Escalating health care costs in the military health system are not sustainable long term. Regular physical activity has been shown to improve health and reduce health care costs. Military members serving in the United States Air Force (USAF) are encouraged to maintain physical fitness year-round and undergo mandatory physical fitness assessments (PFAs) annually. The purpose of this quantitative correlational study was to determine the nature of the relationship between the timing of the PFA and health care utilization (HU) by active duty service members assigned to the United Kingdom's USAF military treatment facility. Donabedian's framework and the logic process model were used to design the study. Archived fitness and health care utilization data were obtained on 361 military members. Findings indicated a strong, positive correlation between the timing of the PFA and HU, which was strongest during the PFA month. Monthly HU 6 months prior to PFA was compared using a 1-way repeated measures ANOVA. Findings indicated a significant difference between T-1 (PFA month), T-2 (1 month prior to PFA), and T-5 (5 months prior to PFA). Paired-samples t tests demonstrated a statistically significant increase in HU from T-5 to T-2. Although findings are not generalizable, they signal a need for further study to evaluate HU variability between populations, to identify at-risk groups, and to inform health and fitness policies that affect the readiness and retention of military members. The DNP project may promote interdisciplinary collaboration between health care providers and senior military leadership, innovation in health care delivery, and evidence-based and cost-conscious policies.

Anxiety can influence an individual's decision-making process; however, researchers have yet to establish whether anxiety has an impact on the healthcare utilization practices of mothers of children with a mental health diagnosis. The purpose of this study was to assess whether trait anxiety, coping styles, and self-efficacy in mothers of children with a mental health diagnosis affected their healthcare utilization decisions. The transactional model of stress and coping was used to analyze the impact of children with mental health disorders on their caretakers. For this study, a quantitative, cross-sectional research design was employed. The 4 survey tools, administered through SurveyMonkey.com as well as in paper form, included the Brief COPE, State-Trait Anxiety Inventory for Adults (STAID-AD), Health Self-Efficacy Measure, and Healthcare Utilization Questionnaire. Study participants (N = 152) were mothers primarily ages 30-49 years (90.8%), Caucasian (57.9%), and high school graduates (63.2%) who were residents of Lawrence County, Pennsylvania. Mothers reported their children were primarily ages 3-6 years (34.2%), Caucasian (49.3%), had a mental health diagnosis, were living in the home, and were currently in mental health treatment. The outcomes of a binary logistic regression found that trait anxiety did not have a significant impact on healthcare utilization. A Sobel test of mediation indicated that coping styles and self-efficacy were not mediating variables between trait anxiety and healthcare utilization. The implications for positive social change as a result of this research may lead to the training of healthcare providers on the specific characteristics of mothers of children with a mental health diagnosis and the development of social policies concerning healthcare utilization.

Defining health and economic burden of Invasive Meningococcal Disease (IMD) in Canada is critical to inform Public Health Policy around immunization programs. A comprehensive literature review was conducted to assess available studies, a lack of comprehensive Canadian data to allow evaluation of total economic burden of IMD was identified in Canada. Thus, this dissertation proposes a prospective cost collection methodology tailored to Canadian data and healthcare utilization (HCU). All patient-related HCU is considered and outlined. HCU is then categorized as direct or indirect and relevant direct and indirect healthcare costs are detailed. Intangible costs are described and methodology for capturing these costs using validated quality of life instruments is proposed. As all published economic evaluations of this disease lack prospective collection of data, this study proposes the use of a patient diary to serve as a memory aid during patient cost-collection interviews.

Objectives: The purpose of this study was to examine rural women s access to maternal health information and its impact on levels of skilled healthcare utilization. Method: A qualitative study involving twenty five (25) pregnant women,five (5) Skilled healthcare providers and five (5) Traditional Birth Attendants (TBAs) was conducted in Chamwino District in Dodoma Region, Tanzania for a period of six months. Due to time and resource limitation the researcher selected two (2) of the 32 wards in the district where the problem of maternal mortality and non-utilization of skilled healthcare was most prominent. The two selected wards were Msanga and Buigiri wards. The researcher used The Health Belief Model and Theory of Planned Behaviour to develop interview questions and focus group guides as well as the interpretation of the findings. The researcher examined how variable factors e.g. maternal health literacy, individual perceptions, local knowledge and care provider-related factors affect pregnant women s health behaviours and utilization of skilled maternal services. The Data was analysed thematically using the 6-stage guide to thematic data analysis with the help of NVIvo Software. Results: The inadequate conditions of the health facilities and the poor working conditions of the care providers affected the provision of quality of maternal services and health information to pregnant women in the study area. The limited access to skilled maternal health information from skilled healthcare providers and lack of alternative sources of reliable health information led pregnant women to seek health information from their Mothers-in-laws, TBAs and other women in the society. However, there was a shortcoming of information inaccuracy as their health advice was not based on previous expert advice but rather on the personal opinion and attitude towards skilled maternal services. The limited access to maternal health information caused majority of pregnant women to underestimate the risks of pregnancy related complications and how they responded to pregnancy danger signs and other ill-health conditions that raised during pregnancy. The majority of pregnant women reported not to seek and kind of care when experienced a health problem. It was also found that during labour some would go to the TBA for childbirth and later go to the dispensary when the TBA failed while others would just go for TBAs opinion and confirmation that it was real labour then go to the health facility. This delayed women s timely access to obstetric care which is essential for positive outcome when a pregnant woman experiences a pregnancy or childbirth complications. Conclusion: The improvement of the quality of skilled healthcare services in rural areas is a prerequisite for achieving desired outcomes in maternal mortality reduction efforts in Tanzania. However, improvement of quality itself is not a panacea if pregnant women are not aware of the services, hence the healthcare providers should also focus in increasing provision of maternal health information to pregnant women. The findings show that the limited access to skilled maternal health information from healthcare providers and lack of alternative sources for reliable health information has constrained majority of these women from becoming maternal health literate hence affecting their levels of utilization of skilled maternal services. The healthcare providers and policy makers should focus on meeting the health information needs of general rural populations and enable them to become well-informed and knowledgeable to make better and well-informed maternal health decisions.

Background: The underutilization of formal, facility-based maternal care is a major contributor to the high maternal mortality rates among women living in rural Africa. Increasing the use of formal maternal care requires exploration of important maternal health issues affecting community members and comprehension of how they perceive the use of formal and traditional maternal care. This thesis aimed to identify the key factors, challenges, and needs of rural populations for the uptake of formal maternal care. Paper 1 explored rural women's preferred choices for sources of maternal care as well as the factors that contribute to their preferences in Africa. Paper 2 explored elders' perceptions about reasons for the underutilization of maternal healthcare and maternal death, as well as potential solutions to improve formal care use in rural Nigeria. Methods: 1) In paper 1, a systematic search on Ovid Medline, Embase, CINAHL, and Global Health identified 40 qualitative studies that elicited women's preferences for maternal care in rural Africa. Reviewers collated the findings and reported on patterns identified across findings using the narrative synthesis method. 2) Data were collected through 9 community conversations with 158 elders in 9 rural Nigerian communities. The data were analyzed inductively through thematic analysis. Results: 1) A variety of preferences for formal, traditional and both formal and traditional maternal care during antepartum, intrapartum and postpartum periods were identified. The majority of the studies reported preferences for formal antenatal care or a combination of traditional and formal antenatal care. During intrapartum, rural women held a wide range of preferences, including facility-based births, traditional births in a domestic setting, as well as a combination of formal and traditional care depending on the onset of complications. The majority of the studies reported preferences for traditional postnatal care involving traditional attendants, self-care, and cultural rituals that fend off witchcraft. The factors that contributed to these preferences were related to the perceived need of formal or traditional maternal care, accessibility to formal or traditional care, and cultural and religious norms, beliefs and obligations. 2) The perceived reasons for the underuse of formal maternal care included poor qualities of care, physical and financial inaccessibility of facility-based services, and lack of knowledge and awareness. Reasons for women's maternal deaths included malaria and blood displacement, facility-based service deficiencies, uptake of traditional maternal care, and poor community awareness and negligence. Increased access to high-quality care, health promotion and education, community support and supernatural assistance were the proffered solutions. Conclusions: The major areas that need improvement across rural Africa include human and material resources availability, technical and interpersonal quality of care in health facilities, physical accessibility, financial accessibility, sociocultural accessibility, cultural and religious sensitivity, and community knowledge and awareness. Generally, the findings reflect the need for multifaceted interventions that engage target populations and consider local contexts, realities, and related needs in order to develop locally acceptable interventions. Such interventions will increase the likelihood of effective and long-lasting positive changes in healthcare utilization and maternal mortality.

A current body of research is finding significant connection between biological, psychological, social, and spiritual factors in health and wellbeing. Some studies have found significant improvements in treatment outcomes for patients who received medical treatment in collaboration with psychosocial therapeutic treatment. In this study, I sought to observe the impact collaborative treatment had on patients with diabetes who were treated at a community health center. I compared the treatment outcomes of a group of patients who received a collaborative treatment, looking to see if their overall health (measured by A1c, a diabetes severity marker) and medical utilization (or their number of doctors’ visits). I found no significant difference in the improvements in health outcomes (A1c) made by my treatment group who received collaborative treatment in addition to standard medical treatment for diabetes management when compared to my control group who received only medical treatment. I did find that collaborative treatment was associated with increases in medical utilization as were increases in age and initial A1c levels. Clinical implications include the need for therapists to be aware of how biological factors, such as age and severity of symptoms, may affect psychosocial-spiritual factors commonly addressed in therapy when working with patients who have chronic illnesses like diabetes. I hope that these findings will lead future research into the association of collaboration and medical utilization in order to find if there are any clinical benefits to recommending increased utilization for patients who are older or begin treatment with higher A1c levels.

Indiana University-Purdue University Indianapolis (IUPUI) / Introduction: The prevalence of those aged 3-25 with an intellectual and developmental disability (I/DD), has increased 17.1% from 1997 to 2008. This study focused on these I/DD: autism spectrum disorder (ASD), cerebral palsy, learning disabilities and spina bifida. Previous studies have found that individuals with an I/DD use health services and the emergency department (ED) more frequently, regardless of payer. Methods: This dissertation will describe and define the characteristics of ED use among children and young adults with an I/DD. A repeated, cross-section of annual data of a national sample distributed by the Agency for Healthcare Research and Quality Healthcare Utilization Project National Emergency Department Sample will be analyzed from 2009-2014. This approach will document the primary clinical reason for ED use, the appropriateness of the need for a visit, and demographic, geographic, and temporal correlates for medical, injury, and psychiatric care visits in the ED. The appropriateness of need will be assessed by the New York University (NYU) Emergency Department Diagnosis Classification method for medical care visits. A logistic regression model will be specified for each visit type. Results: The sample included 386,632 visits with an I/DD diagnosis. The NYU classification method found that 44.6% of all visits for ASD were classified as nonemergent yet the other three I/DD had a non-emergent visit rate ranging 25.9%-28.8%. The ASD sub-sample was 51.8% of all visits for psychiatric care and 50.5% of all visits for injury care. All independent variables tested: admission on weekend, ED trauma level, age, sex, payer source, patient zip code income quarterlies, and patient rurality, were found to be statistically different for each model. Conclusion: The findings indicate the need for development of interventions that are specific to reducing non-emergent ED utilization for children and young adults with a diagnosis of ASD and interventions developed for reduction of emergent ED care for the other I/DD’s. In addition, unique interventions are needed to reduce the utilization of the ED for psychiatric care specifically for the ASD population and utilization of the ED for injury care for all I/DD diagnoses. / 2021-05-08

The increasing prevalence of substance use disorder (SUD) is a major public health crisis in the Unites States. Adolescence is an ideal period for early intervention to reduce the risk of SUDs in adulthood, as research has shown that up to 60% of adult SUD could have been avoided by early intervention in youth. Prior research has typically focused on urban metropolitan areas when describing adolescent substance use. However while the data is varied, several studies have shown that the prevalence of rural adolescent substance use is equal or greater than that of their urban peers, particularly alcohol, tobacco, and prescription drug use, and begin use at an earlier age. There are several methods of treatment for adolescent substance use and SUD, centered on evidence-based practices, which have been shown to be moderately effective at reducing substance use. Despite the existence of these treatment strategies, substantial disparities exists with respect to the number of adolescents who could potentially benefit and the number who actually enroll in treatment. It has been estimated that 90% of adolescents in need of treatment are not able to succeed in receiving it. This highlights the importance of understanding the circumstances in which youth initiate drug use and the unique barriers they must overcome to receive treatment when these behaviors develop into a pattern that impacts daily life. With this information, interventions can be targeted to reduce the magnitude of the most significant barriers in order to increase treatment utilization, especially in rural areas where adolescents face unique challenges to treatment access as a consequence of their remote locations. A literature review was conducted and found the major barriers in access to substance use treatment for adolescents to be a lack of available treatment programs, lack of treatment options including medication treatment, lack of perceived need or motivation for treatment, social stigma, socioeconomic status (SES), familial relationships, and referral services. These studies were all conducted in the United States and published from 2011-2020. The aim of this thesis is to propose a protocol for the completion of a systematic review to determine which barriers exist to adolescents receiving substance use treatment and to examine them in the context of rurality. Healthcare decisions and policy are informed by the best available evidence from systematic research and incorporated into evidence-based practices. A systematic review will summarize the findings of all relevant studies thereby making the key information more accessible to decision makers, including clinicians and policy makers, in order for substance use treatment to become more accessible to adolescents.

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