Disparate healthcare experiences continue to pose a challenge; vulnerable populations such as low-income and racial and ethnic minorities may not be able to afford or utilize care when needed or receive quality care. The sources of disparities are complex and multi-factorial, which include health care system-level factors such as insurance and health care workforce. It is relatively less known to what extent these contribute to disparities related to a patient’s overall health care experience across three important domains – affordability, utilization and satisfaction with care. This dissertation has three objectives. First, to assess how insurance benefit design affects health care utilization among poorest adults. Second, examine the role of insurance in addressing racial and ethnic disparities in access to preventive care. Finally, examine the role of health care providers in differences related to satisfaction with care among low-income patients. To answer questions posed in this dissertation, two different types of datasets are used: a unique hospital administrative data from a coverage program for low-income adults and 2008-2014 Medical Expenditure Panel Survey (MEPS). To examine the role of insurance and health care providers in disparities related to different outcomes of patient experience, several models are estimated; including mixed effects linear probability and negative binomial regressions, decomposition and multivariate linear probability models. Several efforts are being made to address inequalities through coverage expansions, removal of financial barriers for preventive services and incentivizing health care providers to improve patient satisfaction. The findings suggest that differences in utilization and satisfaction with care continue to persist among low-income and racial and ethnic minorities. However, policy levers and system-level reforms including value-based insurance designs that may curb healthcare costs without shifting the cost burden to poorer adults, continued reforms to expand coverage and improve access to a usual of care, and policy interventions that extend beyond improving workforce diversity and enhance provider skills to elicit patient communication preferences may foster positive patient experiences and ameliorate existing disparities. Improving patient experiences of care will thus require policy efforts with a comprehensive multi-level strategy that targets broad sectors – including payers, health care providers and society at large.

Orientador: Nemre Adas Saliba / Banca: Wilton Wilney Nascimento Padilha / Banca: Paulo Zárate Pereira / Banca: Symone Cristina Teixeira / Banca: Marcelo de Castro Meneghim / Resumo: O objetivo deste estudo foi verificar as correlações da doença periodontal, perda dentária e edentulismo com fatores socioeconômicos e demográficos, necessidades e uso dos serviços de saúde bem como o impacto dessas correlações na saúde bucal de adultos e idosos brasileiros e comparar a estimativa padrão de necessidades com a abordagem sócio-odontológica. Os dados utilizados foram obtidos da pesquisa epidemiológica conduzida em 2010 pelo ministério da saúde chamada "SBBrasil 2010". A amostra foi composta de 9779 pessoas entre 35-44 anos e 7619 idosos entre 65-74 anos. Os desfechos em saúde bucal foram: sangramento pós sondagem e/ou cálculo dentário, perda de inserção periodontal, perda dentária e edentulismo. Nível de escolaridade e renda foram utilizados como indicadores socioeconômicos. Gênero, etnia, região de residência, uso de serviços odontológicos, impacto dos dentes nas atividades diárias e outras variáveis foram adicionadas aos modelos para ajustar a análise. Regressão de Poisson foi realizada para verificar as disparidades socioeconômicas e demográficas em saúde bucal com relação aos determinantes proximais e distais disponíveis no banco de dados. O teste de McNemar foi utilizado para comparar as estimativas padrão de necessidade e o respectivo impacto relacionado. Os resultados mostraram associação (p<0.05) entre aspectos socioeconômicos e demográficos e as variáveis de saúde bucal. Pessoas que declararam até 8 anos de educação formal demonstraram maior prevalência em todas as doenças bucais estudadas. Da mesma forma, adultos que declaram renda de até 500 reais, tiveram maior prevalência em três das quatro doenças estudadas. Etnia esteve associada a sangramento pós sondagem e/ou cálculo dentário (PR=1.19) e perda dentária (PR=1.45) entre adultos que declararam-se pardos. Ter realizado... / Abstract: The aim of this study was to verify the correlations of periodontal disease, tooth loss and edentulousness with socioeconomic and demographic factors, health needs and health services as well as the impact of these correlations on oral health among Brazilian adults and elderly and compare the standard estimate of need with a sociodental assessment. The data originated from a national epidemiological survey on oral health conducted in 2010 by the Brazilian Health Ministry ("SBBrasil 2010"). The sample comprised 9779 people between 35-44 years old and 7619 elderly between 65-74 years old. The oral health outcomes were as follows: bleeding on probing and/or dental calculus, periodontal loss of attachment, tooth loss and edentulousness. Education level and declared income were used as indicators of socioeconomic status. Gender, ethnicity, region of residence, use of dental care, impact of teeth in daily activities, and other variables were added to the models to adjust the regression analysis. Poisson regression was performed to verify the socioeconomic and demographic disparities in oral health with regard to the proximal and distal determinants of health available in the data set. McNemar's test was applied to compare standard estimates of need and the respective impact-related. The results showed associations (p<0.05) between socioeconomic and demographic aspects and all oral health variables. People who had up to 8 years of formal education had increased the prevalence to develop any of the oral diseases on this study. As much as adults whom declared income up to 500 BRL, that had increased the prevalence to develop three of the four studied conditions. Ethnicity had association with bleeding on probing/or dental calculus (PR=1.19) and tooth loss (PR=1.45) between adults who declared themselves as brown. Having a consultation... / Doutor

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Background: Much research consistently shows that there are disparities in healthcare delivery. Healthcare disparities affect individuals across a broad range of demographics such as gender, race or ethnicity, and it is also related to socioeconomic factors such as income levels, access to health benefits and insurance, and health literacy. Recent immigrants to Canada encounter a different and unfamiliar healthcare system. This situation presents challenges to the practice of health care delivery. Therefore, it is crucial that innovative strategies be identified to reduce disparities in health care to promote the overall quality of care and public health services. Purpose: The purpose of this dissertation research was two-fold: (1) to examine cultural competence strategies, if any, that are used by healthcare organizations to improve interaction and communication between healthcare providers and their immigrant patients with the purpose to reduce healthcare disparities; and specifically, (2) to explore the use of Information and Communications Technologies (ICTs) to improve communication between healthcare providers and immigrant patients with the objective of reducing healthcare disparities. Methods: This dissertation research employed a mixed methods approach for data collection and analysis. The research was carried out in three phases. In the first phase, a series of focus group discussions with a sample of recent immigrants was conducted. In the second phase, an online survey was conducted to gain insights from healthcare providers regarding the role of ICTs in improving communication with immigrant patients to help reduce healthcare disparities. In the third phase, healthcare providers who participated in the survey were invited to participate in face-to-face, in-depth semi-structured interviews to further reflect on and extend the survey responses. Campinha-Bacote's Cultural Competence Model and Unified Theory of Acceptance and Use of Technology were employed for this dissertation research as its theoretical framework. Results: The findings indicated that the absence of effective communication as well as cultural and language barriers were major issues related to communication between healthcare providers and immigrant patients. The findings also indicated that immigrant patients might need to improve their digital and health literacy skills in order to improve their communication with their healthcare providers. Further, the findings indicated that it was important for healthcare providers to have access to more demographic data on immigrant patients because such data will allow healthcare providers to be better informed on how to most effectively tailor their healthcare services to this population group. Conclusion: Findings obtained from this dissertation research shed light on cross cultural communication issues related to working with immigrant patients that may lead to disparities in health care. Healthcare organizations may use these findings to better inform their decision making with regard to effective patient-provider communication. Finally, the findings bear important implications for the line of research that examines patient-provider communication from immigrant patients' perspectives. They can inform the design of cultural competence strategies for healthcare organizations.

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A main challenge in medicine concerns questions of how to integrate the context and values of patient perspectives with general conceptions of illness and treatment. With medicine increasingly focused on patient-centered and individualized care, approaches to medicine must find ways to gain access to and understand the patient in such a way that recognizes her story as real while at the same time maintaining the value of medicine as an objective practice. Adding to this is the reality that under current models of medicine and decision-making in medicine, healthcare disparities persist for persons belonging to marginalized and vulnerable populations, including racial and ethnic minorities, women, and LGBTQ persons, amongst others. I argue that an approach integrative of shared decision-making built upon a phenomenological framework is a good alternative on which to try and understand questions like these and begin to address disparities in healthcare. / Urban Bioethics

Obesity is currently viewed as one of the most important health concerns in the United States. Researchers have minimally investigated perspectives surrounding obesity within the African-American female population. This lack of research presented a gap in knowledge concerning the perceived social, environmental, and cultural influences of obesity within this population. The research questions asked African-American females about their views toward these influences. This research was guided by tenets of the social cognitive theory and the transtheoretical model for behavioral change. Thirteen African-American females participated in the interviews. The data collected were reviewed and coded using word frequencies and themes. Findings included recurring themes of cultural influences, social disparities, and the lack of access to healthy food sources and health providers. Positive social change could result from this research to help enlighten public health professionals and community planners to understand the perspectives of African-American women's belief systems surrounding obesity. The information delivered by this research could possibly empower the participants to address the issues within their communities with civic leaders and policy makers to create and sustain needed change.

Health disparities in minorities and those of low socioeconomic status persist despite efforts to eliminate potential causes. Differences in the delivery of services can result in different healthcare outcomes and therefore, a health disparity. Some of this difference in care may attribute to discrimination resulting from clinical biases and stereotyping which may provide a possible source for the persistence of health disparities. Health disparities may occur because the delivery of services at some level is inadequate. Disparities resulting from the quality and quantity of care delivered by a practitioner result in differentiated delivery of healthcare, thus unequal health outcomes. The purpose of this study is to evaluate and identify potential disparities in routine screening practices of physician assistants.A randomized sample of practicing physician assistants in Kentucky were analyzed (N= 112) to determine if the race or socioeconomic status of a patient influenced their likelihood of offering different routine screening recommendations and screening test recommendations. Clinical vignettes were created with only the race and socioeconomic status of the patient modified, resulting in four separate vignettes. Through the use of a survey instrument, participants were randomly assigned to one of four written clinical vignettes. Statistical analysis using a MANOVA revealed that the race of a patient had a statistically significant multivariate effect on differences in screening recommendations and race and socioeconomic status had significant multivariate effects on screening test recommendations.Study results suggest that race and socioeconomic status continues to be a significant factor in the prevalence of healthcare disparities. More importantly, this study reveals that Physician Assistants may provide differentiated care based on a patient’s race. Limitations and future directions for this study may be used to examine PA educational curriculums for the inclusion of health disparities and possible continuing medical education opportunities for practicing PAs.

Source: Dissertation Abstracts International, Volume: 70-07, Section: B, page: 4061. Advisers: Sally W. Vernon; Xianglin L. Du. Includes bibliographical references.

Thesis (Dr. P.H.)--University of Texas Health Science Center at Houston, School of Public Health, 2008. / Source: Dissertation Abstracts International, Volume: 69-02, Section: B, page: 0969. Adviser: Charles E. Begley. Includes bibliographical references.