Integrated primary care has been incorporated into a variety of healthcare settings. The benefits of these services are empirically supported by a plethora of studies, which highlight the integration of behavioral and physical healthcare to be beneficial for both patient and healthcare providers. Integrated care models are typically incorporated in Veterans Affairs hospitals, general primary care facilities, and community clinics. Community-based clinics, such as safety-net clinics, typically serve underrepresented populations, and research has shown several mental and physical health disparities to exist among minority populations. Further, the minority stress model posits that distal and proximal minority-based stress processes can result in a cascade of negative health outcomes, such as increased symptomology or poor health-management behaviors. Although minority stressors can lead to this series of consequences, several community and personal strengths may serve as protective factors for marginalized individuals. These processes may occur within safety-net primary care, considering that the populations of interest are underserved. Black patient populations face numerous barriers to healthcare, such as racism, discrimination, and provider bias. Prior literature has shown that prior experiences of racism result in poorer mental and physical health outcomes for Black patient populations. Further, these outcomes have been shown to negatively impact healthcare attitudes and behaviors. The current study aimed to examine how aspects of the minority stress model may operate within safety-net primary care services for Black patient populations. It was hypothesized that racism would predict poorer mental health, which would negatively impact provider trust, and therefore predict lower medication adherence. Using a strengths-based approach, grit and social support were hypothesized to serve as personal and collective buffers to this series of relationship. A path analysis showed that racism significantly predicted mental health, which predicted poorer provider trust; however, the last path of this model, provider trust to medication adherence, was not found to be statistically significant. Thus, the path analysis was broken up into a series of mediations, which explored the relationship between racism and both provider trust and medication adherence through mental health. Mental health was found to mediate the relationship from racism to provider trust and from racism to medication adherence. The moderated mediation effect of social support was found to be non-significant for all mediations, except that grit was moderated the mediation between racism to medication adherence through mental health. These results showed grit served as a personal strength to dampen the associated effects of racism, which may suggest improving intrinsic attitudes and motivation towards long-term health related goals may increase treatment adherence behaviors. Results from this study also confirm the importance of integrated primary care services, as the data suggested high rates of mental health problems, which typically go underreported among Black patients in healthcare settings.

This study examines the worsening position of jobless blue-collar workers in an increasingly meritocratic economy, and uses an innovative crossnational comparative approach to gauge how much the social safety net improves their well-being. I take pairs of unemployed autoworkers who did the same job in the same or similar firms—with the only difference being the country they live in—and compare their outcomes to measure policy effects. My analysis is based on in-depth interviews with seventy-one former autoworkers (divided among American and Canadian workers, and Detroit Three and parts factories) and thirty-six industry and community experts in Detroit, Michigan, and Windsor, Ontario, two metropolitan areas right across the river from one another. It also draws from ethnographic observation within households and the larger Detroit and Windsor areas, which allowed me to put my interviews in context and assemble a rich narrative portrait of unemployment and economic distress. Whereas one school of thought stresses the powerlessness of government in the face of globalization and related economic shifts, and another tends to see an expanded welfare state as a panacea for social ills, I stake out a view somewhere in the middle, arguing that the stronger supports in Canada help unemployed workers cope better with job retraining challenges, health problems, financial difficulties, and fragile family structures, but are limited in their ability to overcome relative inequalities: large gaps in education, family stability, and resources that exist between blue-collar workers and other segments of the labor force. I offer a theoretical and historical framework for understanding the evolution of the labor market and its consequences for less-educated workers, conceiving of the current iteration of capitalism as meritocratic in its focus on human capital as the just arbiter of status, and differentiating this meritocratic orientation from other egalitarian and fraternal approaches to policy and morality in past historical periods. Finally, I examine the meritocratic ideology that blunts political responses to rising inequality, finding that such views, long associated with white-collar professionals, have come to affect the thinking of even unionized blue-collar workers. / Sociology

Dental caries, popularly known as tooth decay or cavities, is among the world's most common health problems. When caught early, it is also one of the most easily resolvable. Yet, advanced decay is a trenchant marker of social inequality and a major contributor to the maldistribution of physical pain and psychosocial suffering. Why? Access to dental care within the U.S. model of fee-for-service dental private practice follows existing lines of social stratification. Dental disparities, a term that calls attention to the relationships between maldistributed disease and maldistributed care, reflect deep ontological, moral, and political differences about responsibility for the prevention and treatment of dental disease, the quality and distribution of dental care, and even what constitutes health and well-being. What kinds of sociopolitical and moral negotiations constitute and transpire around dental disparities? How do these negotiations shape the experiences of patients and providers, and how do their experiences shape these negotiations? What can an ethnography of the dental safety net–a complex, fragile, and unpredictable network of treatment opportunities for low-income families–tell us about health governance more broadly? These are some of the questions that drive my research. In this dissertation, I explore how the sociopolitical relations of dental disparities are enacted through the dental safety net. Drawing on fifteen months of ethnographic research in clinical and community settings in central Appalachia, a region that has come to symbolize the dental crisis in the popular imagination, I show how the dental safety net exemplifies health governance in a neoliberal milieu. A fragmented system characterized by a discontinuity that starkly contrasts the model of health care generally advocated in both private and public medical systems, I argue that the dental safety net in far southwest Virginia does not merely fail to relieve the suffering of marginalized people but also can produce it. For example, the constitution of publicly-funded and charitable dental care can serve to routinize and even incentivize excess extractions among low-income adults while exempting preventive or restorative care. In addition to its effects on underserved patients, the dental safety net is a site through the fraught and contradictory relationships of dental providers and the sociopolitical stakes of the pursuit of oral health equity can be understood. For example, the flexible teamwork arrangements prized in private practice, when posited for the dental safety net, are often interpreted by dentists as risks of pluralization and threats to professional hierarchy that must be contained through legislative means. Borrowing from the crude classificatory scheme used to screen teeth quickly, I show how the dental safety net is decayed, as it bears the wear of overuse beyond maintenance; missing, or better described as an absence than a presence; and filled, like a cavitated tooth or a canaled dental root, with manufactured solutions of variable standards and longevity.

Submitted by Josiane ribeiro (josiane.caic@gmail.com) on 2016-04-06T20:16:43Z No. of bitstreams: 1 0000010487.pdf: 1985872 bytes, checksum: 071f1ed2675c22afe15cdac1266a2aff (MD5) / Approved for entry into archive by cleuza maria medina dos santos (cleuzamai@yahoo.com.br) on 2016-05-02T20:45:23Z (GMT) No. of bitstreams: 1 0000010487.pdf: 1985872 bytes, checksum: 071f1ed2675c22afe15cdac1266a2aff (MD5) / Made available in DSpace on 2016-05-02T20:45:23Z (GMT). No. of bitstreams: 1 0000010487.pdf: 1985872 bytes, checksum: 071f1ed2675c22afe15cdac1266a2aff (MD5) Previous issue date: 2014 / A exploração sexual de crianças e adolescentes (ESCA) retrata um fenômeno complexo e silencioso, que vai muito além das estimativas registradas. Nesse contexto a rede de atendimento, proteção e defesa da criança e do adolescente vítima de exploração sexual são agentes fundamentais na garantia da cidadania e dos direitos violados. No entanto, nem sempre essas redes conseguem alcançar as vítimas. Diante dessa realidade, buscou-se compreender a relação que se estabelece entre a vítima e a rede, tendo como objetivo geral verificar a relação entre os relatos dos profissionais que compõem a rede de proteção e os relatos das vítimas da ESCA quanto a violência propriamente dita, a vitimização e o acolhimento/atendimento nos serviços existentes. O estudo foi dividido em duas etapas e segue a linha de pesquisa da Educação Ambiental Não-Formal, sendo o campo da Educação Ambiental espaço dialógico e reflexivo, que contribui nas problematizações quanto a ESCA, as redes protetivas, as políticas públicas e o protagonismo na infância e juventude. A primeira etapa buscou conhecer os relatos dos profissionais através de uma entrevista semi-estruturada e contou com a participação de quinze representantes distribuídos nos serviços de atendimento, defesa e prevenção do município do Rio Grande. A segunda etapa possibilitou conhecer a percepção e os relatos de vítimas da exploração sexual quanto a violência propriamente dita, as suas causas e quanto aos serviços e programas destinados à proteção integral das vítimas da ESCA. Participaram do estudo dois adolescentes vítimas de exploração sexual e em atendimento no Centro de Referência Especializado de Assistência Social ? CREAS e nas Casas de Acolhimento. A coleta de dados nessa etapa seguiu as orientações metodológicas da inserção ecológica: observações, diários de campo e uma entrevista semi-estruturada. Os resultados foram submetidos a análises quantitativas e qualitativas. As entrevistas foram gravadas e transcritas. Dentre os resultados obtidos no estudo I é possível destacar a falta de sistematização dos dados, o baixo número de casos de ESCA denunciados e a identificação de fatores socioambientais como responsáveis pela vitimização. A análise dos dados ainda aponta para a existência de serviços que acolhem e atendem as vítimas e que investem nos casos quando a família é ativa na proteção. Já os resultados obtidos no estudo II evidenciaram que os serviços protetivos, ora são reconhecidos em sua atuação, ora não representam seu papel na proteção de adolescentes vítimas da exploração sexual. Os relatos de atendimento sugerem que os serviços ainda investem nos casos que são acompanhados pela família. Dessa forma os estudos I e II demonstraram que os serviços protetivos precisam repensar as formas de atuação/articulação, atentando ainda aos fluxos de encaminhamentos realizados nessas esferas. Reconhecer a dinâmica que perpassa pela ESCA e suas especificidades é reconhecer suas vítimas e suas causas, como também ser reconhecido como espaço de garantia de direitos e de proteção as vítimas. / The sexual exploitation of children and adolescents (CSEC) depicts a complex and silent phenomenon, that goes beyond recorded estimates. In this context the service network, protection and defense of children and adolescents victims of sexual exploitation are key agents in the guarantee of citizenship and violated human rights. However, these networks do not always manage to reach the victims. On this reality, we sought to understand the relationship between the victim and the network, aiming to verify the relationship between the accounts of professionals that make up the safety net and the accounts of victims of the CSEC related to the violence itself, victimization and the host/support in existing services. The study was divided into two stages and follows the line of research of Non-Formal environmental education, in the field of Environmental Education dialogic and reflective space, which helps in reflections about problems related to CSEC, protective nets, public policy and their involvement in childhood and youth. The first step sought to know the reports from professionals through a semi-structured interview and was attended by 15 representatives distributed in services, advocacy and prevention of the municipality of Rio Grande. The second step made it possible to know the perception and the reports of victims of sexual exploitation about violence and its causes, besides services and programs aimed at the full protection of the victims of the CSEC. Two teenagers, victims of sexual exploitation and in attendance at the specialized center of reference for Social Assistance - CREAS and in host homes, participated in this study. Data collection in this step followed the methodological guidelines from ecological insert: observations, field diaries and a semistructured interview. The results were submitted to quantitative and qualitative analyses. The interviews were recorded and transcribed. Among the results obtained in study I it is possible to highlight the lack of systematization of the data, the low number of cases of CSEC denounced and the identification of social environmental factors as responsible for victimization. The analysis of the data still points to the existence of services that host and support the victims mainly investing in those cases when the family is active in protection. The results already obtained in study II showed that sometimes protective services are recognized in their acting, and sometimes do not represent well their role in protecting adolescents victims of sexual exploitation. The service reports suggest that the services still invest in cases that are accompanied by family. Thus the studies I and II showed that protective services need to rethink their ways of acting /articulation, paying attention to appliance flows held in those spheres. Recognizing the dynamics that pervades the CSEC and its specificity is to recognize its victims and its causes, as well as be recognized as space of assured rights and protection for victims.

Multiyear trends showing high rates of alcohol and opioid-related misuse as well as opioid-related deaths have renewed attention on both access to and the quality of substance use treatment. In response, diverse healthcare systems that care for the Medicaid population have begun implementing large-scale transformations including new services and provider training requirements. The Centers for Medicaid and Medicare Services has urged state Medicaid programs to use Sections 1115 waiver demonstrations as vehicles for substance use treatment delivery system transformation. For many states, undertaking the Section 1115 waiver demonstration means moving from very limited benefits to a full continuum of new services. States’ ability to achieve such transformations is unknown since demonstration processes are under-reported and considered implementation “black boxes”. Substance use treatment delivery changes are also occurring at the community level, where several hospitals systems have implemented new services to meet the needs of their patient population. However, the influence of these new care models on patient service utilization is unknown. In this dissertation, I use comparative case study design and qualitative content analysis to examine the pre-implementation decision-making processes that Medicaid policymakers in California, Virginia and West Virginia experienced when deciding to enhance their substance use treatment service delivery systems using Sections 1115 waivers. I qualitatively describe how broad sociocultural and local organizational factors influenced Medicaid agencies’ ability to expand access to treatment. I also present a taxonomy of implementation strategies used to translate Medicaid policy into clinical services available in the community. Finally, I present a latent transition analysis to reveal how the nature of substance use treatment services available to patients may influence their service utilization over time. This final quantitative analysis is set within the context of a safety net hospital that provides a comprehensive, low barrier access model for substance use treatment, and primarily serves Medicaid beneficiaries. Results of this dissertation illuminate processes and outcomes associated with pre-, mid-, and post-implementation activities targeting improvements in the delivery of substance use treatment services. / 2023-01-19T00:00:00Z

Political and historical literature largely attributes the political development of the Southern Strategy to the 1964 Barry Goldwater and 1968 Richard Nixon presidential campaigns. The Southern Strategy is commonly explained as the Republican Party’s 1964 campaign decision to abandon Black voters in the North to expand its national political base of support by seeking White voters outside of the South who were angry with the political advancements of the Civil Rights Movement (Aistrup 1996, 5; Bass and DeVries 1976, 27). Discussions of Ronald Reagan’s role in the development of the Southern Strategy describe him more as a beneficiary rather than a significant influence in the Republican Party’s efforts to nationalize Southern racial politics (Aistrup 1996, 12; Black and Black 2002, 4). However, his speeches equated social spending with racial stigmas and pathological behavior. The fusion of economic issues and racial stereotypes has influenced future presidential politics since 1964 with Reagan’s “A Time for Choosing” speech (Reagan 1964). The racialized language used by Reagan in his speech has influenced the rhetorical frame of the Southern Strategy in the last six decades. This qualitative study utilizes content analysis to examine the impact of racially coded language of Democratic and Republican presidents, from Ronald Reagan to Barack Obama, when they argue the legitimacy of the social safety net. The study seeks to expand the knowledge of the prevalence of the politics of pathology, which is defined as the belief that social spending encourages individuals to engage in immoral behavior and is used by presidents to mitigate or cultivate racial resentment.

Data were analyzed from the 1998-2004 Uniform Data System (UDS) to identify trends and predictors of financial performance (costs, productivity, and overall financial health) for health centers (HCs). Several differences were noted regarding revenues, self-sufficiency, service offerings, and urban/rural setting. Urban centers with larger numbers of clients, centers that treated high numbers of patients with chronic diseases, and centers with large numbers of prenatal care users were the most fiscally sound. Positive financial performance can be targeted through strategies that generate positive revenue, strive to decrease costs, and target services that are in demand.

Frequent turnover among a hospital's nursing staff can profoundly impact organizational operating costs. With a national turnover rate of 17% in 2015, understanding the impact of management approaches on nurse attrition is vital to business success. Guided by Homan's social exchange theory, the purpose of this single case study was to explore leadership strategies used by safety-net hospital leaders to increase nursing personnel retention. Data collection consisted of semistructured interviews from a purposive snowball sampling of 8 senior directors working at a safety-net hospital in southern Maryland. Additional information collected involved documents and artifacts related to human resources management policies and guidelines. Constant comparative method enabled the analysis and identification of latent patterns in words used by respondents. Through methodological triangulation, several themes emerged. These themes included engagement and management support, education and career development, teamwork and work atmosphere, recognition, relationship building and communication, and health reform and innovation. According to the study results, increasing employee engagement, offering training and career development, performing technological upgrades, and developing sustainable relationships are appropriate approaches for gaining nursing personnel commitment. The findings of this study are important to senior leaders and middle managers in healthcare and other industries as they seek to attract talented staff members to sustain their organizations. The conclusions in this study may contribute to positive social change through improved nursing staff retention, leading to better patient experiences, healthier communities, and more satisfied customers.

No description available.

Safety net clinics across the country struggle with a lack of resources to tackle the needs presented. Screening programs set up for children and elderly have proven to be effective in triaging need, prioritizing care, and maximizing resources. These programs do not currently exist for working uninsured adults. Research was initiated to answer the question: Does the screening process improve patient care for the community clinic? During a 6-week pilot study a licensed dental hygienist performed 30 screenings in the community clinic setting. Findings were recorded and coded according to patient’s level of need identified. Pre- and posttest data for patient care factors were attained. Statistical tests showed a significant effect on patient care factors. While the evidence existed to support the implementation of screening, more research would quantify the specific impact on this population.