While there is a large body of research demonstrating that Asian-Americans underutilize mental health services compared to other ethnic groups, little is known about how Vietnamese-Americans use formal mental health services. The traumatic war, post-war and refugee journey contributed to incidences of PTSD and other mental disorders. This mixed-method study aims to understand how multigenerational Vietnamese-Americans view their serious mental illness and how past experiences, family structure, and social networks influence mental health and use of mental health services. The theories that guided the research were the Network-Episode Model and Social Network Orientation Theory. Quantitative analyses using data from the National Latino and Asian-American Study (NLAAS) examined the relationship of variables assessing acculturation, social support, cultural identity, and health/mental health status with formal mental health service use for the Vietnamese-American subsample (N=520). The qualitative study explored how Vietnamese-Americans in multigenerational households experience severe mental illness and the reasons that influenced their mental health help-seeking and service use. Semi-structured interviews with 17 members of six multigenerational Vietnamese families from the greater Boston and Los Angeles area were conducted in English, transcribed, and analyzed using thematic analysis. Findings from the study highlight the differences between 1st and 2nd generation Vietnamese respondents and provide insight into how generational culture – the prevailing attitudes, values, and beliefs of each generation – influences the social network support of Vietnamese-Americans and affects their mental health help-seeking behavior. The forced migration severed social networks, restricting 1st generation respondents to rely on small family networks for information and support. The traditional matriarchal hierarchy limited access to treatment as younger 2nd generation Vietnamese-Americans were unable to convince their parents to seek help for serious mental health problems or to get their approval to seek treatment. Cultural values such as belief in spiritual healers and self-reliance also insulated families from seeking professional help. The study found that the types of interactions respondents had with their social networks—whether positive or negative in orientation—shaped their beliefs about who and where they could go to for help with serious mental health problems and was instrumental in creating pathways to mental health service use.

Community-Based Health Insurance (CBHI) in Rwanda was promulgated as the best alternative to address the financial barriers for accessibility to health care services for the poor population and the informal sector. The purpose of this study was to investigate whether CBHI reduce Out-of-pocket health expenses for their members as compared to non-members and to what extent CBHI provide financial protection for the poorest population. This research based itself on secondary source of data primarily collected for a prospective quasi-experimental design which evaluated the impact of Performance-Based Financing. The primary study had reported on the Out-Of-Pocket expenses for health by members and non-members of CBHI; residing in a sample of 1961 households; in addition to their demographics and socio-economic characteristics. The findings indicate that insured individuals were about 2.6 times more likely to utilize health care services than respondents without health insurance. It is also worth noting that households with health insurance coverage were less likely to experience a catastrophic health expenditure than households without health insurance (aOR: 0.744; 95% CI:[0.586 - 0.945]), and that the effect of health insurance coverage was higher in people living in poor households than in people living in middle or richer households / Health Studies / M.A. (Public Health)

Malgré l’intérêt accru du public et de la recherche durant les deux dernières décennies pour le phénomène des jeunes de la rue, certains aspects de leurs réalités sont encore peu examinés et mal connus. L’un de ces aspects concerne la parentalité. Pour mieux comprendre les besoins des jeunes en situation de rue qui sont parents ou en voie de l’être et comprendre dans quelle mesure un service s’adressant spécifiquement à eux arrive à y répondre, cette étude a cherché à décrire et comprendre l’expérience d’utilisation du Service à la famille de l’organisme Dans la rue, telle que vécue par des jeunes qui s’y sont adressés. Plus précisément, les objectifs étaient de : situer le Service à la famille dans la démarche de recherche d’aide des jeunes; comprendre ce qui amène un jeune à utiliser le Service à la famille et les activités qui y sont offertes; décrire l’expérience d’utilisation du service; connaître la perception qu’en ont les jeunes; et estimer leur appréciation du service. Pour ce faire, des entrevues semi-dirigées par téléphone ont eu lieu avec neuf jeunes ayant eu un suivi au Service à la famille, au cours desquelles certains thèmes ont été explorés : la recherche d’aide en lien avec la situation parentale, l’expérience d’utilisation des services et des activités du Service à la famille, le portrait de celui-ci, et la satisfaction à son égard. Au moment de l’entrevue, tous les jeunes étaient parents d’au moins un enfant et la majorité d’entre eux avait fait appel au Service à la famille la première fois durant la grossesse pour de l’aide sous diverses formes en rapport à celle-ci. Des besoins de divers ordres ont amené les jeunes à faire appel au Service à la famille. Ceux-ci pouvaient être comblés, mais pas nécessairement toujours, par le biais des rencontres avec les intervenantes du Service à la famille et par la participation aux activités de groupe offertes par la ressource et, par ailleurs, pouvaient concorder avec les objectifs d’intervention explicites du service. Dans l’ensemble, les entrevues suggèrent que les jeunes perçoivent le Service à la famille et, plus précisément, les intervenantes qui y travaillent, d’un œil favorable. Les interviewés formulent en effet une appréciation positive sur un bon nombre d’éléments se rapportant à leur expérience d’utilisation de la ressource. Des jeunes perçoivent néanmoins des limites dans la capacité du Service à la famille à fournir l’aide attendue, notamment des restrictions budgétaires et une surcharge de travail des intervenantes liée à une forte demande de services. Même si les jeunes n’ont pas nécessairement demandé de l’aide de la ressource dans l’optique de prévenir la violence familiale et la négligence, mandat premier du Service à la famille, une bonne part d’entre eux reconnaissent avoir reçu de l’aide utile à cet égard de la part des intervenantes, notamment lorsqu’ils ont rapporté avoir vécu des relations amoureuses teintées de violence conjugale. Ils reconnaissent également différentes façons par le biais desquelles les intervenantes les auraient encouragés à être bien et à prendre soin d’eux-mêmes afin de pouvoir bien s’occuper de leur(s) enfant(s). Tous les jeunes interviewés ont exprimé une satisfaction à l’égard du suivi reçu au Service à la famille et ils ont affirmé qu’ils le recommanderaient à d’autres personnes. L’approche d’intervention préconisée par la ressource est considérée comme un point fort dans la réponse aux besoins des jeunes. Cette approche aurait permis aux jeunes devenus parents d’être aidés en fonction de ce dont ils avaient besoin à un moment précis. L’un des aspects de l’utilisation du service qui gagneraient à être améliorés, aux yeux des jeunes, est l’accessibilité; l’aide dont les interviewés considéraient avoir besoin n’ayant pas toujours été à leur disposition alors qu’ils l’avaient demandée. Devant la perception d’un manque de disponibilité des intervenantes, des jeunes proposent des pistes d’amélioration qui permettraient à l’aide dispensée par le Service à la famille d’être plus accessible aux jeunes quand ils considèrent en avoir besoin. / Event though there has been an increased public and research interest in the street youth phenomenon in the past two decades, some aspects of their lives, one of them being parenthood, have not been yet thoroughly examined and therefore, remain unknown to a certain extent. In order to gain a better understanding of street youth’s needs related to becoming a parent, as well as an understanding of the extent to which a service specifically tailored for such a population manages to satisfy their needs, this study had the purpose of describing and understanding the service utilization experience of the Service à la famille from the Montreal street youth agency Dans la rue. More specifically, the objectives were to: gain an awareness and understanding of the persons and resources street youths who become parents turn to for help, and the significance of the Service à la famille among these resources; understand what brings a youth to the Service à la famille and what makes him or her use the services and activities offered; and finally, describe the perceptions and estimate the level of appreciation of the Service à la famille. Semi-structured phone interviews were conducted with nine youths who had used the Service à la famille and had had a follow-up. During the interview, the following themes were explored: help seeking related to becoming a parent, the utilization experience of the services and activities offered by the Service à la famille, the portrait of the service, and level of satisfaction regarding the service utilization experience. At the time of the interview, all youths were parents of at least one child, and the majority had first sought help at the Service à la famille during pregnancy to satisfy different needs related to becoming a parent. A variety of needs brought the youths to seek help at the Service à la famille. These needs could be satisfied, but not necessarily at all times, through meetings with the staff and participation in group activities offered by the service. At times, their needs corresponded to the explicit intervention goals of the service. In general, the interviews suggest that youths have a positive perception of the Service à la famille, and more precisely, of the staff. The interviewees named a considerable number of elements they appreciated from their service utilization experience. Youths nevertheless perceive limitations in the ability of the Service à la famille to give help, especially budgetary constraints and the staff’s workload related to high demand of services. Even though youths did not necessarily seek help from the service in order to prevent family violence or negligence, which is the mandate of the Service à la famille, much of them acknowledge having received valuable assistance in this regard on the part of the staff, especially when they reported having been in a violent intimate relationship. They also recognize different ways through which the staff encouraged them to feel good and take care of themselves in order to do the same with their child or children. All interviewees were satisfied with the follow-up they received from the Service à la famille and claimed they would recommend the service to others. The intervention approach advocated by the service is considered to be a strong element in responding appropriately to youths’ needs. This approach appears to have allowed youths who became parents to get the help they needed at a specific moment in time. According to youths, an aspect of service utilization which could be improved is access to help; since the help interviewees needed was not always available when they asked for it. Since youths perceive a lack of staff availability, they offer suggestions for improvement that would allow the aid supplied by the service to be more accessible to youths when they seek help.

INTRODUÇÃO: As doenças crônicas decorrentes do envelhecimento e o estilo de vida não saudável são os grandes fatores responsáveis pela alta morbi-mortalidade e pela grande sobrecarga no sistema de saúde. OBJETIVO: Este estudo analisa a prevalência de hipertensão e diabetes na população de 60 anos ou mais no município de São Paulo - capital e a utilização dos serviços de saúde segundo as variáveis demográficas e socioeconômicas, condições de saúde e estilo de vida. MÉTODOS: Inquérito domiciliar de saúde do tipo transversal que analisou os dados de 872 idosos residentes no município de São Paulo (ISA- Capital) por meio de um questionário dividido em blocos temáticos aplicado em uma amostra por conglomerados e estratificada segundo a escolaridade do chefe de família e nível socioeconômico. Análises bivariadas e multivariadas foram realizadas e geraram três modelos de regressão múltipla de Poisson para verificar a existência de fatores associados à hipertensão, diabetes e à utilização dos serviços. RESULTADOS: A prevalência de hipertensão referida entre os idosos foi de 46,9% e de diabetes 17,9%, valores superiores ao encontrado na população adulta. As maiores taxas de hipertensão foram encontradas entre os idosos que referiram auto-avaliação de saúde ruim/muito ruim e boa, entre os idosos que nunca beberam ou não bebem mais, entre as mulheres e entre os que se hospitalizaram pelo menos uma vez no último ano, independente da idade. Para diabetes, o mesmo resultado foi encontrado para autoavaliação de saúde, entre os viúvos e entre os idosos que se hospitalizaram pelo menos uma vez no último ano. Quanto ao uso do serviço de saúde pelos idosos em geral, a prevalência de utilização foi aproximadamente 30,6% independente de morbidade. Entre os hipertensos, 59.4% procuraram os serviços e 97,1% deles foi atendido no serviço. Entre os diabéticos 53,4% e 96,1% respectivamente sem diferença na procura ou no uso dos serviços entre os que tinham e não tinham hipertensão e diabetes. Em relação às medidas e práticas de controle sobre a HAS e DM, a medida de controle mais conhecida e praticada entre os hipertensos é tomar a medicação de rotina para controle da doença e entre os diabéticos a mais conhecida é a dieta alimentar e praticada é tomar medicação oral de rotina com distinção do nível socioeconômico para algumas medidas. CONCLUSAO: A falta de informação, conhecimento e utilização de medidas de controle destas doenças ainda são insuficientes entre os idosos. Fazem-se necessárias políticas de saúde com foco na capacitação de profissionais e na orientação familiar; enfim, políticas que incentivem não só mudanças no estilo de vida dos idosos, mas que os tornem sujeitos ativos desta mudança, atuantes neste processo. / INTRODUCTION: Chronic diseases due to the ageing process and to the unhealthy lifestyle are the greatest factors responsible for the high morbimortality and for the health system overload. OBJECTIVE: This study analyzes the prevalence of Hypertension and Diabetes of a population over 60 years old from São Paulo city, and the use of health services according to demographic and socioeconomic variables, health status, and lifestyle. METHODS: A cross-sectional household health survey analyzed data from 872 elderly resident in São Paulo city using a questionnaire divided into thematic blocks applied in a stratified cluster sample according to the educational level of the head of the family and socioeconomic level. Bivariate and multivariate analysis were carried out and generated three models of Poisson regression model in order to verify the existence of factors associated to hypertension, to diabetes and to the use of health services. RESULTS: The prevalence of reported hypertension among the elderly was 46.9% and of Diabetes, 17.9%. Such values were above the ones found in the adult population. The highest hypertension rates were found among the elderly who reported bad/verybad health status, among those who never drank or those who stopped drinking, among women, and among those who were hospitalized at least twelve months prior to the interview, independently of the age. Concerning diabetes, the same result was found for the self-assessment of health, among widows and widowers, and among the elderly who were hospitalized at least once in the past year. Concerning the use of health services by the elderly, the prevalence of use was approximately 30.6% independently of the morbidity. Among the elderly with hypertension, 70.1% searched for the service because of the hypertension, 59.4% of them did it because of reported morbidity, and 97.1% of them were assisted by the service they searched. Among the diabetic, 69.9% routinely searched for the service because of the diabetes, 53.4% of them did it because of reported morbidity and 96.1% were assisted by the service they searched, with no difference regarding the search and use of services between those with and without hypertension and diabetes. Concerning the measures and control practice of HAS and DM, the most known and practiced control measure among the elderly with hypertension is taking routine medicine for the control of the disease; and among the diabetic, the most known practice is diet and the most practiced measure is taking routine oral medicine, with a difference of socioeconomic level for some measures. CONCLUSION: There is a lack of information, knowledge and use of control measures of these diseases among the elderly. Health policies focusing on professional training and family guiding are necessary in order to encourage not only changes in the lifestyle of the elderly, but also to make them active agents of this change, acting in this process.

INTRODUÇÃO: As doenças crônicas decorrentes do envelhecimento e o estilo de vida não saudável são os grandes fatores responsáveis pela alta morbi-mortalidade e pela grande sobrecarga no sistema de saúde. OBJETIVO: Este estudo analisa a prevalência de hipertensão e diabetes na população de 60 anos ou mais no município de São Paulo - capital e a utilização dos serviços de saúde segundo as variáveis demográficas e socioeconômicas, condições de saúde e estilo de vida. MÉTODOS: Inquérito domiciliar de saúde do tipo transversal que analisou os dados de 872 idosos residentes no município de São Paulo (ISA- Capital) por meio de um questionário dividido em blocos temáticos aplicado em uma amostra por conglomerados e estratificada segundo a escolaridade do chefe de família e nível socioeconômico. Análises bivariadas e multivariadas foram realizadas e geraram três modelos de regressão múltipla de Poisson para verificar a existência de fatores associados à hipertensão, diabetes e à utilização dos serviços. RESULTADOS: A prevalência de hipertensão referida entre os idosos foi de 46,9% e de diabetes 17,9%, valores superiores ao encontrado na população adulta. As maiores taxas de hipertensão foram encontradas entre os idosos que referiram auto-avaliação de saúde ruim/muito ruim e boa, entre os idosos que nunca beberam ou não bebem mais, entre as mulheres e entre os que se hospitalizaram pelo menos uma vez no último ano, independente da idade. Para diabetes, o mesmo resultado foi encontrado para autoavaliação de saúde, entre os viúvos e entre os idosos que se hospitalizaram pelo menos uma vez no último ano. Quanto ao uso do serviço de saúde pelos idosos em geral, a prevalência de utilização foi aproximadamente 30,6% independente de morbidade. Entre os hipertensos, 59.4% procuraram os serviços e 97,1% deles foi atendido no serviço. Entre os diabéticos 53,4% e 96,1% respectivamente sem diferença na procura ou no uso dos serviços entre os que tinham e não tinham hipertensão e diabetes. Em relação às medidas e práticas de controle sobre a HAS e DM, a medida de controle mais conhecida e praticada entre os hipertensos é tomar a medicação de rotina para controle da doença e entre os diabéticos a mais conhecida é a dieta alimentar e praticada é tomar medicação oral de rotina com distinção do nível socioeconômico para algumas medidas. CONCLUSAO: A falta de informação, conhecimento e utilização de medidas de controle destas doenças ainda são insuficientes entre os idosos. Fazem-se necessárias políticas de saúde com foco na capacitação de profissionais e na orientação familiar; enfim, políticas que incentivem não só mudanças no estilo de vida dos idosos, mas que os tornem sujeitos ativos desta mudança, atuantes neste processo. / INTRODUCTION: Chronic diseases due to the ageing process and to the unhealthy lifestyle are the greatest factors responsible for the high morbimortality and for the health system overload. OBJECTIVE: This study analyzes the prevalence of Hypertension and Diabetes of a population over 60 years old from São Paulo city, and the use of health services according to demographic and socioeconomic variables, health status, and lifestyle. METHODS: A cross-sectional household health survey analyzed data from 872 elderly resident in São Paulo city using a questionnaire divided into thematic blocks applied in a stratified cluster sample according to the educational level of the head of the family and socioeconomic level. Bivariate and multivariate analysis were carried out and generated three models of Poisson regression model in order to verify the existence of factors associated to hypertension, to diabetes and to the use of health services. RESULTS: The prevalence of reported hypertension among the elderly was 46.9% and of Diabetes, 17.9%. Such values were above the ones found in the adult population. The highest hypertension rates were found among the elderly who reported bad/verybad health status, among those who never drank or those who stopped drinking, among women, and among those who were hospitalized at least twelve months prior to the interview, independently of the age. Concerning diabetes, the same result was found for the self-assessment of health, among widows and widowers, and among the elderly who were hospitalized at least once in the past year. Concerning the use of health services by the elderly, the prevalence of use was approximately 30.6% independently of the morbidity. Among the elderly with hypertension, 70.1% searched for the service because of the hypertension, 59.4% of them did it because of reported morbidity, and 97.1% of them were assisted by the service they searched. Among the diabetic, 69.9% routinely searched for the service because of the diabetes, 53.4% of them did it because of reported morbidity and 96.1% were assisted by the service they searched, with no difference regarding the search and use of services between those with and without hypertension and diabetes. Concerning the measures and control practice of HAS and DM, the most known and practiced control measure among the elderly with hypertension is taking routine medicine for the control of the disease; and among the diabetic, the most known practice is diet and the most practiced measure is taking routine oral medicine, with a difference of socioeconomic level for some measures. CONCLUSION: There is a lack of information, knowledge and use of control measures of these diseases among the elderly. Health policies focusing on professional training and family guiding are necessary in order to encourage not only changes in the lifestyle of the elderly, but also to make them active agents of this change, acting in this process.

Malgré l’intérêt accru du public et de la recherche durant les deux dernières décennies pour le phénomène des jeunes de la rue, certains aspects de leurs réalités sont encore peu examinés et mal connus. L’un de ces aspects concerne la parentalité. Pour mieux comprendre les besoins des jeunes en situation de rue qui sont parents ou en voie de l’être et comprendre dans quelle mesure un service s’adressant spécifiquement à eux arrive à y répondre, cette étude a cherché à décrire et comprendre l’expérience d’utilisation du Service à la famille de l’organisme Dans la rue, telle que vécue par des jeunes qui s’y sont adressés. Plus précisément, les objectifs étaient de : situer le Service à la famille dans la démarche de recherche d’aide des jeunes; comprendre ce qui amène un jeune à utiliser le Service à la famille et les activités qui y sont offertes; décrire l’expérience d’utilisation du service; connaître la perception qu’en ont les jeunes; et estimer leur appréciation du service. Pour ce faire, des entrevues semi-dirigées par téléphone ont eu lieu avec neuf jeunes ayant eu un suivi au Service à la famille, au cours desquelles certains thèmes ont été explorés : la recherche d’aide en lien avec la situation parentale, l’expérience d’utilisation des services et des activités du Service à la famille, le portrait de celui-ci, et la satisfaction à son égard. Au moment de l’entrevue, tous les jeunes étaient parents d’au moins un enfant et la majorité d’entre eux avait fait appel au Service à la famille la première fois durant la grossesse pour de l’aide sous diverses formes en rapport à celle-ci. Des besoins de divers ordres ont amené les jeunes à faire appel au Service à la famille. Ceux-ci pouvaient être comblés, mais pas nécessairement toujours, par le biais des rencontres avec les intervenantes du Service à la famille et par la participation aux activités de groupe offertes par la ressource et, par ailleurs, pouvaient concorder avec les objectifs d’intervention explicites du service. Dans l’ensemble, les entrevues suggèrent que les jeunes perçoivent le Service à la famille et, plus précisément, les intervenantes qui y travaillent, d’un œil favorable. Les interviewés formulent en effet une appréciation positive sur un bon nombre d’éléments se rapportant à leur expérience d’utilisation de la ressource. Des jeunes perçoivent néanmoins des limites dans la capacité du Service à la famille à fournir l’aide attendue, notamment des restrictions budgétaires et une surcharge de travail des intervenantes liée à une forte demande de services. Même si les jeunes n’ont pas nécessairement demandé de l’aide de la ressource dans l’optique de prévenir la violence familiale et la négligence, mandat premier du Service à la famille, une bonne part d’entre eux reconnaissent avoir reçu de l’aide utile à cet égard de la part des intervenantes, notamment lorsqu’ils ont rapporté avoir vécu des relations amoureuses teintées de violence conjugale. Ils reconnaissent également différentes façons par le biais desquelles les intervenantes les auraient encouragés à être bien et à prendre soin d’eux-mêmes afin de pouvoir bien s’occuper de leur(s) enfant(s). Tous les jeunes interviewés ont exprimé une satisfaction à l’égard du suivi reçu au Service à la famille et ils ont affirmé qu’ils le recommanderaient à d’autres personnes. L’approche d’intervention préconisée par la ressource est considérée comme un point fort dans la réponse aux besoins des jeunes. Cette approche aurait permis aux jeunes devenus parents d’être aidés en fonction de ce dont ils avaient besoin à un moment précis. L’un des aspects de l’utilisation du service qui gagneraient à être améliorés, aux yeux des jeunes, est l’accessibilité; l’aide dont les interviewés considéraient avoir besoin n’ayant pas toujours été à leur disposition alors qu’ils l’avaient demandée. Devant la perception d’un manque de disponibilité des intervenantes, des jeunes proposent des pistes d’amélioration qui permettraient à l’aide dispensée par le Service à la famille d’être plus accessible aux jeunes quand ils considèrent en avoir besoin. / Event though there has been an increased public and research interest in the street youth phenomenon in the past two decades, some aspects of their lives, one of them being parenthood, have not been yet thoroughly examined and therefore, remain unknown to a certain extent. In order to gain a better understanding of street youth’s needs related to becoming a parent, as well as an understanding of the extent to which a service specifically tailored for such a population manages to satisfy their needs, this study had the purpose of describing and understanding the service utilization experience of the Service à la famille from the Montreal street youth agency Dans la rue. More specifically, the objectives were to: gain an awareness and understanding of the persons and resources street youths who become parents turn to for help, and the significance of the Service à la famille among these resources; understand what brings a youth to the Service à la famille and what makes him or her use the services and activities offered; and finally, describe the perceptions and estimate the level of appreciation of the Service à la famille. Semi-structured phone interviews were conducted with nine youths who had used the Service à la famille and had had a follow-up. During the interview, the following themes were explored: help seeking related to becoming a parent, the utilization experience of the services and activities offered by the Service à la famille, the portrait of the service, and level of satisfaction regarding the service utilization experience. At the time of the interview, all youths were parents of at least one child, and the majority had first sought help at the Service à la famille during pregnancy to satisfy different needs related to becoming a parent. A variety of needs brought the youths to seek help at the Service à la famille. These needs could be satisfied, but not necessarily at all times, through meetings with the staff and participation in group activities offered by the service. At times, their needs corresponded to the explicit intervention goals of the service. In general, the interviews suggest that youths have a positive perception of the Service à la famille, and more precisely, of the staff. The interviewees named a considerable number of elements they appreciated from their service utilization experience. Youths nevertheless perceive limitations in the ability of the Service à la famille to give help, especially budgetary constraints and the staff’s workload related to high demand of services. Even though youths did not necessarily seek help from the service in order to prevent family violence or negligence, which is the mandate of the Service à la famille, much of them acknowledge having received valuable assistance in this regard on the part of the staff, especially when they reported having been in a violent intimate relationship. They also recognize different ways through which the staff encouraged them to feel good and take care of themselves in order to do the same with their child or children. All interviewees were satisfied with the follow-up they received from the Service à la famille and claimed they would recommend the service to others. The intervention approach advocated by the service is considered to be a strong element in responding appropriately to youths’ needs. This approach appears to have allowed youths who became parents to get the help they needed at a specific moment in time. According to youths, an aspect of service utilization which could be improved is access to help; since the help interviewees needed was not always available when they asked for it. Since youths perceive a lack of staff availability, they offer suggestions for improvement that would allow the aid supplied by the service to be more accessible to youths when they seek help.

On December 26th, 2004, 280,000 people lost their lives. A massive earthquake struck Indonesia, triggering a tsunami that affected several countries, including Thailand. The disaster had important implications for health status of Thai citizens, as well as health system planning, and thus underscores the need to study its long-term effect. This dissertation examined the patterns, determinants, and spatial analysis of health service utilization following the tsunami in Thailand. The primary aim was to determine whether tsunami-affected status (personal injury or property loss) and distance to a health facility (public health center or hospital) influenced health service utilization. The study population included Thai citizens (aged 14+), living in the tsunami-affected Thai provinces: Phuket, Phang Nga, Krabi, and Ranong. Study participants were randomly selected from the ‘affected’ and ‘unaffected’ populations. One and two years after the tsunami, participants were interviewed in-person on demographic and socio-economic factors, disaster impact, health status, and health service utilization. Five types of health services were examined: outpatient services, inpatient services, home visits, medications, and informal (unpaid) care. Distance to a health facility was calculated using Geographic Information System’s Network Analyst. The Grossman model of the demand for health care and a distance decay concept provided the foundation for this study. A propensity score method and a two-part model were used to examine the study objectives. There were 1,889 participants. One year after the tsunami, individuals affected by property loss were more likely to use medications than unaffected participants. Two years after the tsunami, individuals with personal injury were more likely to use outpatient services, medications, and informal care than unaffected participants. Distance to a health facility was associated with the use of medications and informal care. The results confirmed the long-term effect of a tsunami. This dissertation may assist the decision- and policy-makers in the identification of those most likely to use health services and in the request of health resources to the affected areas. The patterns, determinants, and spatial analysis of health service utilization found in this study may not be specific to a tsunami and may provide insights on post-disaster contexts of other natural disasters.

On December 26th, 2004, 280,000 people lost their lives. A massive earthquake struck Indonesia, triggering a tsunami that affected several countries, including Thailand. The disaster had important implications for health status of Thai citizens, as well as health system planning, and thus underscores the need to study its long-term effect. This dissertation examined the patterns, determinants, and spatial analysis of health service utilization following the tsunami in Thailand. The primary aim was to determine whether tsunami-affected status (personal injury or property loss) and distance to a health facility (public health center or hospital) influenced health service utilization. The study population included Thai citizens (aged 14+), living in the tsunami-affected Thai provinces: Phuket, Phang Nga, Krabi, and Ranong. Study participants were randomly selected from the ‘affected’ and ‘unaffected’ populations. One and two years after the tsunami, participants were interviewed in-person on demographic and socio-economic factors, disaster impact, health status, and health service utilization. Five types of health services were examined: outpatient services, inpatient services, home visits, medications, and informal (unpaid) care. Distance to a health facility was calculated using Geographic Information System’s Network Analyst. The Grossman model of the demand for health care and a distance decay concept provided the foundation for this study. A propensity score method and a two-part model were used to examine the study objectives. There were 1,889 participants. One year after the tsunami, individuals affected by property loss were more likely to use medications than unaffected participants. Two years after the tsunami, individuals with personal injury were more likely to use outpatient services, medications, and informal care than unaffected participants. Distance to a health facility was associated with the use of medications and informal care. The results confirmed the long-term effect of a tsunami. This dissertation may assist the decision- and policy-makers in the identification of those most likely to use health services and in the request of health resources to the affected areas. The patterns, determinants, and spatial analysis of health service utilization found in this study may not be specific to a tsunami and may provide insights on post-disaster contexts of other natural disasters.

Background. Heart failure (HF) which is a chronic, disabling disorder is mainly found in older people and is one of the leading causes of hospitalisation and readmission around the world. Unfortunately, the mortality and morbidity rates for HF remain high. HF is a complex combination of symptoms which are related to an inadequate perfusion of the body tissues caused by fluid and sodium retention. Hence, enhancing HF patients’ self-efficacy to change their behaviours to perform fluid & sodium control is one of the most important issues for the management of HF. A self-management program has the potential to raise self-efficacy and self-care which is a method to improve health for those with chronic illness and to decrease patients’ health service utilisation and also to enhance these patients’ health status. Aim. The study aims to examine the effectiveness of a self-management program, based on self-efficacy theory, in older people with heart failure in Taiwan. Methods. An experimental design was used to examine the effectiveness of a self-management program on diet and fluid control among HF patients. A total of 93 subjects from two medical centres in Taiwan were randomly assigned to the intervention and control groups. In order to examine the effectiveness of self-management, data were collected at baseline, week 4, and week 12 using the following instruments: self-efficacy for salt and fluid control, HF self-management behaviour, HF related symptoms, and body weight. Moreover, health service utilisation and patient’s evaluation of care received were collected on all patients for the 12 weeks prior to commencing the study and for the 12 week study period. Demographic and disease information was also collected including age, gender, marital state, education, and New York Heart Association (NYHA) functional classification. A structured, individualized self-management training program created by the investigator was implemented for the intervention group through home visits and telephone follow-ups. This program emphasized self-monitoring of diet control and body weight for the self-management of heart failure. The purpose was to improve patients’ self-efficacy in their diet control behaviour. The “diet control” in this study focussed on sodium and fluid restriction. Outcome measures were analysed using the Statistical Package for the Social Sciences (SPSS) 15.0 version, and the level of significance (á) was set at 0.05 for statistical analysis. Results. There were differences for older Taiwanese HF patients’ self-efficacy for salt and fluid control, self-management behaviour, and HF related symptoms for participants who received a self-management intervention compared to those who did not. However, there were no significant differences between the two groups in weight and health serves utilization (p>.001). Conclusion. The self-management program had a positive impact on the improvement of self-efficacy for salt and fluid control, HF related self-management behaviours and symptoms in older Taiwanese with HF. This program may bridge the gap between theory and practice. Health care providers need to provide older people in Taiwan with HF the appropriate skills for self-managing their condition and thereby promoting their health status. These patients with HF and their caregivers have to receive individualized education that emphasizes self-efficacy in the self-management of their disease, thus improving their quality of life.

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No. of bitstreams: 2 Tese - Ana Laura de Sene Amâncio Zara - 2017.pdf: 3959463 bytes, checksum: 51394e12c85247544283c6fdfd6f2bf6 (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Previous issue date: 2016-08-02 / Conselho Nacional de Pesquisa e Desenvolvimento Científico e Tecnológico - CNPq / Outro / Introduction: dengue cost estimates are important to support complete and useful economic evaluations for decision making regarding the incorporation of new technologies, such as vaccines and alternative strategies to control Aedes. Objectives: to estimate the health services utilization (HSU) for outpatients and hospitalized in the public and private sectors, and severity of the disease, in 2012-2013; identify possible sources of data and methodologies for dengue cost estimates in Brazil, considering primary and secondary sources of data; and estimate the total costs of dengue in Brazil, in 2013-2014, considering costs of the disease and control program costs. Methods: for HSU was conducted a multicenter study in six Brazilian capitals, from questionnaires and medical records. For the cost of illness (COI) and the cost of control program were used various sources of information, from microcusteio and macrocusteio methods as data availability. Results: for the HSU study attended 2,035 patients, of whom 1,167 (57.3%) were women, 1,657 (81.4%) were outpatients, 378 (18.6%) were hospitalized, 1,361 (66 9%) patients were in the public sector, and 398 (19.6%) were children (≤ 14 years). In the public sector, patients underwent an average of 1.9 visit, and hospital patients were on average 4.5 medical visits. In the private sector, the patients were, on average, 2.2 visits, and hospital patients were on average 5.1 medical visits. The vast majority of hospitalized patients had complete blood count, platelet count and hematocrit performed, received antipyretic/analgesic, in both public and private sectors. In 2013-2014, the cost of the dengue control program was US$1.2 billion, with 23% corresponding to federal costs and 77% to municipal costs. The costs of the disease varied according to the sources of information. If primary sources were used, direct medical costs amounted to US$1.2 billion, and from secondary sources (HSU), the costs were US$330.2 million. Indirect costs amounted to US$5.2 million, considering the primary sources. Conclusion: HSU patterns varied significantly according to the health sector and the severity of the disease. In general, the pattern of HUS complies with the guidelines of the MS. In 2013-2014, the total cost of dengue ranged from US$1.53 billion to US$1.69 billion. If the number of underreporting cases was adjusted, costs ranged from US$6.86 billion to US$7.78 billion. Dengue imposes substantial costs to the health and economy in Brazil. It is expected that these results can contribute to the economic and welfare planning essential for the sustainability of the dengue control program in Brazil, which generally has its costs underestimated. / Introdução: estimativas de custos da dengue são importantes para subsidiar avaliações econômicas completas e úteis para tomada de decisões quanto à incorporação de novas tecnologias, como vacinas e estratégias alternativas de controle do Aedes. Objetivos: estimar a utilização de serviços de saúde (USS) pelos pacientes ambulatoriais e hospitalizados, nos setores público e privado, e por gravidade da doença, em 2012-2013; identificar possíveis fontes de dados e metodologias para estimativas de custos da dengue no Brasil, considerando fontes primárias e secundárias de dados; e estimar os custos totais da dengue no Brasil, em 2013-2014, considerando custos da doença e custos do programa de controle. Métodos: para USS foi realizado um estudo multicêntrico em seis capitais brasileiras, a partir de questionários e prontuários médicos. Para o custeio da doença e do programa de controle foram utilizadas variadas fontes de informação, a partir de métodos de microcusteio e macrocusteio conforme disponibilidade dos dados. Resultados: para o estudo de USS participaram 2.035 pacientes, dos quais, 1.167 (57,3%) eram do sexo feminino, 1.657 (81,4%) eram pacientes ambulatoriais, 378 (18,6%) foram hospitalizados, 1.361 (66,9%) pacientes eram do setor público, e 398 (19,6%) eram crianças (≤ 14 anos). No setor público, os pacientes realizaram, em média, 1,9 consulta, e os pacientes hospitalizados receberam, em média 4,5 visitas médicas. No setor privado, os pacientes realizaram, em média, 2,2 consultas, e os pacientes hospitalizados receberam, em média 5,1 visitas médicas. A grande maioria dos pacientes hospitalizados teve hemograma completo, contagem de plaquetas e hematócrito realizados e recebeu antipirético/analgésico, em ambos os setores público e privado. Em 2013-2014, o custo do programa de controle da dengue foi de US$1,2 bilhão, sendo 23% correspondente aos custos federais e 77% aos custos municipais. Os custos da doença variaram de acordo com as fontes de informação. Se utilizadas as fontes primárias, os custos diretos médicos chegaram a US$1,2 bilhão, e por fontes secundárias (USS), os custos foram de US$330,2 milhões. Os custos indiretos chegaram a US$5,2 milhões considerando as fontes primárias. Conclusão: os padrões de USS variaram significativamente de acordo com o setor de saúde e com a gravidade da doença. Em geral, o padrão de USS está em conformidade com as orientações do MS. Em 2013-2014, o custo total da dengue variou entre US$ 1,53 bilhão e US$ 1,69 bilhão. Se ajustado o número de casos subnotificados, os custos variam de US$6,86 bilhões a US$7,78 bilhões. A dengue impõe custos substanciais para a saúde e a economia no Brasil. Espera-se que esses resultados possam contribuir para o planejamento econômico e assistencial imprescindíveis para a sustentabilidade do programa de controle da dengue no Brasil, que, em geral, tem seus custos subestimados.