The purpose of this research is to empirically investigate consumers' health care decision choices in a dynamic market setting. The unprecedented demands on the U.S. health care system coupled with the mounting controversies surrounding health care reform suggest that consumers' health care decisions warrant empirical research attention. Toward this end, this dissertation empirically explored (1) the characteristics of consumers who possess a willingness to use non-conventional treatments over conventional treatments, (2) the characteristics of consumers who elect self-medication in lieu of health care practitioner-directed medication, and (3) the salient dimensions of consumers' channel choice for the procurement of health care products. Each of these decision choice factors were tested across two U.S. generational segments to assess whether differences existed across Baby Boomers' and Gen Yers' health care decision choices. The conceptual framework for empirical assessment is Bandura's (1986) social cognitive theory. From Bandura's social cognitive theory, a general model of healthcare decision choice is proposed to assess consumers' states of mind, states of being and states of action (decision choice). Results indicate that social cognitive factors (e.g., self-efficacy, objectivism) play an important role in each of the decision domains explored in this dissertation. Moreover, health value was found to be an important moderator between the social cognitive factors and health care decision choices. The predictors of the health care decision choices were found to vary across the Baby Boomers and Generation Yers on several dimensions, confirming the notion that generational differences may be a salient dimension of consumers' health care decision choice. The research offers several implications for practitioners, academicians and policy makers. Both descriptive and normative implications are gleaned from the research findings. Most notably, the results indicate that consumers' social cognitive factors and health value may be mechanisms for managing health care decisions.

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In recognition of the inherently inflationary nature of retrospective reimbursement, the Reagan Administration enacted legislation that substantially changed Medicare's hospital reimbursement system. The Prospective Payment System (PPS) mandated paying hospitals a fixed payment, set in advance, based on the patient's diagnosis rather than retrospectively paying for all services delivered to a patient. Critics contend that PPS introduces incentives for hospitals to conserve resources during the hospital stay and to shift care to less costly settings, both potentially affecting quality of care to the elderly. The question addressed by this dissertation is whether there were changes in the discharge health status and post-hospital placement of Medicare beneficiaries as a result of the implementation of PPS. Using a quasi-experimental time-series PRE/POST design, data was collected from the medical records of 2,619 Medicare beneficiaries (1,258 in the PRE-PPS period; 1,361 in the POST-PPS period) hospitalized between 1981 and 1986. Two large (300+ beds) and two medium-sized (100-300 beds) hospitals, representative of hospitals in the Portland metropolitan area, served as data collection sites. Medical records were selected from five Diagnosis Related Groups (DRGs): three medical DRGs (stroke, heart failure, and pneumonia) and two surgical DRGs (hip replacement and major joint pinning). Analysis of the data show that overall length of stay declined from 11.3 days in the PRE-PPS period to 8.6 days in the POST-PPS period, a reduction of 2.7 days and significant at the p = $<$.001 level and a significant increase in Dependency between the PRE and POST periods for four of the five DRGs studies (Stroke, Pneumonia, Heart Failure, and Hip Replacement). Finally, an analysis of differences in post-hospital placements shows a significant increase in POST-PPS placements to home alone (p = $<$.05), home health (p =.01), and for hospital transfers (p = $<$.001). Though limited in its generalizability, the data presented in this dissertation support the contention that Medicare patients are leaving the hospital sooner, in more dependent states of health than before PPS, and that greater numbers of potentially high care patients are being discharged to home and to home health.

The aging experience of men and women in rural America is different than that of their urban counterparts. In this study, I identified key disparities in access to health care, mortality, and utilization of health care that result from geographic location. Foundational theories are discussed to illustrate that disparities can originate from historical societal behaviors. Secondary data and literary reviews create a combined qualitative and quantitative approach to explore the rural/urban divide, concluding that the potential for increased disparities as the aging population grows is very real and rural residents remain vulnerable to a poor(er) aging experience. Recommendations for policy and practice, as well as additional research, are made to address the conclusion.

Indiana University-Purdue University Indianapolis (IUPUI) / Traumatic brain injury (TBI) has emerged as a major cause of morbidity among U.S. soldiers who have served in Iraq and Afghanistan. Even mild TBI (mTBI) can result in cognitive impairments that can impact how veterans experience such things as physical symptoms, emotions and behaviors, instrumental activities of daily living, interpersonal interactions, and community reintegration. The purpose of this study was to develop a comprehensive self-management intervention for veterans with mTBI to facilitate their community reintegration upon returning from deployment to combat zones. This study was conducted in two Phases. Phase I entailed collecting qualitative data regarding needs, concerns, strategies used, and advice given by eight veterans with mTBI, guided by a conceptual model derived from Ferrans’ and colleagues’ health-related quality of life model and the TBI literature. Six key categories and predominant themes emerged providing further support for the model (cognitive impairments, physical symptoms, emotions and behaviors, instrumental activities of daily living, interpersonal interactions, and community reintegration). Guided by the conceptual model, a mTBI Veteran Needs and Concerns Checklist and 14 algorithms making up the VETeranS Compensate, Adapt, REintegrate (VETSCARE) intervention were developed. Phase II entailed obtaining review of the mTBI Veteran Needs and Concerns Checklist and the 14 VETSCARE algorithms from six TBI experts. On a scale of 1 to 5, with 5 being strongly agree, expert ratings provided moderate evidence of content validity for the checklist (3.33), and for the 14 algorithms (problem relevance 3.92, accuracy 3.73, feasibility 3.80, acceptability 3.84). The average overall expert rating for the VETSCARE intervention was 3.82. The checklist and the 14 algorithms are being revised based on specific comments provided by the experts. Once revised, the mTBI Veteran Needs and Concerns Checklist and the VETSCARE intervention will be tested for feasibility in a future pilot study with veterans with mTBI who have recently returned from combat zones in Iraq and Afghanistan.

Approximately 1.76 million men and women have served in the Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) military campaigns since October 2001. The transition from living in a war zone to resuming a fulfilling life at home is often difficult for veterans. The purpose of this mixed methods study was to gain understanding of the issues that complicate health for veterans and approaches veterans used to resolve complicating health issues associated with the challenge of coming home from war. Qualitative data collection and analysis was guided by story inquiry method. Quantitative data was collected using the 36-item Short-Form Health Survey, Version 2 (SF-36v2) and analyzed using QualityMetric Health Outcomes[TM] Score Software, Version 4.0. Seven OEF/OIF veterans who had completed at least one tour of duty in Iraq since October 2001 participated in this study. Three themes emerged from the qualitative data that capture the complicating health issues that participants encountered when coming home from war: flipping the switch, figuring out how to belong, and living the stress of a new normal. Two themes emerged from the qualitative data that capture approaches used to resolve complicating health issues associated with returning home from war: connecting with others and choosing a positive attitude. Quantitative data revealed that the majority of participants scored at or above general population norms on three of the subscales that measure physical health, as well as on two of the subscales that measure mental health; however a significant percentage scored below norms on the subscale that measures social functioning (57%) and on the subscale that directly measures mental health (43%). / All three themes describing complicating health issues that emerged during qualitative data analysis resonated with the SF-36v2's measures of mental health, especially social functioning which inquires about experiences with social interactions. Both themes describing movement toward resolving resounded strongly with the SF-36v2's measures of mental health. From this study's findings, changes to policy and practice, education of nurses and post-secondary faculty, and future research have been recommended to continue to assist the war veteran who is coming home. / by LisaMarie Wands. / Thesis (Ph.D.)--Florida Atlantic University, 2011. / Includes bibliography. / Electronic reproduction. Boca Raton, Fla., 2011. Mode of access: World Wide Web.

Heart disease including ischemic heart disease is the highest contributor to death and morbidity in the western world. The studies presented were conducted to determine possible pathways of protection of the heart against ischemia/reperfusion. We employed adenovirus mediated over-expression of Methionine sulfoxide reductase A (MsrA) in primary neonatal rat cardiac myocytes to determine the effect of this enzyme in protecting against hypoxia/reoxygenation. Cells transfected with MsrA encoding adenovirus and subjected to hypoxia/reoxygenation exhibited a 45% decrease in apoptosis as compared to controls. Likewise total cell death as determined by levels of Lactate Dehydrogenase (LDH) release was dramatically decreased by MsrA overexpression. The initial hypothesis that led to our testing sulindac was based on the fact that the S epimer of sulindac was a substrate for MsrA and that this compound might function as a catalytic anti-oxidant based on a reaction cycle that involved reductio n to sulindac sulfide followed by oxidation back to sulindac. To test this we examined the protective effect of sulindac in hypoxia re-oxygenation in both cardiac myocytes in culture and using a Langendorff model of myocardial ischemia. Using this model of myocardial ischemia we showed that pre-incubation of hearts with sulindac, or the S and R epimers of sulindac resulted in protection against cell death. We present several lines of evidence that the protective effect of sulindac is not dependent on the Msr enzyme system nor does it involve the well established role of sulindac as a Cyclooxygenase (COX) inhibitor. Numerous signaling pathways have been implicated in myocardial protective mechanisms, many of which require fluctuations in ROS levels as initiators or mediators. / Sulindac shows very good potential as a preconditioning agent that could induce tissue protection against oxidative damage.Blocking of preconditioning pathways by administration of the PKC blocker chelerythine abrogated the ischemic protection afforded by sulindac. Secondly, an end-effector of preconditioning, inducible nitric oxide synthase (iNOS),was found to be induced by greater than 5 fold after 48 h prior feeding sulindac. / by Ian Moench. / Thesis (Ph.D.)--Florida Atlantic University, 2008. / Includes bibliography. / Electronic reproduction. Boca Raton, Fla., 2008. Mode of access: World Wide Web.

For the past 60 years, American citizens have turned to international adoption as a way to build their families. Unfortunately, international adoptees often spend the first months or years of their young lives in conditions of poverty and/or institutionalized care. Additionally, current U.S. immigration laws dictate that the children receive only a cursory health screening before arrival. As a result, many of the children adopted by Americans arrive to the United States with significant physical, emotional, behavioral, and developmental health problems. Twelve mothers who had adopted children internationally were interviewed for this study. Their stories of obtaining health care for their newly adopted children were shared in descriptive narratives. The themes that emerged from the data analysis were seeing healthy children despite the challenges, struggling to help the children, needing help, missing lost pieces, being different, and wanting more from providers. The overall essence derived from the mothers' experiences was that seeking health care for their newly adopted children was one of hope to achieve wellness for their children and normalcy for their families within the context of loss and a desire for more support. These findings have significant implications for the health care providers who care for them. / by Natalie L. Murphy. / Thesis (Ph.D.)--Florida Atlantic University, 2010. / Includes bibliography. / Electronic reproduction. Boca Raton, Fla., 2010. Mode of access: World Wide Web.

In the United States there exists a clear and disconcerting racial disparity in the distribution of good health, which can be seen in differential levels of morbidity and mortality affecting blacks and whites. Previous research has examined the role of SES in shaping racial health disparities and recent studies have looked specifically at the effect of education on health to explain the racial disparity in health. Higher levels of education are robustly associated with good overall health for both blacks and whites and this association has been examined over the life-course. This research explores racial differences in the effect of education on health in general as well as over the life-course. Specifically, this paper examines race differences in the effects of education on health over the life-course. Pooled data from the National Health Interview Survey were analyzed using multivariate logistic regression to estimate the effects of race, education and age on health. The results of these analyses indicate that blacks receive lower education returns on their health than whites. The effect of education on health was shown to grow in the beginning of the life-course and diminish at the end of the life course in accordance with the mortality-as-leveler hypothesis. The black white health disparity was shown to grow over the life-course among the highly educated, whereas the disparity was consistent over the life-course for the poorly educated.