xi, 149 p. A print copy of this thesis is available through the UO Libraries. Search the library catalog for the location and call number. / Between the early 1900s and the 1952 U.S. Supreme Court case of United States v. Oregon State Medical Society, conflicts over the legality and permissibility of contract medicine raged in Oregon. Organized labor opposed the practice because it restricted their choice of physician, and because they resented mandatory wage deductions to pay for the contracts. Organized medicine resented contract medicine for its imposition of commercial power on physicians. The groups initially attempted to resolve the issue publicly through legislation, but procedural factors and a lack of group cohesiveness prevented a public solution. Beginning in the 1930s, the State Medical Society imposed its own private code of ethics on the medical services market to eliminate contract practice, and used the legislative process to preserve its independence to pursue a private sector solution. Ultimately, the Supreme Court allowed this approach, based partly on its view that medicine was distinct from business. / Committee in Charge: Dr. Daniel Pope, Chair; Dr. Glenn May; Dr. James Mohr

From February to September of 2001, a significant body of qualitive data was collected to investigate barriers for Hispanic participation in Oregon's managed care Medicaid program. As a means to investigate this topic, comments were solicited from physicians, hospital administrators, social service agencies, and low-income Hispanics through semi-structured focus groups and individual interviews. This methodology presents the reader with a rich enthnohistoric and cultural context to the local issues surrounding Hispanic under-participation in Oregon's managed care Medicaid program. Finally, through an analytical framework of critical medical anthropology, connections are drawn from local barriers to state and corporate policies. / Graduation date: 2002

Purpose: The Purpose of this research was to design, implement and evaluate a patient centered asthma intervention pilot program directed by physicians and administered by community pharmacists to a group of Managed Care contracted Oregon Health Plan asthmatics. The evaluation was to determine if the proposed intervention could improve the enrolled asthma patient's related education and quality of life while simultaneously creating economic benefit for the sponsoring health plan. Methods: The study was designed to be a prospective, six month pre and posttest quasi-experimental evaluation combined with a Solomon-like two-control group comparison. All patients in the sponsoring health plan twelve years of age and older who had six months of continuous enrollment were eligible. Enrollment of the target patients was voluntary and the time period of the evaluation (November, 1997 to May, 1998) was purposely conducted to capture the notoriously difficult asthma trigger cold and allergy seasons. Information regarding the cost and frequency of pre and post emergency room visits, hospitalizations, physician's office and medications use and Health Related Quality of Life (HRQL) was collected for the intervention group and control group. Satisfaction information for the major actors was collected and analyzed at posttest. Within group comparisons were conducted using the paired T-test and the unpaired T-test was used for between group comparison. Results: Patients in the intervention group who had their physician and pharmacist fully participate in respectively directing and administering the study protocol showed associated improvements in their quality of life measures. Economic benefit to the health plan is suggested by a cost benefit ratio of 1:5.71 resulting from favorable decreases in health care related resources and improved asthma related medication utilization. Analysis of the satisfaction measures suggests that all the major participants were very satisfied with the intervention. Conclusion: Even though the sample size in this pilot study was relatively small, the resulting information should not be immediately discounted. The evidence suggests that in those cases where the study protocol was followed, favorable economic, HRQL and satisfaction is comparable to larger, previously conducted studies. / Graduation date: 2000

Low-income women in an Oregon city of approximately 35,000 inhabitants have limited access to prenatal care services during their pregnancies. The purpose of this study was to uncover the impacts of several factors on the experiences of twenty-seven health department clients with public health department prenatal care practitioners and with local private obstetricians. Ethnographic interviews were conducted with the clients, two health department practitioners, two local obstetricians, and one local direct-entry midwife. The focal finding that emerged from the research was that the clients preferred the care of the health department practitioners to that of obstetricians, even though the health department providers could not deliver the women's babies. The major impacts on the clients' experiences included fragmented service delivery and availability, economic and social restrictions on prenatal care options, biomedical constructs of a healthy pregnancy, and provider role constructions and attitudes towards Medicaid recipients and uninsured pregnant women. Local physicians' mechanistic philosophy, professional dominance and profit orientation afforded them a narrow understanding of the needs and identities of low-income women. Local public health workers are less professionally autonomous than medical doctors but their service orientation allowed them the potential to better serve low-income clients. Based on the twenty-seven clients' perceptions of their care providers and the services available to them, recommendations are made for more empowering, comprehensive prenatal care services in this county. Recommended changes to the public health system entail expanded funding for more appropriate programs and to establish continuity of care for health department clients from pregnancy through the postpartum period. The incorporation of direct-entry midwives into the prenatal and birthing care options open to low-income women is also recommended. Senate Bill 1063, which creates a process for direct-entry midwives to become state-licensed in order to be reimbursed by the Office of Medical Assistance Programs for perinatal services, is considered in terms of its implications for low-income women, the Oregon community of direct-entry midwives, and the texture of Oregon reproductive health care. / Graduation date: 1994

Cultural competence is a topic that concerns social scientists and medical anthropologists who pay attention to demographic changes and health disparities. This study demonstrates practical approaches to developing cultural competence in medical education by using factors from the social environment to develop protocols for action. With current concerns in domestic and global health care, it is evident that health care organizations struggle to deliver culturally appropriate services. Additionally, educational institutions also struggle to evaluate culturally applied medical practices and competencies. Unlike medical competence, cultural competence is seldom evaluated, and as a result, a gap exists in health care delivery. The purpose of this research is to examine the changes in self-assessment of physician assistant (PA) medical students and graduates, as indications of changes in their medical practice and attitudes. Key objectives explore how PA medical students self-assess their own cultural competence; what factors impact their evaluation, and if change indicates cultural competence. The methodology consisted of a qualitative approach designed to conduct focus group discussions, in-depth interviews, and field work, while results of existing quantitative data was used to inform the study. Triangulation methods substantiated the findings along with environmental and data analysis to provide rigor to this investigation. Participants were students and graduates from a Physician Assistant Studies Program in Oregon. Major findings showed changes in participants' cultural competence self assessment due to a change in self-awareness, exposure and experiences with diverse underserved populations, in domestic and international encounters with the real world. In conclusion, change in self assessment had actually occurred, but the change in the quantitative results really portrayed a level of development on a cultural competency continuum, but not cultural competence itself. It followed from these findings that using components which influenced change along with external and internal environmental factors, provided a basis for a model to establish procedures for action. This strategic model, the praxis of cultural competence, takes critical elements or protocols to move medical students from theory to practice. From the results of this study we can see evidence of closing the gap between the theory of cultural competence and culturally competent practices. / Graduation date: 2005

This study evaluates the role of the Neighborhood Health Coordinators (NHC's) within Kaiser Foundation's Comprehensive Neighborhood Health Services (CNHS) Project. This project was established in September, 1967, under the provisions of the 1966 amendments to the Economic Opportunity Act, to provide and make readily available comprehensive medical care to 1ow-income persons. In compliance with the stipulations of this Act, persons who reside in target areas, designated as depressed neighborhoods, were hired to serve as NRC's. These indigenous non-professionals serve as links or "gatekeepers" between the low-income persons enrolled in this program, and the Kaiser medical care facilities which include the hospital-clinic and three neighborhood health clinics. The NRC's were to enroll these low-income families in the program, and assist them in obtaining appropriate health services. In addition to these primary responsibilities, the NHC’s were to refer their clients to community resources whenever necessary. The impact of the NHC's contact with families enrolled in the program was evaluated on the basis of two major indices: utilization of total medical care services and four specific areas of preventive health care. The findings of this study support the underlying assumption upon which the NRC's were hired and trained; that is, they are effective in increasing the total utilization of out-patient medical services and utilization of specific preventive health services by families with whom they have the most personal contact. In a secondary analysis, characteristics related to several CNRS Project objectives, attitudinal scales and socio-demographic characteristics are examined to determine their relationship to the staff's perception of an "ideal" NHC. This analysis shows that aptitude in interpersonal relationships and personal growth are two characteristics highly associated with rank. Several attitudinal scales, especially powerlessness and dogmatism, are positively associated with rank. Measures of knowledge in the areas of health and medical care programs have a low or negative association with rank. This study does not make an exhaustive investigation of characteristics which may be associated with rank; therefore, other variables considered by the administrative staff in their evaluation of an "ideal” NHC may not have been measured.

This study explores the effects of income, insurance, and source of medical care on access to and utilization of health services. Profiles of dental, physician, and hospital services use are developed for more than 3,500 Oregonians. Low income, lack of health insurance, and/or an inappropriate source of medical care are hypothesized to be barriers to access and utilization. Households which face one or more of these barriers are identified as falling into a "Health Policy Gap." The data for this study were drawn from a 1978 random telephone survey of 1249 Oregon households. The survey was commissioned by the State Health Planning and Development Agency in conjunction with the Northwest Oregon Health Systems Agency, the Western Oregon Health Systems Agency, and the Eastern Oregon Health Systems Agency. The questionnaire was developed by the Oregon State University Research Center. Information was collected on use of health services, insurance coverage, income, household structure, health needs, health behaviors, and health satisfaction. A behavioral model of health services utilization was constructed, dividing the independent variables according to their relative mutability or amenity to policy intervention. Income, insurance, and source of care were selected as policy variables, while other variables less under policymakers' control were labelled household characteristics. The latter were assumed to reflect a household's propensity to consume services. They included household structure, health need, residential mobility, and health behaviors. Dependent variables included measures of dental and physician visits, use of the telephone for physician advice, preventive exams, and hospitalization during the past year. Multiple techniques of analysis were employed. Cross-tabular procedures were applied to investigate the interrelationship of income, insurance, and source of care. Multiple linear regression and partial correlation methods were used to select as control variables household characteristics highly correlated to each measure of health services use. Analysis of variance and multiple classification analysis were used to develop profiles of health services use. These last techniques allowed an examination of the relationship of each policy variable and health measure while applying increasing levels of statistical control. The initial bivariate relationship was studied in isolation; it was then studied while controlling for the other policy variables, and finally while controlling for both the other policy variables as well as selected household characteristic variables. Findings support the hypotheses. Income is found to be related to insurance coverage, and insurance coverage to source of medical care, although income is not found to be directly related to source of care. Low income, lack of insurance, and an inappropriate source of medical care depress use across almost all services. However, their relative barrier effects differ by the measure of service examined. After controlling for the effects of household structure, health need, residential mobility, and health behaviors, the greatest disparity in use of dental services remains due to income, in physician services to insurance and income, and in hospital services to insurance. Clear implications arise for policymakers, whether in the public or private sectors. The low income, the uninsured, and those with an inappropriate source of care face real barriers to access. Since the relative magnitude of these barrier effects vary by the health measure examined, neither income, insurance, nor health system delivery strategies can be assumed to evenly enhance use patterns. Their effects must be separately estimated for differing measures of health services. Furthermore, the relationship between these policy variables needs detailed study before large-scale policy interventions are undertaken. Understanding the complexity of these findings for different measures of health services as well as the interrelationship of income, health insurance, and source of care is crucial in designing and implementing more effective and equitable health policies in the future.

Now more than ever, speech clinicians are being required to justify the effectiveness of their work by showing results. There are different ways to measure outcomes. For example, outcomes may be measured by testing to determine if change has occurred regarding clinical goals, or by comparing the cost of the treatment to the benefit of the treatment to determine if the treatment was economically sound. Another type of measure is subjective outcomes, such as client satisfaction. Subjective outcomes are difficult to define and measure and few studies of this type have been reported in the literature. Because clinical outcome is dependent, at least to some extent, on client satisfaction (Williams, 1994), and because few studies have been reported in the literature regarding client satisfaction with speech and language services, this area became the focus of the current study. This study sought to answer the following questions: (a) Did the parents think their child benefrtted from the articulation intervention services received at the clinic? and (b) What were parents' attitudes regarding the clinical atmosphere and staff? The Consumer Satisfaction Measure of the American SpeechLanguage- Hearing Association (ASHA) was used in this study because it is broad in scope and contains statements relating to the research questions of the current study. Answers to the research questions were derived from the responses to the survey that was mailed to the parents of 86 children who had received articulation services from the PSU Speech and Hearing Clinic. Ninety-five percent of the parental responses regarding whether parents felt that their children benefited from services obtained at the PSU Speech and Hearing Clinic were positive, indicating that parents were satisfied with the services received. Ninety-one percent of the parental responses regarding parent's attitudes toward the clinical atmosphere and staff were positive. It appears that parents hold favorable views regarding the clinical atmosphere and staff and that they were satisfied with the services their children received at the PSU Speech and Hearing Clinic.

The purpose of this study was to investigate the survey as a method of assessing client satisfaction with clinical services and to then assess parental satisfaction of clinical services at Portland State University's language clinic using the survey method. The survey asked questions regarding the parents' perceived benefits from the clinic, their perception of the skills of the clinicians who served their children, and the parents' perception of the clinical atmosphere. Eighty-five Consumer Satisfaction Surveys were mailed to 81 parents of children receiving services at Portland State University Speech-Language Clinic between the years 1987 and 1994. Eleven surveys were returned, all containing a signed consent letter, representing a 13% rate. Determining the cause behind the poor response rate for this particular survey was not difficult. No surveys were returned from the years 1987 through 1989. The highest percentage of return was from the year 1994 (38% ), indicating that higher response rates were achieved if the client was polled within 1 year of using clinical services. To further substantiate this conclusion, two of the parents contacted by telephone refused to participate in the survey, and gave length of time as the reason behind their refusal. The overall response to the survey was positive, indicating a high rate of satisfaction among the survey respondents with the services provided at the Portland State University Speech-Language clinic.

The United States population continues to increase and diversify. The cultural composition within the United States embodies a multitude of people from a variety of belief systems, religious backgrounds, and ethnicities. Within current biomedical practice, many of these differences are often marginalized, leaving populations with unsatisfactory experiences in seeking health care. Cultural competency attempts to address those differences in health care delivery. Many health care institutions are striving to become more culturally competent yet there is not a common understanding of what cultural competency means. In addition, there are many obstacles that limit the implementation of cultural competency in health care delivery. This thesis examines the need for cultural competency in health care, addressing the lack of understanding between institutions regarding cultural competency and assessing its understanding at one particular institution. Recent research at Oregon Health & Science University in Portland, Oregon has provided new insight to the discussion of cultural competency and how uniquely it can be defined in a single institution. Qualitative interviews were conducted with medical students, physicians/physicians-in-training, administrators and nurses/CMA in order to uncover how cultural competency is defined as well as the issues that are involved when delivering culturally competent health care. By being aware of an institution's cultural composition and understanding of cultural competency can help that institution enact health programs and policies that have a better chance of representing and respecting the populations they serve. / Graduation date: 2003