This thesis uses observational study design methods to explore the relationship between depression and various outcomes following acute myocardial infarction (AMI). There are three main studies. First, the relationship between depression and mortality following AMI was measured. The main finding was that the factor determining the increased mortality rate in depressed patients is reduced cardiac functional status. The main implication was that efforts to address increased mortality in depressed patients with cardiovascular illnesses should focus on processes that impact cardiac functional status. Second, the impact of depression on service consumption following AMI was examined. Depressive symptoms were associated with a 24% (Adjusted RR:1.24; 95% CI:1.19-1.30, P<0.001), 9% (Adjusted RR:1.09; 95% CI:1.02-1.16, P=0.007) and 43% (Adjusted RR: 1.43; 95% CI:1.34-1.52, P<0.001) increase in total, cardiac, and non-cardiac hospitalization days post-AMI respectively, after adjusting for baseline patient and hospital characteristics. Depressive-associated increases in cardiac health service consumption were significantly more pronounced among patients of lower than higher cardiac risk severity. The disproportionately higher cardiac health service consumption among lower-risk AMI depressive patients may suggest that health seeking behaviors are mediated by psychosocial factors more so than by objective measures of cardiovascular risk or necessity. Third, methodological issues related to missing data were explored. A systematic review of three psychiatric journals revealed that a small minority of studies (5.8%) addressed the impact of missing data in a meaningful way. An example using real data demonstrated the potential bias introduced by missing data and different ways to address this bias. The paper concludes with recommendations for both reporting and analyzing studies with substantial amounts of missing data. Overall, the studies add to the literature exploring the relationship between depression and outcomes following acute myocardial infarction. Future studies measuring the relationship between depression and mortality will need to factor the mediating relationship between depression and cardiac functional status. The increased health service utilization associated with depression will need to be replicated in other illness models. Together, the studies add to the existing conceptual framework for measuring relationships between depression and outcomes in patients with cardiovascular illnesses.

This thesis uses observational study design methods to explore the relationship between depression and various outcomes following acute myocardial infarction (AMI). There are three main studies. First, the relationship between depression and mortality following AMI was measured. The main finding was that the factor determining the increased mortality rate in depressed patients is reduced cardiac functional status. The main implication was that efforts to address increased mortality in depressed patients with cardiovascular illnesses should focus on processes that impact cardiac functional status. Second, the impact of depression on service consumption following AMI was examined. Depressive symptoms were associated with a 24% (Adjusted RR:1.24; 95% CI:1.19-1.30, P<0.001), 9% (Adjusted RR:1.09; 95% CI:1.02-1.16, P=0.007) and 43% (Adjusted RR: 1.43; 95% CI:1.34-1.52, P<0.001) increase in total, cardiac, and non-cardiac hospitalization days post-AMI respectively, after adjusting for baseline patient and hospital characteristics. Depressive-associated increases in cardiac health service consumption were significantly more pronounced among patients of lower than higher cardiac risk severity. The disproportionately higher cardiac health service consumption among lower-risk AMI depressive patients may suggest that health seeking behaviors are mediated by psychosocial factors more so than by objective measures of cardiovascular risk or necessity. Third, methodological issues related to missing data were explored. A systematic review of three psychiatric journals revealed that a small minority of studies (5.8%) addressed the impact of missing data in a meaningful way. An example using real data demonstrated the potential bias introduced by missing data and different ways to address this bias. The paper concludes with recommendations for both reporting and analyzing studies with substantial amounts of missing data. Overall, the studies add to the literature exploring the relationship between depression and outcomes following acute myocardial infarction. Future studies measuring the relationship between depression and mortality will need to factor the mediating relationship between depression and cardiac functional status. The increased health service utilization associated with depression will need to be replicated in other illness models. Together, the studies add to the existing conceptual framework for measuring relationships between depression and outcomes in patients with cardiovascular illnesses.

This dissertation addresses some of the gaps in the research on pediatric mental health (MH) repeat visits to the emergency department (ED). The primary objectives of this thesis are to systematically review the existing literature on youth MH return visits to the ED and to determine the incremental contribution of family factors in predicting these repeat ED visits. The first study systematically reviewed and qualitatively summarized the available literature to better understand predictor of repeat visits. A search was performed using the following databases: PsycINFO, PubMed, and CINAHL. Reporting followed the PRISMA statement checklist and methodological quality was assessed using the following eight criteria: design, generalizability, breadth of predictors, reporting of effect sizes, additional outcomes, interaction terms, confounding variables, and clear definition of outcome. A total of 178 articles were retrieved; 11 articles met inclusion criteria. Findings revealed that repeat visits to the ED for MH concerns is a complex phenomenon that can be attributed to various demographic, clinical, and MH care access and utilization factors. Common predictors associated with repeat ED MH visits included socioeconomic status, involvement with child protective services, as well as previous and current MH service use. For studies using a six-month repeat window, the most common factors were previous psychiatric hospitalization and currently receiving MH services. This systematic review concluded that in order to further elucidate which variables are most significantly associated with repeat ED visits; future research should consider the use of prospective designs and the inclusion of family factors. Investigating recency and frequency outcomes may also be of importance. The second study aimed to determine if family characteristics are significantly associated with repeat ED visits over and above the contribution of demographic, clinical or service utilization factors. A retrospective cohort study of youth aged six to18 years treated at a tertiary pediatric ED for a discharge diagnosis related to MH was conducted. Data were gathered from medical records, telephone interviews, and questionnaires. Of 266 participants, 70 (26%) had a repeat visit. Receiving MH services within six-months of the index visit, having a parent with a history of treatment for MH concerns, higher severity of symptoms and living closer to the hospital were significantly associated with repeat visits as well as earlier and more frequent repeat visits. Prior psychiatric hospitalization was associated with repeat visits and more frequent repeat visits, while presenting with suicidality was associated with more frequent repeat visits. Family functioning and perceived family burden were not associated with repeat ED visits. This thesis contributes to the growing literature on ED use in pediatric patients with mental illnesses and may be clinically useful to professionals working with repeat visitors. The identification of key factors could provide essential information to ED decision-makers and lead to the development of best practices with this population.

The present study examines the issue of minority participation in a multi-faceted prevention program for youth with problem behavior. Historically, participation in such research programs has been low (Myers, Alvy, Richardson, Arrington, Marigna, Huff, Main, & Newcomb, 1990; Coie, 1996; Spoth & Redmond, 2001). Targeted prevention programs, which design their interventions for populations that are susceptible to negative outcomes, face more obstacles to participation than most participants of universal prevention programs. Targeted populations, specifically families with children with problem behavior, are usually under great duress, suffer multiple hardships, and have high adversity characteristics, (e.g., low socioeconomic status, insularity, single-parent families, and low levels of education). As has long been documented, minority status is usually associated with this heightened risk status (Prinz & Miller, 1991). A common suggestion in the prevention and therapeutic treatment literature is the use of minority staff members to increase the likelihood of participation of minority parents (Prinz, Smith, Dumas, Laughlin, White & Barron, 2001). This argument is most prevalent in the literature regarding Latino clients (Sue, Fujino, Hu, Takeuchi, & Zane, 1991). This study attempts to predict minority parents' participation quality (PQ) from demographic variables (e.g., level of adversity, ethnicity), participation rate (PR) (e.g., amount of participation measured by minutes and contacts), and ethnic matching. This study also offers insight on how PQ and PR relate to one another. The results of this study imply that PQ and PR relate differently for Latino parents than they do for parents from other ethnicities. The relationship of these variables has implications for frequency of dosages in an intervention, especially for interventions that attempt to reach distinct populations.

The purpose of this study was to determine the factors that influence university students use of health services for mental or emotional reasons. Currently accepted models of health service use may not apply to university students due to their unique socio-demographic characteristics and health challenges. The Andersen and Newman model of health service utilization was used as a conceptual framework. The first hypothesis was that many factors that influence use of services in the general population would also apply to the university student population. The second hypothesis was that some student-specific factors would also influence health service utilization for mental or emotional reasons. <p>Data for this study was collected in a survey designed for a larger health needs assessment of University of Saskatchewan undergraduate students. The dependant variable was the use of services for mental or emotional reasons within the past year. Information was also collected for 26 independent variables. A logistic regression was used to determine which of these were related to the dependant variable. <p>The final model of health service utilization for mental/emotional reasons among university students included six independent variables: 1) perceived need for professional help (for emotional problems), 2) previous depression diagnosis, 3) past/present suicide ideation, 4) sexual assault victimization, 5) presence of a family doctor, and 6) gender.<p>The results of this study indicate that many of the factors that influence service use for mental/emotional reasons in the student population are the same as those that exist in the general population. The results also suggest that student-specific factors, such as college, years in university, or academic performance do not influence health service use for mental/emotional reasons. Implications of these findings are discussed.

The purpose of this study was to determine the factors that influence university students use of health services for mental or emotional reasons. Currently accepted models of health service use may not apply to university students due to their unique socio-demographic characteristics and health challenges. The Andersen and Newman model of health service utilization was used as a conceptual framework. The first hypothesis was that many factors that influence use of services in the general population would also apply to the university student population. The second hypothesis was that some student-specific factors would also influence health service utilization for mental or emotional reasons. <p>Data for this study was collected in a survey designed for a larger health needs assessment of University of Saskatchewan undergraduate students. The dependant variable was the use of services for mental or emotional reasons within the past year. Information was also collected for 26 independent variables. A logistic regression was used to determine which of these were related to the dependant variable. <p>The final model of health service utilization for mental/emotional reasons among university students included six independent variables: 1) perceived need for professional help (for emotional problems), 2) previous depression diagnosis, 3) past/present suicide ideation, 4) sexual assault victimization, 5) presence of a family doctor, and 6) gender.<p>The results of this study indicate that many of the factors that influence service use for mental/emotional reasons in the student population are the same as those that exist in the general population. The results also suggest that student-specific factors, such as college, years in university, or academic performance do not influence health service use for mental/emotional reasons. Implications of these findings are discussed.

Adolescence is a very important transition stage between childhood and adulthood. In this stage, due to rapid change physically and mentally, adolescents are more likely to occur physical, psychological, and social problems. Therefore, providing adolescents fine health service is critical. To do so, having a better understanding of the factors associated with health service utilization can help a lot. The main purpose of this study is to understand adolescents¡¦ behavior of health service utilization. Based on Andersen¡¦s behavior model of health service utilization, this study investigated the associations of predisposing characteristics, enabling resource characteristics, and needing characteristics with health service utilization of adolescents. The data used in these analyses were drawn from students in junior high schools of Tainan Providence, of which seven schools were randomly selected and then anonymous questionnaires were distributed to all students. 2,242 of 3,591 students were collected, for a response rate of 55.39%, and the final sample was 1,989. ANOVA and t test were employed to examine health service utilization of adolescents, and multiple regression was used to investigate the factors associated with health service utilization. Several results were found in this study as follows: First, significant differences did exist among junior high students, which indicated that second graders and third graders went to see doctors more times than first graders did. Second, there were 21% and 12% of respondents with experience of hospitalization and operation respectively. Students with hospitalization and operation experience utilized more health services. Third, students with national health insurance were more likely to utilize health services than those without national health insurance. Last, with regard to the relationship between self-perception of health status and health service utilization, the more respondents perceived themselves with problem of physical health or adolescent development, the more health services they utilized. In addition, the perception of emotional problem was negatively related to the utilization of health services. Several suggestions are proposed. First, establish adolescent clinics in all hospitals that are in the level of district hospitals and above to improve medical accessibility. Second, advocate the system of family physician to emphasize continuity and integrity of health care. Moreover, design appropriate clinical education for adolescents to educate them with adequate concept of health care and health utilization, making them understand the idea of health gradient to receive the right treatment in the right place. Last but not least, the health and education administration should reinforce adolescents¡¦ ability of emotional management, provide assistance for them to find out their emotional problems, and help them to receive appropriate health treatment through psychological consultation of adolescent clinics as soon as possible.

The present study examines the issue of minority participation in a multi-faceted prevention program for youth with problem behavior. Historically, participation in such research programs has been low (Myers, Alvy, Richardson, Arrington, Marigna, Huff, Main, & Newcomb, 1990; Coie, 1996; Spoth & Redmond, 2001). Targeted prevention programs, which design their interventions for populations that are susceptible to negative outcomes, face more obstacles to participation than most participants of universal prevention programs. Targeted populations, specifically families with children with problem behavior, are usually under great duress, suffer multiple hardships, and have high adversity characteristics, (e.g., low socioeconomic status, insularity, single-parent families, and low levels of education). As has long been documented, minority status is usually associated with this heightened risk status (Prinz & Miller, 1991). A common suggestion in the prevention and therapeutic treatment literature is the use of minority staff members to increase the likelihood of participation of minority parents (Prinz, Smith, Dumas, Laughlin, White & Barron, 2001). This argument is most prevalent in the literature regarding Latino clients (Sue, Fujino, Hu, Takeuchi, & Zane, 1991). This study attempts to predict minority parents' participation quality (PQ) from demographic variables (e.g., level of adversity, ethnicity), participation rate (PR) (e.g., amount of participation measured by minutes and contacts), and ethnic matching. This study also offers insight on how PQ and PR relate to one another. The results of this study imply that PQ and PR relate differently for Latino parents than they do for parents from other ethnicities. The relationship of these variables has implications for frequency of dosages in an intervention, especially for interventions that attempt to reach distinct populations.

Palliative radiotherapy (PRT) is proven to be effective in palliation of symptoms for end-stage cancer patients. However, little is known about its utilization at the end of life. This research aims to examine the utilization and the practice patterns of PRT at the end of life for cancer patients in British Columbia using population-based data. The pattern observed for PRT1Y dose-fractionation practice in BC are in line with published clinical guidelines and evidence from the literature, which advises “proper” use of PRT in BC as delivered to cancer patients at the end of life. However, after controlling for age, primary cancer site, and survival time, geographic access is found to be significantly associated with PRT1Y utilization. Variations found in PRT1Y rates by geographic access, which is operationalized by the Health Services Delivery Area (HSDA) and travel time, suggests potential underutilization of PRT1Y for patients with suboptimal access. / Graduate / 0992 / 0769 / 0574 / jinhuang@uvic.ca

The three primary purposes of this study were to (1) acquire knowledge of parents’ psychological experiences obtaining a diagnosis and accessing services for their child with ASD by examining the actual situation, as lived through and experienced by the parents, (2) gain knowledge of the meaning of advocacy and empowerment from parents who are living these experiences, and (3) derive possible implications for enhancing services provided by mental health professionals, service providers, and policy-makers to parents of children with autism. I utilized a sequential transformative integrated design, drawing data in Wave II of a larger, on-going investigation examining child, family, and community variables associated with early identification and treatment of autism spectrum disorders in the Pacific Northwest. I conducted a descriptive exploratory analysis to describe all participants from Wave II with respect to measures of sociodemographic variables, parental satisfaction with services, family empowerment, and reported relationships among these variables. Next, I conducted in-depth semi-structured interviews with six participants identifying as low-income and/or ethnic minorities to explore their experiences throughout the process of obtaining a diagnosis and accessing services for their child with ASD. Interviews were recorded and transcribed. Data were analyzed using a phenomenological reduction and integrated with quantitative results. Constituent elements of the parent experiences included, but were not limited to: a desire and/or appreciation for sources of support and information regarding services; engaging in ongoing research and networking to learn about services; a need to be the expert on their child; and fear regarding availability of future services and child’s future after parents die. Constituent elements of empowerment and advocacy showed that these were conceptually and experientially related to one another, such that advocacy functioned as a behavioral manifestation of empowerment for parents in this study. Findings contribute to the literature on family experiences with the diagnostic and service utilization processes for ASD. Findings are discussed in regards to recommendations and implications for mental health professionals, service providers, and policy-makers working towards fostering more supportive and equitable diagnostic and service utilization pathways for these families.