<p><b>Background</b>: Throughout the twentieth century, Brazil developed a Social Health Insurance, providing coverage to formal workers and their dependents. In 1988, the country implemented a health reform adopting a National Health Service model, based on three core principles, universal coverage, open-ended benefit package and striving for health equity. During this transition, formal workers recomposed their privileged access to healthcare through private health insurance, resulting in a two-tier system represented by those with dual coverage&mdash;public and private&mdash;and those who must rely exclusively on the public insurance. Private health insurance coverage has a positive correlation with income, however, between 1998 and 2008 private coverage expanded vigorously among the poor, while remained stable among the rich. The health equity literature in Brazil consistently reports the presence of relevant inequalities in utilization of health services favoring privately insured individuals. A gap in this literature, however, is to determine whether inequalities in utilization of health services remain among insured individuals, i.e., does private insurance improve access regardless of individuals&rsquo; income? </p><p> <b>Methods</b>: The study relies on Andersen&rsquo;s behavioral model as a theoretical framework to analyze data from two rounds (1998 &amp; 2008) of a national household survey, assessing levels of utilization of fourteen dependent variables across income quintiles and calculating concentration indexes as summary measures of inequality. Dependent variable distributions across income are standardized by need using the indirect method. Concentration curves compare the evolution of inequality during that time. Curve dominance is formally tested between survey years. Decomposition analysis identifies the most relevant contributors to inequality. Physician services are analyzed as the probability of having a physician visit and the number of physician visits. Hospital services are analyzed as the number of hospital admissions, the probability of having a hospitalization, and the number of hospital days during the last hospitalization. The latter two variables are broken down according to their financing source, either public (SUS) or private insurance. </p><p> <b>Results</b>: Physician services present very low inequalities, although a statistically significant positive gradient persists in both survey rounds. Poor PHI beneficiaries have an advantage compared to national levels. SUS financed hospitalizations are a rare phenomenon among privately insured individual but strongly concentrated on the poor. Poor PHI beneficiaries utilize private hospital at lower levels than the rich. Compared at a national level, they are at a disadvantage. In 1998, this was not the case, suggesting that insurers may be developing mechanisms to deter hospital utilization among the poor. Premium value and income are the most relevant contributors to inequality in physician and hospital services. </p><p> <b>Conclusions</b>: The Brazilian government (ANS) needs to monitor utilization levels across income and develop policies to increase accountability of PHI products particularly preventing insurers from purposefully pushing their beneficiaries to use SUS hospitals. Greater availability on insurance policies segmented as ambulatory care only and inpatient services only would increase the range of options for consumers that could sort more adequate coverage according to their capacity to pay and healthcare needs. </p>

<p> Advocacy for the counseling profession necessitates a thorough understanding of the factors influencing the hiring and reimbursement of licensed professional counselors. The Patient Protection and Affordable Care Act (ACA) enacted several health care reforms that may influence the utilization of mental health services and the employment of mental health professionals. These reforms included the option for states to expand their Medicaid population (effective January 1, 2014), mental health parity requirements for most insurance plans including Medicaid plans, and increased funding for Federally Qualified Health Centers (FQHCs or health centers). FQHCs, created by Congress in 1989, provide primary care services, including mental health services, to approximately 24 million Americans annually and function as a vital safety net for medically underserved communities and populations. </p><p> The largest source of revenue for FQHCs is Medicaid, and FQHCs receive enhanced reimbursement for services provided to Medicaid patients, known as the Medicaid Prospective Payment System (PPS) rate. Federal law, however, explicitly approves only certain health care professions as billable PPS providers. Licensed clinical social workers (LCSWs), along with psychologists and psychiatrists, are included as billable PPS providers under federal law, but not licensed professional counselors (LPCs). Some states have expanded the list of health care professions able to generate billable PPS encounters at FQHCs to include licensed professional counselors. It is vital for the counseling profession to understand the impact of these reforms and the interplay of federal and state policies related to reimbursement upon the mental health industry. </p><p> The optional Medicaid expansion provision of the ACA created an opportunity for a natural experiment to compare mental health service utilization and employment at FQHCs in Medicaid expansion states versus non-Medicaid expansion states. This quasi-experimental study first tested the causal impact of Medicaid expansion on the number of mental health visits and full-time equivalent (FTE) mental health staff at FQHCs, using state-level data gathered from FQHC reports submitted annually to the Uniform Data System. A count model difference-in-differences analysis strategy compared utilization and employment numbers in 2012-2013 (pre-Medicaid expansion) and 2014-2015 (post-Medicaid expansion) between Medicaid expansion states and non-Medicaid expansion states. Then, a two-sample test of proportions utilizing data from a research-developed employment survey examined the relationship between states approving counselors and states not approving counselors as billable FQHC mental health providers under the enhanced PPS reimbursement and the proportion of LPCs at FQHCs (of the total number of LPCs and LCSWs). </p><p> In both groups of states (Medicaid expansion states and non-Medicaid expansion states), it was evident that there was a substantial increase in the number of mental health visits and FTE mental health staff at FQHCs from 2012 to 2015. Contrary to prediction, the first count model difference-in-differences analysis indicated that non-Medicaid expansion states had a significantly <i> higher</i> rate of change in the number of mental health visits from pre-Medicaid expansion (2012-2013) to post-Medicaid expansion (2014-2015), as compared to Medicaid expansion states (&alpha; = .05, <i>p</i> = .01). Then, contrary to prediction, the second count model difference-in-differences analysis indicated that there was not a significant difference in the rate of change for the number of FTE mental health staff between Medicaid expansion states and non-Medicaid expansion states from pre-Medicaid expansion (2012-2013) to post-Medicaid expansion (2014-2015; &alpha; = .05, <i>p</i> = .13). As predicted, the two-sample test of proportions resulting from the survey responses of 138 FQHCs (60% response rate) indicated that there was a significantly higher proportion of LPCs employed at FQHCs in states approving LPCs as billable FQHC mental health providers under PPS as compared to states not approving LPCs (<i>Z</i> = 4.24, <i>p</i> &lt; .001, Cohen&rsquo;s <i>h</i> = .76). Thus, counselor employment at FQHCs was significantly improved in those states approving counselors as billable PPS providers. It is essential for counselors to understand the impact of federal and state health care policies, such as Medicaid expansion, increased funding of FQHCs, and various Medicaid reimbursement methodologies, to successfully advocate for the profession in the dynamic health care landscape. Counselor educators have a responsibility to convey information to students related to the potential repercussions of billable mental health provider status on their employment opportunities following graduation</p>

<p> The Internal Revenue Service (IRS) requires tax-exempt hospitals to conduct Community Health Needs Assessment (CHNA) every three years, formulate implementation strategies, and report yearly to the IRS and the public the progress of their work. The IRS CHNA incentivizes hospitals to provide programs responsive to community health needs. The purpose of this study was to examine the relationship between community benefit programs and prioritized community health needs in the context of a national IRS reporting requirement through analysis of published community benefit reports among North Carolina&rsquo;s (NC) tax-exempt hospitals. </p><p> This study employed quantitative research that analyzed longitudinal and cross-sectional data; qualitative research that reviewed published documents; and mixed-methods research that analyzed the integrated quantitative and qualitative results. The findings indicate that performing IRS-mandated CHNA did not substantially increase the alignment of community benefit programs with prioritized community health needs but did clearly highlight those needs. NC tax-exempt hospitals continue to focus on providing patient care financial assistance than population health, a strategy misaligned with community health needs. Although the hospitals are beginning to address population health and access to care concerns, their dollar expenditures in these areas paled in comparison to patient care financial assistance. If the IRS&rsquo; purpose in mandating CHNA was to spur a shift in community benefit priorities toward population health needs and away from the traditional patient care financial assistance, then, the evidence from 4 years after the requirement&rsquo;s implementation, indicates it is currently failing in North Carolina. As elucidated in the articles, their ingrained patient-level intervention perspective and desire to recover high unreimbursed costs or lost revenues for providing care to Medicare, Medicaid, and poor patients likely influence the hospitals&rsquo; community benefit programming to favor individual welfare over population health. Nevertheless, policymakers should continue to direct community benefit programs toward population health because it is a step in the right direction. Organizational change takes time and the desired results of policy interventions are usually incremental. Thus, conducting CHNA must remain a legal obligation by non-profit hospitals for maintaining their privileged tax status to facilitate organizational paradigm shift in community benefit programming toward population health programs or community building activities and away from individual welfare.</p><p>

<p> Caregivers&rsquo; compliance with polio vaccine regimens and timely receipt of the recommended 4 doses of polio vaccine are pivotal to eliminating polio. This cross sectional study, conducted in Lagos State, Nigeria, examined polio vaccine compliance and demographic attributes of caregivers&rsquo; for statistically significant associations. Using an adapted health belief model theoretical framework, 1,200 participants were recruited from well-baby clinics in 8 local government areas in Lagos State. Participants completed a brief demographic survey providing data on caregivers&rsquo; age, gender, residence (rural or urban), and their level of education as well as records from their children&rsquo;s immunization cards. Data obtained were tested for associations between caregiver&rsquo;s demographic information and their children&rsquo;s receipt of polio doses within specified timelines using chi-square and logistic regression analysis. Fisher&rsquo;s exact analysis were conducted for variables with frequencies less than 5. The only significant association recorded was between the receipt of Polio Dose A and location of caregivers&rsquo; residence: Rural dwelling caregivers were less likely to receive the first dose of polio. Results showed Polio Dose D to be the dose most likely received in an untimely manner as well as most likely missed of the 4 doses. Logistic regression analysis did not show any variable to be of greater odds in predicting completion of the 4 doses or compliance with timelines of their receipt. Study&rsquo;s results may inspire polio program planners to develop interventions that broaden the immunization coverage for rural dwellers to include nontraditional maternity locations. Positive social change will ensue by the improvement caregivers&rsquo; compliance with full polio dose receipts with timelines, maximizing immunity. </p><p>

This three-essay dissertation examines racial disparities in infant health outcomes and exposure to air pollution in Texas. It also asks whether the EPA's Risk-Screening Environmental Indicators Geographic Microdata (RSEI-GM) might be used to assess the effects of little-studied toxic air pollutants on infant health outcomes. Chapter 1 contributes to the “weathering” literature, which has shown that disparities in infant health outcomes between non-Hispanic black and non-Hispanic white women tend to widen with age. In this study, we ask whether the same patterns are observed in Texas and among Hispanic women, since other studies have focused on black and white women from other regions. We find that black and Hispanic women in Texas do “weather” earlier than white mothers with respect to rates of low birthweight and preterm birth. This differential weathering appears to be mediated by racial disparities in the distribution and response to socioeconomic risk factors, though a large gap between black and white mothers across all ages remains unexplained. Chapter 2 extends the statistical environmental justice literature by examining the distribution of toxic air pollution across infants in Texas. We find that, within Texas cities, being black or Hispanic is a significant predictor of how much pollution one is exposed to at birth. We further find that, among mothers who move between births, white mothers tend to move to significantly cleaner areas than black or Hispanic mothers. In Chapter 3, we use geocoded birth records matched to square-kilometer pollution concentration estimates from the RSEI-GM to ask whether the pollution-outcome relationships that emerge through regression analysis are similar to the effects found in previous research. If so, the RSEI-GM might be used to study the health effects of nearly 600 chemicals tracked in that dataset. We conclude, based on instability of results across various specifications and lack of correspondence to previous results, that the merged birth record-RSEI data are not appropriate for statistical epidemiology research.

The conversion of publicly owned industries and services into privately owned assets has been one of the most radical and controversial global economic trends of the past three decades. The major underlying rationale for this conversion is that public ownership is inherently economically inefficient. This point of view not only ignores the substantive evidence that disapproves this claim, but it also fails to recognize the merits of public ownership in promoting social welfare and health. Public ownership—in the form of public employment—does the latter in two ways: first, by providing employees with better and more equal benefits and working conditions than does the private sector, and second, by ensuring the smooth delivery of affordable quality social services to the public at large. This study quantitatively evaluates the impact of public employment on health at both the national and the individual level. At the national level, a cross-country sample from the 1980s shows that an increase of public sector employment was associated with a statistically and economically significant increase in life expectancy—a major indicator of population health. The association was even more prominent for middle- and low-income countries and for women. At the individual level, using logistic regression on data from a 2006 Chinese household survey, this study finds that public sector employees were statistically more likely to report good or excellent health than private sector employees. Analysis of the data reveals that much of this health premium is attributable to the fact that the public sector provides more permanent jobs than the private sector. Further, the private sector appears to have steep social class-health gradients, while such health inequality is moderate or even absent within the public sector. As a complement to the quantitative findings, this study also conducts a qualitative survey of China’s institutional and social context. It helps to further explain why the public sector in China remains a better employer after the collapse of the “iron rice bowl” system. Several policy implications emerge from this study. First, public sector employment deserves serious consideration as an instrument to promote health and health equality. Second, job security is essential for health; proposals for a more flexible and less regulated labor market are neither theoretically nor empirically justified. And last but not least, if the public sector continues its recent practice of implementing neoliberal policies, such as privatization and deregulation, its health premium over the private sector may go away.

The theory selected as the potential framework for better explaining teenage pregnancy, among a cohort of health-insured sexually active teens, was Social Bond Theory. With this theoretical framework in mind, eight research questions were generated, with the primary focus of interest in determining the correlation between ten social bond scale scores to outcome status (deliver, abort and contracept). A 50-item survey instrument was developed for purposes of this research utilizing original and existing demographic and social bond questions. The questionnaire was adapted for use with a CATI system of telephone interviewing, pretested and finally administered to a total of 213 teenage respondents. Results from the stepwise multiple regression analysis showed that among the respondents who sustained a pregnancy, significant differences existed between the deliver and abort groups. The deliver group was more highly religious (p =.001) and more likely to have come from a family of lower socioeconomic status (p =.001) than were the respondents from the abort group. When comparing the abort and contracept respondents, the only significant difference was that the abort group was less connected with family than were the contraceptors (p =.02). For all demographic measures and all remaining social bond measures, these two groups of respondents were not significantly different. Lastly, it was determined that the young women most likely to be teenage mothers among the study respondents were those who were less hopeful about the future (p =.005), were less involved in school-related activities (p =.018), were more religious (p =.023) and were more likely to be of non-white racial/ethnic status (p =.015) than those who successfully contracepted.

<p> The democratic decentralization of government administration in Indonesia from 1999 represents the most dramatic shift in governance in that country for decades. In this dissertation I explore how health managers in one kabupaten (regency) are responding to the new political environment. Kabupaten health managers experience decentralization as incomplete, pointing to the tendency of central government to retain control of certain health programs and budgets. At the same time they face competing demands for autonomy from puskesmas (health center) heads. Building on Scott&rsquo;s (1985) idea of a &ldquo;moral economy&rdquo; I delve beneath the political tensions of competing autonomies to describe a moral landscape of underlying beliefs about how government ought to behave in the health sector. Through this analysis certain failures and contradictions in the decentralization process emerge, complicating the literature that presents decentralization as a move in the direction of &ldquo;good governance&rdquo; (Mitchell and Bossert 2010, Rondinelli and Cheema 2007, Manor 1999). </p><p> Decentralization brings to the fore the internal divisions within government, yet health workers present a united front in their engagements with the public. Under increasing pressure to achieve global public health goals such as the Millennium Development Goals, health managers engage in multiple translations in converting global health discourses into national and local health policies and in framing these policies in ways that are comprehensible and compelling to the general public. Using the lens of a &ldquo;cultural theory of state&rdquo; (Corrigan and Sayer 1985) I describe how health professionals and volunteers draw on local cultural forms in order to render global frameworks compatible with local moralities. I introduce the term &ldquo;moral pluralism&rdquo; to describe how individual health workers interrelate several moral frameworks in their health promotion work, including Islam, evidence based medicine and right to health. My conclusion is that kabupaten health managers are engaging in two balancing acts. The first is between decentralization and (re)centralization and deals with the proper way to manage health programming. The second is between global health discourses and local cultural forms and concerns the most effective way to convey public health messages in order to bring about behavior change in line with national and global public health goals. This is the first anthropological study of how government officials at different levels negotiate the process of health decentralization in the face of increasing international pressure to achieve global public health goals.</p>

<p>"Harm reduction," or services aimed at reducing the negative effects of high-risk behavior, like drug use, is a fledgling social movement and relatively new type of service provision in the United States. Although it contains guiding principles, it also has many different manifestations. The varying ways in which harm reduction can be implemented reflect the numerous ways in which it can be defined, and this has been a major point of critique in recent literature. Although many sources speak about its definition, very few explore how harm reduction workers actually define their work, and I would argue that harm reduction is actually defined on a daily basis by those performing it. This study explores how service providers both define and practice harm reduction in their everyday activities at a syringe exchange program facility. </p>

Este trabalho toma como objeto as práticas de atenção à saúde desenvolvidas na rede básica de serviços de saúde voltadas para a juventude. O objetivo geral foi analisar as práticas de saúde específicas para a juventude na rede básica de serviços de saúde da Supervisão Técnica de Saúde Butantã, região Centro-Oeste do município de São Paulo, tomando por referência as políticas públicas brasileiras nessa área. Fundamentando-se no campo da Saúde Coletiva, a juventude é compreendida como uma categoria social, o que submete compreensões centradas nas mudanças biológicas a análises mais amplas, enfatizando a existência de várias juventudes, a depender da inserção de classe social dos jovens. Para isso, identificou-se as práticas de saúde específicas para a juventude a partir dos depoimentos dos trabalhadores e analisou-se a tendência dessas práticas frente às políticas públicas brasileiras, em especial aos programas de saúde (federal, estadual e municipal) da juventude. Dessa forma, os trabalhadores constituíram os sujeitos dessa pesquisa. Utilizou-se a entrevista semi-estruturada como técnica para a coleta dos dados e a análise temática como estratégia para a apreensão da realidade. A análise permitiu elencar categorias empíricas - como o setor saúde percebe a juventude, como o setor saúde percebe o processo saúde-doença, como o setor saúde percebe a questão da educação, como o setor saúde percebe os seus problemas, como deveria ser a resposta do setor saúde frente aos seus problemas, o que os serviços de saúde estão oferecendo para a juventude e quando a juventude procura o serviço de saúde – que foram respondidas sob a ótica dos trabalhadores entrevistados. A análise mostrou que além de poucas, as práticas específicas para a juventude são intermitentes e de natureza casuística, dependendo da “boa vontade" dos trabalhadores para o seu desenvolvimento. Sua tendência frente às políticas públicas brasileiras voltadas para a juventude revela a ausência de um sistema de referência uniforme entre os serviços de saúde da rede básica. Para a superação dessas limitações será necessário o reconhecimento das necessidades de saúde da juventude pelos distritos de saúde do município de São Paulo, em especial pela Supervisão Técnica de Saúde Butantã, tomando-as sob a visão da saúde coletiva, ou seja, respeitando a concepção da determinação social do processo saúde-doença, para que definitivamente possa se implementar um programa em nível distrital. Além disso, é imprescindível o apoio dos gestores dos vários níveis de governo e principalmente das chefias imediatas dos trabalhadores executores das práticas de saúde / This research comprises health practices developed in the public health department, specifically towards young people. The main target was to analyse health practices on young people at the public health department of Health Technical Supervision of Butantã Area, a central-west area of the city of São Paulo, taking as reference the Brazilian public politics in this area. Taking theoretical considerations from the Collective Health field, young people are taken as a social category, which causes the research to be centered from biological changes to wider analyses, emphasizing the existence of different groups of young people, according to their social class. For this reason, it identified specific health practices on young people and analysed the tendency of these practices towards Brazilian public politics, specially the youth health program (federal, state and municipal). This way the workers constitute the subject of this research. A pre-stablished interview was used to collect data and the theme analysis as strategy for reality apprehension. The analysis permitted some empirical categories to be listed – how health department sees young people, how health department sees the health-disease process, how health department sees their own matters, how health department sees their own problems, how health department should face their own problems, what health service has been offering young people and when young people look for health service assistance. The analysis showed that young people practices in basic health services are not only low-numbered, but also unsteady and casual, counting on their workers’ willingness to develop it. Their tendency towards Brazilian public politics for young people shows the absence of a straight-guidelined system between health service and health basic system. Overcoming these limitation there requires acknowledgement of young people’s needs for young-people health care by the community districts of São Paulo, especially by those of Health Technical Supervision of Butantã, taking note of the insight of Collective Health, in other words, respecting the social conception of determination of the health-disease process, so that a district-level program can be definitely implanted. Also the support by various levels of government officials is essential, especially by those in charge of the health-department offices