This thesis uses observational study design methods to explore the relationship between depression and various outcomes following acute myocardial infarction (AMI). There are three main studies. First, the relationship between depression and mortality following AMI was measured. The main finding was that the factor determining the increased mortality rate in depressed patients is reduced cardiac functional status. The main implication was that efforts to address increased mortality in depressed patients with cardiovascular illnesses should focus on processes that impact cardiac functional status. Second, the impact of depression on service consumption following AMI was examined. Depressive symptoms were associated with a 24% (Adjusted RR:1.24; 95% CI:1.19-1.30, P<0.001), 9% (Adjusted RR:1.09; 95% CI:1.02-1.16, P=0.007) and 43% (Adjusted RR: 1.43; 95% CI:1.34-1.52, P<0.001) increase in total, cardiac, and non-cardiac hospitalization days post-AMI respectively, after adjusting for baseline patient and hospital characteristics. Depressive-associated increases in cardiac health service consumption were significantly more pronounced among patients of lower than higher cardiac risk severity. The disproportionately higher cardiac health service consumption among lower-risk AMI depressive patients may suggest that health seeking behaviors are mediated by psychosocial factors more so than by objective measures of cardiovascular risk or necessity. Third, methodological issues related to missing data were explored. A systematic review of three psychiatric journals revealed that a small minority of studies (5.8%) addressed the impact of missing data in a meaningful way. An example using real data demonstrated the potential bias introduced by missing data and different ways to address this bias. The paper concludes with recommendations for both reporting and analyzing studies with substantial amounts of missing data. Overall, the studies add to the literature exploring the relationship between depression and outcomes following acute myocardial infarction. Future studies measuring the relationship between depression and mortality will need to factor the mediating relationship between depression and cardiac functional status. The increased health service utilization associated with depression will need to be replicated in other illness models. Together, the studies add to the existing conceptual framework for measuring relationships between depression and outcomes in patients with cardiovascular illnesses.

This thesis uses observational study design methods to explore the relationship between depression and various outcomes following acute myocardial infarction (AMI). There are three main studies. First, the relationship between depression and mortality following AMI was measured. The main finding was that the factor determining the increased mortality rate in depressed patients is reduced cardiac functional status. The main implication was that efforts to address increased mortality in depressed patients with cardiovascular illnesses should focus on processes that impact cardiac functional status. Second, the impact of depression on service consumption following AMI was examined. Depressive symptoms were associated with a 24% (Adjusted RR:1.24; 95% CI:1.19-1.30, P<0.001), 9% (Adjusted RR:1.09; 95% CI:1.02-1.16, P=0.007) and 43% (Adjusted RR: 1.43; 95% CI:1.34-1.52, P<0.001) increase in total, cardiac, and non-cardiac hospitalization days post-AMI respectively, after adjusting for baseline patient and hospital characteristics. Depressive-associated increases in cardiac health service consumption were significantly more pronounced among patients of lower than higher cardiac risk severity. The disproportionately higher cardiac health service consumption among lower-risk AMI depressive patients may suggest that health seeking behaviors are mediated by psychosocial factors more so than by objective measures of cardiovascular risk or necessity. Third, methodological issues related to missing data were explored. A systematic review of three psychiatric journals revealed that a small minority of studies (5.8%) addressed the impact of missing data in a meaningful way. An example using real data demonstrated the potential bias introduced by missing data and different ways to address this bias. The paper concludes with recommendations for both reporting and analyzing studies with substantial amounts of missing data. Overall, the studies add to the literature exploring the relationship between depression and outcomes following acute myocardial infarction. Future studies measuring the relationship between depression and mortality will need to factor the mediating relationship between depression and cardiac functional status. The increased health service utilization associated with depression will need to be replicated in other illness models. Together, the studies add to the existing conceptual framework for measuring relationships between depression and outcomes in patients with cardiovascular illnesses.

The purpose of this study was to determine the factors that influence university students use of health services for mental or emotional reasons. Currently accepted models of health service use may not apply to university students due to their unique socio-demographic characteristics and health challenges. The Andersen and Newman model of health service utilization was used as a conceptual framework. The first hypothesis was that many factors that influence use of services in the general population would also apply to the university student population. The second hypothesis was that some student-specific factors would also influence health service utilization for mental or emotional reasons. <p>Data for this study was collected in a survey designed for a larger health needs assessment of University of Saskatchewan undergraduate students. The dependant variable was the use of services for mental or emotional reasons within the past year. Information was also collected for 26 independent variables. A logistic regression was used to determine which of these were related to the dependant variable. <p>The final model of health service utilization for mental/emotional reasons among university students included six independent variables: 1) perceived need for professional help (for emotional problems), 2) previous depression diagnosis, 3) past/present suicide ideation, 4) sexual assault victimization, 5) presence of a family doctor, and 6) gender.<p>The results of this study indicate that many of the factors that influence service use for mental/emotional reasons in the student population are the same as those that exist in the general population. The results also suggest that student-specific factors, such as college, years in university, or academic performance do not influence health service use for mental/emotional reasons. Implications of these findings are discussed.

The purpose of this study was to determine the factors that influence university students use of health services for mental or emotional reasons. Currently accepted models of health service use may not apply to university students due to their unique socio-demographic characteristics and health challenges. The Andersen and Newman model of health service utilization was used as a conceptual framework. The first hypothesis was that many factors that influence use of services in the general population would also apply to the university student population. The second hypothesis was that some student-specific factors would also influence health service utilization for mental or emotional reasons. <p>Data for this study was collected in a survey designed for a larger health needs assessment of University of Saskatchewan undergraduate students. The dependant variable was the use of services for mental or emotional reasons within the past year. Information was also collected for 26 independent variables. A logistic regression was used to determine which of these were related to the dependant variable. <p>The final model of health service utilization for mental/emotional reasons among university students included six independent variables: 1) perceived need for professional help (for emotional problems), 2) previous depression diagnosis, 3) past/present suicide ideation, 4) sexual assault victimization, 5) presence of a family doctor, and 6) gender.<p>The results of this study indicate that many of the factors that influence service use for mental/emotional reasons in the student population are the same as those that exist in the general population. The results also suggest that student-specific factors, such as college, years in university, or academic performance do not influence health service use for mental/emotional reasons. Implications of these findings are discussed.

Adolescence is a very important transition stage between childhood and adulthood. In this stage, due to rapid change physically and mentally, adolescents are more likely to occur physical, psychological, and social problems. Therefore, providing adolescents fine health service is critical. To do so, having a better understanding of the factors associated with health service utilization can help a lot. The main purpose of this study is to understand adolescents¡¦ behavior of health service utilization. Based on Andersen¡¦s behavior model of health service utilization, this study investigated the associations of predisposing characteristics, enabling resource characteristics, and needing characteristics with health service utilization of adolescents. The data used in these analyses were drawn from students in junior high schools of Tainan Providence, of which seven schools were randomly selected and then anonymous questionnaires were distributed to all students. 2,242 of 3,591 students were collected, for a response rate of 55.39%, and the final sample was 1,989. ANOVA and t test were employed to examine health service utilization of adolescents, and multiple regression was used to investigate the factors associated with health service utilization. Several results were found in this study as follows: First, significant differences did exist among junior high students, which indicated that second graders and third graders went to see doctors more times than first graders did. Second, there were 21% and 12% of respondents with experience of hospitalization and operation respectively. Students with hospitalization and operation experience utilized more health services. Third, students with national health insurance were more likely to utilize health services than those without national health insurance. Last, with regard to the relationship between self-perception of health status and health service utilization, the more respondents perceived themselves with problem of physical health or adolescent development, the more health services they utilized. In addition, the perception of emotional problem was negatively related to the utilization of health services. Several suggestions are proposed. First, establish adolescent clinics in all hospitals that are in the level of district hospitals and above to improve medical accessibility. Second, advocate the system of family physician to emphasize continuity and integrity of health care. Moreover, design appropriate clinical education for adolescents to educate them with adequate concept of health care and health utilization, making them understand the idea of health gradient to receive the right treatment in the right place. Last but not least, the health and education administration should reinforce adolescents¡¦ ability of emotional management, provide assistance for them to find out their emotional problems, and help them to receive appropriate health treatment through psychological consultation of adolescent clinics as soon as possible.

Palliative radiotherapy (PRT) is proven to be effective in palliation of symptoms for end-stage cancer patients. However, little is known about its utilization at the end of life. This research aims to examine the utilization and the practice patterns of PRT at the end of life for cancer patients in British Columbia using population-based data. The pattern observed for PRT1Y dose-fractionation practice in BC are in line with published clinical guidelines and evidence from the literature, which advises “proper” use of PRT in BC as delivered to cancer patients at the end of life. However, after controlling for age, primary cancer site, and survival time, geographic access is found to be significantly associated with PRT1Y utilization. Variations found in PRT1Y rates by geographic access, which is operationalized by the Health Services Delivery Area (HSDA) and travel time, suggests potential underutilization of PRT1Y for patients with suboptimal access. / Graduate / 0992 / 0769 / 0574 / jinhuang@uvic.ca

Many individuals, especially those in rural areas, experience barriers to accessing medical care. Some barriers are attitudinal and represent perceived quality of care, such as patient satisfaction; however, some rural residents report elevated patient satisfaction scores, regardless of limited access to these services. Identifying how perceived need for medical care is related to patient satisfaction has not been previously explored. Using an online survey to collect data from a national sample (n=535), the current study used the Patient Satisfaction Questionnaire-Short Form (PSQ-18) and a single-item measure of perceived need to examine the association between these two variables, and further, whether rural status, measured by a single-item measure, moderated this association. Results indicated a significant negative correlation between patient satisfaction and perceived need, r(423)=-.12, p=.012. Although the overall moderation model was significant, F(5, 388)=7.10, p<.001, perceived need was not significantly associated with patient satisfaction, b=-.14, p=.20, and rurality status did not significantly moderate the relationship, F(1, 388)=.44, p=.51, ��R2=0.01. However, the covariates of income, b=.11, p<.001, and sexual orientation, b=.23, p=.01, significantly predicted patient satisfaction. This study identified an association between patient satisfaction with perceived need for medical care that has not been previously explored, although this relationship was no longer significant in a larger model, indicating other important factors likely influence this relationship and contribute to the elevated satisfaction scores identified in some rural areas. The lack of moderation by rurality may be due to consistently high barriers to accessing care across all regions of the United States; while rural areas certainly experience unique barriers to care, the barriers present in urban environments may be significant enough that level of rurality in itself does not significantly affect the relationship between perceived need and patient satisfaction. Furthermore, this study highlights the importance of social determinants of health in patients’ perceptions of quality of care. Sexual orientation and income emerged as significant predictors of patient satisfaction, in that higher satisfaction was associated with those who identified as heterosexual and had higher income, consistent with previous literature. Further investigation is necessary to determine the reasons why these relationships exist; however, it is important to acknowledge that individuals with low-income and who identify as sexual minorities experience stigma and discrimination in healthcare settings. These negative experiences with healthcare likely influence perceptions and health disparities that exist within these individuals and may directly impact patient satisfaction levels, which may be influential to these findings.

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The purpose of this research study was to explore Mexican women’s perceptions about utilizing mental health services and to explore the barriers encountered during the process. Previous research suggested Mexican women’s diverse experiences when seeking and utilizing mental health services. The study used a qualitative approach with open-ended and closed-ended questions. The sample size of this study was fifteen individuals who self-identified as Mexican women who reside in Southern California recruited using a snowball approach. Major themes identified included Mexican family values and beliefs, cultural barriers, structural barriers, Mexican women’s strengths, and community suggestions for social work practice. This study highlighted their perspective on mental health, cultural and structural barriers, their personal experiences of utilizing mental health services, techniques on managing difficult situations, support systems, identified mental health symptoms, coping methods, cultural values and suggestions to improve mental health services in the general Latino community.

Research Objectives: Osteoporosis has become a significant public health problem in recent years, especially with the growth of the elderly population. Osteoporotic fractures exact a terrible toll on the population with respect to morbidity, cost, and to a lesser extent mortality. These effects can lead to psychological problems, social consequences, functional limitations, and poor quality of life. Thus, knowledge regarding osteoporotic fractures is needed to evaluate the impact of osteoporotic fractures on society, to identify high-risk populations, and to help policymakers to allocate resources accordingly. This study aims to investigate the influence factors of hospital readmissions among osteoporotic fractures patients in Taiwan, and the study results are expected to increase our understanding of the magnitude of the elderly population suffering from osteoporotic fractures and to urge policymakers to develop effective national prevention strategies. Study Design: Using Taiwan¡¦s National Health Insurance database, we identified elderly patients with a hospitalization for osteoporotic fractures between 2001 and 2007. We divided readmissions into different groups (14-day, 30-day, 180-day and over 180-day) and evaluated each group¡¦s demographic, hospital characteristics, and Charlson Comorbidity Index. The claims data are also used to calculate the health services utilization of osteoporotic fractures among those elderly patients with or without readmission of osteoporotic fractures. The data analyses were carried out by Chi-square test, t test, multiple linear regression and multivariate logistic regression. Population Studied: Patients aged 50 or older with osteoporotic fractures were identified based on the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). Principle Findings: Among 5483 osteoporotic fractures patients, 6.9% of them were readmitted within 14 days, 34.7% were readmitted within 30 days and 13.9% were readmitted within 180 days. The medical resource utilizations were significantly higher in patients with readmissions than those without readmission. Age and Charlson Comorbidity Index were significantly affected the probabilities of readmissions. Conclusion: From the perspective of health policy, the issue of osteoporotic fractures will become increasingly important in the future. This national study will help raise awareness of osteoporotic fractures and hopefully motivate public health policy makers to develop effective national prevention strategies against osteoporosis to prevent osteoporotic fractures.