Background and Objectives: Recent immigrants experience unique challenges when accessing health services. Registered Nurses (RNs) working in primary health care (PHC) have the competencies and are well-positioned to facilitate healthcare access for immigrants. Aim: This study explored how PHC-RNs in Ontario support healthcare access and address barriers among recent immigrants. Methods: This study used a qualitative, interpretive descriptive approach and was informed by Levesque et al.’s (2013) access to care framework. Semi-structured interviews were conducted with 10 PHC RNs practising in Toronto, Ottawa-Gatineau, Hamilton, Kitchener-Cambridge-Waterloo, and London. Data were collected and analyzed concurrently using an inductive and deductive approach. Results: Findings show that PHC-RNs play instrumental roles in supporting recent immigrants through facilitating healthcare access across 9 dimensions of Levesque et al.’s (2013) access framework: (1) appropriateness, (2) availability and accommodation, (3) ability to perceive, (4) ability to engage, (5) ability to seek, (6) ability to reach, (7) affordability, (8) ability to pay, and (9) acceptability. RNs addressed significant challenges to health service access for recent immigrants, including language, geographical, and financial barriers. Several opportunities were identified to enhance the PHC RN clinical practice role to improve the delivery of PHC for recent immigrants, such as increasing organizational resources, utilizing their expertise and role beyond the PHC clinic, and promoting culturally appropriate care. Conclusions: PHC-RNs are key facilitators of healthcare access for recent immigrants by coordinating their care, educating, and connecting this population to services across the health system. However, there are opportunities to optimize nursing roles and more effectively utilize their scope of practice within interdisciplinary teams to promote the health of immigrants. / Thesis / Master of Science in Nursing (MSN)

Bakgrund: Samsjuklighet förekommer ofta hos personer med psykisk sjukdom. Det är vanligt att de behöver hjälp inom den somatiska vården. Trots att psykisk sjukdom är utbrett i samhället är detta tillstånd fortfarande behäftat med stigma. En form av stigmatisering är diagnostisk överskuggning, vilket innebär att fysiska symptom felaktigt tolkas som symptom på den psykiska sjukdomen. Detta leder till underdiagnostisering och felbehandling. Stigma kan internaliseras och leda till självanklagelser och undvikande av kontakt med till exempel sjukvården. Syfte: Syftet var att undersöka hur personer med psykisk sjukdom upplever den somatiska sjukvården. Metod: En litteraturöversikt innehållande tolv vetenskapliga artiklar; tio kvalitativa samt två kvantitativa. Resultat: Fyra huvudteman utkristalliserades: ”Att inte bli tagen på allvar”, ”Längtan efter någon som lyssnar”, ”Självanklagelser och skam” samt ”Upplevelser av barriärer”. Diskussion: Resultatet diskuterades mot Erikssons omvårdnadsteori och Nordenfelts teori om värdighet samt mot konsensusbegreppen människa, hälsa och miljö. Det mest framträdande temat var upplevelsen av att inte bli tagen på allvar. Patienterna kände att vårdpersonalen viftade bort deras upplevelser och tolkade att de fysiska symptomen gick att härleda till den psykiska sjukdomen. Detta är exempel på stigma i handling, en företeelse som bidrar till minskad värdighet och vårdlidande hos patienten. / Background: Medical comorbidity is common in people with mental illness. There is still a strong stigma attached to mental illness. One of these could be diagnostic shadowing, a process where health professionals wrongly presume that physical symptoms are consequences of the patient´s mental illness. Diagnostic overshadowing can lead to underdiagnosis and mistreatment of the physical condition. Stigma and self-discrimination could also prevent people with mental illness from seeking treatment. Aim: The aim was to investigate how people with mental illness experience somatic health care. Method: A literature review was conducted which included twelve articles: ten with qualitative design and two with quantitative design. Results: Four main themes emerged: "Experience of not being taken seriously", "Longing for someone who listens", "Self-discrimination and shame" and "Experiences of barriers". Discussion: The results was discussed in relation to Eriksson's nursing theory, Nordenfelt theory of dignity and the consensus concepts of person, health and environment. The most distinct and common theme was the experience of not being taken seriously. The health professionals did not listen to the patients and assumed that the physical symptoms were consequences of the mental illness. This is stigma in action and it contributes to suffering and affects the patient’s sense of dignity.

Le vieillissement de la population associé à un nombre croissant de cancers constituent une réalité épidémiologique qui soulève des interrogations sur l’accès aux soins et le pronosticdes sujets âgés avec un cancer, pour lesquels des disparités ont été mises en évidence. Toutefois, les études présentent plusieurs limites dont l’absence de facteurs spécifiques aux personnes âgées (PA). L’objectif de ce travail était d’étudier les déterminants sociodémographiques, socioéconomiques et cliniques de l’accès aux soins (stade de cancer, traitement) et du pronostic (déclin fonctionnel, survie) chez des PA atteintes d’un cancer. Les travaux ont été réalisés à partir de données issues de registres de cancers et de troiscohortes de PA en Gironde (486 patients de 65 ans et plus, période 2005-14). Les cohortes ont permis de disposer de données telles que le niveau d’éducation, le revenu, la prise demédicaments, la dépendance ou la démence. Selon l’objectif (accès/pronostic), nous avons utilisé différentes méthodes pour prendre en compte le type de données et de critères (régression logistique, modèles multiniveaux, modèles multi-état et de Cox). Notre population était composée pour plus de la moitié de PA de 80 ans et plus, de sexe masculin et ayant un niveau d’éducation supérieur au niveau primaire. Nous nous sommes d’abord intéressés aux déterminants de l’accès aux soins. Aucun déterminant d’un stade avancé de cancer au diagnostic n’a pu être mis en évidence, un niveau d’éducation faible était proche de la significativité pour les cancers avec un stade avancé (p=0,0671). Pour l’accès à un traitement du cancer, nous avons mis en évidence qu’un stade avancé (p=0,003) et la présence d’une démence (p=0,0109) étaient associés à un risque plus faible de recevoir un traitement. Nous avons ensuite étudié les déterminants du pronostic. Les sujets les plus âgés présentaient toujours un risque plus élevé de déclin fonctionnel (p<0,005), quel que soit le critère analysé. Les sujets ayant un faible niveau d’éducation (p=0,027), prenant plus de six médicaments par jour (p=0,047), présentant une démence (p<0,001) ou diagnostiqués à un stade avancé (p<0,001) avaient une probabilité de déclin fonctionnel plus importante, les résultats variant selon le critère. Enfin, à 12, 24 et 36 mois, la probabilité de survie globale était respectivement de 66, 57 et 48%. Le risque de décès était plus élevé chez les hommes (p=0,019), diagnostiqués à un stade avancé de cancer (p<0,001) et sans traitement du cancer (p<0,001), mais aussi chez les fumeurs (actuels et anciens) (p=0,019) et les PA dépendantes (p<0,001). En sus de déterminants classiques de l’accès aux soins ou du pronostic des cancers, nous avons mis en évidence pour les PA, le rôle des déficits cognitifs pour l’accès à un traitement ou sur le pronostic fonctionnel et celui de la dépendance sur la survie. Chez les PA avec un cancer, les facteurs spécifiques aux PA semblent donc essentiels à analyser. L’analyse des liens de causalité entre les déterminants de santé reste un sujet particulièrement intéressant dans cette population de PA comme pour les patients avec un cancer. / The growing incidence of cancer associated to an aging population represents an epidemiologic reality that requires questioning access to care and prognosis in elderly with cancer, for which disparities have been highlighted. However, generally speaking, studies are limited in that they overlook geriatric-specific factors. The aim of this work was to study sociodemographic, socioeconomic and clinical determinants of access to care (cancer stage, cancer treatment) and prognosis (functional decline, survival) in elderly cancer patients. This research project has relied on data from cancer registries and three elderly cohort studies in the French department of Gironde (486 patients aged 65 and over from 2005 to 2014). The cohorts provided data such as education level, income, medication, dependency and dementia. Depending on the aim, we used different statistical methods to analyze different types of data and outcomes (logistic regression, multi-level model, multi-state model, Cox model). More than half of our population was aged 80 and over, male and had high education degrees. First, we studied determinants of access to care. No determinant of advance stage at diagnosis was found, but low education was close to significance for advanced stage (p=0.067). Concerning cancer treatment administration, advanced stage at diagnosis (p=0.003) and diagnosis of dementia (p=0.011) were associated with a lower risk of treatment administration. Second, we studied determinants of prognosis. Older old had higher risk of functional decline (p<0.001), regardless of the outcome. Subjects with low education (p=0.027), taking more than six daily drugs (0.047), presenting diagnosed dementia (p<0.001) or those with advanced cancer stage at diagnosis had higher risk of functional decline, results depending on outcome. At last, overall survival at 12, 24 and 36 months was 66, 55 and 48%, respectively. Risk of death was higher in men (p=0.019), in patients with advanced stage at diagnosis (p<0.001) or without treatment (p<0.001) in current and former smokers (p=0.019) and in dependent elderly patients (p<0.001). In addition to classical determinants of access to care and prognosis in cancer, we demonstrated the impact of cognitive impairment on treatment administration or functional prognosis, and that of dependency on survival. . It appears essential to consider geriatric specific factors in studies on the elderly with cancer population. The causality between health determinants is particularly interesting in the elderly as well as in the cancer populations.

The purpose of this study was to determine the awareness and attitudes of dental hygienists in Ohio regarding the Advanced Dental Hygiene Practitioner (ADHP) as an occupation proposed by the American Dental Hygienists’ Association and to determine whether the ADHP could be a viable career option for Ohio dental hygienists. I developed a survey to assess dental hygienists’ awareness, attitudes, and their views regarding the new mid-level dental provider. The study was limited to licensed dental hygienists in Ohio. The study included a simple random sample of 400 of the 4100 dental hygienists in Ohio obtained by a systematic approach, a random start and selection of subjects at a constant interval. The method of data collection was electronic surveys. Fifty-four dental hygienists (13% of the sample) participated in the study. The results show that most of those responding were aware of the ADHP. Also, their attitude regarding the new mid-level dental provider was positive. Attitudes varied more when the respondents provided data on the adoption of legislation for the new provider. There was no consensus among respondents regarding the ADHP as a viable career option. More robust research is needed on the viability of the ADHP in Ohio.

Le handicap est multifactoriel. Toutes ses composantes sont potentiellement sources d’obstacles et de désavantages. L’originalité de cette thèse est de tenir compte de la complexité de définition du handicap dans l’analyse du recours aux soins de santé primaires. L’objectif ultime des soins de santé primaires est une meilleure santé pour tous, passant par la réduction des exclusions et des inégalités sociales d’accès au système santé. Nous appréhendons le handicap de différentes manières jusqu’à intégrer les trois dimensions d’« une situation de handicap » (dimension fonctionnelle, dimension environnementale, et participation sociale) dans un même modèle explicatif. D’abord, nous analysons la dimension fonctionnelle en considérant les personnes handicapées comme physiquement limitées. Puis, nous investiguons la dimension environnementale par une étude chez les adultes vivant en institution. Enfin, nous adoptons une vision globale du handicap en intégrant simultanément toutes les dimensions par la mesure de capabilités latentes. Le modèle estimé s’approche d’une comparabilité inter-individus révélant, toutes choses égales par ailleurs, les niveaux sur lesquels agir pour pallier les inégalités. Les analyses suggèrent qu’un environnement favorable, sociétal et/ou socioéconomique, pourrait compenser les effets négatifs des limitations et des restrictions cognitives et physiques. Nous concluons sur plusieurs voies possibles afin d’améliorer le recours aux soins primaires : agir sur la dimension environnementale et sur la participation sociale. / Disability is multifactorial. All its components are potential sources of barriers and disadvantages. The originality of this thesis is to take into account the complexity of disability definition to analyze the use of primary health care. The ultimate goal of primary health care is better health for all, reducing exclusion and social inequalities in access to the health care system. We approach disability in different ways, ending with a model that includes the three dimensions of a “disability situation” (functional dimension, environmental dimension and social participation). First we analyze the functional dimension considering people with disabilities as physically limited. Then, we investigate the environmental dimension through analysis among adults living in institutions. Finally, we adopt a global vision of disability that integrates all the dimensions simultaneously through the measures of latent capabilities. The estimated model approximates a fundamental inter-individual comparability and reveals all things being equal, the levels on which to act to overcome inequalities. The analyses suggest that favorable environment, societal and/or socioeconomic could offset the negative impact of the limitations and cognitive and physical restrictions. We conclude on several possible waysto improve the use of primary care: acting on the environmental dimension and acting on social participation.

Cette thèse porte sur les difficultés d'accès aux soins dentaires dans le marché français semi-régulé. L'analyse cible la barrière financière d'accès aux soins dentaires et ainsi le rôle et le mécanisme de fixation des prix. La première partie permet de contextualiser la délivrance des soins dentaires en France et montre que la profession de chirurgiens-dentistes est particulièrement isolée dans le domaine sanitaire français. L'objet de la seconde partie est d'identifier les déterminants de l'accès aux soins dentaires. Nous montrons que le programme de prévention pour les enfants M'T'dents, entièrement gratuit, n'était utilisé que par les ménages les plus aisés et touchait peu les ménages défavorisés qui en ont le plus besoin. L'importance du support social dans l'accès aux soins est aussi affirmée dans notre seconde étude empirique. L'accès primaire aux soins dentaires des adultes présente la principale barrière d'accès. Une fois cette difficulté surmontée, les patients engagent le plus souvent les traitements suivants nécessaires, avec des niveaux de dépenses qui peuvent être importants même pour les moins aisés. À la suite de ces résultats, nous nous sommes intéressés spécifiquement au rôle du prix. Nous avons montré que plus le prix des prothèses dentaires était élevé, plus le renoncement à ces soins pour raisons financières était important. D'après nos travaux, l'intensité de la concurrence impacte négativement la fixation des prix contrairement à la solvabilité de la demande. Les prix entre concurrents sont aussi des compléments stratégiques. Ce sont autant de facteurs susceptibles d'être régulés pour lutter contre le renoncement aux soins dentaires et les inégalités sociales de santé qui en résultent. / This thesis concerns the difficulties to access dental care in the semi-regulated French market. The analysis targets the financial barrier of access to dental care and so the role and the mechanism of price setting. The first part gives the background of the French dental care delivery and shows that the profession of dental surgeons is particularly isolated in the French sanitary domain. In the second part we identify the decisive factors of the dental care access. We show that the free preventive program for the children Lov'Ur'Teeth was used only by the wealthiest and affected little the most disadvantaged households, which need it much more. The decisive impact of the social support in access to dental care is also a strong result in our second empirical study. The primary access to the dental treatment presents the main barrier of access. When people overcome this difficulty, they mostly continue the ensuing necessary treatments, that could be very expensive. Following these results, we focused in the role of the price. We showed that the more the prosthetic prices are high, the more is the renunciation for these cares. According to our works, the intensity of the competition impacts negatively the price setting, contrary to the demand's solvency. The prices between competitors are also strategic complements. That are many potential factors to be regulated to fight against the dental unmet need and the resulting social health inequalities.

The purpose of this quantitative study was to examine the interaction between parents’ own trauma and their assessment of their child’s functioning and its relationship to the parent’s belief that their child would benefit from mental health care services. The parents’ trauma experience was measured using the Adverse Childhood Experiences (ACEs) questionnaire and Trauma History Questionnaire (THQ), and the child’s functioning was measured using the Columbia Impairment Scale (CIS). It was hypothesized that the higher number of traumas a parent experienced was associated with a weaker relationship between a parent’s assessment of their child’s functional impairment and the likelihood a parent recognizes the benefit of mental health care services for their child. One hundred and eighty-four people participated in this study. Data were analyzed using multiple binary logistic regression, and no significant relationship was found between a parent’s assessment of their child’s functional impairment and that parent’s belief that their child would benefit from mental healthcare services. The parent’s childhood THQ score and age were found to have significant positive relationships with the parent’s belief that their child would benefit from mental healthcare services. The variable found to have the most significant positive relationship with the parent’s belief that their child would benefit from mental healthcare services was an educational or healthcare professional telling the parent that the child would benefit from mental health care services. Clinical implications, limitations, and future directions for research were addressed.

This Ph.D. thesis discusses the evolution and current situation regarding availability of healthcare for third countries migrants in the Czech Republic. In terms of methodology, the author has chosen a qualitative approach. The research design is a historical case study. The thesis uses a combination of "desk research" and empirical survey based on 56 in-depth interviews with migrants, healthcare providers and experts who come into contact with migrants during the course of their work. Based on the approach of historical institutionalism, the author is explaining policy of migrants' health insurance evolution in Czech Republic since 1993 till today. The author identifies the key events and the roles of particular actors within the observed "sub- system" of public policy. From the viewpoint of migrants and healthcare providers, the thesis also presents how the current institutionalised set-up of migrants' health policy transfers into the real access to healthcare for migrants. It also identifies the main barriers to health care accessibility and the consequences of possible health care unavailability. Key words: migrants, health care availability, health insurance, historical institutionalism, barriers to health care access

Of the 3.5 million persons infected with chronic HCV in the United States, the African American population is the largest racial group with chronic HCV. Disparities in access to care and treatment involve a complex set of individual, interpersonal, socioeconomic, and environmental factors that influence the course of HCV infection in the African American population, resulting in poorer outcomes and survival. Drawing upon both the theory of reasoned action and the theory of planned behavior, this study was conducted to determine whether the seeking of health care by HCV-positive African Americans and the responses of health care providers to HCV-positive African Americans had improved since 2008 following the introduction of new treatment options, as compared to other HCV-positive racial/ethnic groups, using secondary data analyses with survey datasets from the National Health and Nutrition Examination Survey, 2005-2012. Using chi-square test of difference and logistic regression analyses, the study did not identify a statistically significant relationship between health care seeking behavior and responses from health care providers for HCV-positive African Americans before (2005-2008) and after (2009-2012) the introduction of new treatment options as compared to other HCV-positive racial/ethnic groups. Given the ongoing development of new and improved drugs to treat HCV infection, further research might focus on the HCV-infected population as a whole to ascertain whether differences exist as compared to earlier therapies before 2013. This study may drive social change within the health care community by raising awareness of the risks of HCV infection resulting in less provider bias and the introduction of resources into the African American and underserved communities that will improve outcomes and reduce barriers to care.

Interprofessional education (IPE) is essential for enhancing students’ critical thinking skills and ability to integrate other professionals’ knowledge to ensure mutual respect and shared values for patient-centered care. The needs of medically underserved populations (MUPs) to receive behavioral health and nutritional care integrated with primary care services are significant. This research highlights the data outcomes from six offerings of a graduate IPE course on integrated health care. Funding from a Health Resources and Services Administration (HRSA) Behavioral Health Workforce and Education Training (BHWET) grant provided stipends for graduate social work and school counseling students in their final year of field working with MUPs in integrated care settings. Findings indicate significant increases in integrated care knowledge from pre- to post-course. Students reported appreciating the social justice framework of the course including food security and access to care. Students suggest that the course be required of all, not just stipend recipients. This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under Behavioral Health Workforce Education and Training Program Grant No. M01HP313900100. This information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the U.S. Government.