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Effective communication during a public health emergency depends on the provision of clear messages and close involvement of the affected community. Diverse populations may require individualized approaches to ensure that messages are delivered appropriately. Special attention should be given to those who face barriers to traditional modes of communication.

BACKGROUND: Medication adherence (MA) is critical to successful chronic disease management. It is not clear how social determinants of health (SDH) impact MA. We conducted a systematic review and meta-analysis to summarize the evidence on the relationship between SDH and MA. METHODS: We conducted a systematic review of the literature using a Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) format. A literature search was performed using three databases: PubMed, Scopus, and Cochrane Clinical Trials Register in December of 2018. Included studies were completed in the USA, included adults aged 18 years and older, measured at least one social determinant of health, and medication adherence was the primary outcome measure. Data from included full texts were independently extracted using a standardized data extraction form. We then conducted a meta-analysis and pooled the odds ratios from the included studies for each social determinant as well as for all SDH factors collectively. RESULTS: A total of 3137 unduplicated abstracts were identified from our database searches. A total of 173 were selected for full text review after evaluating the abstract. A total of 29 articles were included for this systematic review. Economic-related SDH factors and MA were mostly commonly examined. The meta-analysis revealed a significant relationship between food insecurity (aOR = 0.56; 95% CI 0.42-0.7), housing instability (aOR = 0.64; 95% CI 0.44-0.93), and social determinants overall (aOR = 0.75; 95% CI 0.65-0.88) and medication adherence. DISCUSSION: Food insecurity and housing instability most consistently impacted medication adherence. Although included studies were heterogenous and varied widely in SDH and MA measurements, adverse social determinants overall were significantly associated with lower MA. The relationship between SDH and MA warrants more attention and research by health care providers and policymakers.

Background: Emergency department (ED) workplace violence is increasingly recognized as an important issue for ED providers. Most studies have occurred in developed countries with established laws and repercussions for violence against healthcare providers. There is a paucity of data on workplace violence against ED providers in less developed countries. The aim of this study was to learn more about workplace violence among healthcare providers in EDs in India. Results: Semi-structured interviews were conducted in-person with physicians, nurses, and paramedics in Indian EDs. Interviews were coded independently using the NVivo qualitative research software. A hybrid thematic analysis approach was used to determine dominant themes. Sixty-three interviews were conducted at 7 sites across India. Interview participants include attending physicians (11), resident physicians (36), nurses (10), and paramedics (5). Events were most often described as involving accompanying persons to the patient, not the patient themselves. Most events involved verbal abuse, although a significant percentage of responses described some kind of physical violence. ED factors such as busy times with high patient volumes or periods of waiting are associated with increased violence, as well as incidents with unanticipated outcomes such as patients with severe illness or death. Decreased levels of health literacy among patients often contribute as the financial stressors of paying for medical care. Providers reported negative consequences of workplace violence on quality of care for patients and their own motivation to work in the ED. Communication strategies were frequently proposed as interventions to mitigate violence in the future including both provider communication as well as public awareness campaigns. Conclusion: Workplace violence is a frequent reality for this sample of Indian ED healthcare providers. Alarming levels of verbal and physical abuse and their impact on patient care are described. This qualitative study identified unique challenges to Indian ED providers that differ from those in more developed settings, including financial stressors, inadequate enforcement of rules governing behavior in the hospital, and an overwhelming frequency of violence emanating from patient family members and attendants rather than the patients themselves. Further investigation into preventive strategies is needed.

In the U.S., emergency departments see millions of patients requiring timely and adequate outpatient follow-up. Using a hypothetical patient presenting with a scripted presentation of hypertension evaluated in the emergency department and requiring close outpatient follow-up, randomly selected providers in the District of Columbia were queried by phone to evaluate their accessibility based on insurance status. Seventy one percent of calls for privately insured hypothetical patients resulted in a successful appointment. Medicaid fee-for-service was associated with a significantly lower rate of successful appointments (36.6%) than private insurance (p=.002.) Uninsured "patients" had only a 13% success rate when considering out-of-pocket payment limitations of less than $50 (p<.001 compared with private). Access to primary care follow-up is poor in the District of Columbia for all types of insurance; however people with Medicaid fee-for-service and the uninsured face especially strong barriers.

Significant disparities exist in health care based on race. Even when controlling for socioeconomic factors, minorities still have lower rates of utilization for certain procedures, higher mortality rates, and differences in usual source of care. There are a multitude of causes for these disparities, including differences based on access to care, the patient-doctor relationship, and insurance status. This article addresses possible factors that account for persistent disparities in health based on race and suggests approaches to remedying these disparities. Although many studies have been done on this topic, further research is needed to examine factors specifically in the emergency department setting.

Significant disparities exist in health care based on race. Even when controlling for socioeconomic factors, minorities still have lower rates of utilization for certain procedures, higher mortality rates, and differences in usual source of care. There are a multitude of causes for these disparities, including differences based on access to care, the patient-doctor relationship, and insurance status. This article addresses possible factors that account for persistent disparities in health based on race and suggests approaches to remedying these disparities. Although many studies have been done on this topic, further research is needed to examine factors specifically in the emergency department setting.

Objective The objective of this study was to evaluate the relationship between self reported cost-related nonadherence to medications and emergency department utilization among a population of Medicare beneficiaries. We hypothesized that persons who reported cost-related medication nonadherence (CRN) would have higher emergency department (ED) use. Methods We conducted a retrospective cohort study of continuously enrolled Medicare beneficiaries from in 2006 and 2007. We used multivariate logistic regression to evaluate the relationship between ED use and CRN. Our principal dependent variable was any emergency department visit within a 364-day period after the initial interview assessing CRN. Our principal independent variables were two variables to denote CRN: mild CRN, defined as a reduction in medication dose or delay in getting medications because of cost, and severe CRN, defined as a medication not being filled at all due to cost. Results Our sample consisted of 7177 Medicare Cost Beneficiary Survey (MCBS) MCBS respondents. Approximately 7.5 percent of these respondents reported mild CRN only (n=541) and another 8.2 percent reported severe CRN (n=581). Disabled Medicare beneficiaries with severe CRN were more likely to have at least one ED visit (1.53, 95% CI 1.03–2.26) as compared to both disabled Medicare beneficiaries without CRN and elderly Medicare beneficiaries in all CRN categories. Conclusions Our results show an association between severe CRN and emergency department use. Disabled beneficiaries under age 65 who report severe CRN were more likely to have at least one emergency department visit, even when adjusting for other factors that impact utilization.