No description available.

No description available.

Preterm birth (< 37 weeks gestation) is a major health burden for affected children. Although the risk of health problems increases as the gestational age decreases, research in the last decades has revealed that even late preterm infants born at 34-36 weeks gestational age have higher mortality and morbidity than term infants. Because late preterm infants constitute three fourths of preterm infants, they are important from both public health and health policy perspectives. This doctoral thesis sought to answer important knowledge gaps in health service utilization of late preterm infants via three studies. Study A, a systematic review and meta-analysis comparing health service utilizations of late preterm infants with those of term infants, found that late preterm infants had increased hospitalization compared with term infants that persisted from the neonatal period through adolescence. Study B is a cohort study evaluating the re-admissions and emergency department visits by late preterm and term singletons and twins for the first 5 years after birth. Study B demonstrated that late preterm infants had higher re-admission rates than term infants although differences in twins were less pronounced than in singletons. Study C is a population-based cohort study with cost analyses assessing the health care costs and resource utilization related to three different discharge timings of late preterm and term singletons: early (< 48 hours), late (48-71 hours), and very-late (72-95 hours) discharge after birth. Study C found that early discharge was not associated with the reduction of health care cost in late preterm infants, and instead was associated with an increase in the cost in term infants over the first year after birth. These findings are useful for parents, care providers, health policy makers, and guideline developers to provide optimal care for late preterm infants. / Thesis / Doctor of Philosophy (PhD)

Réalisé en cotutelle avec l'Université de Paris-Sud / La thèse a pour objectif d’étudier les rapports entre les besoins typiquement hétérogènes des personnes âgées vivant dans la communauté et l’utilisation conséquente des services médicaux et sociaux. Inspirée du concept de la fragilité, l’approche a d’abord consisté à modéliser l’hétérogénéité des besoins en classant les individus – par l’analyse de classes latentes (ACL) – dans des profils-types, chacun représentant une constellation particulière de problèmes de santé. Appliquée aux données recueillies dans le cadre du projet de démonstration du SIPA (Système de services intégrés pour personnes âgées en perte d’autonomie), l’ACL a révélé 4 profils qui se distinguent sur le plan qualitatif par les dimensions physique et cognitive, et sur le plan quantitatif par la gravité des incapacités que les individus manifestent (Article 1). L’analyse des transitions entre les profils sur 1 an et 22 mois montre des changements différenciés selon les profils et le sexe, et confirme la stabilité de la classification et sa sensibilité aux changements d’état de santé. En outre, les profils sont robustes aux effets de la mortalité et de l’attrition due aux sorties d’étude. Les rapports entre les profils, les variables sociodémographiques et les indicateurs de résultats tel l’hébergement et la mortalité appuient la validité de la classification. Les profils ont ensuite servi à modéliser les besoins dans des modèles économétriques ajustés pour étudier l’utilisation et les coûts par profil d’état de santé pour une gamme de services financés par le système public (Article 2). Ces analyses montrent que les profils permettent d’identifier des configurations distinctes d’utilisation et de coûts pour des sous-groupes représentatifs de la population âgée fragile. La sensibilité des profils aux différences d’accès et aux différences d’intensité d’utilisation révèle les choix de ces groupes cibles par les autorités locales dans la prestation des services institutionnels et des services de proximité. Enfin, une analyse fine de ces relations a été menée pour la couteuse période précédant le décès dans le but d’établir si l’intensification des coûts en fin de vie concerne les personnes âgées de manière homogène quelque soit la gravité de leur état de santé (Article 3). Les analyses comparatives des survivants et des décédés montrent une tendance inverse dans les coûts des services selon l’état de santé. Les personnes qui survivent dans des états de santé compromis coûtent significativement plus que leurs homologues relativement sains. En revanche, c’est chez les individus relativement sains, indépendamment de l’âge, qu’on retrouve les coûts de fin de vie les plus élevés – liés principalement aux hospitalisations de courte durée. Combiné aux résultats qui montrent que les coûts sont significativement moindres chez les sujets de plus de 85 ans, ce travail confirme l’hypothèse d’une compression des coûts attribuables à la morbidité chez les décédés les plus âgés. L’originalité de cette thèse tient au fait que très peu de travaux ont tenté de modéliser l’hétérogénéité de l’état de santé dans le but d’étudier ses conséquences sur l’accès, l’intensité et les coûts des services sociaux et médicaux pour notre population de référence. En outre, alors que la pertinence des soins de fin de vie et le maintien à domicile sont au cœur des préoccupations, ce travail est le premier à décrire les rapports entre l’état de santé et les coûts en fin de vie pour les personnes âgées fragiles vivant dans la communauté. / Abstract This thesis aims to study the relationship between the typically heterogeneous needs of community-living elderly and their consequent utilization of health and social services. Inspired by the concept of frailty, the approach consisted in modeling the heterogeneity – by latent class analysis (LCA) – to group individuals into homogenous categories of health status, each representing a constellation of health problems. Applied to the data collected for the demonstration project of the system of integrated services for frail elderly (SIPA), LCA revealed four health state profiles that distinguish the physical and cognitive dimensions of health and capture severity along the disability dimension (Article 1). Transition analyses over 1 year and 22 months showed differentiated and gender-specific patterns of transition probabilities, confirming the sensitivity of the profiles to change in health status. The profiles are stable over time and robust to mortality and lost to follow-up attrition. Relationships between the profiles, sociodemographic characteristics and distal outcomes, such as mortality and institutionalization, confirm the classification’s validity. These profiles were then used in two-part econometric models to study access and costs of several measures of publicly funded services (Article 2). Our results show the profiles are able to identify distinct configurations of service utilization and costs in substantially meaningful subgroups of the frail elderly population. What is important here is that the health state profiles are sensitive to differences, and changes, in available patterns of care in a specific milieu. These differences reveal choices of target groups by local authorities in delivering institutional and community-based services. Finally, a fine analysis of these differences was performed for the costly period preceding death to establish whether the high end-of-life costs affect all elderly homogenously irrespective of the severity of their health state (Article 3). A comparative analysis revealed that survivors’ and decedents’ costs of care trends according to health status go in opposite directions. Severely disabled survivors cost significantly more compared to their relatively healthy counterparts. In contrast, the highest end-of-life costs – driven by acute hospitalizations – belong to the relatively healthy, independent of age. Among survivors and among decedents, the oldest old (85+) cost significantly less compared to younger age groups. Combined, these results support the notion of a compression of costs due to morbidity in the oldest old decedents. The originality of this thesis rests on the fact that few very few studies attempted to model heterogeneity in health status with the goal of estimating its effect on patterns of service utilization. Moreover, in light of the shift towards community-based care as a response to economic pressures and population aging, our work is the first to describe the relationship between health status and end-of-life care in frail community-living elderly.

The current study investigated maternal determinants of mental health service use, namely, individual child therapy, among preadolescent children diagnosed with ADHD. The Behavioral Model of Health Care Utilization (Andersen, 2008) was used as a theoretical framework for the study. Data from the last three rounds of ECLS-K dataset were employed to test a longitudinal model using Bayesian analysis. Socio-demographic variables and maternal mental health were tested as exogenous variables and mother-child relationship variables, discipline variables, and perceived maternal concern about child’s overall behavior and child’s emotional symptoms were tested as intervening variables. Results showed that only maternal mental health remained in the model as an exogenous variable. The effect of mental health on child therapy was mediated by maternal aggravation and maternal concern about overall behavior in one path and by maternal concern about emotional symptoms in another path, suggesting that maternal mental health needs to be considered when attempting to understand help-seeking determinants. Both concern variables were found to have large direct effects on child therapy. The results of the current study showed the importance of maternal mental health and the importance of determinants related to mother-child relationship in a mother’s decision to seek therapy for a child.

La thèse a pour objectif d’étudier les rapports entre les besoins typiquement hétérogènes des personnes âgées vivant dans la communauté et l’utilisation conséquente des services médicaux et sociaux. Inspirée du concept de la fragilité, l’approche a d’abord consisté à modéliser l’hétérogénéité des besoins en classant les individus – par l’analyse de classes latentes (ACL) – dans des profils-types, chacun représentant une constellation particulière de problèmes de santé. Appliquée aux données recueillies dans le cadre du projet de démonstration du SIPA (Système de services intégrés pour personnes âgées en perte d’autonomie), l’ACL a révélé 4 profils qui se distinguent sur le plan qualitatif par les dimensions physique et cognitive, et sur le plan quantitatif par la gravité des incapacités que les individus manifestent (Article 1). L’analyse des transitions entre les profils sur 1 an et 22 mois montre des changements différenciés selon les profils et le sexe, et confirme la stabilité de la classification et sa sensibilité aux changements d’état de santé. En outre, les profils sont robustes aux effets de la mortalité et de l’attrition due aux sorties d’étude. Les rapports entre les profils, les variables sociodémographiques et les indicateurs de résultats tel l’hébergement et la mortalité appuient la validité de la classification. Les profils ont ensuite servi à modéliser les besoins dans des modèles économétriques ajustés pour étudier l’utilisation et les coûts par profil d’état de santé pour une gamme de services financés par le système public (Article 2). Ces analyses montrent que les profils permettent d’identifier des configurations distinctes d’utilisation et de coûts pour des sous-groupes représentatifs de la population âgée fragile. La sensibilité des profils aux différences d’accès et aux différences d’intensité d’utilisation révèle les choix de ces groupes cibles par les autorités locales dans la prestation des services institutionnels et des services de proximité. Enfin, une analyse fine de ces relations a été menée pour la couteuse période précédant le décès dans le but d’établir si l’intensification des coûts en fin de vie concerne les personnes âgées de manière homogène quelque soit la gravité de leur état de santé (Article 3). Les analyses comparatives des survivants et des décédés montrent une tendance inverse dans les coûts des services selon l’état de santé. Les personnes qui survivent dans des états de santé compromis coûtent significativement plus que leurs homologues relativement sains. En revanche, c’est chez les individus relativement sains, indépendamment de l’âge, qu’on retrouve les coûts de fin de vie les plus élevés – liés principalement aux hospitalisations de courte durée. Combiné aux résultats qui montrent que les coûts sont significativement moindres chez les sujets de plus de 85 ans, ce travail confirme l’hypothèse d’une compression des coûts attribuables à la morbidité chez les décédés les plus âgés. L’originalité de cette thèse tient au fait que très peu de travaux ont tenté de modéliser l’hétérogénéité de l’état de santé dans le but d’étudier ses conséquences sur l’accès, l’intensité et les coûts des services sociaux et médicaux pour notre population de référence. En outre, alors que la pertinence des soins de fin de vie et le maintien à domicile sont au cœur des préoccupations, ce travail est le premier à décrire les rapports entre l’état de santé et les coûts en fin de vie pour les personnes âgées fragiles vivant dans la communauté. / Abstract This thesis aims to study the relationship between the typically heterogeneous needs of community-living elderly and their consequent utilization of health and social services. Inspired by the concept of frailty, the approach consisted in modeling the heterogeneity – by latent class analysis (LCA) – to group individuals into homogenous categories of health status, each representing a constellation of health problems. Applied to the data collected for the demonstration project of the system of integrated services for frail elderly (SIPA), LCA revealed four health state profiles that distinguish the physical and cognitive dimensions of health and capture severity along the disability dimension (Article 1). Transition analyses over 1 year and 22 months showed differentiated and gender-specific patterns of transition probabilities, confirming the sensitivity of the profiles to change in health status. The profiles are stable over time and robust to mortality and lost to follow-up attrition. Relationships between the profiles, sociodemographic characteristics and distal outcomes, such as mortality and institutionalization, confirm the classification’s validity. These profiles were then used in two-part econometric models to study access and costs of several measures of publicly funded services (Article 2). Our results show the profiles are able to identify distinct configurations of service utilization and costs in substantially meaningful subgroups of the frail elderly population. What is important here is that the health state profiles are sensitive to differences, and changes, in available patterns of care in a specific milieu. These differences reveal choices of target groups by local authorities in delivering institutional and community-based services. Finally, a fine analysis of these differences was performed for the costly period preceding death to establish whether the high end-of-life costs affect all elderly homogenously irrespective of the severity of their health state (Article 3). A comparative analysis revealed that survivors’ and decedents’ costs of care trends according to health status go in opposite directions. Severely disabled survivors cost significantly more compared to their relatively healthy counterparts. In contrast, the highest end-of-life costs – driven by acute hospitalizations – belong to the relatively healthy, independent of age. Among survivors and among decedents, the oldest old (85+) cost significantly less compared to younger age groups. Combined, these results support the notion of a compression of costs due to morbidity in the oldest old decedents. The originality of this thesis rests on the fact that few very few studies attempted to model heterogeneity in health status with the goal of estimating its effect on patterns of service utilization. Moreover, in light of the shift towards community-based care as a response to economic pressures and population aging, our work is the first to describe the relationship between health status and end-of-life care in frail community-living elderly. / Réalisé en cotutelle avec l'Université de Paris-Sud

Background: Information Communication Technologies (ICT)-mediated support can reduce family caregiver burden and may bridge service gaps caused by time constraints and language or cultural barriers. (Non)-usage behaviour can be explained using Andersen’s Behavioural Model of Health Service Utilization, Venkatesh’s Unified Theory of Use and Acceptance of Technology, Eysenbach’s Law of Attrition, and Wilson’s and Chatman’s Information Behaviour Theories. Purpose: This study aimed to describe and explain (non)-usage behaviour of ehealth services among Chinese caregivers. Method: This two-phase study used a mixed methods design involving 46 Chinese caregivers who cared for a family member with dementia. Usability of the ICT tools designed in the study was tested. Phase I participants (N=28) had access to a bilingual information site and personalized email support from professionals. Phase II participants (N=18) were randomized to use one of three enhanced features. Pre- and post-intervention data were collected, and qualitative interviews were conducted. Results: The Phase I ICT tools supported the core functions without major usability issues. Perceived efforts to use the ICT-mediated services influenced the consent decisions of Phase I caregivers (p=.036). Caregivers initiated service earlier if they had a higher acceptance of the service (p=0.017). Frequent users of email support experienced a decline of perceived burden compared with an escalation of perceived burden by non-users (p=0.023). An older age, greater caregiving competence, and lower English or computer proficiency explained non-usage behaviour. Requirements were identified to enhance the Phase I ICT tools. In Phase II, a test of three enhanced features showed there was no major usability issue. The intervention study found the enhanced features did not influence email use as hypothesized. Qualitative analysis showed usage patterns were explained by caregiver needs, caregiving beliefs, personal capacity, social support, ICT factors, and style of use. Non-users preferred Chinese to English compared with users (p=0.046). Integrating the theories and empirical findings, three concepts were developed to explain (non)-usage behaviour: usage in context, usage paths, and stages of use. Conclusion: Usage and non-usage behaviour can be explained by the service needs in the caregiving context, the use of non-ICT-mediated resources, and the access barriers to Internet use. Use of ICT-based support can be beneficial to caregivers if they do not drop out of the service.

Background: Information Communication Technologies (ICT)-mediated support can reduce family caregiver burden and may bridge service gaps caused by time constraints and language or cultural barriers. (Non)-usage behaviour can be explained using Andersen’s Behavioural Model of Health Service Utilization, Venkatesh’s Unified Theory of Use and Acceptance of Technology, Eysenbach’s Law of Attrition, and Wilson’s and Chatman’s Information Behaviour Theories. Purpose: This study aimed to describe and explain (non)-usage behaviour of ehealth services among Chinese caregivers. Method: This two-phase study used a mixed methods design involving 46 Chinese caregivers who cared for a family member with dementia. Usability of the ICT tools designed in the study was tested. Phase I participants (N=28) had access to a bilingual information site and personalized email support from professionals. Phase II participants (N=18) were randomized to use one of three enhanced features. Pre- and post-intervention data were collected, and qualitative interviews were conducted. Results: The Phase I ICT tools supported the core functions without major usability issues. Perceived efforts to use the ICT-mediated services influenced the consent decisions of Phase I caregivers (p=.036). Caregivers initiated service earlier if they had a higher acceptance of the service (p=0.017). Frequent users of email support experienced a decline of perceived burden compared with an escalation of perceived burden by non-users (p=0.023). An older age, greater caregiving competence, and lower English or computer proficiency explained non-usage behaviour. Requirements were identified to enhance the Phase I ICT tools. In Phase II, a test of three enhanced features showed there was no major usability issue. The intervention study found the enhanced features did not influence email use as hypothesized. Qualitative analysis showed usage patterns were explained by caregiver needs, caregiving beliefs, personal capacity, social support, ICT factors, and style of use. Non-users preferred Chinese to English compared with users (p=0.046). Integrating the theories and empirical findings, three concepts were developed to explain (non)-usage behaviour: usage in context, usage paths, and stages of use. Conclusion: Usage and non-usage behaviour can be explained by the service needs in the caregiving context, the use of non-ICT-mediated resources, and the access barriers to Internet use. Use of ICT-based support can be beneficial to caregivers if they do not drop out of the service.

Ethiopia has one of the largest populations in the world, an estimate of 114 million inhabitants. With more than 40% of the population below the age of 15 the country has to make further progress in meeting its family planning needs. The fertility rate has slowly declined, but the population continues to grow. Efforts to reduce gender disparities and empower women have fallen short in many parts of the world. Evidence suggesting a link between women’s empowerment, health outcomes and health care service utilization. A secondary analysis of the 2016 Ethiopian Demographic and Health Survey was conducted. The aim of this study was to determine the association between women’s empowerment, sociodemographic and reproductive factors and contraceptive use among married women and women living with partner aged 15-49 in Ethiopia. Logistic regression, bivariate, and descriptive analysis was conducted. Decision-making role in regard to husband’s money was a strong predictor for contraceptive use. Women who alone or jointly made decision were more likely to use contraceptives. The state of wealth of women was a significant determinant for contraceptive use. Those with lower education were more likely to use contraceptives compared to those with higher education. Women who did not intend to have more children were more likely to use contraceptives. This study showed that contraceptive use is associated with women’s economic decision-making age, and several sociodemographic and reproductive factors. Improving women’s empowerment, through decision making power can improve contraceptive use and therefore achieve better maternal health.

Population-based administrative data (2009-2012) from several sources were used to compare the health status and access to health services between a cohort of children in care with developmental disabilities (DD) (n=1,212) and a matched comparison group of children in care without DD (n=2,424). The two study groups were compared on a number of measures, including total respiratory morbidity, prevalence of diabetes, mood and anxiety disorders, continuity of care, injury-related hospitalizations, hospital-based dental care, and total number of ambulatory physician visits. Children in care with DD were significantly more likely to have a history of mood and anxiety disorders, respiratory illnesses, diabetes, hospital-based dental care, and injury-related hospitalizations compared to the matched comparison group. Children in care with DD also had significantly higher number of physician visits than children in the matched comparison group. No significant difference between the two study groups was found for continuity of care. / October 2015