Thesis (M.S.P.H.)--University of Michigan, 1935.

Thesis (M.S.P.H.)--University of Michigan, 1933.

Theses (Ed.S.)--Marshall University, 2007. / Title from document title page. Includes abstract. Document formatted into pages: contains iii, 23 pages. Bibliography: p. 22-23.

Unintended pregnancy leads to many public health consequences like lower educational attainment and diminished career opportunities, with higher rates of unintended pregnancies occurring in lower income communities and among women with drug addiction. Beyond preventing unintended pregnancies, effective contraception helps prevent poor birth spacing, thereby reducing the risk of both premature and low-weight births and maternal mortality and morbidity during the peripartum period. Long acting reversible contraceptives (LARCs), such as intrauterine devices (IUDs) and implants, are considered the birth control of choice for women of reproductive potential as they possess a number of advantages: cost-effectiveness, minimal maintenance for 3 to 10 years, reversibility, and high efficacy and continuation rates. Despite these benefits, LARCs have been widely underused in rural communities as a result of many factors including hospital and gynecology department closures, workforce shortages, provider knowledge, and access to care challenges that arise from complex social determinants of health specific to rural US communities. We therefore investigated the knowledge and current practice of clinical providers regarding LARCs counseling and provision in Hawkins County of Northeast Tennessee. Hawkins County is a primarily rural county with clinics serving a large lower income population with a high prevalence of substance use, therefore making it at risk for higher rates of unintended pregnancies. An online survey was sent to all consenting medical providers (NPs, PAs, and physicians) (n=7) to collect information on their practices related to contraception, including LARCs. Following completion of online surveys, semi-structured interviews (n=2) were planned to qualitatively explore providers’ perspectives. Quantitative analysis of survey data and thematic analysis of interviews were conducted. Analysis of survey data shows that though non-OB/GYN primary care providers reported on being somewhat comfortable to comfortable in their ability to counsel patients on LARCs, they reported low levels of actually counseling on LARCs, compared with oral contraception. Furthermore, the survey data also shows low levels of LARC insertion/removal among non-OB/GYN primary care providers, with most noting preference to refer patients to a private OB/GYN provider within the community or the health department. Additionally, non-OB/GYN primary care providers reported little to no interest in including insertion/removal of LARCs within their scope of practice, citing clinic supply, no time for procedures, and low patient desire as reasons. All providers reported believing that there are little to no barriers to obtaining LARCs by patients within Hawkins County.The semi-structured interviews, including one with the county’s main OB/GYN provider, indicated that though there is access to LARCs within Hawkins County, there may still be multiple barriers including possible poor quality of counseling on LARCs by non-OB/GYN primary care providers and preference for counseling specific populations on LARCs rather than all patients of reproductive potential, both of which may contribute to low patient desire for LARCs. This work is a useful starting place for increasing utilization of LARCs within Hawkins County. By exploring current knowledge and practices of primary care providers, we can better address potential systematic barriers to improve access to and utilization of LARCs in rural communities.

The students at a rural middle school in South Central Appalachia are struggling with increased rates of depression and anxiety, toxic stress, and multiple ACEs with few resources to help. With the input of community stakeholders, four medical students from the ETSU Quillen College of Medicine organized and conducted a pre and post survey assessing sixth grade student’s (n=60) perceived stress, coping skills, and parental/guardian relationships before and after four classes focusing on mental health awareness, positive and negative coping skills, and resilience. Pre/post surveys used modified versions of the perceived stress scale, parent adolescent scale, and coping scale for children and youth. Statistically significant relationships were found between the different scales, showing: students who had better coping skills were more likely to perceive less stress in their lives; students who perceived more stress after learning positive coping skills reported using more positive coping skills; and on pre-survey, students who reported a better parent-adolescent relationship also reported using more positive coping skills. Students who reported a less healthy parent-adolescent relationship also reported having more stress in their lives. It was also identified that most students reported academics and grades as well as lack of friendships as their main stressors. Long-term interventions with more sessions are needed in the future to continue to help students in rural middle schools as well as further expand on lessons to better serve these children's needs.

Residents of rural communities have poorer health status than people living in more populated areas. For example, The Urban and Rural Health Chartbook notes that the age-adjusted death rate among younger (1-24 years of age) persons who live in the most rural counties is 31 percent higher than those who live in the most urban counties and 65 percent higher for those who live in suburban counties (Eberhardt, Ingram, Makuc et al., 2001). Explanation for the health disparity experienced by rural residents is complex due to the influence of both community factors and the socioeconomic and behavior patterns of individuals. Access to health care, including preventive care, as well as substantial challenges with health literacy, higher instances of smoking, and lack of health insurance among rural residents, are some of the main causes of this disparity. Rural health networks have been touted by many involved with rural health issues as an effective way to address the health disparity experienced by rural areas. The last fifteen years have seen a growth in the development of rural health networks, with a growing number of grantors, e.g. the Health Resources and Services Administration, The Robert Woods Johnson Foundation and states such as New York, Florida, and West Virginia, funding their development. However, little research has been done on the effectiveness of rural health care networks. While some have evaluated rural health networks, Wellever explains that many questions are left unanswered with "the most fundamental question — whether rural health networks benefit either their members or the rural residents they serve" (1999, p. 133). Thus, it needs to be determined if health networks are in fact a viable means for improving the disparity in rural health and, more importantly, what can be done to make them more effective. This research provides insight into the correlates of effectiveness for a type of health network, vertically integrated rural health networks. Provan and Milward's (2001) framework for evaluating the effectiveness of public-sector organizational networks, which proposes three levels of analysis, i.e., the community, network, and organization/participant, was adapted to analyze the effectiveness of vertically integrated rural health networks. One-on-one interviews, questionnaires, and archival data were used to collect data on the networks sampled. Primarily, data was collected from four networks that were chosen from a larger sample of twenty-one networks to serve as best practices. Analysis of the data collected revealed a few significant predictors for the effectiveness of vertically integrated rural health networks. Financing was found to be the most important predictor, as it was significant at both the community and network levels. Both cohesiveness and the number of problems in the rural environment were also found to be significant predictors but only at the network level. No significant predictors were found at the organizational level; however, organizational and network-level effectiveness were found to be strongly correlated with each other. Overall, networks were found to be more favorable about their effectiveness at the network and organizational levels. / Ph. D.

Resource allocation formulae in Scotland include an adjustment for remoteness and rurality.  However, there is little empirical evidence about the precise effects of remoteness and rurality on hospital costs.  The main objective of this thesis is to identify and examine the reasons as to why hospitals in remote and rural areas incur higher costs, than comparable hospitals in urban areas.  A literature review on the principal determinants of hospital costs and methods of empirical estimation identified input prices, such as labour costs, and output related features, such as delayed discharges, as the most likely influential factors.  A new set of rurality and remoteness measures was developed, so as to perform sensitivity analysis regarding the impact of those measures on hospital costs.  A panel translog hospital cost function was estimated that showed that rurality and remoteness contribute to increased hospital costs, although the size of this effect is relatively small.  An hourly wage equation was estimated to assess how medical and dental staff pay is affected by rurality and remoteness and results confirmed compensating wage differential theory in that, staff working in urban hospitals will get higher pay in order to compensate for higher costs of living.  Finally, a delayed discharge model showed that hospitals in remote and rural areas suffer from longer delayed discharges.  A fixed-effect model was used in the estimation of these models, so as to control for unobserved factors that affect hospital costs and have been proved difficult to control for in the past.  The different measures of rurality did not yield the same results, the measure that best reflected remoteness, instead of rurality, was the most significant across all models.

A THESIS Submitted to the School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, in fulfilment of the requirements for the degree of Doctor of Philosophy Johannesburg, South Africa 2016 / Background: South Africa has a dual high burden of HIV and non-communicable diseases (NCDs). In a response to the dual burden of these chronic diseases, the National Department of Health (NDoH) introduced a pilot of the Integrated Chronic Disease Management (ICDM) model in June 2011 in selected Primary Health Care (PHC) facilities, one of the first of such efforts by an African Ministry of Health. The main aim of the ICDM model is to leverage the successes of the innovative HIV treatment programme for NCDs in order to improve the quality of chronic disease care and health outcomes of adult chronic disease patients. Since the initiation of the ICDM model, little is known about the quality of chronic care resulting in the effectiveness of the model in improving health outcomes of chronic disease patients. Objectives: To describe the chronic disease profile and predictors of healthcare utilisation (HCU) in a rural population in a South African municipality; and assess quality of care and effectiveness of the ICDM model in improving health outcomes of chronic disease patients receiving treatment in PHC facilities. Methods: An NDoH pilot study was conducted in selected health facilities in the Bushbuckridge municipality, Mpumalanga province, northeast South Africa, where a part of the population has been continuously monitored by the Agincourt Health and Socio-Demographic Surveillance System (HDSS) since 1992. Two main studies were conducted to address the two research objectives. The first study was a situation analysis to describe the chronic disease profile and predictors of healthcare utilisation in the population monitored by the Agincourt HDSS. The second study evaluated quality of care in the ICDM model as implemented and assessed effectiveness of the model in improving health outcomes of patients receiving treatment in PHC facilities. This second study had three components: (1) a qualitative and (2) a quantitative evaluation of the quality of care in the ICDM model; and a (3) quantitative assessment of effectiveness of the ICDM model in improving patients‘ health outcomes. The two main studies have been categorised into three broad thematic areas: chronic disease profile and predictors of healthcare utilisation; quality of care in the ICDM model; and changes in patients‘ health outcomes attributable to the ICDM model. In the first study, a cross-sectional survey to measure healthcare utilisation was targeted at 7,870 adults 50 years and over permanently residing in the area monitored by the Agincourt HDSS in 2010, the year before the ICDM model was introduced. Secondary data on healthcare utilisation (dependent variable), socio-demographic variables drawn from the HDSS, receipt of social grants and type of medical aid (independent variables) were analysed. Predictors of HCU were determined by binary logistic regression adjusted for socio-demographic variables. The quantitative component of the second study was a cross-sectional survey conducted in 2013 in the seven PHC facilities implementing the ICDM model in the Agincourt sub-district (henceforth referred to as the ICDM pilot facilities) to better understand the quality of care in the ICDM model. Avedis Donabedian‘s theory of the relationships between structure, process, and outcome (SPO) constructs was used to evaluate quality of care in the ICDM model exploring unidirectional, mediation, and reciprocal pathways. Four hundred and thirty-five (435) proportionately sampled patients ≥ 18 years and the seven operational managers of the PHC facilities responded to an adapted satisfaction questionnaire with measures reflecting structure (e.g. equipment), process (e.g. examination) and outcome (e.g. waiting time) constructs. Seventeen dimensions of care in the ICDM model were evaluated from the perspectives of patients and providers. Eight of these 17 dimensions of care are the priority areas of the HIV treatment programme used as leverage for improving quality of care in the ICDM model: supply of critical medicines, hospital referral, defaulter tracing, prepacking of medicines, clinic appointments, reducing patient waiting time, and coherence of integrated chronic disease care (a one-stop clinic meeting most of patients‘ needs). A structural equation model was fit to operationalise Donabedian‘s theory using patient‘s satisfaction scores. The qualitative component of the second study was a case study of the seven ICDM pilot facilities conducted in 2013 to gain in-depth perspectives of healthcare providers and users regarding quality of care in the ICDM model. Of the 435 patients receiving treatment in the pilot facilities, 56 were purposively selected for focus group discussions. An in-depth interview was conducted with the seven operational managers within the pilot facilities and the health manager of the Bushbuckridge municipality. Qualitative data were analysed, with MAXQDA 2 software, to identify 17 a priori dimensions of care and emerging themes. In addition to the emerging themes, codes generated in the qualitative analysis were underpinned by Avedis Donabedian‘s SPO theoretical framework. A controlled interrupted time-series study was conducted for the 435 patients who participated in the cross-sectional study in the ICDM pilot facilities and 443 patients proportionately recruited from five PHC facilities not implementing the ICDM model (Comparison PHC facilities in the surrounding area outside the Agincourt HDSS) from 2011-2013. Health outcome data for each patient were retrieved from facility records at 30-time points (months) during the study period. We performed autoregressive moving average (ARMA) statistical modelling to account for autocorrelation inherent in the time-series data. The effect of the ICDM model on the control of BP (<140/90 mmHg) and CD4 counts (>350 cells/mm3) was assessed by controlled segmented linear regression analysis. Results: Seventy-five percent (75%) of the 7,870 eligible adults 50+ responded to the health care utilization survey in the first study. All 5,795 responders reported health problems, of whom 96% used healthcare, predominantly at public health facilities (82%). Reported health problems were: chronic non-communicable diseases (41% - e.g. hypertension), acute conditions (27% - e.g. flu), other conditions (26% - e.g. musculoskeletal pain), chronic communicable diseases (3% e.g. HIV and TB) and injuries (3%). Chronic communicable (OR=5.91, 95% CI: 1.44, 24.32) and non-communicable (OR=2.85, 95% CI: 1.96, 4.14) diseases were the main predictors of healthcare utilisation. Out of the 17 dimensions of care assessed in the quantitative component of the quality of care study, operational managers reported dissatisfaction with patient waiting time while patients reported dissatisfaction with the appointment system, defaulter-tracing of patients and waiting time. The mediation pathway fitted perfectly with the data (coefficient of determination=1.00). The structural equation modeling showed that structure correlated with process (0.40) and outcome (0.75). Given structure, process correlated with outcome (0.88). Patients‘ perception of availability of equipment, supply of critical medicines and accessibility of care (structure construct) had a direct influence on the ability of nurses to attend to their needs, be professional and friendly (process construct). Patients also perceived that these process dimensions directly influenced coherence of care provided, competence of the nurses and patients‘ confidence in the nurses (outcome construct). These structure-related dimensions of care directly influenced outcome-related dimensions of care without the mediating effect of process factors. In the qualitative study, manager and patient narratives showed inadequacies in structure (malfunctioning blood pressure machines and staff shortage); process (irregular prepacking of drugs); and outcome (long waiting times). Patients reported anti-hypertension drug stock-outs; sub-optimal defaulter-tracing; rigid clinic appointments; HIV-related stigma in the community resulting from defaulter-tracing activities; and government nurses‘ involvement in commercial activities in the consulting rooms during office hours. Managers reported simultaneous treatment of chronic diseases by traditional healers in the community and thought there was reduced HIV stigma because HIV and NCD patients attended the same clinic. In the controlled-interrupted time series study the ARMA model showed that the pilot facilities had a 5.7% (coef=0.057; 95% CI: 0.056,0.058; P<0.001) and 1.0% (coef=0.010; 95% CI: 0.003,0.016; P=0.002) greater likelihood than the comparison facilities to control patients‘ CD4 counts and BP, respectively. In the segmented analysis, the decreasing probabilities of controlling CD4 counts and BP observed in the pilot facilities before the implementation of the ICDM model were respectively reduced by 0.23% (coef = -0.0023; 95% CI: -0.0026,-0.0021; P<0.001) and 1.5% (Coef= -0.015; 95% CI: -0.016,-0.014; P<0.001). Conclusions: HIV and NCDs were the main health problems and predictors of HCU in the population. This suggests that public healthcare services for chronic diseases are a priority among older people in this rural setting. There was poor quality of care reported in five of the eight priority areas used as leverage for the control of NCDs (referral, defaulter tracing, prepacking of medicines, clinic appointments and waiting time); hence, the need to strengthen services in these areas. Application of the ICDM model appeared effective in reducing the decreasing trend in controlling patients‘ CD4 counts and blood pressure. Suboptimal BP control observed in this study may have been due to poor quality of care in the identified priority areas of the ICDM model and unintended consequences of the ICDM model such as work overload, staff shortage, malfunctioning BP machines, anti-hypertension drug stock-outs, and HIV-related stigma in the community. Hence, the HIV programme should be more extensively leveraged to improve the quality of hypertension treatment in order to achieve optimal BP control in the nationwide implementation of the ICDM model in PHC facilities in South Africa and, potentially, other LMICs. / MT2017

Thesis (M.S.)--West Virginia University, 2003. / Title from document title page. Document formatted into pages; contains x, 108 p. : ill. (some col.), maps. Vita. Includes abstract. Includes bibliographical references (p. 71-73).

Thesis (Ph.D) -- University of Western Sydney, Hawkesbury, 1998. / Thesis submitted for the degree of Doctor of Philosophy. Includes bibliographical references (leaves475-497).