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African American women (AAW) are at a high risk for type 2 diabetes, a debilitating and potentially fatal disease for which there is no cure. The purpose of this study was to extend the research of Mosca et al. (2012) by examining the relationship between caregiver status and self-reported health status for AAW 18 years or older diagnosed with type 2 diabetes. The chronic care model (CCM) provided the theoretical framework for this study. The CCM promoted routine care for patients with chronic illnesses to migrate from acute care to proactive, planned, and risk-based protocols. A binomial logistic regression investigated the relationship between caregiver status, categorized as paid or unpaid, and self-reported health status, which was dichotomized as either good to excellent health or poor to fair health. There was a statistically significant relationship between primary caregiver status and self-reported health status among AAW diagnosed with Type 2 diabetes after controlling for age, education, and marital status (p < .004). Based on the fitted binomial logistic regression model, there were 186 cases of AAW with type 2 diabetes; having a paid caregiver was associated with a lower odds of having good to excellent health (OR = 0.294). About 12.3% of the variance in self-report health status was attributable to caregiver status. Overall, 82.6% of predictions were accurate. Nearly all participants required frequent assistance from a caregiver in the preceding 12 months. These findings suggest a critical need for healthcare service providers to educate caregivers as a means to deliver post-acute care to AAW diagnosed with type 2 diabetes, consistent with the CCM.

Contexte : Les troubles liés à l’usage des substances psychoactives constituent une priorité de santé publique dans le champ des pathologies chroniques. Les indicateurs de type Patient-Reported Outcomes (PRO) offrent des perspectives complémentaires aux indicateurs classiques pour la mesure de l’état de santé des patients et l’appréciation de la qualité des soins. Objectifs : Étudier les propriétés psychométriques de questionnaires de qualité de vie (QV) et les déterminants de la satisfaction précoce vis-à-vis des soins ambulatoires de patients dépendants aux substances de type alcool ou opiacés. Méthode : Les caractéristiques des patients et des médecins ont été recueillies à l’inclusion dans la cohorte SUBUSQOL. La satisfaction précoce a été mesurée quinze jours après la première consultation et ses déterminants ont été testés dans des modèles de régression linéaires multivariés. Les propriétés psychométriques du questionnaire spécifique Q-LES-Q-SF ont été étudiées au préalable sur un échantillon de patients. Résultats : La version française du Q-LES-Q-SF constitue un outil unidimensionnel robuste et fiable, les items du SF-12 et Q-LES-Q-SF présentent peu ou pas de fonctionnement différentiel selon l’âge, le sexe, le niveau d’éducation et le type d’addiction. Peu de variables recueillies sont associées à la satisfaction. Les patients dépendants à l’alcool se révèlent être plus satisfaits des modalités de contact et du délai de rendez-vous et ceux sans aucun antécédent de prise en charge pour leur dépendance plus satisfaits de leur consultation avec le médecin. Conclusion : Les questionnaires SF-12 et Q-LES-Q-SF peuvent être utilisés dans des populations de patients suivis en ambulatoire pour une dépendance aux substances psychoactives / Context: Of chronic diseases, substance use disorders are a public health priority. Patient-reported outcome indicators (PRO) offer additional insights into the classical indicators used to measure the patient’s health status and appreciation of their quality of care. Objectives: to study the psychometric properties of quality of life instruments and to study the determinants of early outpatient satisfaction with ambulatory care in alcohol- or opiate-dependent patients. Method: Patient and physician characteristics were collected in the SUBUSQOL cohort. Early satisfaction with care was measured fifteen days after the first consultation. The determinants of satisfaction were tested using multivariate linear models of regression. Prior data on the self-reported health status of a sample of alcohol- or opiate-dependent outpatients were used to investigate the psychometric properties of a specific questionnaire, the Q-LES-Q-SF. Results: Our results establish that the French version of the Q-LES-Q-SF is a unidimensional, valid and reliable instrument of self-reported health status assessment for use in care or medical research and that few items of the SF-12 and the Q-LES-Q-SF displayed differential functioning according to age, sex, educational level and type of substance use disorder. Our results show that few variables are associated with the level of patient satisfaction. Alcohol dependence was strongly associated with higher satisfaction with appointment making, and patients with no history of previous care for substance use disorders had a higher level of satisfaction with the doctor consultation. Conclusion: The use of the SF-12 and the Q-LES-Q-SF is recommended for outpatients suffering from substance use disorders

The objective of this thesis was to defend an alternative approach by health policy makers for improving health outcomes through investing on social factors of peoples' lives, rather than by increasing health expenditures. In order to defend this theory, this master thesis addresses two research questions: Which are the social determinants of health with largest impact on health status of individuals? And what is the statistical correlation between those social determinants of health and self-reported health status, and psychological health, for Germany, Denmark, Spain and Ireland? The first question was answered by developing a comprehensive research among the mostrelevant literature in the field of social determinants of health and the second through the construction of a statistical multiple regression model. According this study the social determinants with largest impact on the health status of individuals are: physical activity, education level, the welfare state, emotional support, socio-economic status, living conditions, working conditions, and life balance. Regarding the results of multiple regression models all variables followed the expected trend and it was possible to proof significant statistical correlation in 7 of the 8 determinants chosen, especially in the cases of working conditions and life balance, where those having problems managing these aspects of life experienced 50% or in some cases 30% of the health status of individuals with positive experiences in these life dimensions.

African American women (AAW) are at a high risk for type 2 diabetes, a debilitating and potentially fatal disease for which there is no cure. The purpose of this study was to extend the research of Mosca et al. (2012) by examining the relationship between caregiver status and self-reported health status for AAW 18 years or older diagnosed with type 2 diabetes. The chronic care model (CCM) provided the theoretical framework for this study. The CCM promoted routine care for patients with chronic illnesses to migrate from acute care to proactive, planned, and risk-based protocols. A binomial logistic regression investigated the relationship between caregiver status, categorized as paid or unpaid, and self-reported health status, which was dichotomized as either good to excellent health or poor to fair health. There was a statistically significant relationship between primary caregiver status and self-reported health status among AAW diagnosed with Type 2 diabetes after controlling for age, education, and marital status (p < .004). Based on the fitted binomial logistic regression model, there were 186 cases of AAW with type 2 diabetes; having a paid caregiver was associated with a lower odds of having good to excellent health (OR = 0.294). About 12.3% of the variance in self-report health status was attributable to caregiver status. Overall, 82.6% of predictions were accurate. Nearly all participants required frequent assistance from a caregiver in the preceding 12 months. These findings suggest a critical need for healthcare service providers to educate caregivers as a means to deliver post-acute care to AAW diagnosed with type 2 diabetes, consistent with the CCM.

My doctoral thesis examines the broad question of the effect of some recent health policies on health and also tries to measure socioeconomic inequalities. The first essay investigates the effect of public health insurance on people with vulnerable health. The second chapter analyses the effect of the legalization of marijuana on health, while the third chapter measures socioeconomic inequalities in health. In chapter 1, I study the evolution of access to health care for individuals in vulnerable health before and after the Affordable Care Act. I define leakage of health care as the aggregation of accessibility hurdles for individuals in vulnerable health. However, "being in vulnerable health" is a linguistic concept that does not have a sharp mathematical definition. I draw on the fuzzy sets theory and assume a non-dichotomous membership function to capture the linguistic imprecision. However, the task of choosing the "right" membership function remains an issue. To circumscribe this additional issue, I use a stochastic dominance approach to test for changes in leakage. In order to establish causality, I exploit two quasi-experimental settings offered by the dependent coverage and the states in which medicaid expansion took place. In order to use these quasi-experiments in a stochastic dominance framework, I extend Athey and Imbens (2006) changes in changes approach to a bivariate setting. Using data from the National Health Interview Survey, the results from a before and after analysis show that leakages are much lower in 2015 compared to 2009 in the US. These before and after results hold irrespective of a person's sex or socio-economic status. The causal analysis shows that leakages in not having insurance and access are reduced in medicaid expansion states after the ACA. Chapter 2 analyzes the implications of these recreational marijuana legalization (RML) on Body Mass Index (BMI) and some healthy behaviours. I exploit the quasi experimental nature of marijuana legalization policy in states using changes in changes and difference in difference approaches to identify the effect of these recreational marijuana policies. Using data from the Behavioral Risk Factor Surveillance System (BRFSS), the results show that recreational marijuana legalization reduces BMI for the entire population. The effect is mainly in the mid and top part of the BMI distribution. Subgroup analysis shows that the reduced BMI resulting from RML is significant among women but not among men. For females, the effect is found both at the lower tail (being underweight) and at the upper tail (morbid obesity). While we found evidence of a reduction in being overweight for both whites and non-whites due to RML, the reduction in obesity and morbid obesity was only found for non-whites. In addition, RML reduces obesity for those below 45 years. I also found evidence that RML increases alcohol consumption, has no effect on smoking of tobacco and binge drinking but reduces the probability of doing any physical activity. The final chapter explores the measurement of socioeconomic inequality using ordinal variables. Most measures of socioeconomic inequality are developed for ratio scale variables. These measures use the mean as a reference point which is non-robust in the presence of categorical variables. This chapter extends Allison and Foster (2004) median based approach to measuring inequalities to a bivariate case and provides conditions to robustly rank any two distributions of socioeconomic inequalities in well-being or mental health. Using the Canadian Community Health Survey (CCHS), I provide robust ordering for socioeconomic inequalities in well-being and mental health for different sub-populations in 2015. The results show that there is less socioeconomic inequality in life satisfaction, happiness, mental health, and general health status among employed males and females compared to their respective unemployed groups in 2015.