Access to Care and Factors that Impact Access, Patients as Partners in Care and Changing Roles of Health Providers: Volume 29

This chapter provides an introduction to Volume 29, Health-Care Delivery and Reform: Roles of Patients and Providers. This chapter discusses the topic of health-care systems and health-care reform from an American perspective and also focuses on the roles of patients and providers and how recent sociological literature examines some of these issues. It also serves as an introduction to the volume. It explains the organization of the volume and briefly comments on each of the chapters included in the volume.

This chapter examines the process by which men enter registered nursing. Research on men's entrance into atypical fields has looked at either motivational or career paths differences between men and women. I integrate these approaches by examining how men's prior work experience influences their subsequent career decisions and motivations. I find that men who are nurses are more likely to have had a prior health-care job, and this exposure helps them to recast nursing from a “female-only” job to an acceptable career choice. This reorientation job experience is a way for men to overcome informal barriers of “social control” (Jacobs, 1989) to entering a female-dominated occupation. These findings have implications for current efforts by many states and organizations that seek to expand the registered nursing workforce.

Over 3 million intermittently employed and socially disadvantaged workers receive low wages and limited benefits in diverse long-term care settings and employment arrangements as they try to become a positively valued unified occupation: “direct care workers.” Before this occurs, these workers must overcome negative definitions imposed by three powerful institutions: professional guilds, employers, and states. Care workers’ legitimacy is challenged as nursing labels them “unlicensed, assistive personnel,” defining them in terms of their task relationship to nurses rather than their social relationship to clients. Care workers’ identity is obscured as corporate rationalization nullifies their unique contributions with task unbundling, part-time work, short staffing, and turnover undermining bonding with colleagues and clients. State regulation impedes care workers’ integration, segmenting similar workers under different regulatory regimes, defining workers negatively rather than by their educational attainments and competencies. Overcoming this triple negation will require not just cultural change, but also real structural changes, and can occur only through concerted actions involving coalitions. Labor market intermediaries, public authorities, labor unions, workforce investment boards, philanthropic organizations, and government interagency groups are among those supporting direct care workers’ advancement by strategically coordinating licensing, purchasing, and developing the workforce. Recent federal policy changes and health reform legislation have enhanced recognition of this occupation and are providing new resources for its development.

In an effort to address health care disparities, U.S. laws mandate that health care organizations provide free language interpreting and translation anytime a patient and health care provider cannot communicate in the same language. The heretofore absence of legislative and professional oversight in health care interpreting allows for anyone to interpret. A qualitative study was conducted to understand the conditions and practices of bilingual staff who interpret as a secondary part of their job in community health clinics.

Four focus groups were conducted as part of a study on shared decision-making during interpreted medical visits in a busy, urban clinic serving a large number of limited English proficient (LEP) patients. The focus groups were designed to understand the process of interpreting and how interpreters influence medical decisions between LEP patients and their health care providers. To understand the interpreting process from multiple perspectives, one focus group was conducted with users of interpreters – monolingual health care providers (N=6), two with Spanish speaking men (N=10) who were experienced with interpreted health visits, and one with bilingual staff (N=5) who interpret as an ad hoc feature of their job, also known as dual-role medical interpreters.

Dual-role interpreters use different styles while interpreting what is communicated between health care providers and patients. In some cases, they provide near word-for-word interpretation of what is said. In other cases, they summarize and or paraphrase multiple sentences, seek clarity through questions, and deconstruct culturally laden and technical terms. In still other cases, dual-role interpreters combine interpretation styles within a single interactional exchange. Each of the three major styles of interpreting has advantages in medical settings. Specific style is influenced by health care provider preference, interpreter–health care provider trust and familiarity, and interpreter medical knowledge. Interpreters are challenged by the patients’ dialects, educational level, provider personalities, gender issues, and out of clinic relationships with the patients. Contextual conditions and contingencies of reinforcement contributed to varying methods of interpretation. These conditions included organizational policies, language and bilingual communication, and social relations with both the health care providers and the patients.

These findings demonstrate the complexity of medical interpretation and the critical involvement of health care providers and bilingual staff in facilitating interpreted encounters. Findings suggest the need for training both health care providers and interpreters and possible change in reimbursement for services.

Contemporary categorizations of western-style welfare states distinguish a particular pattern of organizing social security mainly found in Scandinavian countries, and sometimes labeled as a “social democratic welfare regime.” This is characterized by general access of the population to a social security system organized and administered by public authorities. This categorization is widely acknowledged, but the Scandinavian “social democratic” model is rarely ever analyzed in detail.

While most health services are provided by public actors, it is often overlooked that health services in Scandinavian countries in certain fields are delivered to a substantial part by private actors. In Norwegian rehabilitation specialist health care, these private actors stand for more than 30% of all service delivery.

Based on a content analysis of publications of the Norwegian Ministry of Health and Care Services we look into the relation between public and private actors in rehabilitation and relate our findings to classifications of Scandinavian welfare states into an institutional, social democratic model.

Health care services are typically viewed as institutions or agencies offering professional care or care supervised by professionals. The concept of availability of health care services involves the degree to which persons can readily find professional care. Few scholars have considered the relevance of these notions to life-circumstances of older homebound women who experience emergent situations (ES) at home such as falls, unintentional injuries, or health problems. During a larger descriptive phenomenological study of the experience of reaching help quickly, 33 of 40 homebound women, aged 85–98 years, who were living alone, reported 57 situations of interest during open-ended interviews over 18 months. The purposes of this facet of the study were (a) to describe the life-world of women who had fortuitous help with ES at home, (b) to categorize helpers involved, and (c) to elaborate the reported influence of such situations on recognizing the risk of being unable to reach help quickly in the future. Life-world was featured by having help right now from someone on the scene. We categorized involved helpers into six types, including four previously identified types of home care helpers as well as (a) “on-the-spot” helpers, acquaintances not among the woman's home care helpers and (b) “at-this-scene-only” helpers, who were not likely to encounter the woman afterwards. In these ES, the home – not the health care institution – was the setting. On-the-scene helpers served as critical health care resources. In contrast to the typical focus on availability of health care services in a public space, availability of on-the-scene helpers in the home, a private space, was critical to the well-being of these old homebound women. This work raises new notions about availability of health care services for older homebound women and offers new perspectives on the key support network concepts of proximity and frequency of contact.

Using data from the General Social Survey (2002), structural equation modeling is employed to examine the intersections and relationships between various socio-demographic and contextual variables, patient trust, and patient preference for behaviors that indicate a desire to be an active health care participant. In so doing, a gap in the literature is addressed by uniting previous research on patient trust with research on patient participation. Findings reveal that patient trust in doctors and various socio-demographic and contextual variables are associated with people wanting to participate in the health care process by learning about medical issues on their own and by contributing to medical decisions. Results also shed new light on past research, which finds a relationship between various socio-demographic variables and patient trust. Specifically, they highlight the importance of distinguishing between patient trust in doctors and patient trust in the broader health care institution and the economic pressures it exerts on doctors. A discussion of what these findings might mean for our understanding of the doctor-patient relationship and the delivery of health care concludes the chapter.

This chapter discusses challenges faced by older adult health-care consumers in obtaining access to responsive care from physicians relevant to a broad spectrum of health issues ranging from prevention to chronic illness and end-of-life care. Based on our prior research with community-dwelling elders (E. Kahana & B. Kahana, 2003, 2010), we propose a conceptual model of consumer self-advocacy for better access to effective health care in late life. We argue that older adults who are well informed and confident health-care partners and who involve their physicians in active dialogue will experience better care, and will be more satisfied with their health care. We present findings from our studies of cancer prevention and from our research focused on end-of-life care relevant to patient self-advocacy. We also discuss the role of educational interventions and of patient empowerment in facilitating greater access to responsive health communication and health care, particularly among elders who are disadvantaged and who have low health literacy.

With an aim to investigate the recent state of the feminist clinics and their negotiation of medical authority in a time of increased technoscientific biomedicalization, and capitalistic health-care system, I conducted a study of two feminist health centers in the Northeast of the United States in 2001–2002. In this chapter, I discuss how the two centers (a nonprofit collective and a for-profit center with a more hierarchical structure) negotiated medical authority in organizational terms as impacted by the larger context of medicine and its interaction with the state, capitalist health-care system, and antiabortion forces. The chapter concludes with a discussion of demedicalization as a multilevel process and implications for feminist care (service delivery) and U.S. Women's Health Movement.

Privatization as a general policy was introduced into Malaysia in the 1980s. Subsequently, selected elements of the public health-care system were privatized. This chapter analyzes the effects of privatization on the health-care system in terms of both intended and unintended consequences. The outflow of experienced specialist doctors from the public sector to the private sector and the emergence of a two-class system of health care in Malaysia have been major unintended consequences of privatization.

This study evaluates whether sociodemographic characteristics, political affiliation, family-related circumstances, self-reported health status, and access to health insurance affect public opinion toward the current US health-care system. Opinions about the health-care system were measured in terms of consumer confidence and perceived need for health-care reform. Data come from the 2008 Cooperative Congressional Election Study (CCES), a nationwide survey of 1,000 respondents. All data were collected in November 2008, thus providing a useful alternative to volatile polling data because they were collected prior to and are thus immune to the polarized tone of the debates that have occurred over the past few years. Overall, we found that public confidence in medical technology and quality of care were consistently high, while confidence in the affordability of medical care was much lower among respondents. Younger adults, those with poor health, and those without health insurance had particularly low confidence in their ability to pay for health care. Although a strong majority of the population agreed that the US health-care system was in need of major reform, support for particular types of government-sponsored health insurance programs was primarily determined by political affiliation. In an era where a large proportion of the population has little access to health care (due to lack of insurance) and where the US government is facing tremendous opposition to the implementation of major reform efforts, it is useful to understand which subgroups of the population are most confident in the current health-care system and most likely to support reform efforts, as well as those who are most resistant to change given their precarious health needs, their inability to access health care (as a result of insurance or noninsurance), or their political affiliation.

Disparities in access to health services continue to exist among adults age 65 and older in the United States despite near-universal insurance coverage provided through Medicare. One potential barrier to health service utilization is knowledge of health insurance coverage. Medicare has been drastically restructured in the recent past, and as the program becomes increasingly privatized, Medicare enrollees are left with more choices, but also a more complicated system through which to navigate. This study examines the relationship between Medicare enrollee knowledge of their Medicare health insurance and sociodemographic factors, health status, and the use of health services. Data was analyzed from the National Health Interview Survey (NHIS), a nationally representative study of the U.S. civilian, non-institutionalized, household population. Included in this study were Black, Hispanic, and White respondents aged 65 and older who participated in the NHIS from 2004 to 2009 (N=30,002). The prevalence of a lack of Medicare knowledge appears to be low among Medicare enrollees, with 13% reporting they did not know the answer to one or more questions about their coverage. Age and chronic illness status were found to be related to Medicare plan knowledge, with older adults and those who were not chronically ill more likely to report they did not know some aspect about their Medicare plan. Respondents who reported not knowing at least one question about their Medicare plan reported significantly fewer medical office visits and more time since they last interacted with a doctor, were less likely to have talked with a medical specialist, and have had surgery over the past year. The findings from this study suggest that knowledge of health insurance coverage is an important correlate of health service utilization, which may be shaped by disparities in access to health insurance across the life course.