A Nonrecursive Causal Model of the Health Care Delivery System*

The phrase “health care delivery system” is often used in both the popular and scientific literature. However, most research only examines one aspect of the system. We specify a causal system that links client characteristics and the structure, process, and outcomes of medical care. We also specify reciprocal effects among three outcomes of medical care: health status, client satisfaction, and visiting the docior. For each effect, we test a medical model hypothesis and two critiques of the medical model; a moderate critique and a radical critique.     

Health Care of American Indian Elderly: Determinants of the Perceived Difficulty Obtaining Access to Health Care

This study examines the perceived areas of difficulty in obtaining access to health care and the factors influencing that difficulty among elderly American Indians in a rural environment. One hundred thirty-seven elderly Indians in the Ponca and Pawnee tribes of Oklahoma were interviewed. Four major difficulties are reported: a long waiting period at Indian health centers, difficulty in making appointments to see physicians, language and cultural barriers to communication with the health care providers, and lack of available transportation. The long waiting period is the most serious problem, and lack of transportation is the least serious. The results of probit analysis show that physical health, automobile ownership, education, employment, and the presence of an informal caregiver are related to difficulty obtaining access to health care. Ways to minimize this difficulty are discussed.     

A Theory of Access*

Abstract The term “access” is frequently used by property and natural resource analysts without adequate definition. In this paper we develop a concept of access and examine a broad set of factors that differentiate access from property. We define access as “the ability to derive benefits from things,” broadening from property's classical definition as “the right to benefit from things.” Access, following this definition, is more akin to “a bundle of powers” than to property's notion of a “bundle of rights.” This formulation includes a wider range of social relationships that constrain or enable benefits from resource use than property relations alone. Using this framing, we suggest a method of access analysis for identifying the constellations of means, relations, and processes that enable various actors to derive benefits from resources. Our intent is to enable scholars, planners, and policy makers to empirically “map” dynamic processes and relationships of access.     

Young African American Males: Barriers to Access to Health Care

African American males continue to experience an unacceptable and disproportionate number of health disparities when compared with other racial and ethnic groups. Young African American males can expect to live the least amount of time when compared to any other ethnic minority or racial sub-group. Understanding the obstacles and barriers that impede access to health care and wellness services among young African American males is essential to begin the process of decreasing health disparities. The goal of this qualitative study was to explore and identify the barriers experienced by young African American males in accessing health care services while also creating a rare opportunity to give voice to young African American males. The study results indicate that young African American males have multiple perceptions of barriers to health care services. Their perceptions fell into three categories: the negative impact of environment or community, lack of finances or no insurance, and distrust of medical practices associated with race history resulting in accessing healthcare as a last resort. Additional research is needed to craft community-based programs to: a) educate young African American males on the importance of preventative strategies to maintain wellness; and b) ensure that the appropriate medical and wellness services are available and reaching young African American males in need.     

Professional Identity for Clinical Social Workers: Impact of Changes in Health Care Delivery Systems

The recent rapid changes in funding and delivery of mental health services have impacted professional identity for social workers. A study of 127 clinical social workers in 3 different practice settings explored the sense of fit between personal and professional values: How much are they in concert and how much are they in conflict? Social workers described values in their own words. The sense of strain between values varied according to workplace setting. Implications for theory, research, practice, and training are discussed.     

Closing the Loophole: A Case Study of Organizing for More Equitable and Affordable Access to Health Care in San Francisco

This paper presents in-depth case study of a successful hybrid political and community organizing campaign to ensure equitable access to health care through the perspective of a grassroots San Francisco community-based organization, the Chinese Progressive Association (CPA), which has been organizing low-income Chinese immigrants for over four decades. First, it outlines the Health Care Security Ordinance (HCSO), which, since its passage in 2006, has established a near-universal health care access program, helping to make health care accessible and affordable to individuals living and working in San Francisco. Then it presents the campaign to save the HCSO, focusing on CPA’s participation in the HCSO coalition. Finally, it discusses health care as it relates to the San Francisco’s affordability crisis and the political economic context in which it is taking place. Despite the limitations inherent in small case studies like this one, it nevertheless provides a valuable opportunity to better understand how one politically progressive city attempted to address the problem of grossly inequitable health care access through the lens of community organizing, advocacy, and coalition building. San Francisco, like many major American cities today, is being confronted with rapid gentrification and growing economic inequality—the backdrop to the HCSO. Through innovative experiments in social responsibility like the HCSO, however, the city has made leaps in health care access. It concludes with lessons learned from local organizing and advocacy to save the HCSO as these may inform other local efforts to promote health care for all.     

A New Model for Long-Term Care: Balancing Palliative and Restorative Care Delivery

ABSTRACT

Nursing homes have been mandated to maintain or promote the physical and psychological functioning of residents since the enactment of the 1987 Omnibus Reconciliation Act. Although this restorative approach to care has improved outcomes for some residents (Institute of Medicine, 2001 Institute of Medicine. 2001. Improving the quality of long term care, Washington, DC: National Academy Press.  [Google Scholar]), it ignores the reality that all permanently placed residents will die. A new model for long-term care, one that includes a simultaneous restorative and palliative approach to care delivery, is proposed. Palliative care principles provide a guiding framework for changing care delivery. Basic tenets, such as resident and family viewed as a unit of care, interdisciplinary teamwork, and interdisciplinary plans of care, provide a basis for specific operational suggestions. Operational strategies, such as psychosocial and spiritual support for family, resident decision making and participation in goal setting, expertise in aggressive pain and symptom control, and bereavement services following resident death, are described.     

Dissociation in Medical Practice: Social Distress and the Health Care System

The average physician has developed several different headv, each representing another selfon the same body. One is that ofthe conventional, ethical professional who wants nothing more than to improve mankind’s health and well-being, the standard model. Another is the scientist who intends to be perceived as calculating, cold, and factual in determining what will or will not assist the ailing patient (Uexkull & Hannes, 1986). His tools are drugs, surgery, and hospitalization for presumed physical and mental ills. The third, and the one that concerns us the most, is what I will call “the neo-capitalist professional hero” (Lifton, 1971). This persona is an evolution of our American dominated internationaL cuLture which the medical profession as a group has honored by honing and poli5hing with extraordinary skil, second only to politicians and bankers, maximizing it to the ftuther detriment of the entire society. Though the body needv all three to function, none of these heads willingly acknowledges or suppOl1s the importance of the others. In what follows, a variety of media, journals, professional books, and a survey are refen"ed to in documenting data about ethical Laxity and fraud in the medical profession. Institutional, social concepts are developed that explain the data, and revealing how sociaL distress is the embodiment of the neo-capitalist professional hero. There are also suggestions for remedies in what follows, which are presented without realistic hope for implementation very soon, unfortunately, since they involve deep changes in established sociaL institutions. However, the country at large has developed some awareness of a problem which has reached epidemic propOrlions in the medical profession. FUrlher increments in awareness promise to tip the balance into positive government action.     

Contradiction and Change of Performance Expectations*

L'auteur propose deux hypotheses pour justifier le fait que les anticipations de ? performance ? changent lorsqu'elles sont mises en présence de faits objectifs qui les contredisent. On peut prédire que ce changement dans les anticipations evolue en fonction de la variété et du niveau des contradictions. Le cas de celui dont les attentes pour soi sont inferieur aux attentes pour les autres est utilise pour des fins expérimentales de verification des hypothèses. A la fin de l'article l'auteur apporte des suggestions dans le but d'améliorer l'arrière-plan théorique des hypothèses. Two hypotheses are proposed on the way specific performance expectations change when confronted with objective evidence that contradicts them. The change in expectations is predicted to be a function of the number and the degree of the contradictions they receive. The case of initial lower expectations for self than for other is used in an experimental test of the hypotheses, and these are confirmed by the results of the test. Some suggestions for the refinement of the hypotheses' theoretical background are discussed at the end.     

Disparities in Access to Health Care Among Middle-Aged and Older Adults with Disabilities

Disability is increasing among middle-aged adults and, reversing earlier trends, increasing among older adults as well. Disability is experienced disproportionately by Black and lower socioeconomic status (SES) individuals. We used Medical Expenditure Panel Survey data to examine health care disparities in access to health care for middle-aged (31 to 64 years of age) and older (65+ years of age) adults with disabilities by race and ethnicity, education, and income (n = 13,174). Using logistic regression, we examined three measures of potential (e.g., usual source of care), and three measures of realized (e.g., counseling related to smoking) access. Middle-aged and older minority individuals with disabilities had lower relative risks of having usual sources of care and higher relative risks of having suboptimal usual sources of care (e.g., a place rather than a person) than White adults with disabilities. There were SES effects observed for middle-aged adults with disabilities across most measures that were, for certain measures, more pronounced than SES effects among older adults with disabilities. These findings are important, since health resources (e.g., a usual source of care) may mediate relations among disability, morbidity, and mortality. Policy actions that may mitigate the disparities we observed include financial incentives to support access to an optimal usual source of care and mechanisms to foster behavioral interventions related to smoking and exercise. Ensuring that these actions address the specific concerns of individuals with disabilities, such as physical accessibility and provider cultural competency, is essential.     

Aged Care Service Delivery in Japan

Summary

The implementation of Japan's Long-Term Care Insurance Scheme in early 2000 presaged many changes in service delivery and much debate among service providers, different levels of government, academic analysts, and major media interests. The first part of this paper gives an account of the major changes in the organization of service delivery that have increased opportunities for private sector providers, including large corporations, and restructured contractual relationships between municipalities and providers in all sectors. New arrangements for client assessment, classification, care management, and extended service types are then outlined. An assessment is then made of the likelihood that the expected outcomes of the scheme will be realized, with the concerns of welfare professionals that the public welfare system is under threat juxtaposed with bureaucratic goals of liberalizing the provision of long-term care.     

Beyond White Pride: Identity,Meaning and Contradiction in the Canadian Skinhead Subculture*

Partant de l'approche culturelle de l'analyse des sous-cultures observées chez les jeunes, cette enquête sur le terrain menée dans une ville de l'Ouest canadien examine les significations que nos sujets accordent à leur appartenance à un sous-groupe de skinheads qui se veut apolitique. Notre étude remet en cause une certaine image que l'on se fait du mouvement skinhead. En dépit des idées reçues qui véhiculent une apparente homogénéité, notre recherche montre que la sous-culture skinhead est à la fois complexe et multidimensionnelle et qu'elle offre à ses membres un choix de modèles de comportements et d'orientations idéologiques, même s'ils sont souvent contradictoires. Notre analyse suggèe aussi que, loin d'être profondément contestataires ou révolutionnaires, les groupes de skinheads peuvent constituer un instrument de reproduction des rapports sociaux, en particulier les rapports entre les sexes, les groupes raciaux et les ethnies. Grounded in a cultural studies approach to youth subcultures and based on participant observation in a Western Canadian city, this study examines the meanings associated with membership for participants in a self-described “non-political” branch of the skinhead subculture. Despite popular images that imply homogeneity, the study shows that the skinhead subculture is both complex and multi-dimensional and that it accommodates, albeit in often contradictory ways, a range of behavioural and ideological opportunities for its members. The study also suggests that, far from being resistant or transformative in any significant way, skinhead groups may represent a vehicle for social reproduction, specifically with respect to gender, race and ethnicity.     

Social Work in Health Care: A Guide to Professional Practice

Abstract

This article describes the evolution of a research program across 18 PhD dissertations over a period of eleven years. Included in this paper is a discussion of the advantages and disadvantages of student and field participation in thematic experimental research. The essential steps in the development of a set of related dissertations also are described. The guidelines for constructing the true experiment as dissertation are outlined. Attention is paid to the resources required to carry out thematic research and the specific ways in which such dissertations have been funded. Characteristics of those students who can best avoid such an approach to a dissertation are examined. Finally the author looks at the product of these dissertations and dissertators in terms of contribution to knowledge, the creation of practitioner manuals for practice interventions, the formation of practice-research faculty, research productivity of these faculty, and the development of the dissertator's clinical skills.     

Suicidal Ideation in the Palliative Care Patient: Considerations for Health Care Practice

In the present study, I outline how four social workers, with experience in working with women who self-starve, commonly known as anorexia nervosa, conceptualise this phenomenon. I conducted single, in-depth interviews with each worker and feminist discourse analysis was chosen as the method of text interpretation. Alternative (non-psychiatric) ways of understanding women's self-starvation were explicitly privileged. Hence, the alternative discourses of feminist and poststructural theories were used to design the research and analyse the data. The literature review outlines the historical ‘discovery’ of ‘anorexia nervosa’ as a discrete illness category. Contemporary and dominant ‘pathological’ perspectives and marginalised ‘cultural’ perspectives are presented. Three dominant themes emerged from the interviews. They were ‘control and perfection’, ‘femininity’ and ‘self-destruction/self-preservation’. These themes are presented, as are their critical implications for social work.     

A Study of Abortion and Problems in Decision-Making*

This paper is directed to people who, sufficiently disturbed by the complex realities of problem pregnancies, are prepared to think beyond the confines of ideology. It is a challenge to people who tend to reduce the problem of unwanted pregnancies either to “abortion on demand” or to “right to life” ideologies, thereby ignoring the relationship dynamics that impact, shape, and enable the process of decision-making with its implications for mutual caring and for long-term trust. Rebalancing the emphases on ideologies and individual rights, this article is multidirectional in approach. It surfaces a concern for the unborn fetus, for the woman and the man involved, and for future human relatedness in which the capacity for trust and accountability are actualized rather than forced to stagnate.     

The Structure of the Chinese Banking System and Credit Access Problems for SMEs

This paper examines the structure and the main characteristics of the Chinese banking industry. In particular, the paper analyses the problematic aspects of credit relations of small and medium enterprises (SMEs). The SMEs are facing several problems in accessing the bank loans market, dominated by the political and contractual weight of state-owned enterprises. However, some recent reforms have improved the situation, a fundamental condition for additional positive results. Nevertheless, further and more pervasive modernization efforts are needed to consolidate these results and to develop the relationships between banks and SMEs.

The Problems for Academic and Entrepreneurial Research in the Use of Health Services: the Case of Unstable Structural Relationships*

Multiple regression analysis was used to determine the longitudinal stability of the structural relationships between the predisposing, enabling, and illness-morbidity characteristics of the population-at-risk and measures of health services utilization. The structural coefficients estimated from the 1971, 1972, and 1973 Health Interview Surveys were examined using the Relative Instability Ratio (RIR) presented in this paper. The RIR values indicate that—except for age, family size, occupation, and family income—all the predisposing, enabling, and illness-morbidity characteristics produce unstable structural relationships. In addition, a negative monotonic relationship was found between the temporal ordering of the groups of characteristics and their ability to produce stable structural relationships. These results demonstrate the need for entrepreneurial health manpower projection techniques and abstract academic explanatory models of health services utilization to become dynamic, rather than remaining in their present static states.     

The Effects of Recent Welfare and Immigration Reforms on Immigrants' Access to Health Care1

This study investigates the impact of the Personal Responsibility and Work Opportunity Reconciliation Act and the Illegal Immigration Reform and Immigrant Responsibility Act, both passed in 1996, on the use of health‐care services in immigrant communities in five Texas counties. The study presents findings of interviews with public agency officials, directors of community‐based organizations, and members of 500 households during two research phases, 1997–1998 and 1998–1999. In the household sample, 20 percent of U.S. citizens and 30 percent of legal permanent residents who reported having received Medicaid during the five years before they were interviewed also reported losing the coverage during the past year. Some lost coverage because of welfare reform restrictions on noncitizen eligibility or because of changes in income or household size, but many eligible immigrants also withdrew from Medicaid “voluntarily.”     

Organization and Delivery of Long-Term Care in Taiwan

Summary

Taiwan reached the World Health Organization (WHO) benchmark of7%aged 65and over for defining an aging population only as recently as 1993. With this proportion projected to double to 14% by 2020, Taiwan faces a rapid increase in need for long-term care. This article presents an account of the current service delivery system, which is divided between health and social affairs administrations, with a substantial role also taken by the Veteran Administration, and growing provision of facilities that operate outside the government-registered system. While a basic level of both institutional and community care services has developed, they are not organized into an integrated service system. Problems arising from the divisions and overlaps in responsibility are identified in relation to competition for resources, differences in regulation and eligibility, funding arrangements and misallocation of resources, and divergent views about the philosophical basis of long-term care. Other aspects of services fall under each jurisdiction, but there is also some overlap. A case study of Taiwan's second largest city, Kaohsiung City, reports the outcomes of these divisions as a thin spread of a range of services rather than a coordinated service network. Several planning exercises have been undertaken in recent years to address these problems, and although at an early stage of implementation, the outcomes of these plans are seen as shaping the future directions of long-term care in Taiwan.     

Socioemotional Problems Among Young Children in Out-of-Home Care: A Comparison of Kinship and Foster Care Placement

This study examined socioemotional problems among children age 0 to 5 years in formal kinship and foster care across a northeastern state. Findings revealed that more than one third of children in both types of care showed socioemotional problems. More children were placed in kinship care when they lived in rural settings, were biracial, or spent time in the neonatal intensive care (NICU) after birth. Unique child and maltreatment characteristics predicted socioemotional problems scores for each placement type. Among children in kinship care, being biracial, spending time in the NICU, and being referred to child welfare for either caregiver substance abuse or neglect were related to socioemotional problems. When children were in foster care, spending time in the NICU, being referred to child welfare for child neglect, or being referred for intimate partner violence were all related to socioemotional problems. The results have implications for child welfare policy and practice, especially in light of increased efforts to place children with kin.