It has long been argued that the organization of the U.S. health care system is shaped by the struggles between capital and labor, and this relationship is of increasing significance today. Transformations from an industrial to a service economy, rising insurance costs, neoliberal social policies, and decreased labor union power have increased the number of Americans with reduced access to health care, especially for service workers and women. This dissertation is an ethnographic study of how workers in two leading unions in the “new” unionism movement, the Retail, Wholesale, and Distribution Service Union (RWDSU) and the United Steelworkers (USW) in urban Central Appalachia, characterize union membership and economic (and benefit) transformations that threaten security for working and middle class families. Using health care as a case study, this dissertation demonstrates the ways in which economic transformations are making health care less affordable for working and middle class families. Through a discussion of the importance of union membership that highlights job protection in the face of the expansion and increasing feminization of service work and the decline in work sponsored benefits, this dissertation details how these processes reduce access to and affordability of health care. In so doing, this research highlights individual pragmatic action and broader union activism in seeking economic and health security for their families. More broadly, new unionism tactics are described in the actions of a Central Labor Council as it seeks to renew community alliances and link rank-and-file concerns of job security to current labor issues, including the Employee Free Choice Act and Right-to-Work legislation, on local, state, and national levels. This dissertation links access to health care problems in this community to broader national issues (e.g. job protection, service work, and outsourcing) and highlights how union members, individually and collectively, are participating in “new” unionism tactics to maintain job security and secure resources, including health care, for their families.

DEVELOPMENT OF A DENTAL ACCESS SURVEY INSTRUMENT FOR CHILDREN WITH AUTISM SPECTRUM DISORDERSBy Roy H. Rogers, B.A., B.S., D.D.S.A thesis submitted in partial fulfillment of the requirements for the degree of Master of Science at Virginia Commonwealth University.Virginia Commonwealth University, June 2003Thesis Director: Frank H. Farrington, D.D.S., M.S.Department of Pediatric DentistryPurpose: The purpose of this study was to develop a survey instrument or questionnaire to evaluate access to dental care for children with autism spectrum disorders.Methods: The research methods of this study were conducted in a 16-step process. Survey questions were evaluated based on analysis of response frequencies and item non-response (missing data), the content of open-ended responses on the questionnaire, the researcher's judgment regarding how well the question worked within the questionnaire design construct, redundancy across questions, and whether or not the question met the project's proposed analytical goal (purpose): to evaluate access to dental care for children with autism spectrum disorders. Judgment-based evaluation of each question was tabulated using Excel spreadsheet format.Results: The overall response rate for the pilot test mailing was 46.8% (22/47). The overall sample size was reduced from n=50 to n=47 due to one undeliverable survey instrument/questionnaire and two survey instrument/questionnaires returned because neither respondent had any children with autism spectrum disorders. The mean age of children sampled was 7.1 years with a standard deviation of 3.6 years. 68.2% (15/22) of the children were male and 31. 8% (7/22) were female. 22.7% (5/22) found it difficult to locate a dentist to treat their child. 54.5% (12/22) of children were treated by a pediatric dentist. 52.9% (9/17) required the use of restraints when being treated by a dentist. 52.4% (11/22) described their child's behavior as uncooperative requiring either nitrous oxide, oral sedatives, or general anesthesia in order to be treated. 81.8% (18/22) of respondents indicated that their child had some form of dental/medical health care coverage including but not limited to private health insurance. Survey questions 9, 10, 14, 15, 20, 25, and 51 were revised, questions 2, 4, 5, 28, and 38 were omitted, and one question was added (question number 4) in the final survey instrument.

Background: Studies have shown that racial and ethnic Minorities have poorer access to medical care when compared to Whites. Much of the research regarding Minority access to care issues reflects national data that has made it difficult to extrapolate findings to accurately reveal disparities that exist within a particular community. The purpose of this study was to determine if there was an association between race and access to medical care in the state of Virginia.Objectives: To determine if there is an association between race/ethnicity and access to medical care when comparing different Minority populations to the White population; assess any differences between Minority populations with regards to access to medical care, and identify other risk factors that may modify the association between race/ethnicity and access to medical care. Methods: Data was collected from the 2002 Behavioral Risk Factor Surveillance System (BRFSS) for N= 4,392 Virginian respondents. Descriptive statistics and prevalences were done to assess the sample based on unweighted data. The weighted sample was then applied for univariate and multivariate analyses with 95% confidence intervals (CI) to examine the risk estimates (odds ratios/ORs) and assess the relationship between race/ethnicity and access to medical care. Pearson chi-square analyses determined which variables to control for in the logistic regression model. SPSS 13.0 software was used for all analyses.Results: Blacks and Hispanics were more likely to be at risk for not having access to medical care (crude ORs = 1.20, 95% CI = 1.19-1.21 and 1.64, 95% CI = 1.61-1.66, respectively) when compared to Whites. Relative to Whites, Asian/Pacific Islanders and Native Americans were more likely to have access to health care (crude ORs = 0.71, 95% CI = 0.70-0.73 and 0.90, 95% CI = 0.84-0.93, respectively). After adjustment for confounders, there was a significant inverse association found between Minority populations and not having access to medical care when compared to Whites. Adjusted ORs for Blacks = 0.71, 95%CI = 0.70-0.72, for Asian/Pacific Islanders 0.80, 95%CI = 0.75-0.80, for Native Americans = 0.74, 95%CI = 0.70-0.78, and Hispanics = 0.59, 95%CI = 0.58-0.60. With regard to the adjusted ORs, there were no notable differences found between the different Minority populations. The relationship between race/ethnicity and access to care appeared to be modified by other predictors in the model. Specifically, female gender, being young or of middle age, no insurance status, poor health status, and little or no income, became stronger predictors for determining those groups who were more at risk for not receiving access to medical care in Virginia as oppose to race. Conclusion: The study strongly recommends that continued surveillance is needed to monitor access to care for Minority populations in the state of Virginia. Further research would be needed to assess these populations access over time, determine how interactions between race and other risk factors affect access, and design interventions that will succeed in teaching us more about the causal pathways that lead to such racial inequalities in access to medical care.

In the U.S., the number of persons who cannot afford health care continues to rise. Providing a "safety net" for such persons is becoming increasingly important. Medical professional volunteerism provides access to health care for people who have little or no access to health care otherwise. At a not-for-profit free health clinic in Tampa, Florida, hundreds of physicians have volunteered their time in an attempt to reduce the health care gap in their community. The clinic sees thousands of persons who have very limited options in regards to their health care. This study investigates the reasons physicians volunteer and the barriers physicians face when providing free medical service. Through a survey, shadowing sessions, and focused in-depth videotaped interviews with volunteer physicians concerning the risks, rewards, experiences, and barriers of professional volunteering, a greater understanding of this important topic was obtained. This applied visual anthropological project was developed in collaboration with the free clinic in order to provide a product which would be of use to the organization at the end of the research process. This research led to an enhanced understanding of this population as well as recommendations in volunteer physician recruitment strategies.

The Muscatine Pediatric Dentistry Clinic (MPDC) at the Muscatine Center for Social Action (MCSA) was established January 4th, 2005. It is a partnership between the MCSA and The University of Iowa's Department of Pediatric Dentistry. MPDC operates Tuesdays (care provided by senior dental students) and Thursdays (care provided by pediatric dentistry residents). Students and residents are supervised by a pediatric dentistry faculty member. MPDC's mission is to provide dental care to low income children residing in Muscatine and Louisa counties, in Iowa. Care includes diagnostic, preventive, restorative, and emergency services. MPDC targets a population that has been traditionally underserved by local dentists including Medicaid-enrolled children and low income children without dental insurance. MPDC offers dental students the opportunity to gain experience treating children with the ultimate goal of increasing the number of practicing general dentists who serve pediatric populations. MPDC completed 6 years of operation on January 4th, 2010. The main goals of this study were to describe patient characteristics, clinical activities and parental satisfaction at the Muscatine clinic and to compare characteristics of the Muscatine clinic to those of the University of Iowa's pediatric dentistry clinic at the College of Dentistry. Clinical activities and patient profile variables for MPDC were reported for the entire fiscal year 2009-10 year. Variables include patient age, gender, type of insurance, number of dental procedures completed, type of treatment received, and number of visits per patient. A satisfaction survey was given to the parent of each patient presenting to the MPDC clinic between November 16th, 2009 and January 17th, 2010. Two broad research questions were addressed in this study: 1) Are parents satisfied with MPDC and the treatment provided to their children? 2) Are there are differences in the population served and treatment provided at the Muscatine clinic and the University of Iowa pediatric dentistry clinic at the College of Dentistry? The results of this study provide information that contributes to a fuller understanding about the population served by MPDC, the treatment received, and parental satisfaction with the clinic. It also compares characteristics of the Muscatine clinic to the University of Iowa's pediatric dentistry clinic at the College of Dentistry. The results of this study may help guide MPDC staff and the University of Iowa's Department of Pediatric Dentistry in future decision-making regarding clinic activities and dental school curriculum.

This study evaluated the associations of individual and neighborhood level risk factors with physical health, mental health, and stress in a diverse urban county. Relatively little research has attempted to disentangle the interactive individual characteristics and neighborhood conditions underlying health outcomes and disparities. To address this, survey data were collected and analyzed from 1,107 residents living in one of the 114 census tracts in DeKalb County, GA. Using multilevel structural equation modeling techniques, this study found that neighborhood level measures of the social and built environment were not associated with the health outcomes under study after controlling for neighborhood level income and education. Alternatively, individual level perceptions of the social and built environment and measures of access to health care were significantly associated with physical health, mental health, and perceived stress. This study also found that the association between low individual income and poor physical health was more pronounced for participants who lived in low-income neighborhoods than participants who lived in high-income neighborhoods. Additionally, this study found that Black residents reported significantly better mental health compared to White residents when they lived in high-income neighborhoods, and Black participants reported significantly more stress compared to White participants when they lived in low-income neighborhoods. Results of this study further scientific understanding of the role of neighborhood processes in health disparities and potentially help inform the development of programs and policies related to neighborhood conditions and health disparities.

Objectives: To determine access to dental care among preschool children of Arabic-speaking immigrant families; to investigate the influence of social and cultural factors on access to dental care; and to measure preschool children’s oral health as reported by their parents. Methods: This survey used a semi-structured questionnaire to interview 100 Arabic-speaking parents of children under the age of 5 who were identified from community centres. Five scales were used to measure acculturation, social capital, oral health literacy, oral health knowledge, and health literacy. Results: Only 34% of families had visited the dentist to obtain dental care for their preschool children. Nineteen-percent of Arabic parents in our sample rated their children’s oral health as being fair or poor. None of the scales used in this study had a significant impact on access to dental care; however, higher scores on these scales tended to be associated with better access to dental care.

Objectives: To determine access to dental care among preschool children of Arabic-speaking immigrant families; to investigate the influence of social and cultural factors on access to dental care; and to measure preschool children’s oral health as reported by their parents. Methods: This survey used a semi-structured questionnaire to interview 100 Arabic-speaking parents of children under the age of 5 who were identified from community centres. Five scales were used to measure acculturation, social capital, oral health literacy, oral health knowledge, and health literacy. Results: Only 34% of families had visited the dentist to obtain dental care for their preschool children. Nineteen-percent of Arabic parents in our sample rated their children’s oral health as being fair or poor. None of the scales used in this study had a significant impact on access to dental care; however, higher scores on these scales tended to be associated with better access to dental care.

The purpose of this dissertation is to effectively understand, measure, and model the impact of Access to Care (AC) on Patient Safety (PS) through the creation of a model that evaluates their interdependence. Through the use of statistical tools and through the combination of variables that define patient access to health care and patient safety, a Patient Access and Safety (PACSA) index is developed. The calculated Patient Access and Safety index provides information to both providers and patients about the impact of access and safety on treatment outcomes. The input variables used to support this research are Patient Access Factors (PAF) (Age, Insurance Type, Visit Type, List Price, and Days To an Appointment) and Patient Safety Factors (PSF) (Severity of Diagnosis, Race, and Gender). In this model, 7,535 observations were used from a single organization based in South Florida, in order to develop the index. The PACSA index offers a tool that helps providers, healthcare staff and patients evaluate patient safety as it is impacted by access to healthcare through the calculated index. This index produces an equation that examines the relationship between access to care and patient safety using the following relationship: PACSA=∑_(i=0)〖(.645〖PSF〗_i- .645〖PAF〗_i )+0.399〗An extensive literature review identifies the connection between AC and PS and the relationships governing these two concepts. Although large organizations like the World Health Organization (WHO), Agency for Healthcare Research and Quality (AHRQ), and Institute of Healthcare Improvement (IHI) have studied these concepts independently, there has not been a study that used a factor or index to describe the relationship. As the healthcare delivery system becomes more complex, and consumers demand better treatment outcomes, there is a growing need to analyze these concepts jointly. This study focuses on diabetic retinopathy (DR). This is a condition experienced by chronic Diabetic patients, and it is one of the major causes of blindness (National Eye Institute, 2009). The increase in the occurrence of Diabetes worldwide has heightened the disease and inspired clinical research. In 2002, it was estimated that the disease stemming from Diabetes, namely DR, accounted for about 5% of world blindness, representing almost 5 million blind people. If left untreated or undetected, about 2% of people become blind, and about 10% develop severe visual impairment. By the year 2030, a possible 36 million people will have acute visual impairments and 7.2 million people will possibly be blind worldwide. In the United States, there are 18 million people with Diabetes, and 30% have Diabetic Retinopathy (5.3 million Americans over the age of 18) (ATA Report 2004; AHRQ, 2004; WHO, 2004). Although this study focused on DR, the model has been designed with the ability to be applied to other diseases and conditions. The goal of creating the PACSA index is to help healthcare workers understand when to schedule patients within the context of access and safety. Current appointment schedules, which are the tools used by healthcare workers, use a “New patient vs. Follow up patient” design. The PACSA challenges the current scheduling schema. No longer will patients be categorized into “New vs. Follow Up” visits. Instead, they will be evaluated for access to care requirements and patient safety needs from the initial point of entry into the health system. The recommendation is to start designing schedules based on PACSA (low PACSA, medium PACSA, and high PACSA). In this new paradigm, the low PACSA would describe patients that have low disease complexity, low number of risk factors, and can wait a little longer for their appointment without having complications of disease from lack of treatment. On the contrary, the high PACSA would include a subset of patients that have high disease complexity, high number of risk factors, and require immediate appointment and medical continuity of care to have the best treatments and outcomes. The PACSA index can serve as a visual guide for decisions regarding access and patient safety requirements. Two key components of quality within healthcare include access to care and patient safety. To create “congruent system integration” (Maier-Speredelozzi, 2007), there must exist synchronization of all healthcare delivery operations. The Patient Access and Safety Index (PACSA) provides a framework for integrating these two components. This research and the indices developed can offer benefits to health care organizations, patients, physicians, and government entities by providing a versatile tool to help improve access to health care and patient safety.

Access to bevacizumab, an important component of oncology treatment regimens, may be limited. This survey of oncologists in the US (n = 150), Europe (n = 230), and emerging markets (EM: Brazil, Mexico, and Turkey; n = 130) examined use of and barriers to accessing bevacizumab as treatment of advanced solid tumors. We also assessed the likelihood that physicians would prescribe a bevacizumab biosimilar, if available. Bevacizumab was frequently used as early-line therapy in metastatic colorectal cancer, metastatic non-squamous non-small-cell lung cancer, and metastatic ovarian cancer (all markets), and as a second-line therapy in glioblastoma multiforme (US, EM). A greater percentage of EM-based physicians cited access-related issues as a barrier to prescribing bevacizumab versus US and EU physicians. Lack of reimbursement and high out-of-pocket costs were cited as predominant barriers to prescribing and common reasons for reducing the number of planned cycles. Overall, similar to 50% of physicians reported they "definitely" or "probably" would prescribe a bevacizumab biosimilar, if available. Efficacy and safety data in specific tumor types and lower cost were factors cited that would increase likelihood to prescribe a bevacizumab biosimilar. A lower cost bevacizumab biosimilar could address the unmet needs of patients and physicians worldwide, and may have the greatest impact on patient outcomes in EM.