Healthcare institutions today struggle to provide care that is timely, efficient, culturally sensitive, and patient-centered. Key recommendations [of the IOM] were directed toward improving provider cultural sensitivity and developing more effective communication strategies... Within the last decade, the Institute of Medicine’s (IOM) study of the extent of racial and ethnic disparities in the healthcare system confirmed the existence of health disparities, most notably that minorities were less likely than others to receive needed services. Key recommendations for addressing these disparities were directed toward improving provider cultural sensitivity and developing more effective communication strategies for the differing populations seen in healthcare institutions (IOM, 2003).

 Since 2003, the United States Department of Health and Human Services (U. S. DHHS) Agency for Healthcare Research and Quality (AHRQ) has reported on important core measures and national priorities for improving healthcare quality and reducing health disparities. The 2010 National Healthcare Disparities Report (U.S. DHHS, 2011) concluded that healthcare quality and access to care are often below standard for minority and low-income groups, particularly those who live in inner city and rural areas. AHRQ, working with the IOM, identified eight national priorities, including population health, access, patient and family engagement, and care coordination. While the AHRQ report pointed to large-scale structural disparities in access to healthcare, we noticed many patients in our practice actually had access to healthcare, yet failed to show up for appointments even though we reminded them via a phone call and letter. We wondered if there might be a better communication process for us to use, one more appropriate for the women served by our clinic.

...many patients in our practice actually had access to healthcare, yet failed to show up for appointments even though we reminded them...Nurses and other healthcare providers at our Obstetrics and Gynecology (OB-GYN) Clinic for low-income women at a Midwestern hospital were concerned that the inner city, predominantly African American, patients served by the clinic were sometimes not receiving the care they needed due to missed appointments. The goal of our Magnet®-designated hospital’s Center for Diversity and Cultural Competence (CDCC) is to reduce healthcare disparities and promote an environment in which all patients receive quality healthcare services. Increasing the appointment attendance rate has been identified as a priority to support this CDCC goal. Monthly missed clinic appointment rates had ranged from 22% to 64% for obstetric visits and 19% to 60% for gynecologic visits over the previous two years. By comparison, a nearby OB-GYN practice serving a general population experienced a missed appointment rate that averaged 10% per month during the same time period.

...missed appointments result in unnecessary costs associated with inefficient use of healthcare providers’ time and longer patient wait times for appointments.  Missed OB-GYN outpatient appointments can have serious implications in healthcare, including late diagnosis of gestational diabetes or gestational hypertension, thereby increasing the risk of poor pregnancy outcomes for both mother and child. Missed gynecologic visits can lead to a lapse in contraceptive use, thus risking an unplanned pregnancy or delayed care for abnormal Pap tests. Additionally, missed appointments result in unnecessary costs associated with inefficient use of healthcare providers’ time and longer patient wait times for appointments (Capko, 2007).

Our clinic staff did not have adequate information regarding the reasons for missed appointments or the preferred communication method for notifying and reminding patients about scheduled appointments. Common practices among clinics serving low-income women include sending postal mailed reminders of upcoming visits or making reminder phone calls a day or two in advance. However, we lacked evidence regarding the best way to reach our patients.

We noticed that most patients did have a cellular phone and used it to provide emergency contact information, to check the phone calendar, and/or to converse while waiting. Mobile technologies, such as cell phones with short message service text-messaging capability, have become an important part of everyday life for millions of people in the US and around the world (Cellular Telecommunications Industry Association [CTIA], 2010). We wondered whether text-message reminders could potentially improve our ability to communicate with clinic patients and serve as a helpful and cost-effective means for reducing missed appointments.

The overall cost of sending a single reminder letter (or reminder phone call) can be as high as $1.25 or more per letter or call. In contrast the cost for text-message reminders, after the initial start-up cost, would be around 20 cents each because a large number of text-message reminders can be sent out through automated means. Perhaps most importantly, we wondered if text messages would actually be preferred by some of our patients and more appropriate for their life situations.

This study aimed to examine the reasons for missed appointments and patient’s choices for appointment reminders from the patients’ perspectives so as to provide effective and culturally sensitive care in our OB-GYN clinic. Specifically, we wondered whether the low-income women served by this clinic would like a text message, a letter delivered by the postal service, and/or a telephone reminder for an upcoming appointment.

Literature Review

We conducted a literature review to explore whether mobile communication technologies might help reduce missed clinic appointments. This section will summarize the literature addressing factors that influence missed appointments, interventions utilized to reduce missed appointments, and trends in mobile technologies.

Factors That Influence Missed Appointments

Studies have shown that forgetfulness is one of the main reasons for missing an appointment.  Factors that influence missed appointments have been found to be complex and multifactorial (George & Rubin, 2003; Lacy, Paulman, Reuter & Lovejoy, 2004). Studies have shown that forgetfulness is one of the main reasons for missing an appointment (Campbell, Chez, Queen, Barcelo & Patron, 2000; Car, Ng, Atun & Card, 2008; George & Rubin, 2003; Neal, Hussain-Gambles, Allgar, Lawlor & Dempsey, 2005). Researchers have found that together forgetfulness and confusion over the date or time of the appointment have been reported by over 40% of individuals who missed appointments (George & Rubin, 2003; Neal et al., 2005). These findings must be understood against a backdrop of personal challenges that may impact a person’s ability to seek healthcare when needed or remember a scheduled visit. Single parenthood, unstable housing arrangements, job inflexibility, transportation issues, lack of childcare, and unsafe neighborhoods are realities that many low-income women must deal with on a daily basis. Other reasons cited for missed appointments include work obligations; cost of care; feeling too ill to attend; and emotional reasons, such as fear or embarrassment related to the reason for the appointment (Campbell et al., 2000; George & Rubin, 2003; Lacy et al., 2004; Neal et al., 2005; Quinn, Detman, & Bell-Ellison, 2008). In a sample of ethnically diverse men and women at a university-based, urban, family-practice clinic, perceived disrespect and not understanding the scheduling system were additional reasons given for missing appointments without notifying the clinic staff (Lacy et al., 2004).

Interventions to Decrease Missed Appointments

Researchers who have examined interventions utilized to reduce missed appointments in primary care have proposed solutions such as educating patients about the importance of attending appointments, reminding patients of appointments by phone calls or letters, and providing patients with transportation to appointments (George & Rubin, 2003). In some studies, these strategies were demonstrated as helpful in general practice settings. In our clinic, however, patient education and phone call or letter reminders have not had much impact on the high missed-appointment rates. Furthermore, women insured by Medicaid, (which included most of the women in our clinic), had access to transportation services if they made arrangements sufficiently in advance of the appointment.

Studies examining the impact of text message reminders on attendance at healthcare visits have been carried out in several countries, including the US, United Kingdom, Australia, China, and Malaysia (Chen, Fang, Chen, & Dai, 2008; Denizard-Thompson, Feiereisel, Stevens, Miller, & Wofford, 2011; Downer, Meara, Da Costa, & Sethuraman, 2006; Geraghty, Glynn, Amin, & Kinsella, 2008; Hogan, McCormack, Traynor, & Winter, 2008; Koshy, Car, & Majeed, 2008; Krishna, Boren, & Balas, 2009; Leong et al., 2006; Milne, Horne, & Torsney, 2006). Researchers who have conducted these studies in a variety of outpatient settings have concluded that text message reminders can have a positive impact on attendance at healthcare visits in primary care and can be cost effective. It was noted that missed appointment rates were significantly lower, by as much as 50%, for those who had access to texting compared to those who were not sent a text message reminder about their upcoming appointment (Downer et al., 2006; Hogan et al., 2008; Leong et al., 2006; Milne et al., 2006). Two studies compared the efficacy of text message reminders and phone call reminders to a control group that received no appointment reminders. Researchers found that attendance rates were significantly higher in the groups that received either a text message or phone reminder compared to the control group (Chen et al., 2008; Leong et al., 2006).

In a review of 29 studies that involved missed appointments, Hasvold and Wootton (2011) found that sending out reminders by manual phone calls, text messaging, or automated phone calls decreased missed appointments by 34%. Manual phone calls were the most effective, reducing missed appointments by 39%, compared to automated reminders (i.e. phone or text messages) that reduced nonattendance by 29%.

Researchers have also studied preferences regarding types of reminders. In a qualitative study that assessed parental readiness for text-message immunization reminders, Kharbanda, Stockwell, Fox, and Rickert (2009) found that all 28 adults in their sample were interested in receiving text message reminders and many preferred them to mail or phone reminders. Denizard-Thompson et al. (2011) assessed patient interest in using mobile technology for future appointments and found that the proportion of patients who indicated that they would use the Internet or text messaging to make a future appointment was higher than those reporting current use of these technologies, indicating that some patients may be in favor of using new technologies even when they are not currently using them. Patients may perceive that they will have these resources more readily available in the future or plan to share access with a friend or family member.

Trends in Mobile Technologies

By the end of 2010, CTIA reported more than 302 million cell phone subscribers in the US. According to Lenhart, Ling, Campbell, and Purcell (2010), use of cell phones and text messaging is increasing in all age groups, but this trend is particularly noticeable among teens and young adults. A Pew Internet report released in 2010 disclosed that overall, cell phone owners who sent or received text messages increased to 72%, compared to 65% in 2009 (Smith, 2010). Use of text messaging is highest among 18 to 29 year old cell phone owners, with 95% of those surveyed indicating that they send and/or receive text messages (Lenhart et al., 2010). The Pew report is the result of a collaborative effort between the University of Michigan and the Pew Research Center’s Internet and American Life Project. Findings were based on survey data from telephone interviews of 2,252 adults, including 744 reached by cellular phone.

It is important that healthcare providers be aware of the increasing need to contact patients by cellular phone because some patients may no longer use a landline.  Another significant trend is the decline in household landline-telephone coverage with a corresponding increase in households having a wireless service. In 2010, the U.S. Federal Communication Commission (FCC) reported that from 2007 until 2009, households with only wireless service increased from 15.9 to 28.7 million while those with only landline service decreased from 27.9 to 17.5 million. According to the National Health Interview Survey, during the last half of 2010 three of every ten U.S. homes had only wireless telephones, an increase of 3.1 percentage points since the first half of 2010 (Centers for Disease Control and Prevention [CDC], 2011). Adults living near or in poverty were more likely than higher income adults to be living in households with only wireless telephones (CDC, 2011). It is important that healthcare providers be aware of the increasing need to contact patients by cellular phone because some patients may no longer use a landline.

Importantly, cellular phones are the first technology with a documented trend toward more use by other ethnicities compared to Caucasians. African-Americans and English-speaking Latinos were found to be among the most active users of cell phones (Denizard-Thompson et al., 2011; Smith, 2010). According to the Pew Report, more African Americans and Latinos than Caucasians own a cell phone (87% vs. 80%) and minority cell phone owners use a greater range of the features on their phones (Smith, 2010). In their study of low-income patients in an adult medicine clinic, Denizard-Thompson et al. (2011), found that text messaging was more common among African Americans (compared to Caucasians), females, and patients under the age of 50 years. In summary, wireless mobile technology has the potential to improve healthcare communication and increase utilization in certain underserved populations as long as patients have a cellular phone, can afford a wireless plan, and have the ability to skillfully use specific features on their phone.

The Study

This section will describe the study setting and sample, along with the procedures used to collect the data and the data analysis. It will also present findings, discuss the implications of these findings in light of both our clinic patients and mobile technology trends in healthcare, and consider the limitations of this study.

Setting and Sample

This study was conducted at an academic, Magnet®-designated hospital center OB-GYN clinic in the Midwestern US. A cross-sectional interview/survey design was used. The clinic served primarily low-income, inner city women, approximately 80% of which were African American, 10% Caucasian, and 10% of another ethnicity. Approximately 90% of the participants lived below the 2010 federal poverty guidelines. Medicaid insured 80% of the clinic patients; 5% were privately insured with high co-pay, low-coverage plans; and the remaining 15% were self-pay. In this clinic five advanced practice nurses and 27 residents in obstetrics and gynecology conducted 24,000 visits annually with visits scheduled throughout the week for prenatal care, gynecological care, and colposcopy examinations. The Institutional Review Board of the hospital and university medical school affiliate approved this study prior to data collection.

The 60 participants in this study included African Americans (80%), Caucasians (10%), and members of other ethnic groups (10%). Fifty two of the participants were younger than 36 years of age.

Data Collection Procedures

The convenience sample was recruited from daily clinic appointment records that listed missed appointments. A specific day each week was selected for data collection, starting with Monday and advancing by one day each week to ensure that all days of the week were included in this study. Our intention was to collect data each week. However, during some weeks trained clinic staff members were not available to make phone calls for data collection purposes. When this occurred, the data collection day was advanced in the following week when data collection resumed. Data collection continued until an endpoint where saturation of descriptive findings was evident and sample size (N=60) was sufficiently large to meet the aims of this study (Morse, 1995).

Participants were clinic patients, 18 years of age or older, who had both provided a contact telephone number and missed a scheduled appointment for prenatal care, gynecologic care, or colposcopy examination within the previous two weeks. At the time this study was conducted, patients were routinely asked to provide a landline or ‘home’ phone number, and this was the number used to call the patient. Both new and returning patients of nurse practitioners and OB-GYN residents were contacted and invited to participate in the study. This method of sampling was utilized to promote a representative sample of the overall clinic population. The data collection occurred among both gynecologic and obstetric patients and was equally distributed on all five days of the week.

Five clinic staff members were trained to conduct interviews by phone to the selected patients and, using an interview guide, to collect information about the circumstances contributing to a recent missed appointment. Interviewers invited and recorded qualitative comments, in addition to the survey responses, so as to provide more depth to our understanding of missed appointments. A maximum of three calls was made to each potential participant. Once the participants were reached by phone, they were provided with a description of the study and asked if they would participate in a five to seven minute telephone interview. If they consented, a code number was assigned to maintain confidentiality of responses.

Participants were asked several yes/no questions and one open-ended question about the circumstances of their missed appointment. The yes/no questions, listed in Table 1, were based on information gathered from the literature as well as from observations made by clinic staff. To minimize the possibility of influencing the participants’ replies, interviewers were cautioned to ask questions in a straightforward manner and to follow the interview guide. As an additional safeguard, participants were informed that one of the aims of the research project was to determine what actions the clinic might take to help patients attend their scheduled appointments. This information was important because we did not want participants to feel embarrassed about missing a prior appointment; rather we wanted to create an environment where they would feel comfortable giving their honest responses and opinions. Participants were asked to give the main reason for their missed appointment.

Before concluding the interview, participants were asked whether they had tried to cancel their appointment and whether they had encountered any difficulties when they attempted to cancel. Participants were also asked whether they had rescheduled their missed appointment. If they had not yet rescheduled, the interviewer offered to assist them in rescheduling.

Data Analysis

The responses to the interview questions were collected on an interview response form designed to collect both closed- and open-ended responses. The responses were then coded and included with the participant’s age and information regarding visit type. Although the sample was too small and homogeneous for inferential statistical analysis, we did use STATA (StataCorp, College Station, TX) to analyze the data. We focused on descriptive analyses and an independent samples t-test to compare the mean age of those who were not aware that they had missed an appointment and those who were aware.

Findings

Data collection was carried out over a five-month period of time. A total of 175 phone calls were made to 95 patients who had recently missed appointments. Of these, 63 patients were successfully contacted and all but 3 agreed to participate in a brief interview. Ages of the 60 participants ranged from 18 to 55 (M = 27.33, SD = 8.4). The participants were predominantly young women, with 86.7% (n = 52) younger than 36 years of age. This age distribution was representative of the population of our clinic. The ages of the 32 who were not successfully contacted ranged from 18 to 35 (M = 24.44, SD = 4.59). The most common reason given for a recently missed appointment was forgetfulness.

The reasons reported for missed appointments at this clinic are provided in Table 2 which gives the main reason for each missed appointment.  Nearly 27% of the participants (n=16) reported that they had forgotten that they had an appointment; 8.3% (n = 5) reported that they were confused about the date and/or time of the appointment. Furthermore, 5% (n = 3) of the sample said that they did not recall being informed about their upcoming appointments. An administrative error of this nature typically happens when a patient is transferred from an outside clinic or between services within the hospital ambulatory care system. Clinic secretaries make the requested appointment but may fail to contact the patient with the appointment information.

The mean age of those who were not aware of a missed appointment was 28 years (M=28.11, SD=9.44), compared to the mean age of those who were aware which was 26.5 years (M=26.55, SD=7.63); t(58)=0.67, p=0.5). Hence this difference was not statistically significant. Taken together, over 40% of the sample reported missing a recent appointment due to forgetfulness, appointment-time confusion, or administrative error.

Nearly 17% (n = 10) of the sample identified transportation problems as the main reason for the missed appointment, while 15% (n = 9) reported work or school conflicts. Other reasons, such as childcare issues, personal illness, family issues, no insurance, and oversleeping were cited by a smaller number of participants as shown in Table 2. No significant relationships were found between the type of visit (new vs. return visit) and the missed-appointment reason.

When asked whether they had received a phone call and postal mail reminder of their upcoming visit, only 30% (n = 18) of the participants remembered receiving even one of these reminders. These findings suggest that phone calls and mailed reminders were not very effective for this sample.

When asked if they had a cell phone for personal use, and if they would like a text-message reminder of an upcoming appointment, all but one participant replied that they had a cellular phone for personal use, and 95% (n = 57) stated that they would like to have a text-message reminder for their upcoming appointments. Some respondents were quite enthusiastic about this option. Of the three participants who did not want a text-message reminder, two stated that they did not know how to use text messaging while the third participant said that she did not currently have a cellular phone. The two participants who did not know how to use text messaging were over 40 years of age.

The majority of the sample indicated that although they would like a text-message reminder, they were in favor of phone and postal mail reminders as well. It was not possible to determine specific reminder preferences because most of the participants declined to specify; 11.7% (n = 7) indicated that they would also like to have a phone call reminder while 68.3% (n = 41) indicated that they would like all three reminders.

Of interest, a subgroup of 16.7% of the participants (n = 10), whose mean and median age was 27 years, stated that they did not want either a telephone or letter reminder, only a text message. Reasons given for a missed appointment in this subgroup included forgetfulness, transportation problems, and school or work conflicts. Anecdotally, a few of the participants in this subgroup mentioned that they were very busy with jobs and children and did not always check voice or postal mail. Hence they would likely miss a reminder left by either of these methods, while they would more easily receive a text message.

We also inquired about appointment cancellation. Of the 36 participants who missed appointments for reasons other than forgetfulness, confusion, or administrative error, 94.4% (n = 34) indicated that they had not tried to cancel in advance of the appointment time. Two participants reported that they had tried to cancel their appointments but were unsuccessful because the appointment desk was closed for lunch. They did not leave a message or call back after the lunch hour suggesting that the cancellation process needs to be convenient for patients in order to be effective.

Discussion and Implications

Overall we found that 40% of low-income, inner city women who missed a recent appointment at an inner city OB-GYN clinic either forgot they had an appointment, were confused about the date and/or time of the appointment, or missed an appointment due to administrative error. Importantly, we found that 70% of the sample indicated that they did not recall receiving either a phone call or letter reminder of the upcoming appointment although reminder phone calls and postal letters were standard practice. More effective appointment reminders could potentially improve clinic attendance.

These findings suggest that new communication technologies may enhance, but should not completely replace traditional methods... Phone calls and postal letter reminders might be the preferred option for older patients and those with social and physical challenges. Ninety-five percent of the sample indicated that they would like a text message reminder of an upcoming appointment. Although 80% of the sample liked telephone and/or postal letter reminders as well as text-messages, it would not be cost-effective to provide text message, telephone, and postal letter reminders especially when traditional reminders were not found to be very helpful in this sample. Furthermore, if three different reminders were received for a single appointment, some patients may feel annoyed or overwhelmed. These findings suggest that new communication technologies may enhance, but should not completely replace traditional methods. A more reasoned approach would be to balance preferences and costs while tracking results and adopt the reminder options that are cost effective and most likely to result in patient’s keeping their appointments. Nurses are cautioned that there is little information available on use of text messaging among patients over 50 years of age. Phone calls and postal letter reminders might be the preferred option for older patients and those with social and physical challenges.

Decisions such as how many messages should be sent, when the message(s) should be sent, and wording of messages are administrative decisions as they have cost and privacy implications. Interviewers were prepared, if queried, to explain that a text message reminder would simply provide the appointment date and time, the clinic phone number, and a brief request to call if the appointment needed to be changed. While the option to text back that one cannot keep an appointment might be convenient, it is also much more complicated and would require carefully trained staff to skillfully handle a variety of reply text responses.

Transportation problems were noted to be the second most common reason cited for a missed appointment. Transportation remains a salient barrier to clinic attendance, especially for low-income populations. Although public transportation is available in our urban location, adverse weather conditions, walking distance to the local bus stops, and challenges of travel with young children sometimes provide insurmountable obstacles to taking the bus. Transportation assistance through Medicaid was available, but only if scheduled several days in advance; this was not practical when transportation or childcare arrangements fell apart at the last minute. Additional community resources are needed to help meet transportation needs.

Most clinic patients in this study did not call to cancel and reschedule their appointments. As a result, their appointment times could not be offered to other patients. Appointment cancellation is important in busy clinics where a backlog of patients can be waiting for earlier appointment times. When all available appointments are booked, patients either have to wait to be seen or find an alternative source of healthcare, such as an urgent care center or emergency room. While we did not plan to collect descriptive data on barriers to appointment cancellation, during the interview some participants offered that they were not aware that they should cancel their appointments and some commented that the automated clinic telephone system was inconvenient. These findings are consistent with those reported by Lacy et al. (2004) indicating that patients who miss appointments without notifying staff often do not understand the scheduling system and may feel disrespected by a healthcare system that seems to ignore their time, opinions, and feelings. Nurses need to be aware of these findings and take time to explain attendance policies as well as suggest best methods for making contact if an appointment cannot be kept. More information is needed about this finding so that culturally sensitive solutions can be found.

Given widespread ownership and utilization of cell phones, voice or text messaging to assist in disease management and self-care is increasing, though still in early stages of development. Use of cell phones and text messaging to enhance standard care in disease management has been tested with notable positive results in diabetes, asthma, HIV/AIDS, schizophrenia, and hypertension (Car, Ng, Atun, & Card, 2008; Krishna et al., 2009). Text messaging has been studied and found to be effective in promoting healthy behaviors, such as smoking cessation, weight loss, medication adherence, increased physical activity, and vaccination compliance (Car et al., 2008; Gerber, Stolley, Thompson, Sharp, & Fitzgibbon, 2009; Karbanda et al., 2009; Krishna et al., 2009; Sahm, MacCurtain, Hayden, Roche, & Richards, 2009).

Text messaging is currently offered as an option for appointment reminders by many private medical and dental offices in the US and by major commercial drugstore chains to inform participants that their prescriptions are filled and ready for pick-up. With text messaging becoming increasingly widespread in the healthcare arena, more research is needed to determine (a) whether text-message appointment reminders will be accepted and effective in populations that are diverse in gender, age, and ethnicity, and (b) under what circumstances text messages can most appropriately be utilized.

Study Limitations

The results of this study were limited by a small sample size, homogeneity of the sample, and non-randomized selection of subjects. Sample size and selection preclude generalizing these findings to other settings, age groups, diverse ethnicities, and genders. Although the interviewers were trained, bias cannot be excluded in the way survey questions were asked. Additionally, it would have been helpful to know whether participants owned a cell phone or shared one and how often they sent or received text messages. Knowing patients’ insights as to why they did not receive the telephone or postal letter appointment reminders would also be helpful.

Conclusion

Mobile technologies in particular will most likely be an integral part of healthcare in the future as a means for patients to stay in touch with providers and to receive important messages for health promotion and/or chronic disease management. This study has demonstrated acceptance of text messages as appointment reminders in a young, female, inner city, low-income, clinic population. This finding is consistent with the widespread cellular phone use of this population reported in existing literature. We can expect new best practices in managing clinic appointments and maintaining communication with patients to evolve as our technology evolves. Mobile technologies in particular will most likely be an integral part of healthcare in the future as a means for patients to stay in touch with providers and to receive important messages for health promotion and/or chronic disease management. Because cellular phones are the first mobile technology with widespread use over a considerable range of demographics, they are especially promising tools for communicating with traditionally hard-to-reach populations such as teens, young adults, and those of low socioeconomic status. Our findings indicate that within the low-income population our clinic serves, many individuals would definitely choose text-message appointment reminders if they were offered to them.

Author

Nancy J. Cibulka, PhD, RN, WHNP-BC, FNP-BC
E-mail: cibulkan@slu.edu

Dr. Cibulka received her BS from the University of Wisconsin (UW) in Madison. She returned to UW to complete her MS in nursing and certification as a Woman’s Health Nurse Practitioner. She earned a second certification as a Family Nurse Practitioner (FNP) at the University of Missouri, St. Louis. She received her PhD in Nursing from Saint Louis University where she holds a faculty position and coordinates the FNP program. Dr. Cibulka practices at Barnes-Jewish Hospital where she has initiated health promotion projects and works to improve healthcare delivery to low-income, inner city women.

Harry W. Fischer, MA
E-mail: hfischer84@gmail.com

Mr. Fischer received his BFA from Maryville University in St. Louis, MO. He received his MA in Geography from the University of Illinois, Urbana-Champaign where he is now a PhD candidate in Geography with a minor in statistical methods. Mr. Fischer is a Fulbright Scholar working on issues of public service delivery for vulnerable rural population in developing countries. He has traveled extensively in Asia and is the recipient of a National Science Foundation Doctoral Dissertation Improvement Grant.

Anna J. Fischer, BFA
E-mail: fischer.ajf@gmail.com

Ms. Fischer received her BFA in Graphic Design from Maryville University in St. Louis, MO. She is currently a Master of Public Policy Candidate with a Geographic Information Science & Technology (GIST) certificate at the University of Southern California. Ms. Fischer focuses on social policy and equity issues, with a specialization in the use of new technologies to enhance policy decision making and analysis. She has experience working with diverse and low-income populations as a program director and manager in nonprofit organizations.

© 2012 OJIN: The Online Journal of Issues in Nursing
Article published March 26, 2012