Objectives: Women with substance use disorders often experience unique challenges to obtaining contraception and adhering to user-dependent methods. As a result, this at-risk population of women tends to have higher than average rates of unintended pregnancy. The objective of this study was to describe contraceptive use, pregnancy intentions, and adequacy of access to reproductive healthcare among women receiving opioid agonist therapy in northeast Tennessee. Methods: A cross-sectional survey was piloted among female patients aged 18 to 55 years from two opioid agonist therapy clinics. Descriptive analyses were conducted using logistic regression to evaluate the statistical significance of bivariate associations. Results: Of 91 participants, 84% reported having health insurance, with 70% perceiving having adequate access to health care. More than half had a history of unwanted pregnancy (53%), among whom few (23.1%) reported the consistent use of contraception at time of conception. Although most desired to avoid pregnancy (90%), only 59% of women reported the current use of regular contraception. Most of those not using regular contraception believed that they were not at risk for pregnancy (54.3%). Conclusions: Although most participants reported adequate access to health care and a desire to avoid pregnancy, few reported the consistent use of regular contraception. Furthermore, misperceptions regarding pregnancy risk were common among participants. Research is needed to identify barriers to contraceptive acceptance and causes of pregnancy risk misperceptions in this population of women at increased risk of unintended pregnancy.

This study examined the role of health care access and health care resources in the association between subjective aging and activities of daily living among older adults. We examined subjective aging in the context of subjective cognitive decline (SCD) relationships in three studies: (1) a scoping review of healthcare access (HCA) and resources (HCR) on dementia and COVID-19 among African American older adults; (2) subjective cognitive decline in basic activities of daily living (bADL) across age cohorts, older adults and (3) subjective cognitive decline in instrumental activities of daily living (IADL) across older adults' moderation by HCA and mediation by HCR. For the scoping review, we utilized the population, concept, and context inclusion and exclusion criteria for study admissibility for articles published on dementia and COVID-19 studies in English language journals that published from January 2019 to December 2022. The two empirical studies utilized the 2021 round 11 of the National Health and Aging Trends dataset of older adults aged 70 to above 90 funded by the National Institute for Aging. We employed multiple regression and the bias-corrected percentile Bootstrap with 5000 samples using standard path-analytic approaches for the moderated-mediation approach for the two empirical studies. Findings from the scoping review indicated racial and age disparities affected older African American adults with dementia and COVID-19, associated with lower HCA and marginal HCR. Results of mediation–moderation analysis showed SCD, lower HCR, and HCA predict a decline in bADL to be higher among the older-old age (80-89) compared to the middle-old age (70-79) or oldest-old (90 years +) cohorts. We observed similar effects for IADL. The findings from the two empirical studies suggest a "doughnut" effect by which the older-old age cohort of 80-89 may be coping less well with their bADL, as well as IADL, while the oldest-old may have adapted to functional loss in their everyday living and/or comprises adults who may have passed a mortality selection despite a more significant burden of comorbidity.

Ancrée d’abord dans la charité, se métamorphosant dans la philanthropie libérale, dans la fraternité révolutionnaire, puis dans la solidarité républicaine, la fondamentalisation de l’accès aux soins des pauvres a finalement trouvé refuge dans les droits de l’Homme. Depuis la loi d’orientation relative à la lutte contre les exclusions du 29 juillet 1998, elle se traduit ainsi en France par l’affirmation d’un droit fondamental à la protection de la santé. Cette mutation est loin d’être anodine. L’action des pouvoirs publics et la responsabilité de la société dans la lutte contre l’exclusion sociale en santé s’en trouvent déportées du terrain économique et caritatif vers le terrain juridique. L’accès aux soins des pauvres ne relève plus seulement d’un devoir moral, mais aussi d’une obligation juridique en vertu du droit international des droits de l’Homme et des exigences constitutionnelles françaises. Mais quel est donc le contenu de cette obligation juridique ? Quelles sont la nature et la portée réelle de la notion juridique de droit fondamental à la protection de la santé, et de son emploi en lieu et place de celle de pauvreté ? Comment peut-elle s’inscrire dans un processus dynamique et pragmatique d’universalisation de l’accès aux soins ?C’est ainsi à une étude critique de la juridicisation contemporaine de l’accès aux soins des pauvres que la recherche s’attelle. Certes, la fondamentalisation de l’accès aux soins des pauvres se déploie désormais sur la base d’un droit fondamental à la protection de la santé. Mais le choix des moyens et des voies de réalisation de ce dernier ne fait pas consensus, et les juges hésitent toujours à sanctionner et contrôler pleinement le respect de son application. L’universalité de sa proclamation ne s’est pas encore muée en universalité de sa concrétisation. L’émergence d’un droit fondamental pour garantir l’accès aux soins des pauvres n’est en effet pas sans poser de difficultés. Ces dernières qui s’expriment de façon de plus en plus criante aujourd’hui tiennent à la tension irréductible entre son horizon d’universalité et sa pratique discriminatoire et ségrégative, mais aussi à son interactivité avec les autres droits jugés fondamentaux dans un monde où la santé est devenue un marché globalisé et la solidarité peut être assimilée à un délit.Malgré son inscription au sommet de la hiérarchie des normes, le droit à la santé reste en effet l’un des plus inégalement appliqués. S’il induit un principe d’égal accès aux soins, sa mise en œuvre catégorielle et différenciée pour les plus démunis entre en tension avec l’universalisme des droits de l’Homme. Aussi, l’effectivité des droits créances aux soins dépend fortement des finances publiques et donc des volontés politiques. Elle pose la question des devoirs de solidarité à imposer aux citoyens. Or, l’importance politique prise par l’économie dans le monde actuel vient particulièrement entraver les développements juridiques de la solidarité dans l’accès aux soins, en réduisant le rôle et les capacités de l’État providence. S’institue progressivement une forme de précarité sociale généralisée qui compromet l’accès aux soins de nombreuses personnes. En réintégrant les droits de l’Homme dans le débat, les nouvelles politiques de lutte contre la pauvreté tendent cependant à redonner sens au projet humaniste. L’éthique politique moderne en particulier, et la notion qui la traverse aujourd’hui, l’inclusion sociale, influencent les réflexions doctrinales, et avec elles les représentations du droit comme outils de la justice distributive. Désormais, les juristes se préoccupent des notions d’effectivité, de justiciabilité et d’exigibilité des droits sociaux aux soins. De nouvelles réponses sociales et juridiques émergent afin de donner aux personnes précaires et pauvres les capacités d’exercer pleinement leur droit fondamental à la protection de la santé. / Be in motivated by group or individual interest, the desire to help the poor appears as a constant around the world and throughout history. Originally anchored in charity, then reincarnated in liberal philanthropy, in the fraternity of the revolution, and in republican solidarity, the fundamentality of healthcare access for the poor finally found its home in Human Rights. Since the Framework Act on Measures to Combat Exclusion of 29 July 1998, the protection of health has been considered a fundamental right in France.This new incarnation is far from anodine. Government action and social responsibility in the fight against social exclusion in healthcare, have moved from an economic and charitable framework to a legal one. Healthcare access for the poor is no longer considered as just a moral duty, but also a legal obligation enshrined in international Human Rights law and the French Constitution. But what is the real content of this legal obligation? What is the nature and real application of the legal notion of a fundamental right to the protection of health, and how is this used to reduce poverty? How can we take poverty into account in the dynamic and pragmatic process of the universalisation of access to healthcare.This research thus attempts a critical study of contemporary legislation on healthcare access for the poor. Certainly, the fundamentality of healthcare access for the poor follows naturally from the fundamental right to the protection of health. But there is no consensus on the manner and means of its implementation, and the judiciary has hesitated to fully sanction and control its application. The universality of the proclamation has not yet been translated into universality of its realization. The emergence of a fundamental right guaranteeing access to healthcare for the poor is not without its difficulties. These difficulties, today more visible than ever, arise from the irreducible tension between the theoretical universality of this right and its discriminatory and segregative practice. Challenges also arise from the interaction of this and other rights considered fundamental in a world where health has become a globalized market and solidarity perhaps akin to a crime.Despite its place at the summit of the hierarchy of norms, the right to health remains one of the most unequally applied. If it demands a principle of equal access to healthcare, its discriminatory and segregational implementation among the poorest is at odds with the universalism of Human Rights. Moreover, the ability to claim the right to healthcare is highly dependent on public finances and political will. It requires that a duty of solidarity be imposed on citizens. However, the political importance given to the economy in the world today impedes on the legal development of solidarity in healthcare access, reducing the role and capacity of the welfare state. A generalized form of social precariousness is gradually being established, compromising access to healthcare for many people. By reintroducing Human Rights to the debate, new policies in the fight against poverty are beginning to bring meaning back to this humanist project. Modern political ethics in particular, and the current drive for social inclusion, are influencing doctrinal reflections, and with them the perception of the law as a tool for redistributive justice. Thus, lawyers now consider the notions of effectiveness, justiciability and accountability when addressing social rights to healthcare. New social and legal responses are emerging to empower people living in poverty or insecurity to fully exercise their fundamental right to the protection health.

Introduction: The burden of road traffic injuries (RTI) is worsening globally, particularly in low- and middle-income countries (LMIC) and among the young and economically productive populations. A major barrier to improving road safety in India and other LMIC is that existing RTI data sources are severely limited by poor population coverage and data quality. This dissertation explores the reliability and feasibility of using a novel data source with verbal autopsy (VA) methods for the purposes of RTI surveillance in India. Methods: The reliability of the VA methods was assessed using physician agreement on the specific categories of injury death as the metric. Next, a nationally representative household mortality survey with VA methods was used to directly estimate the age- and gender-specific RTI death rates and to identify context-specific RTI risk factors in India. Finally, a national spatial database was constructed to quantify potential access to trauma care in relation to the spatial distribution of RTI deaths in India. Results: Across a broad array of application settings in India, the level of physician agreement was high indicating that the VA methods were reliable in distinguishing RTI deaths among other specific categories of injury deaths. The estimated 183,600 RTI deaths in 2005 from the mortality survey were over 50% more than the national police statistics. Of these RTI deaths, 65% were males between ages 15-59 years, 68% were pedestrians and other vulnerable road users, and over 55% occurred at the scene of collision, within minutes of collision, and/or involved a head injury. The existing community health centres and district hospitals in the Indian public health system had inadequate trauma care capacity but were suitably located to allow broad spatial access to timely trauma care for the majority of RTI deaths in India, which were most problematic in the northern states of Punjab, Haryana, Himachal Pradesh and in Tamil Nadu. Conclusions: Properly designed VA studies can provide accurate and reliable RTI surveillance data and assist in identifying context-specific road safety interventions.

Introduction: The burden of road traffic injuries (RTI) is worsening globally, particularly in low- and middle-income countries (LMIC) and among the young and economically productive populations. A major barrier to improving road safety in India and other LMIC is that existing RTI data sources are severely limited by poor population coverage and data quality. This dissertation explores the reliability and feasibility of using a novel data source with verbal autopsy (VA) methods for the purposes of RTI surveillance in India. Methods: The reliability of the VA methods was assessed using physician agreement on the specific categories of injury death as the metric. Next, a nationally representative household mortality survey with VA methods was used to directly estimate the age- and gender-specific RTI death rates and to identify context-specific RTI risk factors in India. Finally, a national spatial database was constructed to quantify potential access to trauma care in relation to the spatial distribution of RTI deaths in India. Results: Across a broad array of application settings in India, the level of physician agreement was high indicating that the VA methods were reliable in distinguishing RTI deaths among other specific categories of injury deaths. The estimated 183,600 RTI deaths in 2005 from the mortality survey were over 50% more than the national police statistics. Of these RTI deaths, 65% were males between ages 15-59 years, 68% were pedestrians and other vulnerable road users, and over 55% occurred at the scene of collision, within minutes of collision, and/or involved a head injury. The existing community health centres and district hospitals in the Indian public health system had inadequate trauma care capacity but were suitably located to allow broad spatial access to timely trauma care for the majority of RTI deaths in India, which were most problematic in the northern states of Punjab, Haryana, Himachal Pradesh and in Tamil Nadu. Conclusions: Properly designed VA studies can provide accurate and reliable RTI surveillance data and assist in identifying context-specific road safety interventions.

Healthcare systems and medical services all over the world have been facing a significant reliability crisis that has peaked in the past couple of decades from a series of criticisms regarding inequality. It is well-established that the inequality problem, especially in the Latin American region is an abiding and deep-routed phenomenon particularly in regards to gendered relationships, which has only recently been given the necessary attention.  Therefore, this study investigates the equality of healthcare access from a gendered perspective, as a result of gender inequality in Mexico. The foregoing issue shall be analysed by giving an overview of the pre-existing situation in Mexico and by examining the recent data from 2020 and 2021 resulting from the COVID-19 pandemic. In this context, gender inequality in the country will be analysed from a theoretical perspective, while statistical data will be used to examine the possible existence of a pattern and the societal influences on it in relation to healthcare. In times like these, when the whole planet has been affected by a pandemic, the ongoing discrimination and inequalities regarding healthcare access have been brought to the surface. Many discussions have taken place regarding racial inequality in the sector and its effects on minorities such as black or immigrant communities globally. However, the focus given to the gender inequality in the health sector and how it has been affected by the pandemic is minimal. For this reason, this study introduces an innovative and relevant perspective to the current healthcare discussion in connection to gender inequality in Mexico.

This study explores how socioeconomic status influences lifestyle choices and chronicdiseases in Sweden. It investigates prevalent chronic diseases across different socio economicgroups and assesses policy interventions to address disparities. Theoretical frameworks suchas chronic disease prevention, health lifestyle and fundamental causes theories inform theanalysis. The method of this study is used to gather and analyse sensory data for the study. Itdescribed the systematic search for relevant articles, inclusion and exclusion criteria, dataextraction and thematic analysis. Ethical considerations are also addressed and maintained.The results highlighted socioeconomic disparities in lifestyle and chronic disease burden inSweden and other countries. The results show varying impacts in health behaviours andoutcomes based on socioeconomic status, emphasising on the need for targeted interventionwhich address preventable health conditions. The discussion of the study provides a detailedinterpretation of the results by linking theories and methods used.

No description available.

Background South Africa has experienced the most severe consequences of the HIV/AIDS pandemic. Every community has been affected in some way, many experiencing huge increases in mortality,particularly before antiretroviral therapies (ART) were readily available. However, the micro-level understanding of the HIV epidemic in South Africa is weak, because of a lack of detailed data for most of the population. This thesis is based on detailed individual follow-up in the Agincourt Health and Demographic Surveillance Site (HDSS) located in the Agincourt subdistrict of Mpumalanga Province and investigates micro-level determinants of HIV epidemiology and the impact of treatment provided. Methods The Agincourt HDSS has followed a geographically defined population since 1992,approximately the time when the HIV/AIDS epidemic first became apparent. This population based surveillance has included capturing details of all deaths, with cause of death determined by verbal autopsy, as well as the geographical location of individual households within the overall Agincourt area. Background information on the roll-out of ART over time was also recorded. Results A comparison immediately before and after the major roll-out of ART showed a substantial decrease in HIV-related mortality, greater in some local communities within the area than others. Individual determinants associated with a decreased risk of HIV/AIDS mortality included proximity to ART services, as well as being female, younger, and in higher socioeconomic and educational strata. There was a decrease in the use of traditional healthcare sources and an increase in the use of biomedical healthcare amongst those dying of HIV/AIDS between periods before and after the roll-out of ART. Conclusions Understanding micro-level determinants of HIV/AIDS infection and mortality was very important in terms of characterising the overall epidemic in this community. This approach will enable public health interventions to be more effectively targeted towards those who need them most in the continuing evolution of the HIV/AIDS epidemic.

Les temps d’attente pour une prise en charge en orthopédie et en neurochirurgie ont considérablement augmenté au Québec et au Canada engendrant d’important problèmes d’accès aux soins. Face à ces délais déraisonnables, les modèles de pratiques avancées en physiothérapie (PAP), qui confèrent une plus grande autonomie et responsabilité aux physiothérapeutes, représentent une alternative prometteuse. Cette thèse vise à évaluer l'efficacité de ces modèles de soins dans la prise en charge des troubles musculosquelettiques (TMS). À cette fin, trois revues systématiques avec méta-analyses ont été conduites afin d’évaluer l’état des connaissances sur les modèles de PAP pour les TMS. De plus, trois études ont été menées au Québec avec le modèle de CareAxis, où des physiothérapeutes en pratiques avancées (PPA) effectuent l'évaluation, le diagnostic et le triage chirurgical de patients référés pour une consultation en chirurgie de la colonne. Celles-ci incluent une étude d’observations rétrospective évaluant l’efficacité du modèle, un essai contrôlé randomisé (ECR) pragmatique sur l’efficacité d’une prise en charge à séance unique comparée à une prise en charge à séances multiples, ainsi qu’une étude qualitative visant à explorer les perceptions des patients et des PPA envers ce nouveau modèle de soins. Les trois revues systématiques ont montré que les modèles de PAP améliorent l’accès aux soins, que le diagnostic et le triage des candidats potentiellement chirurgicaux émis par les PPA sont valides et concordants avec ceux des médecins spécialistes et que l’efficacité clinique, en termes de douleur et d’incapacité, des modèles de PAP est au moins comparable aux soins médicaux standard, tout en réduisant les coûts par patient pour le système de santé. Par ailleurs, les patients ont rapporté des niveaux de satisfaction plus élevés envers les modèles PAP qu’envers les modèles standards. Pour ce qui est du modèle de CareAxis, l’étude d’observations démontre que le modèle a le potentiel d’améliorer l’accès aux soins en réduisant les temps d’attente. De plus, les diagnostics et les décisions de triage chirurgical des PPA sont comparables à ceux des chirurgiens de la colonne. Des améliorations significatives en termes de réduction de la douleur et des incapacités ont été rapportées, tant dans l’étude d’observations que dans l’ECR. Ce dernier a permis de conclure que l’ajout de cinq séances de suivis incluant de la physiothérapie multimodale n’apporte pas de bénéfices significatifs lorsque comparé à l’approche d’une seule séance, et ce, malgré une préférence des patients pour l’approche à séances multiples. Cette préférence a également été observée dans l’étude qualitative, où les patients et PPA ont souligné les bénéfices du modèle de CareAxis en comparaison au modèle standard, tout en soulignant que le modèle présente certaines limites. En conclusion, les modèles de PAP, dont le modèle de CareAxis, ont le potentiel d’améliorer l’accès aux soins tout en offrant une qualité de soins en termes de diagnostic, de triage chirurgical et d’évolution des patients au moins comparable au modèle médical standard. L’efficacité clinique des approches à séance unique ou multiples est comparable. Les patients ont rapporté des taux élevés de satisfaction envers le modèle de CareAxis. / Waiting times for orthopedic and neurosurgery care have significantly increased in Quebec and Canada, leading to significant health care access problems. Faced with these unreasonable delays, advanced practice physiotherapy (APP) models, which included increased autonomy and responsibilities for physiotherapists, represent a promising alternative. The aim of this thesis is to evaluate the effectiveness of these models of care in managing musculoskeletal disorders (MSKDs). Three systematic reviews with meta-analyses were conducted to assess the state of knowledge on APP models of care for MSKDs. In addition, three studies were carried out in Quebec using the CareAxis model, in which advanced practice physiotherapists (APPT) perform the assessment, diagnosis, and surgical triage of patients referred for a spinal surgery consultation. These included a retrospective observational study evaluating the APP model effectiveness, a pragmatic randomized controlled trial (RCT) on the effectiveness of a single session versus multiple sessions of care, and a qualitative study aimed at exploring the perceptions of patients and APPTs towards this new model of care. The three systematic reviews showed that APP models improve health care access, the diagnosis and triage of potential surgical candidates performed by the APPTs are valid and concordant with those of medical specialists. The clinical effectiveness, in terms of pain and disability, of APP models is at least comparable to standard medical care, while reducing health care cost per patient. Furthermore, patients reported higher levels of satisfaction with the APP models than with standard medical models. As for the CareAxis model, the observational study demonstrates that the model has the potential to improve health care access by reducing waiting times. Moreover, the diagnoses and surgical triage decisions of the APPTs are comparable to those of spine surgeons. Significant improvements in terms of pain and disability reduction were reported, both in the observational study and in the RCT. The RCT concluded that adding five follow-up sessions including multimodal physiotherapy does not provide significant benefits compared to the single-session approach, despite patients' preference for the multiple-session approach. This preference was also observed in the qualitative study, where patients and APPTs highlighted the benefits of the CareAxis model compared to the standard model, while noting that the model has certain limitations. In conclusion, APP models, including the CareAxis model, have the potential to improve health care access while offering a quality of care in terms of diagnosis, surgical triage, and patient outcomes that is at least comparable to the standard medical model. The clinical effectiveness of single or multiple session approaches is comparable. Patients reported high satisfaction rates with the CareAxis model.