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1.  Proceedings of the 14th annual conference of INEBRIA 
Holloway, Aisha S. | Ferguson, Jennifer | Landale, Sarah | Cariola, Laura | Newbury-Birch, Dorothy | Flynn, Amy | Knight, John R. | Sherritt, Lon | Harris, Sion K. | O’Donnell, Amy J. | Kaner, Eileen | Hanratty, Barbara | Loree, Amy M. | Yonkers, Kimberly A. | Ondersma, Steven J. | Gilstead-Hayden, Kate | Martino, Steve | Adam, Angeline | Schwartz, Robert P. | Wu, Li-Tzy | Subramaniam, Geetha | Sharma, Gaurav | McNeely, Jennifer | Berman, Anne H. | Kolaas, Karoline | Petersén, Elisabeth | Bendtsen, Preben | Hedman, Erik | Linderoth, Catharina | Müssener, Ulrika | Sinadinovic, Kristina | Spak, Fredrik | Gremyr, Ida | Thurang, Anna | Mitchell, Ann M. | Finnell, Deborah | Savage, Christine L. | Mahmoud, Khadejah F. | Riordan, Benjamin C. | Conner, Tamlin S. | Flett, Jayde A. M. | Scarf, Damian | McRee, Bonnie | Vendetti, Janice | Gallucci, Karen Steinberg | Robaina, Kate | Clark, Brendan J. | Jones, Jacqueline | Reed, Kathryne D. | Hodapp, Rachel M. | Douglas, Ivor | Burnham, Ellen L. | Aagaard, Laura | Cook, Paul F. | Harris, Brett R. | Yu, Jiang | Wolff, Margaret | Rogers, Meighan | Barbosa, Carolina | Wedehase, Brendan J. | Dunlap, Laura J. | Mitchell, Shannon G. | Dusek, Kristi A. | Gryczynski, Jan | Kirk, Arethusa S. | Oros, Marla T. | Hosler, Colleen | O’Grady, Kevin E. | Brown, Barry S. | Angus, Colin | Sherborne, Sidney | Gillespie, Duncan | Meier, Petra | Brennan, Alan | de Vargas, Divane | Soares, Janaina | Castelblanco, Donna | Doran, Kelly M. | Wittman, Ian | Shelley, Donna | Rotrosen, John | Gelberg, Lillian | Edelman, E. Jennifer | Maisto, Stephen A. | Hansen, Nathan B. | Cutter, Christopher J. | Deng, Yanhong | Dziura, James | Fiellin, Lynn E. | O’Connor, Patrick G. | Bedimo, Roger | Gibert, Cynthia | Marconi, Vincent C. | Rimland, David | Rodriguez-Barradas, Maria C. | Simberkoff, Michael S. | Justice, Amy C. | Bryant, Kendall J. | Fiellin, David A. | Giles, Emma L. | Coulton, Simon | Deluca, Paolo | Drummond, Colin | Howel, Denise | McColl, Elaine | McGovern, Ruth | Scott, Stephanie | Stamp, Elaine | Sumnall, Harry | Vale, Luke | Alabani, Viviana | Atkinson, Amanda | Boniface, Sadie | Frankham, Jo | Gilvarry, Eilish | Hendrie, Nadine | Howe, Nicola | McGeechan, Grant J. | Ramsey, Amy | Stanley, Grant | Clephane, Justine | Gardiner, David | Holmes, John | Martin, Neil | Shevills, Colin | Soutar, Melanie | Chi, Felicia W. | Weisner, Constance | Ross, Thekla B. | Mertens, Jennifer | Sterling, Stacy A. | Shorter, Gillian W. | Heather, Nick | Bray, Jeremy | Cohen, Hildie A. | McPherson, Tracy L. | Adam, Cyrille | López-Pelayo, Hugo | Gual, Antoni | Segura-Garcia, Lidia | Colom, Joan | Ornelas, India J. | Doyle, Suzanne | Donovan, Dennis | Duran, Bonnie | Torres, Vanessa | Gaume, Jacques | Grazioli, Véronique | Fortini, Cristiana | Paroz, Sophie | Bertholet, Nicolas | Daeppen, Jean-Bernard | Satterfield, Jason M. | Gregorich, Steven | Alvarado, Nicholas J. | Muñoz, Ricardo | Kulieva, Gozel | Vijayaraghavan, Maya | Adam, Angéline | Cunningham, John A. | Díaz, Estela | Palacio-Vieira, Jorge | Godinho, Alexandra | Kushir, Vladyslav | O’Brien, Kimberly H. M. | Aguinaldo, Laika D. | Sellers, Christina M. | Spirito, Anthony | Chang, Grace | Blake-Lamb, Tiffany | LaFave, Lea R. Ayers | Thies, Kathleen M. | Pepin, Amy L. | Sprangers, Kara E. | Bradley, Martha | Jorgensen, Shasta | Catano, Nico A. | Murray, Adelaide R. | Schachter, Deborah | Andersen, Ronald M. | Rey, Guillermina Natera | Vahidi, Mani | Rico, Melvin W. | Baumeister, Sebastian E. | Johansson, Magnus | Sinadinovic, Christina | Hermansson, Ulric | Andreasson, Sven | O’Grady, Megan A. | Kapoor, Sandeep | Akkari, Cherine | Bernal, Camila | Pappacena, Kristen | Morley, Jeanne | Auerbach, Mark | Neighbors, Charles J. | Kwon, Nancy | Conigliaro, Joseph | Morgenstern, Jon | Magill, Molly | Apodaca, Timothy R. | Borsari, Brian | Hoadley, Ariel | Scott Tonigan, J. | Moyers, Theresa | Fitzgerald, Niamh M. | Schölin, Lisa | Barticevic, Nicolas | Zuzulich, Soledad | Poblete, Fernando | Norambuena, Pablo | Sacco, Paul | Ting, Laura | Beaulieu, Michele | Wallace, Paul George | Andrews, Matthew | Daley, Kate | Shenker, Don | Gallagher, Louise | Watson, Rod | Weaver, Tim | Bruguera, Pol | Oliveras, Clara | Gavotti, Carolina | Barrio, Pablo | Braddick, Fleur | Miquel, Laia | Suárez, Montse | Bruguera, Carla | Brown, Richard L. | Capell, Julie Whelan | Paul Moberg, D. | Maslowsky, Julie | Saunders, Laura A. | McCormack, Ryan P. | Scheidell, Joy | Gonzalez, Mirelis | Bauroth, Sabrina | Liu, Weiwei | Lindsay, Dawn L. | Lincoln, Piper | Hagle, Holly | Wallhed Finn, Sara | Hammarberg, Anders | Andréasson, Sven | King, Sarah E. | Vargo, Rachael | Kameg, Brayden N. | Acquavita, Shauna P. | Van Loon, Ruth Anne | Smith, Rachel | Brehm, Bonnie J. | Diers, Tiffiny | Kim, Karissa | Barker, Andrea | Jones, Ashley L. | Skinner, Asheley C. | Hinman, Agatha | Svikis, Dace S. | Thacker, Casey L. | Resnicow, Ken | Beatty, Jessica R. | Janisse, James | Puder, Karoline | Bakshi, Ann-Sofie | Milward, Joanna M. | Kimergard, Andreas | Garnett, Claire V. | Crane, David | Brown, Jamie | West, Robert | Michie, Susan | Rosendahl, Ingvar | Andersson, Claes | Gajecki, Mikael | Blankers, Matthijs | Donoghue, Kim | Lynch, Ellen | Maconochie, Ian | Phillips, Ceri | Pockett, Rhys | Phillips, Tom | Patton, R. | Russell, Ian | Strang, John | Stewart, Maureen T. | Quinn, Amity E. | Brolin, Mary | Evans, Brooke | Horgan, Constance M. | Liu, Junqing | McCree, Fern | Kanovsky, Doug | Oberlander, Tyler | Zhang, Huan | Hamlin, Ben | Saunders, Robert | Barton, Mary B. | Scholle, Sarah H. | Santora, Patricia | Bhatt, Chirag | Ahmed, Kazi | Hodgkin, Dominic | Gao, Wenwu | Merrick, Elizabeth L. | Drebing, Charles E. | Larson, Mary Jo | Sharma, Monica | Petry, Nancy M. | Saitz, Richard | Weisner, Constance M. | Young-Wolff, Kelly C. | Lu, Wendy Y. | Blosnich, John R. | Lehavot, Keren | Glass, Joseph E. | Williams, Emily C. | Bensley, Kara M. | Chan, Gary | Dombrowski, Julie | Fortney, John | Rubinsky, Anna D. | Lapham, Gwen T. | Forray, Ariadna | Olmstead, Todd A. | Gilstad-Hayden, Kathryn | Kershaw, Trace | Dillon, Pamela | Weaver, Michael F. | Grekin, Emily R. | Ellis, Jennifer D. | McGoron, Lucy | McGoron, Lucy
doi:10.1186/s13722-017-0087-8
PMCID: PMC5606215
2.  Diagnoses Treated in Ambulatory Care Among Homeless-Experienced Veterans: Does Supported Housing Matter? 
Purpose
Little is known about how permanent supported housing influences ambulatory care received by homeless persons. To fill this gap, we compared diagnoses treated in VA Greater Los Angeles (VAGLA) ambulatory care between Veterans who are formerly homeless—now housed/case managed through VA Supported Housing (“VASH Veterans”)—and currently homeless.
Methods
We performed secondary database analyses of homeless-experienced Veterans (n = 3631) with VAGLA ambulatory care use from October 1, 2010 to September 30, 2011. We compared diagnoses treated—adjusting for demographics and need characteristics in regression analyses—between VASH Veterans (n = 1904) and currently homeless Veterans (n = 1727).
Results
On average, considering 26 studied diagnoses, VASH (vs currently homeless) Veterans received care for more (P < .05) diagnoses (mean = 2.9/1.7). Adjusting for demographics and need characteristics, VASH Veterans were more likely (P < .05) than currently homeless Veterans to receive treatment for diagnoses across categories: chronic physical illness, acute physical illness, mental illness, and substance use disorders. Specifically, VASH Veterans had 2.5, 1.7, 2.1, and 1.8 times greater odds of receiving treatment for at least 2 condition in these categories, respectively. Among participants treated for chronic illnesses, adjusting for predisposing and need characteristics, VASH (vs currently homeless) Veterans were 9%, 8%, and 11% more likely to have 2 or more visits for chronic physical illnesses, mental illnesses, and substance use disorder, respectively.
Conclusion
Among homeless-experienced Veterans, permanent supported housing may reduce disparities in the treatment of diagnoses commonly seen in ambulatory care.
doi:10.1177/2150131916656009
PMCID: PMC5016249  PMID: 27343544
homelessness; supported housing; Veterans; ambulatory care; health disparities
3.  Project QUIT (Quit Using Drugs Intervention Trial): A randomized controlled trial of a primary care-based multi-component brief intervention to reduce risky drug use 
Addiction (Abingdon, England)  2015;110(11):1777-1790.
Aims
To assess the effect of a multi-component primary care (PC)-delivered BI for reducing risky drug use (RDU) among patients identified by screening.
Design
Multicenter single-blind two-arm randomized controlled trial of patients enrolled from February 2011 to November 2012 with 3-month follow-up. Randomization and allocation to trial group were computer-generated.
Setting
Primary care waiting rooms of 5 federally qualified health centers (FQHCs) in Los Angeles County (LAC), USA.
Participants
334 adult primary care patients (171 intervention; 163 control) with RDU scores (4–26) on the WHO Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) self-administered on tablet PCs; 261 (78%) completed follow-up. Mean age was 41.7 years; 63% were male; 38% were Caucasian.
Intervention(s) and Measurement
Intervention patients received brief (typically 3–4 minutes) clinician advice to quit/reduce their drug use reinforced by a video doctor message, health education booklet, and up to two 20–30 minute follow-up telephone drug use coaching sessions. Controls received usual care and cancer screening information. Primary outcome was patient self-reported use of highest scoring drug (HSD) at follow-up.
Findings
Intervention and control patients reported equivalent baseline HSD use; at follow-up, after adjustment for covariates in a linear regression model, intervention patients reported using their HSD an average of 2.21 fewer days in the previous month than controls (p<0.005). No compensatory increases in use of other measured substances were found (p>0.10).
Conclusions
A clinician-delivered brief intervention with follow-up counseling calls may decrease drug use among risky users compared with usual care in low-income community health centers of Los Angeles County, USA.
doi:10.1111/add.12993
PMCID: PMC4948983  PMID: 26471159
brief intervention; primary care; motivational interviewing; risky drug use; randomized controlled trial; community health centers
4.  Serving homeless Veterans in the VA Desert Pacific Healthcare Network: A needs assessment to inform quality improvement endeavors 
This report describes a needs assessment of VA programs for homeless Veterans in Southern California and Nevada, the geographic region with the most homeless Veterans in the nation. The assessment was formulated through key informant interviews. Current service provisions are discussed, along with salient unmet needs for this vulnerable population.
doi:10.1353/hpu.2013.0124
PMCID: PMC4720128  PMID: 23974403
Homeless people; Veterans; quality improvement; needs assessment
5.  VA Health Service Utilization for Homeless and Low-income Veterans 
Medical care  2014;52(5):454-461.
Background
The US Department of Housing and Urban Development (HUD)-VA Supportive Housing (VASH) program—the VA’s Housing First effort—is central to efforts to end Veteran homelessness. Yet, little is known about health care utilization patterns associated with achieving HUD-VASH housing.
Objectives
We compare health service utilization at the VA Greater Los Angeles among: (1) formerly homeless Veterans housed through HUD-VASH (HUD-VASH Veterans); (2) currently homeless Veterans; (3) housed, low-income Veterans not in HUD-VASH; and (4) housed, not low-income Veterans.
Research Design
We performed a secondary database analysis of Veterans (n = 62,459) who received VA Greater Los Angeles care between October 1, 2010 and September 30, 2011. We described medical/surgical and mental health utilization [inpatient, outpatient, and emergency department (ED)]. We controlled for demographics, need, and primary care use in regression analyses of utilization data by housing and income status.
Results
HUD-VASH Veterans had more inpatient, outpatient, and ED use than currently homeless Veterans. Adjusting for demographics and need, HUD-VASH Veterans and the low-income housed Veterans had similar likelihoods of medical/surgical inpatient and outpatient utilization, compared with the housed, not low-income group. Adjusting first for demographics and need (model 1), then also for primary care use (model 2), HUD-VASH Veterans had the greatest decrease in incident rates of specialty medical/surgical, mental health, and ED care from models 1 to 2, becoming similar to the currently homeless, compared with the housed, not low-income group.
Conclusions
Our findings suggest that currently homeless Veterans underuse health care relative to housed Veterans. HUD-VASH may address this disparity by providing housing and linkages to primary care.
doi:10.1097/MLR.0000000000000112
PMCID: PMC4714600  PMID: 24714583
veterans; homelessness; supportive housing
6.  Assessing the Contribution of the Dental Care Delivery System to Oral Health Care Disparities 
Objectives
Existing studies of disparities in access to oral health care for underserved populations often focus on supply measures such as number of dentist. This approach overlooks the importance of other aspects of dental care delivery system such as personal and practice characteristics of dentists that determine the capacity to provide care. This study aims to assess the role of such characteristics in access to care of underserved populations.
Methods
We merged the 2003 California Health Interview Survey and a 2003 survey of California dentists at the Medical Study Service Areas (MSSA). We examined the role of overall supply and other characteristics of dentists in income and racial/ethnic disparities in access, which was measured by annual dental visits and unmet need for dental care due to costs.
Results
We found that some characteristics including higher proportion of dentists who were older, white, busy or overworked, and did not accept public insurance or discounted fees in the MSSA inhibited access for low income and minority populations.
Conclusions
These findings highlight the importance of monitoring characteristics of dentists in addition to traditional measures of supply such as licensed dentist to population ratios. The findings identify specific aspects of the delivery system such as dentists’ participation in Medicaid, provision of discounted care, busyness, age, race/ethnicity, and gender should be regularly monitored. These data will provide a better understanding of how the dental delivery system is organized and how this knowledge can be used to develop more narrowly targeted policies to alleviate disparities.
doi:10.1111/jphd.12064
PMCID: PMC4276727  PMID: 24964016
7.  Effect of a Primary Care based Brief Intervention Trial among Risky Drug Users on Health-related Quality of Life 
Drug and alcohol dependence  2014;0:254-261.
Background
Improvement in quality of life (QOL) is a long term goal of drug treatment. Although some brief interventions have been found to reduce illicit drug use, no trial among adult risky (moderate non-dependent) drug users has tested effects on health-related quality of life.
Methods
A single-blind randomized controlled trial of patients enrolled from February 2011 to November 2012 was conducted in waiting rooms of five federally qualified health centers. 413 adult primary care patients were identified as risky drug users using the WHO-ASSIST and 334 (81% response; 171 intervention, 163 control) consented to participate in the trial. Three-month follow-ups were completed by 261 patients (78%). Intervention patients received the QUIT intervention of brief clinician advice and up to two drug-use health telephone sessions. The control group received usual care and information on cancer screening. Outcomes were three-month changes in the Short Form Health Survey (SF-12) mental health component summary score (MCS) and physical health component summary score (PCS).
Results
The average treatment effect (ATE) was non-significant for MCS (0.2 points, p-value=0.87) and marginally significant for PCS (1.7 points, p-value=0.08). The average treatment effect on the treated (ATT) was 0.1 (p-value=0.93) for MCS and 1.9 (p-value=0.056) for PCS. The effect on PCS was stronger at higher (above median) baseline number of drug use days: ATE=2.7, p-value=0.04; ATT=3.21, p-value=0.02.
Conclusions
The trial found a marginally significant effect on improvement in PCS, and significant and stronger effect on the SF-12 physical component among patients with greater frequency of initial drug use.
doi:10.1016/j.drugalcdep.2014.06.034
PMCID: PMC4127148  PMID: 25042213
Primary care clinics; Illicit drug use; Screening; Brief intervention; Quality of life
8.  A Self-Report Measure of Clinicians' Orientation toward Integrative Medicine 
Health Services Research  2005;40(5 Pt 1):1553-1569.
Objective
Patients in the U.S. often turn to complementary and alternative medicine (CAM) and may use it concurrently with conventional medicine to treat illness and promote wellness. However, clinicians vary in their openness to the merging of treatment paradigms. Because integration of CAM with conventional medicine can have important implications for health care, we developed a survey instrument to assess clinicians' orientation toward integrative medicine.
Study Setting
A convenience sample of 294 acupuncturists, chiropractors, primary care physicians, and physician acupuncturists in academic and community settings in California.
Data Collection Methods
We used a qualitative analysis of structured interviews to develop a conceptual model of integrative medicine at the provider level. Based on this conceptual model, we developed a 30-item survey (IM-30) to assess five domains of clinicians' orientation toward integrative medicine: openness, readiness to refer, learning from alternate paradigms, patient-centered care, and safety of integration.
Principal Findings
Two hundred and two clinicians (69 percent response rate) returned the survey. The internal consistency reliability for the 30-item total scale and the five subscales ranged from 0.71 to 0.90. Item-scale correlations for the five subscales were higher for the hypothesized subscale than other subscales 75 percent or more of the time. Construct validity was supported by the association of the IM-30 total scale score (0–100 possible range, with a higher score indicative of greater orientation toward integrative medicine) with hypothesized constructs: physician acupuncturists scored higher than physicians (71 versus 50, p<.001), dual-trained practitioners scored higher than single-trained practitioners (71 versus 62, p<.001), and practitioners' self-perceived “integrativeness” was significantly correlated (r=0.60, p<.001) with the IM-30 total score.
Conclusion
This study provides support for the reliability and validity of the IM-30 as a measure of clinicians' orientation toward integrative medicine. The IM-30 survey, which we estimate as requiring 5 minutes to complete, can be administered to both conventional and CAM clinicians.
doi:10.1111/j.1475-6773.2005.00425.x
PMCID: PMC1361208  PMID: 16174147
Integrative medicine; complementary and alternative medicine; clinicians' orientation; reliability; validity
9.  Chronic disease management for recently homeless Veterans: a clinical practice improvement program to apply home telehealth technology to a vulnerable population 
Medical care  2013;51(3 0 1):S44-S51.
Background
Though vulnerable populations may benefit from in-home health information technologies (HIT) that promote disease self-management, there is a “digital divide” in which these groups are often unlikely to use such programs. We describe the early phases of applying and testing an existing Veterans Administration (VA) HIT care management program, Care Coordination Home Telehealth (CCHT), to recently homeless Veterans in the U.S. Department of Housing and Urban Development-VA Supportive Housing (HUD-VASH) program. Peers were used to support patient participation.
Methods
CCHT uses in-home messaging devices to provide health education and daily questions about clinical indicators from chronic illness care guidelines, with patient responses reviewed by VA nurses. Patients could also receive adjunctive peer support. We used medical record review, Veteran interviews, and staff surveys to “diagnose” barriers to CCHT use, assess program acceptability, explore the role of peer support, and inform future quality improvement.
Subjects
Fourteen eligible Veterans in HUD-VASH agreed to CCHT participation. Ten of these Veterans opted to have adjunctive peer support and the other four enrolled in CCHT usual care.
Results
Though barriers to enrollment/engagement must be addressed, this subset of Veterans in HUD-VASH was satisfied with CCHT. Most Veterans did not require support from peers to engage in CCHT but valued peer social assistance amidst the isolation felt in their scattered-site homes.
Conclusions
HIT tools hold promise for in-home care management for recently housed Veterans. Patient-level barriers to enrollment must be addressed in the next steps of quality improvement, testing and evaluating peer-driven CCHT recruitment.
doi:10.1097/MLR.0b013e31827808f6
PMCID: PMC3786687  PMID: 23407011
Homeless; disease management; peer support
10.  Race/ethnicity, parent-identified emotional difficulties, and mental health visits among California children 
Variability in mental health services utilization by race/ethnicity was evaluated with a Behavioral Model approach. Subjects were 17,705 children 5–11 years of age in the 2005, 2007, and 2009 California Health Interview Surveys. Parents identified minor emotional difficulties in 18.7% of these children (ranging from 14.8% in Asians to 24.4% in African Americans) and definite or severe difficulties in 7.4% (5.5% in Asians to 9.7% in ‘other race’). Overall, 7.6% of children had at least one mental health visit in the prior year (2.3% in Asians to 11.2% in African Americans). Parent-identified need was the most salient predictor of mental health visits for all racial/ethnic groups. Beyond need, no consistent patterns could be determined across racial/ethnic groups with regard to the relationship between contextual, predisposing, and enabling measures and mental health service utilization. Different factors operated for each racial/ethnic group, suggesting the need for studies to examine mental health need, mental health service use, and determinants by racial/ethnic subgroup. These findings suggest that a ‘one-size-fits-all-approach’ with regard to policies and practices aimed at reducing mental health disparities will not be effective for all racial/ethnic groups.
doi:10.1007/s11414-012-9298-7
PMCID: PMC3568225  PMID: 23070565
Mental health services; children; access to care; Behavioral Model of Health Services Utilization; race; California Health Interview Survey
11.  Prevalence, Distribution, and Correlates of Hepatitis C Virus Infection Among Homeless Adults in Los Angeles 
Public Health Reports  2012;127(4):407-421.
SYNOPSIS
Objective
We documented the prevalence, distribution, and correlates of hepatitis C virus (HCV) infection among urban homeless adults.
Methods
We sampled a community-based probability sample of 534 homeless adults from 41 shelters and meal programs in the Skid Row area of downtown Los Angeles, California. Participants were interviewed and tested for HCV, hepatitis B, and HIV. Outcomes included prevalence, distribution, and correlates of HCV infection; awareness of HCV positivity; and HCV counseling and treatment history.
Results
Overall, 26.7% of the sample tested HCV-positive and 4.0% tested HIV-positive. In logistic regression analysis, independent predictors of HCV infection for the total sample included older age, less education, prison history, and single- and multiple-drug injection. Among lifetime drug injectors, independent predictors of HCV infection included older age, prison history, and no history of intranasal cocaine use. Among reported non-injectors, predictors of HCV infection included older age, less education, use of non-injection drugs, and three or more tattoos. Sexual behaviors and snorting or smoking drugs had no independent relationship with HCV infection. Among HCV-infected adults, nearly half (46.1%) were unaware of their infection.
Conclusions
Despite the high prevalence of HCV infection, nearly half of the cases were hidden and few had ever received any HCV-related treatment. While injection drug use was the strongest independent predictor, patterns of injection drug use, non-injection drug use, prison stays, and multiple tattoos were also independent predictors of HCV. Findings suggest that urgent interventions are needed to screen, counsel, and treat urban homeless adults for HCV infection.
PMCID: PMC3366378  PMID: 22753984
12.  Impact of Hepatitis B and C Infection on Health Services Utilization in Homeless Adults: A Test of the Gelberg-Andersen Behavioral Model for Vulnerable Populations 
Health Psychology  2011;31(1):20-30.
Objective
Homeless people have disproportionately high rates of viral hepatitis. The Gelberg-Andersen Behavioral Model for Vulnerable Populations (predisposing, enabling, and need variables) was expanded to predict prevalence and awareness of hepatitis B (HBV) or hepatitis C (HCV) infection as well as health services utilization (HSU) among homeless adults using structural equation modeling.
Design
A population-based sample of 534 homeless adults in Los Angeles’ “Skid Row” was interviewed and tested for HBV and HCV.
Main outcome measures
HBV/HCV seropositivity, awareness of seropositivity, and HSU in the previous 12 months.
Results
Seropositivity (43%), usually unknown (72% of seropositives), was predicted by injection drug use, alcohol use, older age, and risky sexual behavior. No regular source of care, risky sexual behavior, less case management, and greater age predicted not knowing one’s positive status. Health insurance, younger age, alcohol use, perceived bad health and more medical conditions predicted emergency room (ER) use; ER use was less likely among seropositives. Hospitalizations were predicted by more medical conditions and greater percentage of life homeless and were less frequent among African-Americans and males. Ambulatory visits were predicted by a regular source of care, case management, more education and perceived bad health; they were less likely among seropositives.
Conclusion
The Gelberg-Andersen Behavioral Model provided a useful guide for predicting HBV/HCV positivity as well as HSU in homeless adults. Most hepatitis-positives did not know their status and used health services less often than other homeless adults. More aggressive detection of hepatitis B and C among homeless adults is needed.
doi:10.1037/a0023643
PMCID: PMC3235541  PMID: 21574705
homeless adults; hepatitis; health services utilization; Gelberg-Andersen Behavioral Model for Vulnerable Populations
15.  Health and Health Care Disparities among Homeless Women 
Women & health  2010;50(8):719-736.
While disparities in health and health care between vulnerable (e.g., minorities, low income) and majority populations are well documented, less is known about disparities within these special populations that are large and diverse. Such knowledge is essential to determine the most needy within these generally needy populations and to plan interventions to reduce their health and health care disparities. With data from 1,331 women residing in Los Angeles County, in one of the largest, most comprehensive studies of the health of homeless women to date, we examined the health and health care disparities among homeless African American, Latina and white women. We further explored if race/ethnicity and other factors that predispose homeless women to poor health or enable them to obtain better health care were associated with their unmet need for medical care. We found that white, non-Latina women were more likely to report unmet need than African Americans and Latinas, and women suffering from drug abuse, violence, or depression were most in need of care. These findings should be considered in targeting and addressing the special needs of homeless women of different racial/ethnic groups.
doi:10.1080/03630242.2010.532754
PMCID: PMC3084601  PMID: 21170815
homeless women; disparities; health; health care
16.  Psychiatric Comorbidity and Mortality among Veterans Hospitalized for Congestive Heart Failure 
Military medicine  2010;175(10):732-741.
A Behavioral Model of Health Services Utilization approach was used to examine the impact of comorbid mental illness on mortality of veterans admitted to Veterans Affairs Medical Centers in fiscal year 2001 with a primary diagnosis of congestive heart failure (n= 15,497). Thirty percent had a psychiatric diagnosis, 4.7% died during the index hospitalization and 11.5% died during the year following discharge. Among those with mental illness, 23.6% had multiple psychiatric disorders. Multivariable logistic regression models found dementia to be positively associated with inpatient mortality. Depression alone (excluding other psychiatric disorders) was positively associated with one-year mortality. Primary care visits were associated with a reduced likelihood of both inpatient and one-year mortality. Excepting dementia, VA patients with a mental illness had comparable or higher levels of primary care visits than those having no mental illness. Patients with multiple psychiatric disorders had more outpatient care than those with one psychiatric disorder.
PMCID: PMC3131142  PMID: 20968262
17.  Self-Reported Utilization of Eye Care among Latinos: The Los Angeles Latino Eye Study (LALES) 
Ophthalmology  2010;117(2):207-15.e1.
Purpose
To identify the prevalence and determinants of self-reported eye care utilization in Latinos.
Design
Population-based ocular epidemiological study in Latinos age 40+ living in La Puente, California.
Participants
5,455 participants.
Methods
Univariate, multivariable and stepwise logistic regression analyses were conducted to identify predisposing, enabling and need variables associated with self-reported eye care utilization.
Main Outcome Measures
Prevalence of self-reported utilization: eye care visit, having had a dilated examination in the past 12 months, ever having had a dilated examination, and odds ratios for factors associated with self-reported utilization.
Results
Overall, 36% of participants reported an eye care visit and 19% reported having a dilated examination in the past year. Fifty-seven percent reported ever having had a dilated eye examination. Greater eye care utilization was associated with older age, female gender, bilingual language proficiency (English and Spanish), more education, having health insurance, having a usual place for care, having a regular provider of care, greater number of co-morbidities, visual impairment, and lower vision-specific quality of life scores.
Conclusions
Increasing utilization and access to eye care for Latinos should be a priority because visual impairment has significant impacts on well-being and mortality.
doi:10.1016/j.ophtha.2009.07.015
PMCID: PMC2835414  PMID: 20018380
Latino/Hispanic; Utilization; Eye Care; Vision; LALES
18.  Racial disparities in access to care for men in a public assistance program for prostate cancer 
Journal of community health  2008;33(5):318-335.
California’s IMPACT program provides all its enrollees with health insurance and social service resources. We hypothesized that racial/ethnic disparities in access to care might be attenuated among men served by this program. Our objective was to evaluate racial/ethnic differences in health services utilization and patient-reported health care outcomes among disadvantaged men in a prostate cancer public-assistance program, and to identify modifiable factors that might explain persistent disparities in this health care setting. We performed a retrospective cohort study of 357 low-income men enrolled in IMPACT from 2001 through 2005. We evaluated realized access to care with two health services utilization measures: (1) use of emergency department care without hospitalization and, (2) frequency of prostate-specific antigen testing. We also measured two patient-experience outcomes: (1) satisfaction with care received from IMPACT, and (2) confidence in IMPACT care providers. We observed significant bivariate associations between race/ethnicity and patient-experience outcomes (p<0.05), but not utilization measures. In multivariable models, Hispanic men were more likely than white men to report complete satisfaction with health care received in IMPACT (adjusted OR=5.15, 95% CI 1.17-22.6); however, the association between race/ethnicity and satisfaction was not statistically significant (p=0.11). Language preference and self-efficacy in patient-physician interactions are potentially-modifiable predictors of patient-experience outcomes. We observed no racial/ethnic disparities in health services utilization among disadvantaged men served by a disease-specific public assistance program. The greater satisfaction and confidence among Hispanic men are explained by modifiable variables that suggest avenues for improvement.
doi:10.1007/s10900-008-9105-9
PMCID: PMC2683352  PMID: 18496745
Prostate cancer; Low-income; Uninsured; Race/ethnicity; Disparities; Public assistance; self-efficacy
19.  Racial and Ethnic Disparities in Access to Physicians with HIV-related Expertise 
OBJECTIVE
Professional medical associations recommend that physicians who treat patients with human immunodeficiency virus (HIV) have a measurable form of disease-specific expertise, such as high HIV patient volume or infectious diseases certification. Although it is known that racial/ethnic minorities generally have worse access to care than do whites, previous work has not examined disparities in the use of physicians with HIV-related expertise.
DESIGN, SETTING, AND PARTICIPANTS
We linked data from a prospective cohort study of 2,207 persons with HIV receiving care in the United States with a cross-sectional survey of 404 physicians caring for them. Using multivariate analysis, we estimated the association of patient race/ethnicity with the experience and training of their physicians, controlling for health status, socioeconomic status, demographic characteristics, and geographic variation in provider supply.
RESULTS
Compared with white patients, African Americans were less likely to have an infectious diseases specialist as a regular source of care (odds ratio [OR], 0.60; 95% confidence interval [CI], 0.37 to 0.95). Persons of Alaskan Native, American Indian, Asian, Pacific Islander, or mixed racial background were also less likely than whites to have an infectious diseases specialist (OR, 0.44; 95% CI, 0.23 to 0.83). Conversely, Latino patients had physicians whose HIV patient volume was, on average, 24% higher than the physicians of white patients (incident rate ratio, 1.24; 95% CI, 1.03 to 1.50).
CONCLUSIONS
Some groups of racial/ethnic minorities are less likely than are whites to have infectious diseases specialists as a regular source of care. The finding that the physicians of Latino patients had relatively higher HIV caseloads suggests that this particular patient subpopulation has access to HIV expertise. Further work to explain racial/ethnic differences in access to physicians will help in the design of programs and policies to eliminate them.
doi:10.1111/j.1525-1497.2005.40109.x
PMCID: PMC1490084  PMID: 15836534
race/ethnicity; health services accessibility; specialty care; physicians
20.  Disparities in HIV Treatment and Physician Attitudes About Delaying Protease Inhibitors for Nonadherent Patients 
BACKGROUND
Current HIV treatment guidelines recommend delaying antiretroviral therapy for nonadherent patients, which some fear may disproportionately affect certain populations and contribute to disparities in care.
OBJECTIVES
To examine the relationship of physician's attitude toward prescribing protease inhibitors (PIs) to nonadherent patients with disparities in PI use and with health outcomes.
DESIGN
Prospective cohort study.
PATIENTS AND SETTING
A national probability sample of HIV-infected adults in the United States and their health care providers was surveyed between January 1996 and January 1998. We analyzed data on 1,717 patients eligible for PI treatment and the 367 providers who cared for them.
MEASUREMENTS
Providers’ attitude toward prescribing PIs to nonadherent patients, time until patients’ first receipt of PIs, mortality, and physical health status.
MAIN RESULTS
Eighty-nine percent of providers agreed that patient adherence is important in their decision to prescribe PIs (Selective) while 11% disagreed (Nonselective). Patients who had a Selective provider received PIs later than those with a Nonselective provider (P = .05). Adjusting for patient demographics and health characteristics and provider demographics, HIV knowledge, and experience, Latinos, women, and poor patients received PIs later if their provider had a Selective attitude but as soon as others if their provider had a Nonselective attitude. African-American patients received PIs later than whites, irrespective of their providers’ prescribing attitude. Patients with Selective providers had similar odds of mortality than those with Nonselective providers (odds ratio, 1.1; 95% confidence interval, 0.6 to 2.0), but had slightly worse adjusted physical health status at follow-up (49.1 vs 50.4, respectively; P = .04), after controlling for baseline physical health status and other patient and provider covariates.
CONCLUSIONS
Most providers consider patient adherence an important factor in their decision to prescribe PIs. This attitude appears to account for the relatively later use of PI treatment among Latinos, women, and the poor. Given the rising HIV infection rates among minorities, women, and the poor, further investigation of this treatment strategy and its impact on HIV resistance and outcomes is warranted.
doi:10.1111/j.1525-1497.2004.30429.x
PMCID: PMC1492193  PMID: 15061746
African Americans; health services accessibility; HIV; Latinos; patient compliance
21.  Health Care for Homeless Women 
OBJECTIVE
Homelessness is a significant and growing problem in the United States. Women and families are the fastest growing segments of the homeless population. Homelessness increases the risk of having health problems and encountering barriers to care. This study determines how much perceived unmet need for medical care there is among homeless women, what homeless women perceive to be barriers to health care, and how barriers and other factors are associated with unmet needs.
DESIGN
Cross-sectional study of homeless women, utilizing structured interviews.
SETTING AND PARTICIPANTS
Community-based probability sample of 974 homeless women aged 15 to 44 years.
MAIN OUTCOME MEASURES
Perceived unmet need for medical care in the past 60 days. Relationship between unmet need and demographic variables, place of stay, source of health care, insurance, and perceived barriers to care.
RESULTS
Of the 974 women, 37% reported unmet need for medical care. Controlling for other factors, the odds of unmet need were lower among those with a regular source of care (odds ratio [OR] to .35, 95% confidence interval [CI], .21 to 58), while having health insurance was not significantly associated. The odds of unmet need were higher among those who experienced the barriers: not knowing where to go (OR 2.27, 95% CI, 1.40 to 3.69), long office waiting times (OR 1.89, 95% CI 1.27 to 2.83) and being too sick to seek care (OR 2.03, 95% CI, 1.14 to 3.62).
CONCLUSIONS
There is significant unmet need for medical care among homeless women. Having a regular source of care was more important than health insurance in lowering the odds of unmet need. Homeless women must be educated regarding sources of care, and clinics serving the homeless must decrease waiting times.
doi:10.1046/j.1525-1497.2003.20909.x
PMCID: PMC1494940  PMID: 14687278
barriers; homeless; unmet need; vulnerable population; women
22.  Use of faith-based social service providers in a representative sample of urban homeless women 
There are few quantitative studies on the characteristics of homeless persons who use faith-based social service providers. To help address the lack of information in this area, we analyzed survey data on 974 participants in the University of California at Los Angeles (UCLA) Homeless Women’s Health Study, a representative sample of homeless women at shelters and meal programs in Los Angeles County. The primary objective of this analysis was to estimate the association of religious affiliation, race/ethnicity, income, and other client characteristics with the use of faith-based programs. In interviews at 78 homeless shelters and meal programs, study respondents provided information about their religious affiliation and other social and demographic characteristics. The names of the organizations were examined, and those with names that referenced specific religions or contained words connoting religiosity were designated as “faith based”. At the time they were selected for study participation, 52% of respondents were using the services of faith-based providers. In multivariate logistic regression analysis, lower odds of using these providers were estimated for participants with no religious affiliation (compared with Christian respondents) and for African Americans and Latinas (compared with whites). There is evidence of systematic differences between the clients of faith-based and secular social service providers. The benefits of increased funding through a federal faith-based policy initiative may accure primarily to subgroups of clients already using faith-based programs.
doi:10.1093/jurban/jtg051
PMCID: PMC3455976  PMID: 12930877
Homelessness; Policy; Religious beliefs; Social work; Utilization; Women
23.  Tuberculosis Skin Testing Among Homeless Adults 
OBJECTIVE
To document the prevalence of tuberculosis (TB) skin test positivity among homeless adults in Los Angeles and determine whether certain characteristics of homelessness were risk factors for TB.
DESIGN
Cross-sectional study.
SETTING
Shelters, soup lines, and outdoor locations in the Skid Row and Westside areas of Los Angeles.
PARTICIPANTS
A representative sample of 260 homeless adults.
MEASUREMENTS AND MAIN RESULTS
Tuberculosis tine test reactivity was measured. The overall prevalence of TB skin test positivity was 32%: 40% in the inner-city Skid Row area and 14% in the suburban Westside area. Using multiple logistic regression, TB skin test positivity was found to be associated with living in crowded or potentially crowded shelter conditions, long-term homelessness, geographic area, history of a psychiatric hospitalization, and age.
CONCLUSIONS
Homeless adults living in congested inner-city areas are at high risk of both latent and active TB. Endemic risk factors and limited access to medical care support the need for aggressive treatment of active TB cases and innovative programs to ensure completion of prophylactic regimens by homeless individuals with latent infection.
doi:10.1046/j.1525-1497.1997.12101.x
PMCID: PMC1497050  PMID: 9034943
tuberculosis; homeless persons; screening
24.  Impact of municipal health services Medicare waiver program 
Health Care Financing Review  1987;8(3):13-25.
A major goal of the municipal health services program (MHSP) was improvement of health services for the elderly while containing Medicare reimbursement. A Health Care Financing Administration financed Medicare waiver program provided some additional benefits to Medicare Part B enrollees who used the MHSP clinics. Disadvantaged and sicker elderly groups were underrepresented in MHSP facilities. However, even after taking these differences between MHSP and other patients into account, analyses of Medicare records showed that participants in this program had lower reimbursement for hospital inpatient, outpatient, and emergency room services. Also, participants had higher reimbursements for physicians' ambulatory and ancillary care. The net result was total Medicare reimbursements were decreased for program participants.
PMCID: PMC4192844  PMID: 10312113

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