Thesis advisor: Shanta Pandey / A growing body of literature, particularly from low and middle-income countries, has focused on the role of male involvement in maternal care as a crucial strategy to improve maternal and neonatal health outcomes. The purpose of this three-paper dissertation is to add to this evidence base within the context of India, and to gain an in-depth understanding of one aspect of male involvement – that is, male partner attendance in antenatal care. This dissertation utilized data from the National Family Health Survey (NFHS-3, 2005-06 and NFHS-4, 2015-16) and was framed using the Social Ecological Model, Connell’s Theory of Gender and Power and a Gender-Transformative lens. Paper 1 summarized the levels of male partner attendance in antenatal care and assessed changes over time. Further, multivariable logistic regression models were used to examine the factors influencing male partner attendance in antenatal care. The results show an overall increase in male partner attendance in India during the period of 2005-06 to 2015-16, with the Southern region reporting the highest level of male partner attendance in both years. Higher level of education and household wealth, increased knowledge of pregnancy-related complications, older age at marriage, and women’s autonomy were positively associated with male partner attendance in antenatal care. Paper 2 examined the association between male partner attendance in antenatal care and maternal health service utilization. Controlling for all socio-demographic variables and adjusting for report of pregnancy complications, the results showed that women who were accompanied by a male partner for antenatal care reported increased odds of maternal health service utilization (early initiation of antenatal care, frequency of antenatal care contacts and institutional delivery). While the place of residence (rural/urban) did not influence the association between male partner attendance and maternal health service utilization, region had a significant moderating effect. Paper 3 examined the association between antenatal care and infant birth weight, adjusting for gestational age. Further, the analysis also assessed whether the relationship between antenatal care and infant birth weight varied by male partner attendance. Findings indicate that early initiation of antenatal care and maternal immunization was associated with reduced odds of low birth weight among infants. The results showed that male partner attendance in antenatal care did not have a moderating influence. Taken together, the findings of the three papers have implications for policy and practice; further, they provide support for interventions that aim for a more inclusive and gender-transformative approach to maternal and neonatal health. / Thesis (PhD) — Boston College, 2021. / Submitted to: Boston College. Graduate School of Social Work. / Discipline: Social work.

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Background: Place of death is a commonly reported indicator for assessing palliative care quality, but does not provide details of healthcare service utilization at the end-of-life, such as acute care. In particular, early palliative care has shown to reduce acute care service use, but findings are mostly limited to cancer patients with few population-based data available. Objectives: The purpose of this research is to: 1) explore place of care trajectories in the last 2 weeks of life in a general population and among distinct illness cohorts, and 2) investigate whether early versus late palliative care affects acute care use and other publically-funded services in the last 2 weeks of life. Research Design: A retrospective population-based cohort study using linked administrative health data to examine all Ontario decedents between April 1st, 2010 and December 31st, 2012. Methods: Descriptive statistics were used to examine place of care trajectories and service utilization trends in the last 2 weeks of life. Multivariable logistic regression analyses were conducted to assess in the 2 weeks before death: 1) the odds of using an acute care setting (yes/no), and 2) the odds of time spent (≤1 week or >1week) in acute care settings among users. Results: Overall, 235,159 decedents were identified. About 32% had cancer, 31% had organ failure, and 29% had frailty. Overall, 29% of decedents used a hospital two weeks before death, but this increased to 61% on the day of death. Those with cancer were the largest users of palliative-acute hospital care, while those with organ failure were the largest users of acute- hospital care. Assessing palliative care timing, 27% were early palliative care recipients, 13% were late. About 45% of early recipients had a community-based palliative care initiation, 74% of late recipients had a hospital-based initiation. Late recipients were more likely to use acute care settings; this was further modified by disease: comparing late to early recipients, cancer decedents were nearly two times more likely to spend >1 week in acute care settings (OR=1.84, 95%CI:1.83-1.85), frailty decedents were three times more likely (OR=3.04, 95%CI:3.01-3.07), and organ failure decedents were four times more likely (OR=4.04, 95%CI:4.02-4.06). Conclusion: Place of care trajectories differ greatly by disease cohort. Exploring place of care trajectories can provide details not evident when reporting solely place of death. Furthermore, early palliative care was associated with reduced acute care service use in cancer and non-cancer patients. Late initiations were associated with greater acute care use, and had the largest effect on those with organ failure and frailty, suggesting potential opportunities for improvement in non- cancer populations. / Thesis / Master of Science (MSc)

It is widely accepted that the home environment may act as a socio-geographic focus of both disease transmission and of learned health behaviour. Households also appear to be units of convergence for factors identified in the literature as relating to the utilization of health services. This thesis is devoted to an examination of the role of the home environment, as well as of personal characteristics and accessibility, in the utilization of health services in Grenada, West Indies. The theoretical framework that informs this work is a holistic systems-orientated Socio-Ecological Model of Utilization. The empirical analysis draws upon the results of a detailed household survey conducted in five communities on the western portion of the island. Visits to homes containing children less than eight years of age isolated socio-demographic characteristics and information pertaining to residential mobility, household physical and behavioural environment, accessibility, self-reported morbidity and self-reported utilization. Records of patient visits over the previous two years for non-trauma events were abstracted from the medical records of area clinics, hospitals and physicians attending to the sample communities. Bivariate analyses between components of variables were conducted at both household and individual service use levels. These indicated that 1) service utilization was highly clustered around "high user" households and individuals; 2) considerable discrepancies emerged between self-reported and actual utilization; 3) the complexity of relationships between elements of the home environment was highlighted; and 4) there was a consistency with which certain elements of the home environment were statistically associated with health service use across a wide spectrum of illnesses. These observations were further confirmed in multivariate analyses, in which a small number of variables were able to retrospectively predict the presence or absence of service use by both adults and children with a high degree of model specificity and sensitivity. The implications of this work for development and health care planning in Grenada is discussed. The meaningful application of this work in Grenada is seen to hinge upon the extent to which relevant variables are amenable to change or act as proxy variables whose underlying nature of association with utilization remains to be adequately explored. A number of suggestions are advanced concerning the manner in which the study of health service utilization might be approached in the future. / Thesis / Master of Arts (MA)

Résumé: Introduction: Cette étude s’intéresse à l’expérience de soins de patients aînés de 70 ans et plus atteints de cancer entourant une visite à l’urgence. Elle repose sur plusieurs résultats d’études démontrant que ces personnes présentent des besoins spécifiques non comblés, les amenant à utiliser les services d’urgence pour y répondre. Peu d’études se sont intéressées à leur expérience de soins et encore plus rarement dans le contexte d’une visite à l’urgence. But : Mieux comprendre l’expérience de soins des patients aînés atteints de cancer entourant une visite à l’urgence. Cette étude comprend quatre objectifs soit : 1) établir le profil des patients de 70 ans et plus ayant consulté l’urgence pour un problème lié à leur cancer dans les 12 mois précédant l’étude; 2) identifier les raisons et les facteurs amenant ces patients à consulter les services d’urgence; 3) identifier les stratégies de coping utilisées avant d’aller à l’urgence et 4) décrire l’expérience de soins de ces patients à l’urgence. Méthode: Une étude à devis mixte simultané a été entreprise. Une analyse descriptive des bases de données administratives a été réalisée pour documenter le profil sociodémographique, clinique et l'utilisation des services des patients aînés atteints de cancer de 70 ans et plus qui ont visité l'urgence d'un centre hospitalier au Québec, le Canada (n = 792, Objectifs 1-2). Ensuite, des entrevues semi-structurées ont suivi (n = 11) et ont été analysées par une analyse de contenu en profondeur (Objectifs 2, 3, & 4). Résultats: Un total de 792 patients aînés atteints de cancer ont visité l'urgence pour un total de 1572 visites. Les raisons de consultation les plus fréquentes étaient de nature respiratoire (15,8%), digestive (13,4%) et les troubles cardiovasculaires (8,2%). Plus de la moitié des visites était réalisée de jour. L’anxiété, les problèmes d’accessibilité et la détérioration importante de la santé étaient des facteurs qui influençaient le recours aux services d’urgence. Les patients ont été en mesure de déployer une multitude de stratégies de coping pour faire face à leurs problèmes de santé. Par ailleurs, l’expérience de soins est un processus unique, vécu de manière très individuelle. Conclusion: Cette étude décrit l’expérience de soins de patients aînés atteints de cancer à l’urgence et souligne plusieurs domaines d’amélioration des services en périphérie de l’urgence, mais aussi au sein même du service d’urgence. / Abstract: Introduction: Older cancer patients are known to have specific unmet needs due to the complexity of their health care, leading them to use emergency services. However, it is known that emergency rooms are not well-suited to the needs of the elderly. Few studies have focused on the health care experience of older cancer patients and even less so in the context of emergency room (ER) visits. Purpose: This study aims to better understand the experience of older cancer patients in the context of ER visits for unexpected health deterioration related to cancer. We sought to: 1) establish the profile of patients aged 70 years and older who made ER visits for problems related to their cancer in the 12 months preceding the study; 2) identify the reasons and factors that motivate older patients with cancer to make ER visits; 3) identify coping strategies used by older cancer patients prior to ER visits; and 4) describe the health care experience of older cancer patients in the context of ER visits. Methods: A concurrent mixed-method design was used. Descriptive analysis of administrative databases was first conducted to document the socio-demographic, clinical, and service utilization profile of elderly cancer patients aged 70 years and older who visited the ER of a hospital in Québec, Canada (n = 792, Objectives 1-2). Semi-structured interviews were subsequently conducted (n = 11) and then analysed using in-depth content analysis (Objectives 2, 3, & 4). Results: The sample of 792 older cancer patients made a total of 1,572 ER visits. The most frequent medical reasons for ER visits were respiratory (15.8%) and digestive (13.4%) concerns, and cardiovascular conditions (8.2%). Content analysis of the qualitative data suggested that older cancer patients made most of the ER visits when experiencing high levels of anxiety, when other cancer care services were unavailable, or because of a serious life-threatening health condition. Patients were able to use a variety of coping strategies to deal with health issues. Furthermore, the care process is experienced uniquely for each individual. Conclusion: This study describes the health care experience of older cancer patients in the context of ER visits and suggests areas of improvement both outside of and within emergency services.

In this dissertation, I examine individual decisions in occupational choice, labor supply, and health care utilization. Occupational choice decisions of female college graduates on whether to teach or not are analyzed to understand the role of fertility and relative wages using a panel estimation method. I also compare the behavioral changes in the labor force participation among teachers and non-teachers conditional on the presence of a new-born baby. Using the human capital model where a worker decides her hours of work responding to wages, and her human capital is accumulated proportional to her hours of work, I predict that the positive relationship between entry wages and post wages. Empirical evidence suggests that the shock in entry wages may be attributed to post wage differentials. I examine individuals?? choice of health insurance plan and utilization of health care services. Empirical evidence shows that there is favorable self-selection into health maintenance organizations (HMOs) plans and that HMO members use more of office-based and hospital outpatient services. It suggests ineffectiveness of HMO plans in reducing utilization.

In this dissertation, I examine individual decisions in occupational choice, labor supply, and health care utilization. Occupational choice decisions of female college graduates on whether to teach or not are analyzed to understand the role of fertility and relative wages using a panel estimation method. I also compare the behavioral changes in the labor force participation among teachers and non-teachers conditional on the presence of a new-born baby. Using the human capital model where a worker decides her hours of work responding to wages, and her human capital is accumulated proportional to her hours of work, I predict that the positive relationship between entry wages and post wages. Empirical evidence suggests that the shock in entry wages may be attributed to post wage differentials. I examine individuals?? choice of health insurance plan and utilization of health care services. Empirical evidence shows that there is favorable self-selection into health maintenance organizations (HMOs) plans and that HMO members use more of office-based and hospital outpatient services. It suggests ineffectiveness of HMO plans in reducing utilization.

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There is extensive research over the decades around health care services utilization trends, however, limited data and research exists around student utilization of campus health centers. Furthermore, there is very minimal data on student utilization trends of campus health services since the onset of the Covid-19 pandemic. Since a crucial component to fostering healthy and safe college campuses is through campus health services, it clearly indicates a need for further research on the trends and perceptions of students’ campus health services utilization. This study examines utilization rates of students through exploring key demographic characteristics of students, including their perceptions toward utilization of campus health services, for their physical well-being and medical care. This dissertation is a secondary data analysis of the American College Health Association-National College Health Assessment. This study’s specific aims were to examine if key characteristics exist of students utilizing campus health centers, and if those trends still exist or had shifted after the Covid-19 pandemic. The data was used to evaluate if there are significant relationships between student demographics and their respective perceptions of campus health services. Drawing on a nationally representative sample of undergraduate students, data analysis found various statistical significance based on the various steps in the Andersen Behavioral Model of Health Services Use. The results confirmed there are barriers to college student utilization of health services, specifically for certain race/ethnicity, international students, having an active health insurance policy, and how they perceive health being a priority on campus. Given the vital role that student health services have on college campuses, efforts to increase campus health service utilization should be considered through targeted programming and more inclusive staffing and service offerings.