This document describes a study that examined how unmet basic needs cluster in low-income populations and how the effectiveness of health interventions may vary based on levels of unmet basic needs. The study analyzed data from a randomized controlled trial where low-income callers to a 211 helpline received cancer screening referrals along with one of three interventions: verbal referral only, verbal referral plus a printed reminder, or verbal referral plus navigation from a health coach. Latent class analysis identified three classes of unmet basic needs among participants. Logistic regression found that for those with relatively more or money-specific unmet needs, the navigator intervention was more effective at linking them to health referrals, while the printed reminder worked as well as the navigator for those
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External validation of an electronic phenotyping algorithm to detect attentio...TÀI LIỆU NGÀNH MAY
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Barriers to Access Quality Healthcare Services among Physically Challenged Pe...Premier Publishers
Despite the increase in the number of health services provided and Kenya’s commitment to equal access to quality healthcare for all by the year 2030, the physically challenged persons still find difficulty in accessing health services for reasons attributable to health care related factors. This study targeted the physically challenged persons in Gem Sub-county, Kenya. Stratified and systematic random sampling was used to select 108 people with physical disability. Data was collected using semi-structured questionnaire and analyzed using SPSS, version 23. Descriptive data were summarized in tables and charts while x2 test was used to detect the relationship between relevant variables (α= 0.05). This study confirmed that environmental accessibility of the hospitals, their location and infrastructure leading to the hospitals greatly influence ability of people with physical disabilities to access quality healthcare(p<0.05). All the healthcare facilities were not adequately equipped to handle people with disabilities. The healthcare system-related factors had influence negatively on access of quality care to the physically handicapped persons in Gem sub County.
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Barriers to Access Quality Healthcare Services among Physically Challenged Pe...Premier Publishers
Despite the increase in the number of health services provided and Kenya’s commitment to equal access to quality healthcare for all by the year 2030, the physically challenged persons still find difficulty in accessing health services for reasons attributable to health care related factors. This study targeted the physically challenged persons in Gem Sub-county, Kenya. Stratified and systematic random sampling was used to select 108 people with physical disability. Data was collected using semi-structured questionnaire and analyzed using SPSS, version 23. Descriptive data were summarized in tables and charts while x2 test was used to detect the relationship between relevant variables (α= 0.05). This study confirmed that environmental accessibility of the hospitals, their location and infrastructure leading to the hospitals greatly influence ability of people with physical disabilities to access quality healthcare(p<0.05). All the healthcare facilities were not adequately equipped to handle people with disabilities. The healthcare system-related factors had influence negatively on access of quality care to the physically handicapped persons in Gem sub County.
Exploring the role of racial associations within life and psychiatry the diss...TÀI LIỆU NGÀNH MAY
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Mark Strand, PhD, CPH, Professor, North Dakota State University discusses how the nonprofit Evergreen has worked in close partnership with the Shanxi Province Health Bureau in China since 1994, focusing on training and health system strengthening at the CCIH 2018 conference.
The Knowledge of and Attitude to and Beliefs about Causes and Treatments of M...Premier Publishers
Stigma and discrimination associated with mental illness are a common occurrence in the Sub-Saharan region including Eritrea. Numerous studies from Sub-Saharan Africa suggest that stigma and discrimination are major problems in the community, with negative attitudes and behavior towards people with mental illness being widespread. In order to assess the whether such negative attitudes persist in the context of Eritrea this study explored the knowledge and perceptions of 90 Eritrean university students at the College of Business and Economics, the University of Asmara regarding the causes and remedies of mental illness A qualitative method involving coded self-administered questionnaires administered to a sample of 90 university students to collecting data at the end of 2019. The survey evidence points that almost 50% of the respondents had contact with a mentally ill person suggesting that the significant number of the respondents experienced a first-hand encounter and knowledge of mental illness in their family and community. The findings show an overall greater science-based understanding of the causes of mental illness to be followed by recommended psychiatric treatments. The survey evidence indicates that the top three leading causes of mental illness in the context of Eritrea according to the respondents are brain disease (76%), bad events in the life of the mentally ill person (66%) and substance abuse or alcohol taking, smoking, taking drugs like hashish. (54%). The majority of the respondents have a very sympathetic and positive outlook towards mentally ill persons suggesting that mentally illness does not simply affect a chosen individual rather it can happen to anybody regardless of economic class, social status, ethnicity race and religion. Medical interventions cited by the majority of the respondents as being effective treatments for mental illness centered on the idea that hospitals and clinics for treatment and even cures for psychiatric disease. Changing perceptions of mental illnesses in Eritrea that paralleled the very caring and sympathetic attitudes of the sample university students would require raising public awareness regarding mental illness through education, using the mass media to raise public awareness, integrating mental health into the primary health care system, decentralizing mental health care services to increase access to treatment and providing affordable service to maintain positive treatment outcomes.
The prevalence, patterns of usage and people's attitude towards complementary...home
The prevalence of CAM in Chatsworth is similar to findings in other parts of the
world. Although CAM was used to treat many different ailments, this practice could not be
attributed to any particular demographic profile. The majority of CAM users were satisfied with
the effects of CAM. Findings support a need for greater integration of allopathic medicine and
CAM, as well as improved communication between patients and caregivers regarding CAM usage.
Exploring the role of racial associations within life and psychiatry the diss...TÀI LIỆU NGÀNH MAY
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Mark Strand, PhD, CPH, Professor, North Dakota State University discusses how the nonprofit Evergreen has worked in close partnership with the Shanxi Province Health Bureau in China since 1994, focusing on training and health system strengthening at the CCIH 2018 conference.
The Knowledge of and Attitude to and Beliefs about Causes and Treatments of M...Premier Publishers
Stigma and discrimination associated with mental illness are a common occurrence in the Sub-Saharan region including Eritrea. Numerous studies from Sub-Saharan Africa suggest that stigma and discrimination are major problems in the community, with negative attitudes and behavior towards people with mental illness being widespread. In order to assess the whether such negative attitudes persist in the context of Eritrea this study explored the knowledge and perceptions of 90 Eritrean university students at the College of Business and Economics, the University of Asmara regarding the causes and remedies of mental illness A qualitative method involving coded self-administered questionnaires administered to a sample of 90 university students to collecting data at the end of 2019. The survey evidence points that almost 50% of the respondents had contact with a mentally ill person suggesting that the significant number of the respondents experienced a first-hand encounter and knowledge of mental illness in their family and community. The findings show an overall greater science-based understanding of the causes of mental illness to be followed by recommended psychiatric treatments. The survey evidence indicates that the top three leading causes of mental illness in the context of Eritrea according to the respondents are brain disease (76%), bad events in the life of the mentally ill person (66%) and substance abuse or alcohol taking, smoking, taking drugs like hashish. (54%). The majority of the respondents have a very sympathetic and positive outlook towards mentally ill persons suggesting that mentally illness does not simply affect a chosen individual rather it can happen to anybody regardless of economic class, social status, ethnicity race and religion. Medical interventions cited by the majority of the respondents as being effective treatments for mental illness centered on the idea that hospitals and clinics for treatment and even cures for psychiatric disease. Changing perceptions of mental illnesses in Eritrea that paralleled the very caring and sympathetic attitudes of the sample university students would require raising public awareness regarding mental illness through education, using the mass media to raise public awareness, integrating mental health into the primary health care system, decentralizing mental health care services to increase access to treatment and providing affordable service to maintain positive treatment outcomes.
The prevalence, patterns of usage and people's attitude towards complementary...home
The prevalence of CAM in Chatsworth is similar to findings in other parts of the
world. Although CAM was used to treat many different ailments, this practice could not be
attributed to any particular demographic profile. The majority of CAM users were satisfied with
the effects of CAM. Findings support a need for greater integration of allopathic medicine and
CAM, as well as improved communication between patients and caregivers regarding CAM usage.
Running head UNION COUNTY, GEORGIA .docxtoltonkendal
Running head: UNION COUNTY, GEORGIA 1
UNION COUNTY, GEORGIA 2
Union County, Georgia
Kimberly Crawford
January 30, 2017
Kaplan University
The following paper will answer the asked questions.
Name of County and State
Union County, Georgia.
County population with racial and gender breakdowns
As of July 1, 2015 estimates, the County population was 22, 267 individuals. Of this, 51.7% were Females, while as the males were 48.3%. The white people were 96.5%, the African Americans were 1.0%, the American Indian and Alaska Natives were 0.5%, Asians were 0.7%, Hispanics were 3.2%, and people with two or more races present accounted for 1.3%.
Number of Senior Citizens
The number of senior citizens was 32.5%.
Number of Disabled Individuals
The number of disabled individuals under the age of 65 was 13.9%.
Number of Children
The number of children was 16.1%.
Of the populations above, I choose the senior citizens. The first health concern for this population is elder abuse. At this age, this people are not able to actively take care of themselves like they would a while back. For this reason, they constantly required to be taken care of, in almost all the aspects of their lives. However, elder abuse is a common occurrence in which, the caregivers neglect this population so much, to the extent of some of them even dying. It is such a shame that such a thing might happen to such a delicate population. A second health concern for this population, is the risk of heath disease and other chronic diseases. According to the Centre for Disease Control (CDC), heart disease is one of the leading killers for the senior citizens because at this age, they are delicate and their hearts are very weak (Motooka et al., 2006).
The senior citizens require a number of community health interventions and public policies, which are aimed at ensuring they lead a comfortable life. For instance, they should have access to caregivers when they cannot adequately take care of themselves (Takano, 2002). In addition, they should have access to proper diets, and they should be provided with as much assistance as possible when they are at home and in public places. They should also have regular medical check-ups, to ascertain their health conditions, as well as have access to a hospital and a personal doctor in case they need consultation before their regular sessions (Anderson, 2003). Regular exercises is also good for ensuring their lives are going on smoothly.
Health Risk Assessment
In the health risk assessment tests, I took the eating behaviour test. The questions asked basically were about the kind of foods and drinks that I take on a daily basis, how often I take the meals per day, the rate and posture at which I take the meals, my favourite comfort food, and the circumstances under which I take th ...
Effects of Community-Based Health WorkerInterventions to Imp.docxSALU18
Effects of Community-Based Health Worker
Interventions to Improve Chronic Disease
Management and Care Among Vulnerable
Populations: A Systematic Review
Kyounghae Kim, RN, MSN, Janet S. Choi, MPH, Eunsuk Choi, RN, PhD, MPH, Carrie L. Nieman, MD, MPH, Jin Hui Joo, MD, MA,
Frank R. Lin, MD, PhD, Laura N. Gitlin, PhD, and Hae-Ra Han, RN, PhD
Background. Community-based health workers (CBHWs) are frontline
public health workers who are trusted members of the community they
serve. Recently, considerable attention has been drawn to CBHWs in pro-
moting healthy behaviors and health outcomes among vulnerable pop-
ulations who often face health inequities.
Objectives. We performed a systematic review to synthesize evidence
concerning the types of CBHW interventions, the qualification and
characteristics of CBHWs, and patient outcomes and cost-effectiveness
of such interventions in vulnerable populations with chronic, non-
communicable conditions.
Search methods. We undertook 4 electronic database searches—PubMed,
EMBASE, Cumulative Index to Nursing and Allied Health Literature, and
Cochrane—and hand searched reference collections to identify randomized
controlled trials published in English before August 2014.
Selection. We screened a total of 934 unique citations initially for titles
and abstracts. Two reviewers then independently evaluated 166 full-
text articles that were passed onto review processes. Sixty-one studies
and 6 companion articles (e.g., cost-effectiveness analysis) met eligi-
bility criteria for inclusion.
Data collection and analysis. Four trained research assistants extracted
data by using a standardized data extraction form developed by the
authors. Subsequently, an independent research assistant reviewed
extracted data to check accuracy. Discrepancies were resolved through
discussions among the study team members. Each study was evaluated
for its quality by 2 research assistants who extracted relevant study
information. Interrater agreement rates ranged from 61% to 91% (av-
erage 86%). Any discrepancies in terms of quality rating were resolved
through team discussions.
Main results. All but 4 studies were conducted in the United States.
The 2 most common areas for CBHW interventions were cancer pre-
vention (n = 30) and cardiovascular disease risk reduction (n = 26). The
roles assumed by CBHWs included health education (n = 48), counseling
(n = 36), navigation assistance (n = 21), case management (n = 4), social
services (n = 7), and social support (n = 18). Fifty-three studies provided
information regarding CBHW training, yet CBHW competency evalua-
tion (n = 9) and supervision procedures (n = 24) were largely under-
reported. The length and duration of CBHW training ranged from 4
hours to 240 hours with an average of 41.3 hours (median: 16.5 hours) in
24 studies that reported length of training. Eight studies reported the
frequency of supervision, which ranged from weekly to monthly. There ...
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Running head APPLICATIONS OF THE PRECEDE-PROCEED MODEL 1.docxSUBHI7
Running head: APPLICATIONS OF THE PRECEDE-PROCEED MODEL 1
APPLICATIONS OF THE PRECEDE-PROCEED MODEL 4
Applications of the PRECEDE-PROCEED Model
Joseph Toole
Health Promotion and Disease Prevention
3 Jan 2016
Unprotected sexual intercourse among teens is one of the major negative health behaviors in the current society. The sexual intercourse among teens has predisposed teenagers to sexually transmitted diseases and early pregnancy. The rate of intercourse among the teenagers has been on the rise and this raises eyebrows on the intervention strategies that need to be adopted in reducing the behavior among the teenagers. The major reason why the health behavior has been on the increase is due to influence by the media and lack of information among the teenagers. It is therefore important to address the problem before it becomes a major disaster in the society.
The behavior of intercourse is problematic to the society. One of the factors that make it problematic is how the teenagers are predisposed to sexually transmitted diseases. Most of the teenagers are not informed on the health dangers of their behaviors and end up risking their lives. Some of the sexually transmitted diseases are very dangerous and could lead to death such as HIV/AIDs, which means that if the health behavior is not taken care of, then more teenagers are expected to die. It is therefore important that the behavior is paid the attention that it deserves before the mortality rate resulting from the behavior increases (Li, 2009).
There are a number of predisposing, reinforcing, and enabling factors that influence unprotected sexual intercourse among the teenagers. One of these factors is the media. The media has played a major role in influencing sexual intercourse among teenagers. Nowadays, the media brings programs that even show the people having sexual intercourse. Since teenagers always want to experiment what they see, they will want to try it out, leading to unprotected sexual intercourse. With the introduction of internet and smart phones, teenagers nowadays can watch anything and since it is difficult to filter the content from the internet, it becomes impossible to control what the teenagers are watching. The other PRE factor considered to increase the prevalence of unprotected sexual intercourse among the teenagers is lack of information about sex by the teenagers. Even though many teenagers are exposed to the internet and other sources of information, they do not have information on how to practice safe sex. The parents are also shying away from educating their children, an aspect that makes the teenagers oblivious of the dangers involved in practicing unprotected sex. Most of the teenagers practice unsafe sex since they do not know the health dangers involved. Some of them think that pregnancy is the only thing that should be avoided during sex not knowing that there are other many health dangers that can be avoided by having safe sex ...
Module 4 DiscussionPopulation and community health are extremely.docxaudeleypearl
Module 4 Discussion
Population and community health are extremely important for the well being of our population. Healthcare providers play important roles in improving population health and are also the health educators for their community. Population health is the outcomes of a group of individuals, including the distribution of such outcomes within the group. Community health is a branch of public health which focuses on people and their role as determinants of their own and other people’s health in contrast to environmental health, which focuses on the physical environment and its impact on people’s health. All healthcare professionals can take many actions to promote population and community health. There are many ideas about actions that need to be taken to improve the health among the population in Miami and the communities within the city.
I went to Broward College for my BSN and the last class we had to take before graduate from the program was community health. The purpose of this class was to integrate us as healthcare provider in the community which allowed us to help the less fortunate people or the vulnerable population. A group of us chose to complete the class with the homeless population in Broward county. We went to the homeless shelters to provide primary care to the homeless individuals by taking their blood pressure, blood sugar, and so on. We literally had an open clinic at each of the homeless shelters. We had doctors and nurse practitioners that volunteer to provide care to them. It is extremely important for healthcare professionals to promote community health to the homeless population because it can help decrease illnesses and many diseases among them.
According to Tsai, Jenkins, & Lawton (2017), individuals who are homeless represent the most vulnerable, indigent group in the United States and thus may have great medical needs that must be addressed to prevent sicknesses and illness. A few studies have shown access to healthcare can improve the health and lives of various patient populations (Tsai et al, 2017). Lack of access to healthcare or lack of health insurance is one of the major issues in the United States. The homeless population is among the vulnerable populations that suffer more due to their lack of healthcare coverage. By volunteering to help, healthcare providers can improve their quality of life. These individuals are not able to purchase or pay for the most basic health insurance and will not be able to get any treatment without us (healthcare providers) volunteering to help at their shelters.
According to Bernstein, Meurer, Plumb, & Jackson (2015), reported rates of diabetes and hypertension in the homeless population range from 2% to 18% for diabetes and 18% to 41% for hypertension. The percentages of homeless individuals being diagnosed with diabetes and hypertension will continue to increase because they do not have access to healthcare. there is also a growing consensus that the adult home.
Running Head HEALTH NEEDS ASSESSMENT1HEALTH NEEDS ASSESSMEN.docxwlynn1
Running Head: HEALTH NEEDS ASSESSMENT 1
HEALTH NEEDS ASSESSMENT 7
Health Needs Assessment
Student’s Name:
Course Number:
Course Title:
Professor’s Name:
Date:
Health Needs Assessment
Health assessment can be defined as a care program which involves the identification of special needs of person or a group of people and the way those needs are addressed by health facilities or the entire health system. Health assessment also involves the evaluation of the health status of an individual(s) through the performance of a physical examination after recording their health history. Health assessments are different from diagnostic tests because the latter is carried out when a person is already exhibiting the signs and/or symptoms of a particular disease (Turnock, 2012).
Measure of Public Health
Measures used in assessing health are different and the first measure of public health is mortality. Mortality is the rate of deaths occurring in a particular population. It has been very common for the numbers and rates of death to be used in measuring public health. Globally, some diseases such as cancer, cardiovascular diseases, diabetes and hypertension among others have been observed to be the leading causes of death. In order for policies to be formulated mortalities which are specific on particular age groups are considered as they provide more awareness on health status of that age group. The same way, when mortality data is stratified on the basis of ethnicity or race, the health disparities available are quantified (Pennel, McLeroy, Burdine, Matarrita-Cascante & Wang, 2016).
Morbidity is the second measure that is used to measure public health. It can literally be said to mean the rate of incidence of a disease or illness in a specified group of individuals or a population. This rate of morbidity can be estimated through use of the rates of hospitalizations recorded among a group or a population. This kind of measure is easy and advantageous in that it is not difficult to get access to the rates of hospitalizations. Although they are of very good use when carrying out certain analyses, they can be biased indicators of the health status (Turnock, 2012). For example, in cases where there are increasing rates of outpatient treatment when handling conditions which require hospitalization can adversely and substantially affect the usefulness of the information or data recorded for assessing health status.
Measuring disability is another dimension of morbidity that looks into non-fatal health complications. Certain problems such as pain in joints and bones often a result of arthritis can be said to be main contributors of disability. Other chronic conditions such as lung problems, heart disease, stroke, diabetes etcetera are also known to be causers of disability. High rates of disability could be taken to mean that the general health status of the population is at risk diseases (Giger, 2016). Apart from the mentioned three, the other m.
Rosemary Frasso's presentation from the
Penn Urban Doctoral Symposium
May 13, 2011
Co-sponsored with Penn’s Urban Studies program, this symposium celebrates the work of graduating urban-focused doctoral candidates. Graduates present and discuss their dissertation findings. Luncheon attended by the students, their families and their committees follows.
Public health is defined as “the approach to medicine that is concerned with the health of the community as a whole” ("Definition of Public Health", 2013). Without public health, health care would be in vain. A person could be in perfect health one day, come in contact with a person with a contagious disease, and be dead within twenty-four hours. This paper will discuss the local health department.
New approaches for moving upstream how state and local health departments can...Jim Bloyd, DrPH, MPH
Growing evidence shows that unequal distribution of wealth and power across race, class, and gender produces the differences in living conditions that are “upstream” drivers of health inequalities. Health educators and other public health professionals, however, still develop interventions that focus mainly on “downstream” behavioral risks. Three factors explain the difficulty in translating this knowledge into practice. First, in their allegiance to the status quo, powerful elites often resist upstream policies and programs that redistribute wealth and power. Second, public health practice is often grounded in dominant biomedical and behavioral paradigms, and health departments also face legal and political limits on expanding their scope of activities. Finally, the evidence for the impact of upstream interventions is limited, in part because methodologies for evaluating upstream interventions are less developed. To illustrate strategies to overcome these obstacles, we profile recent campaigns in the United States to enact living wages, prevent mortgage foreclosures, and reduce exposure to air pollution. We then examine how health educators working in state and local health departments can transform their practice to contribute to campaigns that reallocate the wealth and power that shape the living conditions that determine health and health inequalities. We also consider health educators’ role in producing the evidence that can guide transformative expansion of upstream interventions to reduce health inequalities.
1
Literature Review Assignment
STUDENT NAME
Class
Date
2
Part A: Annotated Bibliography
Article 1: Immigration as a Social Determinant of Health
Castañeda, H., Holmes, S. M., Madrigal, D. S., Young, M.-E. D., Beyeler, N., & Quesada, J.
(2015). Immigration as a Social Determinant of Health. Annual Review of Public
Health, 36(1), 375–392. doi: 10.1146/annurev-publhealth-032013-182419
Abstract
Although immigration and immigrant populations have become increasingly important foci in
public health research and practice, a social determinants of health approach has seldom been
applied in this area. Global patterns of morbidity and mortality follow inequities rooted in
societal, political, and economic conditions produced and reproduced by social structures,
policies, and institutions. The lack of dialogue between these two profoundly related
phenomena—social determinants of health and immigration—has resulted in missed
opportunities for public health research, practice, and policy work. In this article, we discuss
primary frameworks used in recent public health literature on the health of immigrant
populations, note gaps in this literature, and argue for a broader examination of immigration as
both socially determined and a social determinant of health. We discuss priorities for future
research and policy to understand more fully and respond appropriately to the health of the
populations affected by this global phenomenon.
Annotated Bibliography
The article reports on the importance of identifying social determinants and the effects of
socially determined structures among immigrant populations in the United States. The study
identifies ways in which immigrants health outcomes are based on biases due to using
3
information based on group behaviors instead of on an induvial case. The impact of migrant and
immigrant individuals, physical and mental health in these communities’ changes as social,
economic, and political policies take place. This article is helpful in that broadens the
immigration experience including more central factors than just language, income, or education
as the cause of all health related problems in this community. But to show factors of power
structures and the ability to put in place effective health interventions that respond to direct
causes of poor or declining health in these populations.
Article 2: Fear by Association: Perceptions of Anti-Immigrant Policy and Health Outcomes
Vargas, Edward & Sanchez, Gabriel & Juárez, Melina. (2017). Fear by Association: Perceptions
of Anti-Immigrant Policy and Health Outcomes. Journal of Health Politics, Policy and
Law. 42. 3802940. 10.1215/03616878-3802940.
Abstract
The United States is experiencing a renewed period of immigration and immigrant policy
activity as well as heightened enforcement of such policies. This intensified activity can affect
various aspects of im ...
2. Given the impact of unmet basic needs on health outcomes and the
heterogeneity of unmet basic needs experienced by low-income popu-
lations, the objective of this study was to understand how these
hardships may cluster and how the effectiveness of different health-
focused interventions might vary across vulnerable population sub-
groups with different basic needs profiles. This secondary analysis of a
unique prospective intervention study addresses both questions.
2. Methods
The Institutional Review Board at Washington University in St. Louis
approved this study. The parent study that provided the data for this
secondary analysis is registered in ClinicalTrials.gov (#NCT01027741).
2.1. Study setting
The study took place at United Way 2-1-1 Missouri, a telephone in-
formation and referral helpline that serves 99 of 114 counties in the
state and received 160,000 calls in 2013. 2-1-1 is a federally designated
dialing code (like 9-1-1 for emergency services) that links callers to
health and social services in their community (Daily, 2012). Callers are
predominantly poor and seeking help with basic needs like paying util-
ity bills and getting food (Kreuter, 2012; Thompson et al., 2016). Al-
though relatively few callers contact 2-1-1 about health services,
studies have shown that the health needs of 2-1-1 callers greatly exceed
those of the general population (Purnell et al., 2012; Kreuter et al., 2012;
Eddens et al., 2011).
2.2. Study sample and recruitment
From June 2010 to June 2012, after receiving standard service, a ran-
dom sample of callers to 2-1-1 Missouri was selected to participate in a
surveillance phase of the project by completing a brief health risk as-
sessment. Of these, 10,472 callers (58%) were eligible for the risk assess-
ment (age ≥ 18, living in Missouri, English-speaking, calling with a
service request for themselves, willing to provide date of birth and gen-
der, not currently in extreme crisis). Nearly all of these (95%; n = 9947)
were invited to take the risk assessment and 4761 (48%) completed it.
Completers with at least one prevention need (n = 3816) were invited
to participate in the trial phase of the project, a longitudinal intervention
study. Those who agreed, consented and completed a baseline assess-
ment (n = 1521; 40%) were then randomized to one of three study
groups. Participants who also completed the 1-month follow up (n =
1090; 72%) comprise the analysis sample.
Drop-out rates did not differ by study group, nor were drop-outs dif-
ferent from completers in experiencing any of the seven unmet basic
needs. They were younger (39.7 vs. 43.9 years) and more likely to be
poor (62% vs. 55% income b$10K/year), employed (29% vs. 19%) and
have a child at home (63% vs. 51%). Additional details of the study de-
sign and methods are available in a previous report (Kreuter et al.,
2012).
2.3. Risk assessment to identify prevention needs
Items from the 2008 Behavioral Risk Factor Surveillance System
were used to assess needs for mammography, Pap testing, colonoscopy,
HPV vaccination for self and daughter, smoking cessation and smoke
free home policies, recommended prevention behaviors that are avail-
able for free or low cost to low-income populations in most states. Re-
ferrals were offered to women ages 40 and older who had no
mammogram in the last year; women ages 18 and older who had no
Pap test with the last two years1
; men and women ages 50 and older
who had no colonoscopy in the last 10 years; women ages 18–26 and
those with a female child ages 9–17 years old living in their home
who had not received the HPV vaccination; current smokers; and
those without a total ban on smoking in their household. Prevention re-
ferrals were limited to three per caller consistent with standard 2-1-1
procedure.
If a caller had more than three needs, a prioritization algorithm de-
termined which health referrals he or she received. In descending
order, the priorities were: colonoscopy, mammography, HPV vaccine
for self or girl in home, Pap test, smoking cessation, and smoke free
home policy. This order was set to maximize statistical power for each
health outcome based on the expected proportion of the sample (from
lowest to highest) that would need the referral, not on the public health
importance or the strength of evidence for the recommended cancer
control measure.
2.4. Interventions
Participants were randomized to one of three intervention groups.
Of those who completed the baseline and 1 month follow up, 365
(34%) received verbal referral only, 372 (34%) received verbal
referral + tailored print reminder, and 353 (32%) received verbal
referral + navigation.
2.4.1. Verbal referral
Based on each caller's responses to the risk assessment questions, a
computer algorithm identified and prioritized their prevention needs,
which were addressed moments later by a 2-1-1 information specialist
who delivered a scripted referral (Kreuter et al., 2012). Referrals
consisted of three parts: (Fiscella and Williams, 2004) risk assessment
feedback (e.g., “You said you've never had a mammogram”); (DeFur et
al., 2007) recommended action and importance (e.g., “Once you turn 40,
getting a mammogram every 1 to 2 years is the best way to fight breast
cancer. Mammograms can find breast cancer when it's easier to treat
and cure”); and, (Harper and Lynch, 2007) offer of referral to a free or
low-cost service (e.g., “There's a good chance you can get a free mam-
mogram through a program called Show Me Healthy Women. Would
you like the phone number for that program?”). For each accepted refer-
ral, the information specialist identified the closest service provider to
the caller's residence and verbally shared the referral phone number
and/or address, information about its hours of operation, and documen-
tation that may be required to obtain services.
2.4.2. Tailored print reminder
Within one working day of receiving the verbal referral,
participants in this group were mailed a printed tailored reminder
(4-page full color booklet) of the health referral they received. The
reminder consisted of: (Fiscella and Williams, 2004) a short personal
story tailored to the problem that led the participant to call 2-1-1 and
the prevention referral to which the participant has been referred
(i.e., modeling (Lemelin et al., 2009)); (DeFur et al., 2007) an accom-
panying matched photo personalized to the participant's age, race,
and gender; (Harper and Lynch, 2007) action details providing a
clear and simple summary of information the caller would need to
access the prevention referral(s); and (Goldman and Smith, 2002)
motivation and preparation information describing why the
preventive health service was important and suggesting questions
to ask when contacting the referral. All content adhered to health
literacy and health communication best practices, and was written
at a Flesch-Kincaid 4th Grade Level. The tailored personal story
addressed up to three cancer-control needs.
2.4.3. Navigator/health coach
Navigators (called “coaches” to participants) explained each
needed preventive health service and its importance, answered
callers' questions, elicited and addressed barriers to action with a
1
Recommendations for Pap testing changed during the study period. In the first four
months of recruitment, women ages 18–26 were offered referrals if they had not Pap test
in the last year.
71M.W. Kreuter et al. / Preventive Medicine 91 (2016) 70–75
3. variety of strategies including arranging transportation, making
appointments, and providing verbal reminders to the participant.
Two women similar in age to the average 2-1-1 caller were given
extensive training by a counseling psychologist and a social worker
who had previously worked as a navigator. Training consisted of
mastering health content for the six focus areas, problem-solving
techniques, counseling concepts and approaches, and research
protocol and documentation. Many cycles of rehearsal and feedback
preceded the launch of the intervention, after which navigator calls
were recorded, monitored and discussed.
Participants received their first navigator call within one working
day of completing the baseline assessment and receiving the verbal
referral. The initial call introduced the navigator, explained the
navigation relationship and sought to establish rapport. Then a
flyer was mailed to the participant containing the name, picture
and contact information for their navigator. The navigator re-
contacted the participant soon after to ensure receipt of the flyer
and follow up on any issues since their initial conversation.
Telephone interactions continued for up to four months with the
number, length and frequency of calls determined by participants'
needs, interest and willingness. Either navigator or participant
could initiate a call. On average, participants engaged in three calls
with a navigator (M = 3.1, SD = 1.8), which lasted slightly longer
than five minutes each (M = 16.2 min total, SD = 31.5).
3. Measures
3.1. Unmet basic needs
The baseline survey assessed participants' perceived likelihood that
their safety, housing, food, and financial needs would be met in the
next month. These items were adapted from Segal's (Segal et al.,
1993) Personal Empowerment scale and another scale developed by
Blazer (Blazer et al., 2005). Five questions beginning with: “How likely
is it that…” included “…someone will threaten to hurt you physically
in the next month?”, “…you will have a place to stay all of next
month?”, “…you and others in your home will get enough to eat in
the next month?”, “…you will have enough money in the next month
for necessities like food, shelter and clothing?”, and “…you will have
enough money in the next month to deal with unexpected expenses?”
(1 = very unlikely to 4 = very likely). Participants were also asked to
rate the safety of their neighborhood (1 = very unsafe to 4 = very
safe) and the amount of space in their home given the number of people
living there (1 = not enough living space, 2 = about the right amount,
3 = more than enough). From these items, we created seven dichoto-
mous variables. If a need was very unlikely or unlikely to be met in
the next month, it was considered unmet (0), otherwise it was consid-
ered met (Fiscella and Williams, 2004); living in an “unsafe” or “very
unsafe” neighborhood and reporting “not enough living space” were
also considered unmet (0) basic needs.
3.2. Contacting referrals
At 1 month follow-up, participants were asked if they remembered
receiving a health referral (yes/no/don't remember). Those who re-
membered were asked if they had contacted any of the specific health
referral(s) they received (yes/no/don't remember). Those who did not
remember receiving a health referral were considered to have not
contacted any referrals.
3.3. Covariates
Participants' gender, race/ethnicity, education, marital status, in-
come, employment status and general health status were obtained at
baseline (Table 1). For ease of LCA interpretation, many variables were
dichotomized (e.g., self-rated health: very good/excellent vs good/fair/
poor).
3.4. Reasons for calling 2-1-1
For each participant, up to 3 reasons for calling 2-1-1 were recorded.
Reasons were collapsed into eight categories: utilities, rent/mortgage,
housing, food assistance, employment, home and family, health, and
other.
3.5. Data analyses
Analyses were conducted March–July 2015. Latent class analysis
(LCA) is used to find groups of cases in multivariate categorical data
(Lanza and Rhoades, 2013). We used a two-step approach for the anal-
ysis. First, we examined whether the sample was heterogeneous with
regard to participant's basic needs using a LCA. The LCA was based on
the seven dichotomous measures of unmet basic needs. PROC LCA in
SAS v9.2 was used to estimate a series of latent class models from 2 to
4 classes to identify distinct subgroups of participants with different
basic needs. Akaike Information Criterion (AIC) and the sample-size
Table 1
Participant characteristics; 2010–2012 Missouri 2-1-1.
Mean age (years; SD) 43.9 (13)
Gender (n = 1090) %
Female 85.6
Race/ethnicity (n = 1085)
African-American 59.2
White 30.1
Other 10.5
Income (n = 1054)
b $10,000 47.1
Education (n = 1089)
Less than high school 28.7
Employment (n = 1090)
Employed 18.9
Marital status (n = 1089)
Never married 38.8
Children in home (n = 1090)
Child aged b18 years living in home 50.7
Health insurance (n = 1089)
None 38.8
Public (Medicare or Medicaid) 36.6
Private 7.7
More than one type 13.4
Self-rated general health (n = 1088)
Poor 18.2
Fair 31.8
Good 30.3
Very good 14.3
Excellent 5.4
Service request from 2‐1-1 (n)a
Bills (794) 72.8
Home and family (457) 42.1
Employment (95) 8.7
Health (97) 8.9
Housing (59) 5.4
Other (134) 12.3
Needed preventive health service (n)b
Colonoscopy (406) 53.5
Mammogram (570) 65.8
HPV for self (119) 76.5
HPV for girl aged b18 years (232) 66.4
Pap test (932) 26.8
Smoking cessation (1090) 62.5
Smokefree home policy (1090) 54.4
Note: Values may not equal 100% due to missing data; “Don't know” and “Refused”
responses were excluded from analysis. GED = General Educational Development
test; HPV = human papilloma virus.
a
Percent of total (N = 1090). Total percent is N100 because participants could
have more than one service request.
b
Percent is calculated as percent of eligible. Number eligible is in parentheses.
72 M.W. Kreuter et al. / Preventive Medicine 91 (2016) 70–75
4. adjusted Bayesian Information Criterion (BIC) were calculated. A lower
AIC or BIC value suggests a better fitting and more parsimonious model.
After determining the optimal number of latent classes based on both fit
indices and the conceptual interpretability of each class solution, the fol-
lowing covariates were added to the LCA model: gender, income, race,
age, education, employment status, having a child in the home, marital
status (never married vs. ever married), and self-rated health. Non-sig-
nificant covariates were removed from the final model. Similar to a mul-
tinomial regression model, the LCA regresses the probability of class
membership on each covariate. Beta coefficient tests for predicting la-
tent class membership by covariates and odds ratios and 95% confidence
intervals were calculated.
Second, participants were classified into one of the subgroups
resulting from the LCA and we examined descriptive statistics by class.
For each latent class separately, chi-square analyses were used to exam-
ine the association between calling a referral and study group. Then we
estimated a binary logistic regression model predicting the probability
of calling any health referral by latent class assignment, intervention
group (verbal referral only, verbal referral + tailored reminder, verbal
referral + navigation), and the interaction between the two variables.
Odds ratios (OR) and 95% confidence intervals (CI) of the interaction
are reported.
4. Results
4.1. Participant characteristics
Participant characteristics did not significantly differ across the three
intervention groups. Participant characteristics are shown in Table 1;
most participants were women, African American or White, and report-
ed very low income. Participants' mean age was 43.9 years. Most partic-
ipants had called 2-1-1 seeking help with bills (73%) and/or home and
family needs like food, clothing, and household goods (42%). Rates of
unmet cancer prevention needs varied by the percent eligible for each
service. Ten percent of the analysis sample had 4 or more needs, but
only received three referrals, consistent with 211 procedures.
4.2. Identifying latent classes of unmet basic needs
Fit statistics for the 2 to 4 class models are shown in Supplement
Table 1, which support a three class solution. The frequency of the
seven binary basic needs is shown in Table 2 for each class. Compared
to the other latent classes, Class 1 (C1) had relatively few unmet basic
needs and comparatively greater financial security. Class 2 (C2) had rel-
atively greater unmet needs. Class 3 (C3) had specific unmet needs for
money.
4.3. Relationships between covariates and latent classes
The final LCA model included race, marital status, income, employ-
ment status, having a child in the home, and self-rated health. Odds ra-
tios and 95% confidence intervals for covariates of latent class
membership are shown in Table 3. Participants in latent class C1 were
less likely to be white and earn less than $10,000/year, and were more
likely to be employed, have a child in the home, and report better health
compared with those in C3 (Table 3). Participants in latent class C2 were
significantly more likely to have a child in the home compared with
those in C3. Participants in latent class C2 were more likely to have
never been married and earn less than $10,000/year, and less likely to
be employed or in good health compared with C1 (Table 3).
4.4. Predicting health referral contacts by latent class and intervention
group
Table 4 shows the results of the logistic regression analysis. Of the
participants in C1, those who were assigned to receive the tailored or
navigator intervention were more likely to contact a health referral
than those who received a verbal referral only. The difference between
the tailored and navigation interventions was not statistically signifi-
cant (Table 4). Of the participants in C2 and C3, those assigned to receive
the navigator intervention were more likely to contact a health referral
than those who received a tailored reminder or verbal referral only
(Table 4).
Table 2
Percent unmet basic needs in full study sample and by latent class; 2010–2012 Missouri 2-1-1.
Basic needs items Full sample (n =
1081)
C1: Fewer needs (n =
292)
C2: Many needs (n =
228)
C3: Money needs (n =
561)
Unlikely to have enough money for unexpected expenses in the next
montha
89.2 65.4 100.0 97.2
Unlikely to have enough money for necessities in the next montha
70.4 2.4 98.3 94.5
Not enough living space in my home 27.0 24.0 97.4 0
Neighborhood is unsafe from crimeb
21.6 23.6 27.9 48.5
Unlikely to get enough to eat in the next montha
15.8 1.7 28.1 18.2
Unlikely to have a place to stay all of next montha
16.0 5.5 26.8 17.1
Likely to be threatened physically in the next monthc
4.8 3.1 10.1 3.6
a
Percent “unlikely” + “very unlikely”.
b
Percent “unsafe” + “very unsafe”.
c
Percent “very likely” + “somewhat likely”.
Table 3
Odds ratios for covariates for latent class membership and p-values of beta parameter tests; 2010–2012 Missouri 2-1-1.
Latent class
(C1 vs C3) (C2 vs C3) (C2 vs C1) p-Valuea
White vs. African American/other 0.45 (0.27–0.75) 0.69 (0.39–1.25) 1.55 (0.83–2.90) 0.0041
Never married vs. ever married 0.74 (0.47–1.15) 1.42 (0.75–2.69) 1.94 (1.11–3.38) 0.0261
b$10,000 vs. ≥$10,000 0.64 (0.42–0.98) 1.06 (0.66–1.69) 1.66 (1.04–2.64) 0.0480
Employed vs. other 1.77 (1.09–2.86) 0.69 (0.35–1.34) 0.39 (0.21–0.72) 0.0028
Child in home vs. none 2.29 (1.36–3.85) 4.16 (1.91–9.03) 1.82 (0.77–4.27) b0.0001
Self-rated health (Very good/excellent vs. good/fair/poor) 1.90 (1.17–3.08) 0.58 (0.29–1.17) 0.31 (0.16–0.58) b0.0001
C1 = Fewer needs; C2 = Many needs; C3 = Money needs.
a
p-Value from the significance test for the multinomial logistic regression coefficient predicting latent class membership.
73M.W. Kreuter et al. / Preventive Medicine 91 (2016) 70–75
5. 5. Discussion
We observed three distinct patterns of unmet basic needs within
this low-income population. Common intervention approaches pro-
moting preventive health services were differentially effective among
participants with different patterns of unmet basic needs.
Our findings reinforce those of previous studies that have shown
that unmet basic needs are heterogeneous in economically vulnerable
populations (DeWilde, 2004; Mayer and Jencks, 1989; Roy and Raver,
2014). In our sample of nearly universally low-income adults, there
was wide variability in the experience of unmet basic needs, especially
in the areas of financial, housing, and food security. The use of latent
class analysis is a strength of the study. In much of the research examin-
ing multiple indicators of poverty, investigators have created indices of
disadvantage by summing the number of needs or harmful exposures a
person experiences. While there is clear evidence that such cumulative
disadvantage has harmful and dose-response effects on human health
(Bauman et al., 2006; Lemelin et al., 2009; Johnson-Lawrence et al.,
2015), a simple additive approach treats different types of needs as in-
terchangeable. Latent class analysis provides additional information by
identifying underlying subgroups that are mutually exclusive and differ
qualitatively on the types and patterns of needs experienced (DeWilde,
2004; Moisio, 2004; Rose et al., 2009).
Our study extends previous work by demonstrating for the first time
that the effectiveness of different interventions targeted to low SES pop-
ulations can vary by basic-needs profiles. The relatively greater effec-
tiveness of the navigator intervention among participants with the
most unmet basic needs reinforces a foundational aim of navigation:
To improve health outcomes by reducing barriers experienced by low-
SES and minority individuals (Paskett et al., 2011). Although the naviga-
tion intervention tested in this study was not designed to address basic
needs (Kreuter et al., 2012), the flexibility and client-centric orientation
of this approach likely presents many opportunities for navigators to
help in addressing basic needs (Jean-Pierre et al., 2011; Ferrante et al.,
2011).
The relative ineffectiveness of the tailored intervention among those
with multiple unmet basic needs may be due to the fact that these indi-
viduals are less likely to pay attention to the materials or even remem-
ber receiving them (Capelletti et al., 2015), perhaps because they are
focused on more pressing problems, fear that the mailed reminder is a
bill, or are living in temporary housing and do not receive mail regularly.
For participants with fewer basic needs (C1), mailed tailored reminders
were just as effective as a navigator in getting participants to contact a
health referral. Given that navigator interventions are generally more
intensive, time consuming, and costly (Jandorf et al., 2013), this finding
has considerable practical implications.
Because intervention outcomes differ by participants' basic needs,
finding new ways to quickly and accurately identify subgroups of eco-
nomically vulnerable individuals could help in targeting health dispari-
ty-reducing strategies in the same way that personalized medicine is
revolutionizing treatment protocols for many diseases (Chadwell,
2013). More research is needed to identify a minimal set of basic
needs or other indicators of deprivation that can be efficiently and reli-
ably measured and that predict a better (or lesser) response to different
evidence-based, health promoting interventions. It may also be useful to
determine whether the types of health needs vary by basic need profile,
since some interventions may be more effective than others in stimulat-
ing responses to referrals for certain health behaviors and services
(Kreuter et al., 2012).
A possible limitation of the study is the relatively small number of
basic needs we measured. Our brief assessment included only 1 or 2
items each for housing, food, safety and financial needs. It's possible
that additional indicators within these categories (e.g., housing quality)
and/or additional categories (e.g., sleep) could alter or enrich the latent
classes that emerged from our analyses. Recent studies have tested nav-
igation-type interventions that address a similar set of basic needs as in
our study, as well as other social needs like child care, education and job
opportunities (Haas et al., 2004; Garg et al., 2015). Like our findings,
they demonstrate success in improving health or other outcomes in
part by linking individuals with existing community resources. It is
not clear how such interventions would work in developing countries
or low-resource contexts where such help may be less available. Future
research should continue to explore a broader set of basic and social
needs variables and the effects of hybrid health interventions that ad-
dress them.
Because participants who were lost to follow-up between the base-
line and 1-month assessment differed on several demographic vari-
ables, we repeated the latent class analysis with the baseline only
sample. Results showed the same number and interpretation of latent
classes as the 1-month sample (data not shown). The equivalence
across samples suggest stability of the classes.
6. Conclusion
There is increasing recognition that unmet basic needs are strongly
and independently associated with a range of negative health outcomes
in vulnerable populations. Newer still are findings suggesting that al-
though unmet basic needs can undermine certain prevention interven-
tions (Capelletti et al., 2015), the likelihood of prevention interventions
working increases when basic needs are addressed (Thompson et al.,
2016). Findings from the current study advance our understanding by
comparing effects of multiple interventions among subgroups of low-
income adults with different sets of unmet basic needs. Scientific inqui-
ry has only scratched the surface in this promising area of health dispar-
ities research and practice. If further research confirms and extends the
findings reported here, the public health implications would be consid-
erable, requiring fundamentally different intervention approaches.
Supplementary data to this article can be found online at http://dx.
doi.org/10.1016/j.ypmed.2016.08.006.
Conflict of interest
All authors have no conflicts of interest.
Financial disclosures
All authors have no financial disclosures.
Table 4
Contacted any cancer control referral at 1-month follow-up by latent classes of unmet basic needs assessed at baseline; 2010–2012 Missouri 2-1-1.
Latent classes of unmet basic
needs
% contacted a referral OR (95% CI)
All Verbal
referral
Tailored
reminder
Navigator χ2
p-value
Tailored reminder vs. verbal
referral
Navigator vs. verbal
referral
Navigator vs. tailored
reminder
C1 (n = 292; 26.8%) 22.3% 12.1% 25.2% 30.2% 0.0083 2.45 (1.16–5.15) 3.14 (1.47–6.71) 1.28 (0.68–2.42)
C2 (n = 228; 20.9%) 26.3% 18.8% 21.2% 39.2% 0.0088 1.16 (0.52–2.57) 2.78 (1.30–5.95) 2.40 (1.19–5.95)
C3 (n = 561; 51.5%) 23.7% 19.3% 20.7% 31.1% 0.0131 1.09 (0.66–1.82) 1.89 (1.18–3.03) 1.73 (1.08–2.78)
Note. The number of participants assigned to latent classes does not equal 100% due to missing data.
C1 = Fewer needs; C2 = Many needs; C3 = Money needs.
74 M.W. Kreuter et al. / Preventive Medicine 91 (2016) 70–75
6. Acknowledgments
This study was supported by funding from the National Cancer Insti-
tute (P50-CA095815); however, the funder had no involvement with
the design, conduct, analysis or reporting of the study. We thank the
2-1-1 Information Specialists and callers who participated in this study.
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