The past few decades have witnessed an increased focus on the importance of oral health on the social, psychological and developmental well-being in children. Although effective and advanced dental prevention measures and treatment options are increasingly available, dental decay remains one of the most common chronic childhood diseases in the United States and around the world. Recently, the World Health Organization Assembly called attention to the significant burden oral disease has maintained in all countries around the world. Additionally, multiple studies have described disparities in oral health with a disproportionate amount of dental disease concentrated in children with special health care needs, those that live with poor families or that live in isolated or rural communities. In response to this issue there has been renewed focus on combating access to oral health care issues. One approach that has been suggested is the utilization of non-dental health professionals in assessing oral health, performing basic preventive steps and referral of high-caries risk children for further care. These non-dental professionals are often in a better position to evaluate children at an early age, are more likely to see poor children early and to provide care for them on a continuing basis when compared to dentists. However, several barriers have been mentioned in the literature that prevent or deter these non-dental health professionals from taking on a more active role in this access to care issue. Of which has been a reported lack in oral care education and training for medical care professionals. Additionally, collectively few studies have specifically identified the importance of different suggested influencing factors. In our present study, three main analyses were conducted. The first analysis assessed the oral-health knowledge, practices, and factors influencing the ability and willingness of Iowa pediatricians' to assess and refer high caries-risk children. In which, a 22-item survey was mailed to all licensed pediatricians in Iowa. Chi-square statistics and logistic regression models were used to analyze data. On questions regarding comfort levels when performing oral-health related practices on children under 3, physicians reported high levels of comfort with all specified issues. The majority of respondents routinely gave the name of a dentist to the caregiver when referring, where as only 4% made use of local care coordination services and only 9% actually made the dental appointment. Sixty-five percent referred all children 12 months or older to a dentist in accordance with AAPD and AAP guidelines. The ability to locate a dentist willing to accept Medicaid or uninsured children was noted as the major referral barrier. Bivariate and multivariate logistic regression analyses indicated that pediatricians who had higher frequency of seeing oral-health problems (p=0. 0.0488), greater mean total number of children seen per week (p=0.0431), and believed that children should have their 1st dental visit no later than 12 months of age (p=0.0196) were more likely to make frequent referrals to a dentist compared to their counterparts. The second analyses assessed Saudi medical interns' oral-health knowledge, and other factors influencing their ability and willingness to perform oral-health related practices for high caries-risk children. In which, a 15-item survey was emailed to all eligible graduating fifth year medical students at King Khalid University Hospital to address these areas of interest. Chi-square statistics and logistic regression models were used to analyze data. Similar to our first study physicians noted high levels of comfort with all specified oral health practices. However, students generally rated their medical training fair or poor in preparing them for oral-health assessments compared. Additionally, although 90% of respondents noted that the role of primary physicians in counseling/referring children with oral health was important; 60% did not agree with the AAPD and AAP guidelines that state that all children should be referred to a dentist by 12 months of age. Multivariate logistic regression analyses revealed several statistically significant variables that predict the likelihood of performing various oral-health related practices. The choice of public-health oriented future clinical goals, the level of oral-health knowledge, how interns rated their oral health training in medical school, and the average number of children seen per week, all - to varying degrees - proved important predicator variables for the likelihood of performing them once in practice. In our third study focus was placed on assessing the effectiveness of an electronic educational intervention on improving primary care practitioners' knowledge, willingness, and comfort levels in identifying children who are at high risk for developing dental caries. Following the educational program, a 16-item survey was emailed to all participants to address the areas of interest. Bivariate correlation and linear regression were used to analyze data. Respondents gave a higher percentage of correct responses to the knowledge questions post-intervention compared to pre-intervention with an average increase of 63%. Additionally, nearly all respondents agreed with the statement that all children 12 months and older should be seen by a dentist in accordance the AAP & AAPD. Furthermore, physicians noted improved levels of comfort with all specified oral health practices. Most notable, following the educational intervention, 91% of respondents rated them-selves as comfortable in counseling, compared to only 25.6% that did so before the educational program. The only exception on comfort issues pertained to performing emergency treatments on young children with a majority of interns (92%) still considering themselves as neutral or uncomfortable in doing so. Multiple linear regression analyses revealed several statistically significant variables that predict the likelihood of performing various oral-health related practices. Increased oral health knowledge, higher self-perceived comfort levels and seeing oral-health problems more frequently all proved important predicator variables for the likelihood of performing oral-health related services. Collectively, these three analyses lead us to several main conclusions and future education recommendations. Educating medical practitioners and students about basic oral health recommendations and referral guidelines provides an excellent opportunity to alert medical professionals about the importance and timing of these dental referrals. Ultimately, earlier referrals by physicians can help improve dental utilization among high risk children, especially among lower income and rural families. Additionally, providing these medical professionals with experience opportunities in assessing the oral health of young children may improve both physician willingness and likelihood to perform various oral health practices for young children. Overall, increasing both knowledge and personal experience of training physicians' could lead to greater comfort levels in dealing with oral health issues affecting young children. Furthermore, establishing effective care coordinator services to assist in linking various health care professionals more directly; may also increase physician willingness to assess and refer high-caries-risk children by making the referral process easier for physician offices. This step helps in saving time and effort, two deterrents noted by physicians.

Objective: To determine who avoids the dentist and declines recommended dental treatment due to cost. Methods: A secondary data analysis was undertaken. Weights were utilized to ensure data were nationally representative. Univariate and bivariate descriptive statistics were calculated and logistic regressions were used to observe the characteristics that were predictive of reporting cost barriers to care. Results: Over 17 per cent of the Canadian population reported avoiding a dental professional due to cost, and 16.5 per cent reported declining recommended dental treatment due to cost. These individuals had a higher prevalence of needing treatment, had more untreated decay, missing teeth, and reported having poor oral health and oral pain often. Having no insurance, lower income, and reporting “poor to fair” oral health were the greatest predictors of reporting cost barriers to care. Conclusions: Individuals who report cost barriers experience more disease and treatment needs than those who do not.

Objective: To determine who avoids the dentist and declines recommended dental treatment due to cost. Methods: A secondary data analysis was undertaken. Weights were utilized to ensure data were nationally representative. Univariate and bivariate descriptive statistics were calculated and logistic regressions were used to observe the characteristics that were predictive of reporting cost barriers to care. Results: Over 17 per cent of the Canadian population reported avoiding a dental professional due to cost, and 16.5 per cent reported declining recommended dental treatment due to cost. These individuals had a higher prevalence of needing treatment, had more untreated decay, missing teeth, and reported having poor oral health and oral pain often. Having no insurance, lower income, and reporting “poor to fair” oral health were the greatest predictors of reporting cost barriers to care. Conclusions: Individuals who report cost barriers experience more disease and treatment needs than those who do not.

Les traitements antirétroviraux (TARV) sont proposés à large échelle en Afrique sub-Sahariennedepuis plus de dix ans, au départ destinés à contrôler la morbidité sévère des personnes à un stade avancé del’infection à VIH. Les recommandations pour initier les TARV ont ensuite évolué à mesure que les étudescliniques et épidémiologiques mettaient en évidence les bénéfices thérapeutiques et préventifs d’une initiationprécoce des TARV. Des essais randomisés sont actuellement en cours en Afrique australe pour vérifier lesbénéfices d’une approche universelle de dépistage et de traitement à des stades précoces de l’infection à VIH(approche « Test and Treat ») sur l’incidence du VIH en communauté. Cependant, la couverture antirétroviraleest encore loin d’être optimale au sud du Sahara, notamment en Afrique du Sud où 6,3 millions de personnesvivent avec le VIH. L’objectif de cette thèse est de comprendre quelles sont les barrières à l’initiation des TARVen nous intéressant à une zone rurale fortement touchée par le VIH au sein de la province sud-africaine duKwaZulu-Natal. Après avoir brièvement décrit le suivi des patients de l’entrée dans un large programme desoins VIH jusqu’à l’initiation des TARV, nous avons mesuré l’évolution des taux d’initiation des TARV suite àl’expansion des critères d’éligibilité dans ce programme. Nous avons ensuite identifié certaines barrières àl’initiation des TARV en croisant les données du programme de soins VIH à celles recueillies au sein d’unesurveillance démographique. Les résultats de cette thèse permettent de mieux appréhender les questionsrelatives à l’accès aux TARV qui pourraient se poser avec une approche « Test and Treat ». / Antiretroviral treatments (ART) have been available in sub-Saharan Africa for more than ten years.Their use was initially targeted with the strict aim to control severe morbidity in individuals with an advancedHIV disease. International guidelines for initiating ART have subsequently evolved as clinical andepidemiological studies highlighted the therapeutic and preventive benefits of early ART initiation. Randomizedtrials are currently underway in several southern African countries to measure the benefits of the universal“Test and Treat” approach on HIV incidence in a community. However, ART coverage is still far from optimal insub-Saharan Africa, especially in South Africa where 6.3 millions of individuals are living with HIV. We thusaimed to better understand what are the barriers to ART initiation by focusing on a rural area heavily affectedby HIV in the province of KwaZulu-Natal, South Africa. We first briefly described the journey HIV-infectedindividuals embark on, from entry into a large HIV treatment and care programme to ART initiation. Then wemeasured the temporal evolutions of ART initiation rates according to the changes of clinical guidelines. Wefinally identified some barriers to ART initiation linking data from the HIV care programme with those from ademographic surveillance system. The results of this thesis will help to better understand the issues relative toaccess to ART that might arise with the universal “Test and Treat” approach, especially in South Africa.

Purpose: The Veteran's Health Administration (VHA) has created a training program for interdisciplinary teams of providers on the unique treatment needs of transgender veterans. An overview of this program's structure and content is described along with an evaluation of each session and the program overall. Methods: A specialty care team delivered 14 didactic courses supplemented with case consultation twice per month over the course of 7 months through video teleconferencing to 16 teams of learners. Each team, consisting of at least one mental health provider (e.g., social worker, psychologist, or psychiatrist) and one medical provider (e.g., physician, nurse, physician assistant, advanced practice nurse, or pharmacist), received training and consultation on transgender veteran care. Results: In the first three waves of learners, 111 providers across a variety of disciplines attended the sessions and received training. Didactic topics included hormone therapy initiation and adjustments, primary care issues, advocacy within the system, and psychotherapy issues. Responses were provided to 39 veteran-specific consult questions to augment learning. Learners reported an increase in knowledge plus an increase in team cohesion and functioning. As a result, learners anticipated treating more transgender veterans in the future. Conclusion: VHA providers are learning about the unique healthcare needs of transgender veterans and benefitting from the training opportunity offered through the Transgender Specialty Care Access Network-Extension of Community Healthcare Outcomes program. The success of this program in training interdisciplinary teams of providers suggests that it might serve as a model for other large healthcare systems. In addition, it provides a path forward for individual learners (both within VHA and in the community) who wish to increase their knowledge.

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Background: Patient experience is a crucial measure of patient-centeredness and quality care delivery. Digital health may contribute to patient experience by offering tailored and accessible avenues of care. Purpose: I explored how access to digital health, including telehealth, electronic health records, and online booking, may be associated with improved primary care experience for Ontario adults. Methods: This cross-sectional study included Ontario adults (16 years or older) who responded to waves 27 to 29 of the Health Care Experience Survey (HCES) between May 2019 and February 2020. Adults who did not see their primary care provider within the past 12 months or did not have a primary care provider were excluded. Outcomes included a summed patient experience score derived from five HCES experience-related questions and time to appointment for a health concern. Associations between outcomes and digital health interventions were tested through chi-square tests and logistic regression while adjusting for confounders and stratifying by health care utilization. Results: 3,700 participants met the inclusion criteria, where 2204 remotely communicated with their primary care provider (59.6%), 98 digitally accessed health records (2.6%), and 120 booked an appointment online (3.2%). We observed no significant associations between digital health tools and patient experience or time to appointments through chi-square tests. Participants with over three primary care visits in the past year who accessed online booking were 84% less likely to report poorer experience scores than participants without online booking access [Adjusted OR 0.16, 95% CI 0.02 – 0.56, p < 0.05]. Participants with three or fewer primary care encounters who accessed online booking, compared to the same reference group, were 72% less likely to report having a same or next day appointment with their primary care provider [Adjusted OR 0.25, 95% CI 0.08 – 0.64, p < 0.01]. Significant associations were observed between other sociodemographic factors and patient experience and access to care outcomes. Interpretation: The associations between digital health access and patient experience and access to care were inconsistent across different analyses. Despite experimental studies observing the benefits of digital health adoption in primary care, the effect is unclear in the real-world context. Furthermore, drawing conclusions on the relationship between digital health and quality care outcomes was limited due to the lack of adoption of digital health before the COVID-19 pandemic. As digital health adoption grows, future research should utilize the availability of further data to evaluate the effectiveness of digital health in Ontario primary care. / Thesis / Master of Science (MSc) / Patient outcomes such as experience and timeliness of care are frequently viewed as aims of quality health care. Although past studies indicate digital health supports quality care, the real-world effectiveness of digital health is underexplored in Ontario. This thesis aimed to explore relationships between real-world use of digital health in Ontario and primary care experience and access using survey data. This study found very few survey respondents used digital health before the COVID-19 pandemic. The primary care experience and access to care of adults who did use digital health did not differ very much from adults who did not use the technology. Some outcomes differed in adults who booked their primary care appointment online compared to those who did not; however, the study could not conclude on the relationship. Other personal factors such as age and residence area impacted the quality of primary care. This study was limited due to the lack of digital health users. Future studies should explore digital health's impact on patient outcomes beyond the pandemic.

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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.