provider, and 2) actual receipt of medical care. Multivariate techniques were used to model problems with access as a function of mental disorders, controlling for demographic, insurance, and health variables. RESULTS: While people who reported mental disorders showed no difference from those without mental disorders in likelihood of being uninsured or of having a primary care provider, they were twice as likely to report having been denied insurance because of a preexisting condition or having stayed in their job for fear of losing their health benefits. Among respondents with insurance, those who reported mental illness were no less likely to have a primary care provider but were about two times more likely to report having delayed seeking needed medical care because of cost or having been unable to obtain needed medical care. CONCLUSIONS: People who reported mental disorders experienced significant barriers to receipt of medical care. Efforts to measure and improve access to health care for this population may need to go beyond simply providing insurance benefits or access to general medical providers.     

The impact of PTSD, depression, and substance use disorders on disease burden and health care utilization among OEF/OIF veterans.

Growing evidence suggests that posttraumatic stress disorder (PTSD) is associated with poorer health status (e.g., more medical disease, physical symptoms, and sick visits to health care professionals) among veterans who served in Operation Enduring Freedom (OEF) in Afghanistan and Operation Iraqi Freedom (OIF) in Iraq. We investigated whether PTSD, depression, and substance use disorders independently predicted health status over time among OEF/OIF veterans. Information regarding psychiatric and medical conditions and health care utilization was culled for 4,463 OEF/OIF veterans enrolled in Veterans Administration primary care for a period of 6 years. Data were analyzed using multilevel modeling and generalized estimating equations. Results suggest that PTSD, depression, and substance use disorders are independently associated with increased medical disease burden and mental health care utilization but not increased medical health care utilization. The association between PTSD and medical disease burden strengthened over time. These data suggest that OEF/OIF veterans with PTSD may be at risk for increasingly poorer physical health in terms of medical disease burden over time. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Ambulatory health care use by patients in a public hospital emergency department

OBJECTIVE: To describe primary care clinic use and emergency department (ED) use for a cohort of public hospital patients seen in the ED, identify predictors of frequent ED use, and ascertain the clinical diagnoses of those with high rates of ED use. DESIGN: Cohort observational study. SETTING: A public hospital in Atlanta, Georgia. PATIENTS: Random sample of 351 adults initially surveyed in the ED in May 1992 and followed for 2 years. MEASUREMENTS AND MAIN RESULTS: Of the 351 patients from the initial survey, 319 (91%) had at least one ambulatory visit in the public hospital system during the following 2 years and one third of the cohort was hospitalized. The median number of subsequent ED visits was 2 (mean 6.4), while the median number of visits to a primary care appointment clinic was O (mean 1.1) with only 90 (26%) of the patients having any primary care clinic visits. The 58 patients (16.6%) who had more than 10 subsequent ED visits accounted for 65.6% of all subsequent ED visits. Overall, patients received 55% of their subsequent ambulatory care in the ED, with only 7.5% in a primary care clinic. In multivariate regression, only access to a telephone (odds ratio [OR] 0.48; 95% confidence interval [CI] 0.39, 0.60), hospital admission (OR 5.90; 95% CI 4.01, 8.76), and primary care visits (OR 1.68; 95% CI 1.34, 2.12) were associated with higher ED visit rates. Regular source of care, insurance coverage, and health status were not associated with ED use. From clinical record review, 74.1% of those with high rates of use had multiple chronic medical conditions, or a chronic medical condition complicated by a psychiatric diagnosis, or substance abuse. CONCLUSIONS: All subgroups of patients in this study relied heavily on the ED for ambulatory care, and high ED use was positively correlated with appointment clinic visits and inpatient hospitalization rates, suggesting that high resource utilization was related to a higher burden of illness among those patients. The prevalence of chronic medical conditions and substance abuse among these most frequent emergency department users points to a need for comprehensive primary care. Multidisciplinary case management strategies to identify frequent ED users and facilitate their use of alternative care sites will be particularly important as managed care strategies are applied to indigent populations who have traditionally received care in public hospital EDs.     

Impact of a children's health insurance program on newly enrolled children

CONTEXT: Although there is considerable interest in decreasing the number of US children who do not have health insurance, there is little information on the effect that health insurance has on children and their families. OBJECTIVE: To determine the impact of children's health insurance programs on access to health care and on other aspects of the lives of the children and their families. DESIGN: A before-after design with a control group. The families of newly enrolled children were interviewed by telephone using an identical survey instrument at baseline, at 6 months, and at 12 months after enrollment into the program. A second group of families of newly enrolled children were interviewed 12 months after the initial interviews to form a comparison sample. SETTING: The 29 counties of western Pennsylvania, an area with a population of 4.1 million people. SUBJECTS: A total of 887 families of newly enrolled children were randomly selected to be interviewed; 88.3% agreed to participate. Of these, 659 (84%) responded to all 3 interviews. The study population consists of 1031 newly enrolled children. The children were further classified into those who were continuously enrolled in the programs. The 330 comparison families had 460 newly enrolled children. MAIN OUTCOME MEASURES: The following access measures were examined: whether the child had a usual source of medical or dental care; the number of physician visits, emergency department visits, and dentist visits; and whether the child had experienced unmet need, delayed care, or both for 6 types of care. Other indicators were restrictions on the child's usual activities and the impact of being insured or uninsured on the families. RESULTS: Access to health care services after enrollment in the program improved: at 12 months after enrollment, 99% of the children had a regular source of medical care, and 85% had a regular dentist, up from 89% and 60%, respectively, at baseline. The proportion of children reporting any unmet need or delayed care in the past 6 months decreased from 57% at baseline to 16% at 12 months. The proportion of children seeing a physician increased from 59% to 64%, while the proportion visiting an emergency department decreased from 22% to 17%. Since the comparison children were similar to the newly enrolled children at enrollment into the insurance programs, these findings can be attributed to the program. Restrictions on childhood activities because of lack of health insurance were eliminated. Parents reported that having health insurance reduced the amount of family stress, enabled children to get the care they needed, and eased family burdens. CONCLUSIONS: Extending health insurance to uninsured children had a major positive impact on children and their families. In western Pennsylvania, health insurance did not lead to excessive utilization but to more appropriate utilization.     

Psychiatric care and health insurance reform

Concerns about cost, access, and quality of health care in the United States have led to a variety of legislative proposals that would reform our health care system and its financing. Health insurance benefits for mental illness, including substance abuse, are treated differently from medical/surgical benefits, with stricter limits on outpatient visits and hospital days. Medicare, Medicaid, and most private health insurance plans contain this historic disparity of coverage for mental illness compared to general medical illness. Psychiatric services are also distinguishable because of the large public sector reimbursement for mental illness treatment and support. Principles for a more equitable design of mental health benefits include a non-discriminatory approach; payment on the basis of service rather than diagnosis; application of cost containment for care of mental illness on the same basis as care of general medical illness; retention of the public sector as a backup system for high-cost, long-term care; encouragement of lower-cost alternatives to the hospital through the development of a continuum of care; and a recognition of the distinction between psychotherapy and medical management. All current approaches to universal health care fall short of these principles. A research agenda is needed now more than ever in order to articulate the case for complete coverage of mental illness and substance abuse.     

A comprehensive program for mental health and behavioral medicine in a large children's hospital.

Primary health care services are differentiated from secondary or tertiary levels of care. Problems of illness-related psychopathology, sometimes called psychosomatic or behavioral medicine, are differentiated from traditional forms of emotional disturbances such as neurosis, psychosis, and personality disorders. It is shown how primary mental health care and behavioral medicine combine to form a special branch of child psychology known as pediatric, medical, or health care psychology. A program for work of this type in a large children's hospital is outlined. (12 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Social support, life stress, and subsequent medical care utilization.

246 men and 191 women (aged 40–72 yrs) were monitored for medical care utilization in a health maintenance organization (HMO) over a 5-yr period. Rates of utilization were related to initially obtained indicators of life stress and social support and to interactions between life stress, social support, and age. Predictors of male and female HMO use are discussed. Multiple regression permitted a distinction between immediate and delayed effects of stresses on HMO visits. Implications regarding the buffering hypothesis for the mitigating effects of social support on the likelihood of health breakdown are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The effects of rotation on spatial attention

OBJECTIVE: To clarify whether out-of-hours health centre visits and referrals to hospital are equally distributed in the three different duty models being used for health care in southwestern Finland. DESIGN: A medical audit of 2926 health centre visits and 223 referrals to hospitals by general practitioners (GPs) on duty. The duty models were formed on the basis of a possibility to utilize a local health centre during nights and weekends. Two-month follow-up period. SETTING: Primary health care. Population 46438. MAIN OUTCOME MEASURES: Out-of-hours visits to health centres and referrals to hospital, and the effect of age and duty model on referrals and visits. RESULTS: Patients over 64 years of age received most of the referrals although they visited the health care centre less frequently than the 0-14 year-olds (p < 0.001). The people who had an opportunity to utilize their local health centres visited more during out-of-hours than those who did not have this opportunity (p < 0.001). CONCLUSIONS: The health centre visits were not equally distributed in the three examined duty models. The over 64 year-olds in particular had the least visits and the most referrals.     

The consequences of universalizing health services: children's use of health services in Catalonia

The purpose of this study was to assess the role of needs and social factors in the use of health services among children under age 15 in Catalonia, Spain, where health care reform was explicitly designed to facilitate universal access to primary care according to health needs. Data from the Catalan Health Interview Survey of 1994, a multistage probability sample (2,433 children under 15 years old), were analyzed. Multiple regression examined the relationship between health needs and number of visits in the last year, controlling for the effect of sociodemographic characteristics. Two logistic regression equations were selected to predict heavy (more than seven visits per year) and light (less than two visits) utilization of services. The multiple regression model explained 14.3 percent of the variance in number of visits, with health status perception, disability, reported chronic condition, restriction of activities, and having had a recent accident by far the most important determinants. No familial socioeconomic characteristics, including social class, education, or family size, influenced the extent of use. In contrast to health systems not designed to achieve either universal access according to need or strong primary care, universal access to health services in Catalonia appears to enhance the use of services among children with health needs, regardless of socioeconomic characteristics.     

Do research interviews cause distress or interfere in management? Experience from a study of cancer patients

Professional organizations advocate universal access to medical care as a primary approach to improving health in the population. Access to medical services is critical to outcomes of acute processes managed in an inpatient hospital, the setting of most medical education, research, and training, but seems to be limited in its capacity to affect outcomes of outpatient care, the setting of most medical activities. Persistent and widening disparities in health according to socioeconomic status provide evidence of limitations of access to care. First, job classification, a measure of socioeconomic status, was a better predictor of cardiovascular death than cholesterol level, blood pressure, and smoking combined in employed London civil servants with universal access to the National Health Service. Second, disparities in health according to socioeconomic status widened between 1970 and 1980 in the United Kingdom despite universal access (similar trends were seen in the United States). Third, in the United States, noncompletion of high school is a greater risk factor than biological factors for development of many diseases, an association that is explained only in part by age, ethnicity, sex, or smoking status. Fourth, level of formal education predicted cardiovascular mortality better than random assignment to active drug or placebo over 3 years in a clinical trial that provides optimal access to care. Increased recognition of limitations of universal access by physicians and their professional societies may enhance efforts to improve the health of the population.     

Mixed anxiety and depression.

Reviews evidence from community, primary care, and psychiatric samples to determine whether there is a group of patients who have mixed symptoms of anxiety and depression that are below diagnostic thresholds for either group of disorders. A review of the data strongly suggests that such a group of patients exists and that, despite lacking sufficient symptoms to meet diagnostic thresholds from the revised 3rd edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III—R; American Psychiatric Association, 1987), they often have significant impairment in social and vocational functioning. Because many of these patients also suffer from medically unexplained somatic symptoms, they may be more likely to frequently use nonpsychiatric medical care. Longitudinal studies suggest that persons with mixed anxiety-depression symptoms may represent a population who are at increased risk for more severe mood and anxiety disorders. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Lipid disorders in NIDDM: implications for treatment

BACKGROUND: In France health insurance coverage is universal (see note at the end of the text), nevertheless some people remain uninsured. In this high-risk population, the lack of insurance coverage contributes to the aggravation of health, by reducing access to medical care. In 1992, the Baudelaire consultation was incorporated into the outpatient clinic of Saint-Antoine hospital (Paris, France), to provide the uninsured with the same access as any other patient--but free of charge--to medical care. Social care was also provided in particular by assisting the uninsured in applying for insurance coverage. Our objectives were to quantify the delay in obtaining insurance coverage and to study whether the sociodemographic characteristics of these patients were associated with inequalities in terms of delays. METHODS: All patients attending the consultation for the first time in 1994 were included (n = 623). Because of differences linked to the French social security system, analysis was performed into two groups according to the existence of a prior insurance coverage. Delay in obtaining or recovering insurance coverage was considered as the key variable. The socio-demographic factors linked to the rates of access to insurance coverage were determined using Cox proportional hazards regression models. We also examined the factors linked with the existence of a prior insurance coverage by logistic regression modeling. RESULTS: Within one year 96% of the patients who had had insurance coverage in the past, and 63% of the patients who had not, were insured. No factor, whether nationality, educational level, socio-professional category, family situation, type of housing, made of income was found to be linked with obtaining or recovering insurance coverage. However, nearly all these factors were related with the existence of prior insurance coverage. CONCLUSIONS: Our approach of systematically providing social care allows 70% of uninsured patients to obtain insurance coverage within one year. This approach probably contributes to an improvement by facilitating access to mainstream health care. Moreover, no difference in delay in obtaining insurance coverage was found associated with sociodemographic characteristics.     

Health care access of young people not attending school in precarious situations

The legislations of July 1992 and January 1993 and the decree of 27th March 1993 offer the possibility for medical care to all, including many young people who do not have any rights when they need urgent medical attention. This study covers the proposals of professionals from the Languedoc and Roussillon regions who are responsible for the social and professional insertion of young people and their rights of access to medical care. These professionals serve both as the principal means of access to medical aid for young people and as the main obstacles to this aid which occurs as a result of the interaction between professional occupational practice and the behaviour of the young people concerned. From this study the following conclusions were drawn: this legislation excludes alien young people in an illegal situation; the potential availability of these rights is limited by arbitrary decision in administration; the period of coverage of these rights is long and complex; the financial obstacle is real for all young people who do not have free access to medical aid; the obstacles resulting from social interactions are frequent; there are many holes in the institutional network.     

A military application of a medical self-care program

The cost of health care is a growing concern to the military. Many military clinic appointments and emergency department visits are unnecessary; they are for minor, self-limiting illnesses and injuries that could be treated at home. Military health care can no longer afford the luxury of treating minor illnesses and injuries in the hospital setting. This paper examines one method for military beneficiaries to obtain health care services appropriately. A selected group of military family members received a medical self-care book and an education session, which resulted in more appropriate decision-making about when to use the health care system. This was a 6-month, experimental study using control and experimental groups, with surveys before and after the study period. The self-care book was used 628 times to help make more informed decisions about when to seek medical care. The mean number of clinic and emergency room visits (p = 0.02) decreased for those using the medical self-care book.     

Community mental health services for the Spanish-speaking/surnamed population.

Discusses reasons why the Spanish-speaking/surnamed population receives mental health care of a different kind, of a lower quality, and in lesser proportions than any other ethnically identifiable population. This underutilization cannot be explained because of the substitution of either folk medicine or faith healing. Race and social class of the therapist seem to affect the patient's response to treatment, and middle-class values are often misapplied to lower-class patients. 3 models for improved services to this population are described: a professional adaptation model, a family adaptation model, and a barrio service center model. (39 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)