Thesis (M.S.)--University of Michigan, 1980. / Running title: CHN's referral activity.

Maternal and newborn health is one of the main indicators of a good health system. The study wished to develop a strategy to improve the referral system for maternal and newborn care. To identify issues for improvement, the researcher explored the appropriateness of referrals, referral pathways and challenges, and provider costs for maternal and newborn care at health centres and hospitals levels. The researcher selected a sequential explanatory mixed method research design. Two primary hospitals and six health centres were purposively selected for participation. The first phase collected quantitative data by reviewing the health facilities’ medical records for services provided and health service costing, respectively. Data collection covered one Ethiopian fiscal year (8 July 2017 to 7 July 2018). Based on the existing human resource arrangement and care needs, the health service costing found that a single midwife at health centre level spent half of the expected time for delivery care. The cost estimates of various types of care delivery care indicated that delivery care at health centre and hospital levels cost $27.5 to $30.2, and $34.7 to $37.8, respectively. The primary hospitals incurred four times the cost for newborn intensive care units and Caesarean sections compared to normal delivery care. In the second phase, the researcher collected qualitative data from 26 purposively selected key informants in interviews. The findings indicated that the selected hospitals and health centres had a referral system, but several factors impeded its effective implementation. Knowledge of referral pathways determined the referral practices at the lower level of the system. The number of inappropriate referrals to primary hospitals indicated a need to mobilize and educate the community on the services available and protocols of care. In general, most referrals could have been managed at health centre level. Emergency medical transportation is a critical component of the referral system; delays in transportation determine the outcome of care at hospital level. Ambulance management was generally poor, lacked a tracking system, and was negatively affected by confusion and lack of coordination between facilities. The available ambulances were not well equipped or well-staffed for emergency management. Moreover, there were frequent breakdowns due to limited budget for maintenance and running costs. The quality of maternal care depends on the quality of the labour monitoring. However, partograph utilization was not consistently practised. Admitted cases were not properly monitored because of the high caseload and limited supervision support. In many cases, healthcare professionals tended to “treat charts” rather than promote evidencebased practice while providing care. The quality of practice was challenged by insecurity in the working environment but strengthened by good teamwork and available consultation support. The implementation of the existing referral system depended on the people involved; the use of performance indicators; follow up by management, and an accountability framework. The findings of the two phases of the study and review of other countries’ experiences on the identified problems, led to the development of draft strategy and then a consultation with relevant experts produced the final strategy. The strategy includes interventions to improve the practices at the sending and receiving facilities as well as suggestions to improve the communication, transportation and overall governance system. Then, taking into consideration all the phases of the study, the researcher makes recommendations for practice and further research. / Health Studies / D. Litt. et Phil. (Healht Studies)

Patterns of representation of African Americans in K-12 special education programs vary across the United States. A school district in Arizona has a 13% African American population, yet the African American special education representation is 17%. The purpose of this grounded theory study was to generate an understanding of the processes related to special education referral and assignment of African American elementary students as perceived by 7 teachers and 6 parents in the school district. Inductive analysis including open, axial, and selective coding led to the categorization of three themes: complexity in the referral process, inadequate teacher-parent communication and lack of shared knowledge, and inadequate teacher training. A key finding was parents' dependency on teachers for placing children in special education without the requisite knowledge to ask questions or make critical choices for their children. Parents' powerlessness and lack of knowledge may contribute to the overrepresentation of African American children in special education programs in the district. Findings may be used to educate parents and train teachers in the processes of referral and assignment of students to special education programs.

Doctor of Philosophy / Curriculum and Instruction Programs / Socorro G. Herrera / Throughout the last several decades, rises in CLD student populations and teacher accountability have factored in the increased numbers of CLD students being referred for, and placed in, special education. Because traditional evaluation processes do not reliably distinguish student learning problems that result from culturally/linguistic difference from those associated with innate disability, once referred, most CLD students go on to be placed in special education. Since over-referral is a key factor in over-representation, the purpose of this qualitative study was to identify and examine the student and teacher factors associated with referral of bilingual CLD students for special education evaluation. The primary sources of data for this study were school records generated by classroom teachers, and semi-structured interviews with teachers who had referred bilingual CLD students for special education evaluation. Qualitative data garnered from these sources permitted identification and description of CLD student learning behaviors, and teacher interpretations thereof, which factored into referral of these students for special education. Results, obtained through review and analysis of 27 referral records and six teacher interview transcripts indicated that lack of teacher preparation was a significant factor in the teacher's ability to appropriately perceive and respond to CLD student learning behaviors. Most notably, grade-level teachers tended to overrate the CLD student's English language proficiency based upon observations made within the school setting. Once determined to have enough English, the CLD student's language needs were essentially disregarded throughout the pre-referral (intervention) process. Student failure with unaccommodative interventions appeared to reinforce teacher perceptions of prereferral as a confirmatory process rather than the means by which student learning problems could be resolved. These phenomena were compounded by the teacher's expressed deference for psychological test data and preference for special education placement. Teachers form observation-based opinions about CLD student language proficiencies which can derail the instructional and intervention process for CLD students and lead to inappropriate referrals for special education. Further research is needed to determine the reliability of such teacher impressions and methods by which these teachers can better identify and respond to CLD student's language assets and needs.

Background: To accelerate the coverage of skilled birth attendance, in 2005, the Indian government initiated a conditional cash transfer (CCT) programme, Janani Suraksha Yojana (JSY) that provides cash to women upon delivering in health facilities. The attempt to increase the utilization of facilities through the JSY, given the health system’s fragile state, has raised concerns about the programme’s success at achieving its intended goal of reducing maternal mortality ratio (MMR). Aim: To understand the implementation of the CCT policy to promote institutional births in India, with a special focus on nine of India’s poorer states. Methods: Thesis uses both quantitative and qualitative methods. The changes in coverage and inequalities in institutional births in the nine states following the initiation of JSY were analysed by comparing levels before and during the programme using state and district level data. The association between the coverage of institutional births and MMR was assessed using regression analysis (I). The change in socioeconomic inequalities in institutional births was estimated using the concentration index and concentration curve, and contributions of different factors to inequalities was computed by decomposition analysis (II). The quality of referral services was studied by conducting a survey of health facilities (n=96) and post-partum women (n=1182) in three districts of Madhya Pradesh. Conditional logistic regression was used to study the association between maternal referrals and adverse birth outcomes, while spatial data for referrals were analysed using Geographical Information Systems (III). Semi-structured interviews were conducted with government and non-government stakeholders (n=11) to explore their perceptions of the JSY, and the data were analysed using a thematic framework approach (IV). Results: In five years, institutional births increased significantly from a pre-programme average of 20% to 49%. However, no significant association between district-level institutional birth proportions and MMR was found (I). The inequality in access to institutional delivery care, although reduced since the introduction of JSY, still persists. Differences in male literacy, availability of emergency obstetric care (EmOC) in public facilities and poverty explained 69% of the observed inequality. While MMR has decreased in all areas since the introduction of JSY, it has declined four times faster in the richest areas than in the poorest (II). Adjusted odds for adverse birth outcomes among those referred were twice than in those who were not referred (AOR 2.6, 95% CI 1.1-6.6). A spatial analysis of the inter-facility transfer time indicated that maternal deaths occurred despite good geographic access to EmOC facilities (III). While most health officials considered stimulus in the form of JSY money to be essential to promote institutional births, non-government stakeholders criticised JSY as an easy way of addressing basic developmental issues and emphasised the need for improvements to health services, instead. Supply-side constraints and poor care quality were cited as key challenges to programme success, also several implementation challenges were cited (IV). Conclusions: Although there was a sharp increase in coverage and a decline in institutional delivery care inequalities following the introduction of JSY, the availability of critical care is still poor. CCT programmes to increase service utilization need to be essentially supported by the provision of quality health care services, in order to achieve their intended impacts on health outcomes.

A survey instrument was designed to evaluate factors influencing consumer selection of an orthodontist and consumer perception of different forms of media advertising (radio, television, newspaper, magazine, direct mail, and billboard) by orthodontic practices. The surveys were distributed by 8 orthodontic offices in and around the Richmond, Virginia area. Out of 676 surveys, 655 (97%) were returned. Respondents most often cited dentist and patient referrals as how they learned of the orthodontic practices they visited (50%- 57%). However, a caring attitude and good practitioner reputation were cited as the top reasons influencing selection of an orthodontist (53% and 49% respectively). Fourteen percent to 24% of respondents felt that advertising orthodontists would offer a lower quality of care than non-advertising orthodontists. Newspaper, magazine, and direct mail advertisements were viewed more favorably than radio, television and billboard advertisements. Chi-square analyses revealed few statistically significant differences in perception between different income and education groups.

Thesis advisor: Hideo Konishi / This dissertation covers three essays in modelling the market competitions with the presence of consumer search. The first two essays add on Wolinsky's (1986) model to investigate firms' optimal choice of their way of doing business in response to the changing consumer search behaviors during the information age. The third essay modifies the Varian's (1980) model to provide a new mechanism to rationalize the countercyclical markups in supermarkets. The first essay concerns the formation of referral alliance. It extends the Wolinsky's (1986) model to a three-stage game with two types of products produced by a continuum of firms with each one having strength in a single type only. In the first stage, firms simultaneously decide on the formation of referral alliances, in which each alliance consists of a pair of firms producing different types of products. In the second stage, they set price simultaneously. In the third stage, each consumer who only values one type of product searches sequentially for the right product. We show that firms with low ability to deal with the unmatched consumers are positively assorted together in the formation of referral alliance with multiple equilibrium possible. The proliferation of referral alliance always benefits consumers but not necessarily firms. One the one hand, it intensifies competition and drives down the market price. On the other hand, it increases the mass of consumers participating in the search market. The price elasticity of demand together with our stability condition govern the changes in consumer and social welfare as the search cost varies. The reduction in search cost always increases consumer and social welfare only if the equilibrium is stable with elastic demand. The policy implication from our results is that it might be more effective to improve consumer and social welfare by inducing more firms to participate in the referral alliances rather than reducing the consumers' search cost. The second essay studies the incentives for stores to invest effort in serving customers if effort is costly and might be merely persuasive that reduces consumption utility. We incorporate a sales agent to each store in Wolinsky's (1986) model, in which the sales agent is paid either by fixed wage or by commissions. The commissions motivate sales agents to provide more advice, which could be indeed useful to increase clients' willingness to pay or merely persuasive without affecting it. Consumers are sophisticated that understand the dual roles of effort before visiting firms, but they might be impressionable and therefore could not stay away from the effect of persuasion when they are making the purchasing decision. When consumers are heterogeneous in terms of their impressionability, they are sorted into stores with fixed wage and commissions in the equilibrium. The composition of stores varies with the search cost and the ability of sales agents to increase consumers' willingness to pay (effectiveness of advice). When the advice is relatively ineffective, there will be an increase in mass of fixed wage stores in response to a reduction in search cost. The reverse is true when the advice is sufficiently effective. Additionally, the mass of fixed wage stores always increases as the advice becomes less effective. The competitive equilibrium outcome might imply that there are too little commission-based stores, so it could be social welfare enhancing by encouraging more consumers to visit the stores with commissions. The third essay provides a simple mechanism that rationalizes the countercyclical markups in supermarkets with the presence of a warehouse club. We first provide a mechanism on the higher supermarket prices upon the entry of the warehouse club. The new warehouse club attracts price-sensitive consumers away from supermarkets, which reduces the price elasticity of the consumers in the supermarket regime. This relaxes price competition resulting in higher supermarket prices. After that we apply the same mechanism to explain the countercyclical markups in supermarkets. During economic booms, the time value of consumers increases making them less willing to visit the warehouse club. Thus, economic booms increase the amount of price-sensitive consumers in supermarkets, intensifying price competition and inducing a lower price relative to cost in booming times. / Thesis (PhD) — Boston College, 2015. / Submitted to: Boston College. Graduate School of Arts and Sciences. / Discipline: Economics.

Com o objetivo de estudar o processo de referência de pacientes que procuram um Hospital Universitário, pela primeira vez e analisar algumas características destes pacientes e as inter relações entre a localização do domicílio, a utilização de outros serviços, as dificuldades e facilidades apresentadas pelos pacientes, para procurar o Hospital, foram investigados todos os pacientes que procuraram um Hospital Universitário. O trabalho foi realizado no período de cinco semanas de outubro e novembro de 1983, a saber: de 3 a 7, 17 a 21 e 24 a 27 de outubro e de 7 a 11 e 21 a 25 de novembro. Através de entrevistas foi preenchido um formulário com questões sobre características do paciente tais como: sexo, idade, nível de instrução; ocupação, local de residência, gravidade dos sinais e sintomas que os levaram a procurar o Hospital, motivo da demanda, distância do domicílio ao Hospital, utilização de outros serviços, tipos de encaminhamento. A hipótese diagnóstica foi obtida do prontuário do paciente, após a consulta. Foram estudados 1.601 pacientes, sendo 59,53 por cento do sexo feminino e 40,47 por cento do sexo masculino. A maior concentração de pacientes pertence ao grupo etário de 15 a 24 anos (24,49 por cento ), seguido pelo de 25 a 34 anos (17,86 por cento ). O nível de instrução mostrou-se bastante baixo, uma vez que, 54,63 por cento tinha o primeiro grau incompleto e 30 por cento analfabetos. A ocupação que apareceu com maior freqüência foi as donas de casa (43,94 por cento ), seguida pelos agricultores (15,51 por cento ), trabalhadores dos serviços dos desportos e das diversões (13, 64 por cento ). Como Hospital Regional 46,34 por cento dos pacientes procedem da região de Ribeirão Preto e 37,48 por cento do próprio município, onde está localizado. A procedência de pacientes na zona rural aumenta proporcionalmente, em relação à urbana a medida que se afasta do município de Ribeirão Preto. De maneira geral, os pacientes da zona urbana procuram mais precocemente o Hospital, quando residem mais próximo dele. A maioria dos pacientes que residem próximo e procuram o Hospital é portador de sinais e sintomas considerado leve, aumentando a proporção de sinais e sintomas graves entre os pacientes que residem mais distantes do Hospital. 32,57 por cento dos pacientes portadores de sinais e sintomas leves e 25,12 por cento dos portadores de sinais e sintomas graves não procuraram outro serviço, antes de demandarem ao Hospital e informaram não ter procurado outro serviço, por falta de recursos para pagar assistência médica e não confiar no Centro de Saúde. Dentre os pacientes que procuram outros serviços antes, apenas 54,4 O por cento foram referidos para o Hospital e 87,36 por cento destes não receberam orientação para, após o atendimento no Hospital, retornarem a seu serviço de origem. O fluxo de pacientes ao Hospital diminuiu paulatinamente, no decorrer da semana. As doenças do sistema nervoso e dos órgãos dos sentidos ocupam o primeiro lugar entre as hipóteses diagnósticas dos pacientes que procuram o Hospital, pela primeira vez. Dos 1601 pacientes atendidos, 14,74 por cento não foram registrados, conforme rotina estabelecida pelo Hospital, podendo gerar estatísticas imperfeitas. O estudo do processo de referência ao Hospital mostrou-se importante para o conhecimento das características dos pacientes, das inter relações com os outros serviços e das peculiaridades própria do Hospital, como subsídio para organização da assistência à saúde. / With the objective to study the process of referral of patients who look for a University Hospital for the first time and to analyze some characteristics of these patients and the interrelationships between the location of their homes, the use of other services and the difficulties or the facilitation met by the patient to contact the hospital, all the patients who looked for a University Hospital were investigated. The study was conducted over a period of five weeks from October 3 to 7, 17 to 21 and 24 to 27 and from November 7 to 11 and 21 to 25, 1983. Each patient was interviewed and a form was filled out with answers to questions of the characteristics of the patient such as sex, age, level of education, occupation, place of residence, seriousness of the signs and symptoms that led him to look for the Hospital, reason for the demand, distance of the residence from the Hospital, type of referrals. The diagnostic hypothesis was taken from the patient\'s medical record after his medical visit. A total of 1601 patients were studied; 59.53 per cent were women and 40.43 per cent were males. Most patient were concentrated in the 15 to 24 year age range (24.49 per cent ), followed by the 25 to 34 year age range (17.86 per cent ). The level of education was quite low, since 54.63 per cent had not completed elementary school and 30 per cent were illiterate. The most frequent types of occupation were: housewife (43.94 per cent ), followed by rural workers (15.51 per cent ) and by workers in suports and amusement services (13.64 per cent ). Since this is a Regional Hospital, 46.34 per cent of the patients were from the Ribeirão Preto region and 37.48 per cent from the town itself in which the Hospital is located. The origin of patients from the rural zone increased proportionally in relation to the urban zone with the distance from Ribeirão Preto. In general, the patients from the urban zone look earlier for the Hospital when they live closer to it. Most of the patients living close to the Hospital had signs and symptoms considered mild, with an increase in the proportion of serious signs and symptans anong the patients who live farther away from the Hospital. 32.57 per cent of the patients with mild signs and symptoms and 25.12 per cent of the patients with serious signs and symptoms did not look for any other service before contacting the Hospital and informed that they had not lookes for other services because of lack of money to pay for medical assistance and because they did not trust the health center. Among the patients who had previously looked for other services, 54.40 per cent were referred to the Hospital and 87.36 per cent of these did not receive guidance to return to the original service after being attended at the Hospital. The flow of patients to the Hospital decreased little by little with each passing week. Diseases of the nervous system and of the sensory organs occupied first place among the diagnostic hypotheses for the patients who looked for the Hospital for the first time. Of 1601 patients attended, l4.74 per cent were not registered according to the routine established by the Hospital, a fact that may give rise to imperfet statistics. The study of the process of referral to the Hospital proved to be important in terms of learning about the characteristics of the patients, the interrelationships with the other services and the peculiarities of the Hospital, as an aid in organizing health assistance.

This dissertation studies an economy where efficiency depends on the correct match between projects and two experts. A low-skill expert has low fixed cost and low productivity, so he is more efficient in handling low-potential or low-difficulty projects. And the opposite is true for a high-skill expert. The dissertation studies the effectiveness of markets and organizations in overcoming asymmetric information issues, experts' incentives to acquire project information at a cost, and how experts use the information to facilitate the correct match. The first chapter studies a market where a referring expert privately knows a project's potential and may refer it at any price. Inspection benefits the referred expert. First, it allows him to find out the project's potential before accepting the referral offer. Second, it allows him to tailor production effort to the project's potential for maximum efficiency. In equilibrium, the referring expert pools projects into subsets and refers each subset at a different price. A higher price signals a subset of projects with higher potentials. The referred expert almost always inspects and then uses the information to make the acceptance decision. Each subset must be small enough to incentivize the referral at a price, but also large enough to incentivize inspection by the referred expert. The second chapter studies contract design within an organization. A principal has to rely on the two experts to learn about projects' difficulties. If information cost is small, the principal can implement the first best by an optimal mechanism with the low-skill expert acting as a gatekeeper. The low-skill gatekeeper expert is incentivized to acquire information and report it truthfully. Subsequently, the principal efficiently assigns the project based on the report. The third chapter studies a market where each of the two experts can exert a variable effort to acquire project information imperfectly. In the first best, experts coordinate their information acquisition efforts. In the market, either one or both experts acquire information. The two experts may fail to coordinate because one acquires information for efficient match but the other acquires information again to protect himself.

Much of the practice is clinical neuropsychology is performed in the role of consultant and although the neuropsychologist is dependent upon referrals made from outside sources, relatively little attention has been devoted to the investigation of the referral process. Surveys of clinicians and referral sources have reported breakdowns of referral sources by discipline and general topics of referral questions based on recollection, but direct analysis of referral patterns across the same period has not been undertaken. The purpose of the study is to document the advancement of neuropsychology from providing psychological testing to establishing itself as a multifaceted discipline with a significant diagnostic purview that is regularly relied upon to contribute to important decisions in the lives of patients. By examining the referral questions rather than neuropsychologists' or referral sources' recollection of referrals, this study expands what is known about referral content and patterns. In an effort to explain question content without relying upon recollection, a coding rubric was designed to capture the breadth of presenting problems and requests seen in the original referral questions. Two-thousand-six-hundred referral questions were selected from the odd year over the 25 year period from 1983 to 2007, yielding a total of 2600 referral questions. Cochran's Kappa was used to conduct interrater reliability analyses in three stages across the entire rating process. Content analysis showed that 79.1% of all questions had at more than minimal content. The most common request was for assistance with diagnostic considerations, which was present in 66.4% of all cases. Assistance with differential diagnoses was requested in 27.4% of all cases with the majority of these composed of requests for assistance in differentiating between psychiatric and neurological or other medical considerations. There was evidence for a trend over time in the gradual decline of requests for assistance with psychiatric differential diagnosis and requests for the MMPI from 1993 to the present. Memory problems and dementia are the most common presenting problems, although there is evidence of a slight decline in these evaluations beginning in 1997. Requests for specific recommendations, particularly those related to making recommendations regarding treatment planning were found to steadily increase across the sampling period. Limitations and implications for practice were discussed.