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3. IMPROVING ACCESSIBILITY AND QUALITY OF MEDICAL CARE, EDUCATION, AND REFERRAL SERVICES HRSA asked the committee to address the need to improve accessibility and quality of education and referral services among RECA populations. Given uncertainty concerning the health benefits of intensive medical screening, improving the accessibility and quality of health education is of paramount importance. Among the things education programs will provide to the target population is an increase in their ability to participate fully and freely in decision-making regarding medical screening and medical evaluation. Education programs may also enable the target populations to avail themselves of the legal remedies provided by RECA. Improving the accessibility and quality of education lies within the framework of intervention. Success in RESEP’s mission will require changing the behavior of the target audience (patients, clinicians, and related government agencies). Barriers to that goal must be identified and addressed by appropriate intervention strategies. Among the barriers are knowledge deficits and skills, psychosocial issues, such as fear of physicians, diverse cultural norms, and turf battles; lack of organizational resources, for example, medical technology, and staff; and public policies that fail to allocate adequate resources to the program. Appropriate behavior-change theories must be selected and applied, including adult learning theory and educational best practices (Chickering and Gamson, 1991). Much research has been done on addressing the barriers to behavior with intervention strategies. The table below displays the connections among barriers, interventions, and outcomes. Barriers to Behavior Change Intervention Strategies Outcomes Knowledge deficits and skills Educational programs Reduction of deficits and skills Individual psychosocial Issues Psychosocial Strategies, such as use of informed opinion leaders Resolution of psychosocial barriers Lack of organizational resources Examination and remediation of organizational barriers Resolution of the organizational barriers to accelerate change Public-policy problems Identification of public-policy components that interfere with goals Development of supportive strategy
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Research has shown that applying inappropriate strategies to some barriers has had minimal success (Bero et al., 1997, Davis et al., 1995). But barriers often overlap and require multifaceted strategies. Therefore, the following needs to be established before any intervention: Identification of specific target audiences for the intervention. Who are the target audiences of an intervention? The current grantees appear to have focused primarily on potentially eligible uranium miners and secondarily on ore transporters, uranium millers, downwinders, and onsite nuclear-test participants. We believe that HRSA should require clear identification of the multiple community groups, including the staff of local health-care organizations and clinicians, as well as the potential RECA recipients. Clear identification of the barriers HRSA and its grantees are trying to address and the outcomes they seek. Future grantees should be encouraged to state clearly what outcomes they seek to achieve. They may need to use a multifaceted intervention aimed at different behavior-change objectives. Some assumptions may need to be re-examined. For example, with respect to improving accessibility to services, the current grantees seem to assume that miners’ lack of knowledge about RECA legislation is the single barrier to be faced and that they will use the provided services more if this is remedied. What evidence supports this assumption? Potential knowledge-deficits are important barriers to examine, but usually there are several barriers—such as interpersonal tensions, organizational limitations, and public-policy issues for the audience in question— that must be overcome by the grantees to accomplish their objectives (Davis et al., 1995). We describe below one of the barriers and behavior-change strategies mentioned in the table above. Deficits in knowledge and knowledge-based skills Every education program should include learning outcomes and an assessment plan that documents the degree to which the grantees’ objectives are met by their proposed program. We suggest that among the outcomes is a decrease in the knowledge deficit regarding exposure and risk, the diseases identified by the RECA legislation, the benefits and harms of screening and evaluation, referral services, medical treatment, and follow-up care. An educational program should also address new laws and regulations and technical changes. Barriers Deficits in knowledge and deficits in knowledge-based skills, such as communication and critical thinking, are the main barriers in educating the target populations. HRSA and its grantees should take advantage of available health-education and communication programs (particularly risk communication). However, one
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difficulty in developing pedagogic tools (such as brochures, informational Web sites, lectures, and PowerPoint presentations) is that many strategies assume that a person who receives information will accept, assimilate, and apply it (Davis et al., 1995; Eisenbergl, 1986). That is often not the case. There has been a transformation of educational pedagogy in the formal education setting because of the recognition of that erroneous assumption. Strategies Adult learning theory and the work of educators (Chickering and Gamson, 1991) seek to change the passive learner into an active learner, transforming traditional practices of education on a banking model to educational practices on an interventionist model. A set of six approaches, known as “best practices in education”, can be adapted to the learning outcomes for both RECA populations and its HRSA grantees: Encourage contact between health-care educators and RECA participants inside and outside the grantee facilities to enhance motivation and involvement in patient education. Enhance collaborative education among social groups and subcultures, wherein participants work together and with key group members to facilitate their own education. Create active learning opportunities that give RECA participants and the HRSA grantees the opportunity to apply information to their daily lives. Provide prompt feedback, allowing RECA participants and HRSA grantees to understand what they know and don’t know. Feedback should begin with help in assessing existing knowledge. Allocate realistic amounts of time for effective education of RECA participants and HRSA grantees. Encourage participants to expect that they are capable of understanding and using the relevant health-care information. The committee will discuss other barriers in a comprehensive and concerned manner in its final report. On the basis of the committee’s deliberation thus far on education and referral services, the committee believes that the most effective educational, organizational, psychosocial, and public-policy interventions for achieving the objectives of the RECA legislation could best be directed toward medical and social professionals who provide service to the RECA community, including people who might be eligible for compensation.
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