This dissertation comprises three main chapters, book-ended by an introduction and a concluding chapter. Chapters 2 and 3 examine the impacts of health insurance programs in the Philippines and Indonesia on healthcare utilization, healthcare expenditures, and health outcomes. Chapter 4 then examines the age-related trajectories of health-related quality of life of Canadians with diabetes. In Chapter 2, we examine the impact of the national health insurance program of The Philippines on maternal and health outcomes among poor mothers. We find that the program is associated with greater likelihood of prenatal care visits, facility-based birth delivery, and post-natal care, and the impact is most pronounced among the poorest women, but we do not observe improvements in birthweight. In Chapter 3, we evaluate the impact of Jamkesmas, the largest subsidized health insurance in Indonesia, on healthcare utilization, health outcomes, and healthcare expenditures. We find that Jamkesmas is associated with higher probability of using outpatient care and inpatient care and lower out-of-pocket healthcare expenditures, but no significant impact on catastrophic healthcare expenditures and health outcomes. In Chapter 4, we characterize the age-related-trajectories of health-related quality of life of Canadians with diabetes. We find that women and low-income individuals with diabetes experience a lower health-related quality of life trajectories, but there is no evidence that the rate of deterioration of their health-related quality of life is faster than their counterparts without diabetes. / Dissertation / Doctor of Philosophy (PhD)

N/A / Thesis / Master of Science (MS)

The purpose of this project was to augment self-efficacy, outcome expectations, and self-regulatory skills for women with breast cancer through a quality of life intervention based on Social Cognitive Theory. Relationships between social cognitive variables, positive coping behaviors, and quality of life were explored. The intervention was conducted in collaboration with an established cancer treatment center and provided information, guided feedback, and mastery experiences in a supportive environment for breast cancer survivors. A total of 32 women were enrolled and randomized to either the 8-week intervention or standard-care. With a final n of 14, the lack of statistical power made it difficult to determine whether differences existed between the two groups. Data trends suggested that some women benefited from the program. Implications for the content and delivery of future psychosocial interventions with cancer patients were discussed. / Ph. D.

Several assumptions of the indirect reflective model of the Multidimensional Students’ Life Satisfaction Scale (MSLSS) were tested to assess its validity as a measure of adolescents’ satisfaction with life generally and with five important life domains (family, friends, living environment, school, and self perception). We also examined whether adolescents’ perceived mental and physical health status significantly explained their global quality of life (QOL) and whether these relationships were mediated by their satisfaction with the five life domains. The data were taken from a cross-sectional health survey of 8,225 adolescents in 49 schools in British Columbia, Canada. Global QOL was measured using Cantril’s ladder and a single-item rating of the adolescents’ satisfaction with their QOL. Confirmatory factor and factor mixture analyses were used to examine the measurement assumptions of the MSLSS, and structural equation modeling was applied to test the hypothesized mediation model. The Pratt index (d) was used to evaluate variable importance. The adolescents did not respond to all MSLSS items in a consistent manner. An abridged 18-item version of the MSLSS was therefore developed by selecting items that were most invariant in the sample. Good model fit was obtained when the abridged MSLSS was used to test the hypothesized mediation model, which explained 76% of the variance in global QOL. Relatively poorer mental health and physical health were significantly associated with lower satisfaction in each of the life domains. Global QOL was predominantly explained by the adolescents’ mental health status (d = 30%) and by their satisfaction with self (d = 42%) and family (d = 20%). Self and family satisfactionwere the predominant mediating variables of the relationships between mental health (45% total mediation) and physical health (68% total mediation) and global QOL.Satisfaction with life domains and perceived physical and mental health can be viewed as conditions that potentially contribute to adolescents’ global QOL. Questions about adolescents’ experiences with important life domains require more attention in population health research so as to target appropriate supportive services for adolescents, particularly those with mental or physical health challenges. / Michael Smith Foundation for Health Research / Canadian Nurses Foundation / Trinity Western University

The literature available on financial aid addresses how aid promotes access and equal educational opportunity by enabling students to matriculate into college. The literature also discusses how financial aid impacts students' ability to persist to degree completion. However, there seems to be little research on how financial aid affects students' lives while they are in college. The present study attempted to address this gap in the existing literature by examining the differences in quality of life between college students receiving financial aid and those not receiving such aid. For purposes of this study, quality of life was defined by four dimensions culled from the literature: (a) material possessions; (b) housing; (c) use of time; and (d) support mechanisms. Financial aid was defined as any need-based grant, loan, or work-study money awarded to a student. Data were collected using the Quality of Life survey developed specifically for this study. The survey consisted of 59 items that were designed to measure the four dimensions of students' quality of life. The target sample for this study consisted of 600 first year undergraduate students: 300 financial aid recipients and 300 non-aid recipients. The findings revealed significant differences in three of the four areas: material possessions, use of time, and support mechanisms. These findings suggest that those who administer financial aid programs and those responsible for creating financial aid policies may wish to consider the role financial aid plays in the quality of life of students. / Master of Arts

Heart disease is a major health problem affecting the octogenarian today. As age increases, so does the risk for heart disease. One accepted treatment for heart disease is open-heart surgery. The incidence of open-heart surgery performed on the octogenarian is increasing. Open-heart surgery has risks. It is costly and stressful for the patient and family. A major focus of the last decade has been on healthcare costs, outcomes, and quality of life. While information on functional status of the octogenarian following open-heart surgery is available, there is little information available related to the perceived quality of life in the octogenarian following open-heart surgery. Comprehensive tools specific to this population are also not available. The purpose of this study was to examine the perceived quality of life and functional status in the octogenarian following open-heart surgery. The theoretical framework used for this study was the Quality of Life (QOL) model adapted for cancer survivors (QOL-CS) (Ferrell et al., 1995). A descriptive research design was used. The sample frame included eligible octogenarians, who underwent open-heart surgery between January 1, 1998 and February 1, 1999, by a group of cardiac surgeons in the Central Florida area. The New York Heart Association (NYHA) functional status was used to assess the participant's functional level. To assess quality of life, the Quality of Life Scale/Cancer Survivor (Ferrell, Grant, & Hassey-Dow, 1995), in modified form, was used. Both instruments were assessed by a panel of experts to establish content validity. The QOL-CS tool had established validity, internal consistency, and reliability based on the literature review. Crohnbach's alpha measure of internal consistency was also performed on the revised tool. Pfeiffer's Short Portable Mental Status Questionnaire (SPMQ) was administered to assess the participant's mental status prior to their completing the QOLCS tool. The tools were administered over the phone or at the participants home based on their preference. Inclusion criteria were that the participant be between 80 and 90 years old at the time of having open-heart surgery. They also had to be mentally competent and able to understand the English language. The participants completed the SPMQ, a demographic questionnaire, and the QOL-CS modified for this population. The NYHA functional classification was made based on the participant's reported symptoms. Twenty-five people were operated on that fit the criteria and time frame, ten died prior to initiation of the study. Fifteen people were eligible for inclusion in the study, three were unable to be contacted and one refused to participate. Eleven subjects participated in the study. The QOL-CS tool analyzed the domains of physical, psychological, social, and spiritual well being on a Likert scale of one to ten. The mean results were as follows; physical 7.2, psychological 7.2, social 7.1, and spiritual 5.0. A majority of the subjects (73%) were in a NYHA functional class of I or II. The remaining subjects were in class III. This study revealed that for this group, quality of life was above average following open-heart surgery. Further research is needed on larger samples to confirm these results. As more and more open-heart surgeries are performed on the octogenarian, research should continue on the functional outcomes and quality of life associated with these interventions. A tool to examine quality of life, specific to this unique population should be developed.

Approximately 21,550 women were diagnosed with Ovarian Cancer (OVCA) in 2009 and 14,600 died from their disease, making it the number one killer of women among gynecological cancers. Seventy percent of cases of OVCA are not detected until the disease has progressed to stage III or stage IV. Both diagnosis and aggressive treatments for late-stage OVCA can have a negative impact on women's psychosocial well-being resulting in anxiety, depression, and fear. The purpose of this integrative review of literature was to evaluate interventions designed to improve psychosocial well-being in women with OVCA. This review of literature was conducted using the CINAHL, PsycINFO, and MEDLINE databases using various key terms including "ovarian cancer or neoplasm" and "psychological and psychosocial", "well-being", "fear or anxiety or depression". Five studies met the inclusion criteria and were included in this review. These interventions include psychosocial, psychoeducational, and personal counseling interventions. The findings indicate that these interventions result in a significant improvement in participant's psychosocial well-being including decreased depressive symptoms, fear, and anxiety. This evidence supports that there is a need for psychosocial intervention in women with OVCA. It also suggests that women with OVCA benefit from tailored interventions and one-on-one educational and counseling sessions. Clinicians can use this information to anticipate potential problems in their client's psychosocial well-being and provide more education and support or refer them for counseling. More research is needed about reducing the psychosocial sequelae that results in women with OVCA.

No / To investigate the cross-cultural validity of international Dutch-English comparisons when using the Dutch Rivermead Mobility Index (RMI), and the intra-test reliability and construct validity of the Dutch RMI. METHODS: Cross-cultural validity was studied in a combined data-set of Dutch and English patients undergoing rehabilitation after stroke, who were assessed with the Dutch version of the RMI and the original English RMI, respectively. Mokken scale analysis was used to investigate unidimensionality, monotone homogeneity model fit, and differential item functioning between the Dutch and the English RMI. Intra-test reliability and construct validity were studied in the Dutch patients by calculating the reliability coefficient and correlating the Dutch RMI and the Dutch Barthel Index. RESULTS: The RMI was completed for Dutch (n = 200) and English (n = 420) patients after stroke. The unidimensionality and monotone homogeneity model fit of the RMI were excellent: combined Dutch-English data-set (coefficient H = 0.91); Dutch data-set (coefficient H = 0.93); English data-set (coefficient H = 0.89). No differential item functioning was found between the Dutch and the English RMI. The intra-test reliability of the Dutch RMI was excellent (coefficient rho = 0.97). In a sub-sample of patients (n = 91), the Dutch RMI correlated strongly with the Dutch Barthel Index (Spearman's correlation coefficient rho = 0.84). CONCLUSION: The Dutch RMI allows valid international Dutch-English comparisons, and has excellent intra-test reliability and construct validity.

No / In a developing country such as South Africa, where needs surpass resources, elderly persons living in institutional care due to dementia are generally viewed as well-cared for if their basic needs for security, food and personal hygiene are met. Due to the disabling effect of the condition, residents are often unable to engage independently in occupations that they find meaningful, requiring staff support to enable them to do this. In South Africa staff training on dementia and person-centred care (PCC) is limited, which in turn impacts on how staff interact with residents. This often results in persons with dementia being deprived of opportunities for engagement and occupation that have the potential to bring about well-being. The first author conducted an initial pilot feasibility study to assess Dementia Care Mapping (DCM), a method used internationally to help improve the quality of formal dementia care, at three identified residential care facilities in South Africa. DCM is an observational tool that involves observing care from the perspective of the person with dementia. This paper examines whether DCM could be used as a means to develop quality dementia care in formalcare settings in South Africa despite a lack of human and financial resources.

Yes / Area level factors, such as deprivation and urban/rural settings, have been associated with variation in local resources and services and health inequality in later life. The aim of this study is to investigate the potential impact of deprivation and urban/rural areas on capability to live well with dementia and to examine whether availability of informal carers modified the associations. The analysis was based on a large cohort study of 1547 community-dwelling people with dementia across Great Britain. Quality of life, life satisfaction, and well-being were measured as indices of "living well." Multivariate modelling was used to investigate differences in living well measures across deprivation quintiles and urban/rural areas adjusting for sociodemographic factors and number of comorbidities and stratifying by three groups: those living with a carer, those with a noncoresident carer and those without a carer. Negative dose-response relationships between deprivation and measures of quality of life (-2.12; 95% CI: -3.52, -0.73), life satisfaction (-1.27; 95% CI: -2.70, 0.16), and well-being (-5.24; 95% CI: -10.11, -0.36) were found in participants living with a carer. The associations were less clear in those with a noncoresident carer and those without a carer but these two groups generally reported lower scores on living well indicators than participants living with a carer. There was no urban/rural difference. The findings suggest inequalities in living well with dementia according to levels of deprivation. Additional resources are needed to improve postdiagnostic care in highly deprived areas and support those who have no informal carer.