Introduction : Les personnes âgées originaires de l’Asie de l’Est (PAAE) font partie intégrante de la population québécoise sujette à utiliser des services de réadaptation. Toutefois, elles peuvent avoir des difficultés à en bénéficier, notamment en raison des écarts culturels et sociétaux entre leur pays d’origine et d’accueil, ce qui pourrait les désavantager par rapport à la population générale. Objectif : Comprendre les expériences d’utilisation des services de réadaptation chez les PAAE, du point de vue des professionnelles et professionnels de la réadaptation et des personnes proches aidantes. Méthodologie : Une recherche qualitative descriptive a été menée. Neuf cliniciennes (huit ergothérapeutes et une physiothérapeute) et trois personnes proches aidantes ont participé au projet. Les données ont été collectées via quatre groupes de discussion focalisée et une analyse thématique a été effectuée. Résultats : Selon les cliniciennes et les personnes prochaines aidantes, les expériences d’utilisation des services de réadaptation chez les PAAE sont influencées par quatre facteurs : 1) les défis de la communication relatifs à la barrière linguistique et la réticence des PAAE à exprimer leurs besoins ; 2) la forte implication de la famille afin de soutenir la récupération et d’assurer le maintien à domicile ; 3) les croyances et perceptions en santé reliées à la définition de l’autonomie et aux décisions de santé ; et 4) les défis dans l’alliance thérapeutique. Conclusion : Ces facteurs sont à considérer tant au niveau de l’évaluation que de l’intervention en réadaptation auprès des PAAE. Ils peuvent constituer de pistes d’amélioration afin que les services rendus soient mieux adaptés à leurs besoins tout en tenant compte de leurs réalités culturelles. / Introduction: East Asian origin older adults (EAOA) form an important part of the population in Quebec who are likely to use rehabilitation services. However, they may face difficulties in benefiting from these services, partly due to cultural and societal differences between their countries of origin and their host countries, which could disadvantage them compared to the general population. Objective: To understand EAOAs’ experiences in using rehabilitation services from the perspective of rehabilitation professionals and caregivers. Methodology: A descriptive qualitative research study was conducted. Nine clinicians (eight occupational therapists and one physical therapist) and three caregivers participated in the project. Data were collected through four focus groups and a thematic analysis was conducted. Results: According to the rehabilitation professionals and caregivers of this study, EAOAs' experiences of rehabilitation services utilization are shaped by four factors: 1) communication challenges related to language barriers and EAOAs' reluctance to express their needs; 2) the strong involvement of family in supporting the recovery and in ensuring that elderly people to remain at home; 3) health beliefs and perceptions regarding the definition of autonomy and health-related decisions; and 4) challenges in the therapeutic alliance. Conclusion: These factors should be taken into consideration in rehabilitation care with EAOA both in terms of assessment and intervention. They may constitute avenues for improvement to better adapt the services provided to the needs of these individuals while also considering their cultural realities.

Refugees who have fled from the ongoing civil war in Syria that arrived in Germany often develop post-traumatic stress symptoms (PTSS). The aim of this study was to determine health care services utilization (HCSU), health care costs and health-related quality of life (HrQoL) of Syrian refugees with mild to moderate PTSS without current treatment in Germany. The study was based on the baseline sample of a randomized controlled trial of a self-help app for Syrian refugees with PTSS (n = 133). HCSU and HrQoL based on the EQ-5D-5L and its visual analogue scale (EQ-VAS) were assessed with standardized interviews. Annual health care costs were calculated using extrapolated four-month HCSU and standardized unit costs. Associations between health care costs, HrQoL and PTSS severity were examined using generalized linear models. Overall, 85.0% of the sample utilized health care services within four months. The mean total annual health care costs were EUR 1920 per person. PTSS severity was not associated with health care costs. The EQ-5D-5L index score and the EQ-VAS score was 0.82 and 73.6, respectively. For Syrian refugees with higher PTSS severity, the EQ-5D-5L index score was lower (−0.17; p < 0.001). The HCSU and the resulting health care costs of Syrian refugees with mild to moderate PTSS without current treatment are low and those with a higher PTSS severity had a lower HrQoL.

No description available.

In this study, the utilization of palliative care services, acute care services, and location of death for clients who were palliative and receiving services from Champlain Community Care Access Centre (CCAC) in Ontario during their last month of life were investigated. An adaptation of Andersen?s Behavioral Model of Health Services Utilization provided context and structure to this study. This is an historical, quantitative descriptive study using chart audits for data collection. The data on CCAC clients who were palliative and who died during the month of July 2009 were tracked during their last month of life. Collection of socio-demographic data, services provided through CCAC, emergency department visits, hospital admissions, and location of death provided the data for this study. The clients who died at home used more CCAC services than those who died at other locations and frequently community palliative care physicians provided their medical care. The findings of this study included: 1) The majority of the clients, who expressed a preference, died in their preferred location. 2) The role of community palliative care physicians was an important component of the services that supported the clients to die in their location of choice. 3) Over 25% of the study sample died in a hospital and the clients used a large number of in-patient hospital days with one quarter of the hospital deaths taking place in an emergency department or an intensive care unit. 4) During the last month of life, 25% of the clients received chemotherapy and/or radiation therapy. 5) The clients who died at home used more CCAC services than those who died in other locations and who used institutional resources. The implications for practice, policy, research, and education are discussed.

In this study, the utilization of palliative care services, acute care services, and location of death for clients who were palliative and receiving services from Champlain Community Care Access Centre (CCAC) in Ontario during their last month of life were investigated. An adaptation of Andersen?s Behavioral Model of Health Services Utilization provided context and structure to this study. This is an historical, quantitative descriptive study using chart audits for data collection. The data on CCAC clients who were palliative and who died during the month of July 2009 were tracked during their last month of life. Collection of socio-demographic data, services provided through CCAC, emergency department visits, hospital admissions, and location of death provided the data for this study. The clients who died at home used more CCAC services than those who died at other locations and frequently community palliative care physicians provided their medical care. The findings of this study included: 1) The majority of the clients, who expressed a preference, died in their preferred location. 2) The role of community palliative care physicians was an important component of the services that supported the clients to die in their location of choice. 3) Over 25% of the study sample died in a hospital and the clients used a large number of in-patient hospital days with one quarter of the hospital deaths taking place in an emergency department or an intensive care unit. 4) During the last month of life, 25% of the clients received chemotherapy and/or radiation therapy. 5) The clients who died at home used more CCAC services than those who died in other locations and who used institutional resources. The implications for practice, policy, research, and education are discussed.

This dissertation consists of three empirical essays investigating different aspects of health care for children and families. The first essay examines the effectiveness of adherence to American Academy of Pediatrics guidelines for preventive pediatric health care. Using a national longitudinal sample of children age two years and younger, we investigate whether compliance with prescribed periodic well-child care visits has beneficial effects on child health. We find that increased compliance improves child health. In particular, higher compliance lowers future risks of fair or poor health, of some history of a serious illness and of having a health limitation. The second essay examines child health care utilization in relation to maternal labor supply. We test the hypothesis that working-mothers trade off the advantages of greater income against the disadvantages of less time for other valuable tasks, such as seeking health care for their children. This tradeoff may result in positive, negative, or no net impacts on child health investment. We estimate health care demand regressions that include separate variables for mother’s labor supply and her labor income. Our results indicate that higher maternal work hours reduce child health care visits; higher maternal earnings increase them. In addition, wage-employment, as opposed to self-employment, is detrimental to child health investment. A further finding is that preventive care demand for younger children is less sensitive to maternal time and income changes. We also find that detrimental time effects dominate beneficial income effects. The third essay studies intra-household resource allocation as it pertains to its demand for preventive medical care. We test the income-pooling hypothesis of the common preference model by using individual specific medical care consumption data and present evidence on the allocation of household resources to the medical needs of the child, husband and wife. Our results are in line with the findings of previous studies that emphasize the ongoing importance of the traditional gender role of woman as the primary caregiver. We find that the resources of the wife have a greater positive impact on child’s and her own preventive care demand than does the resources of the husband. In contrast to most studies from developing countries, we find that US families do not exhibit differential health care demand based on child gender. It is also noteworthy that the wife’s education level has a greater positive impact than that of her husband does on both the husband’s and her own preventive care utilization. / text

In this study, the utilization of palliative care services, acute care services, and location of death for clients who were palliative and receiving services from Champlain Community Care Access Centre (CCAC) in Ontario during their last month of life were investigated. An adaptation of Andersen?s Behavioral Model of Health Services Utilization provided context and structure to this study. This is an historical, quantitative descriptive study using chart audits for data collection. The data on CCAC clients who were palliative and who died during the month of July 2009 were tracked during their last month of life. Collection of socio-demographic data, services provided through CCAC, emergency department visits, hospital admissions, and location of death provided the data for this study. The clients who died at home used more CCAC services than those who died at other locations and frequently community palliative care physicians provided their medical care. The findings of this study included: 1) The majority of the clients, who expressed a preference, died in their preferred location. 2) The role of community palliative care physicians was an important component of the services that supported the clients to die in their location of choice. 3) Over 25% of the study sample died in a hospital and the clients used a large number of in-patient hospital days with one quarter of the hospital deaths taking place in an emergency department or an intensive care unit. 4) During the last month of life, 25% of the clients received chemotherapy and/or radiation therapy. 5) The clients who died at home used more CCAC services than those who died in other locations and who used institutional resources. The implications for practice, policy, research, and education are discussed.

Introcução: Estima-se que, no mundo, mais de 350 milhões de pessoas de todas as idades tenham depressão. Em 2010, a depressão foi a segunda principal causa de anos vividos com incapacidade. Embora haja tratamentos eficazes, a proporção de casos diagnosticados e tratados é baixa em todo o mundo, menor ainda nos países de média e baixa renda. Objetivos. Estimar a prevalência de Episódio de Depressão Maior (EDM) na população de 20 anos ou mais cadastrada na Estratégia Saúde da Família (ESF) em dois municípios do Estado do Amazonas (Coari e Tefé); avaliar a associação de EDM com características individuais e investigar a associação entre EDM e utilização de serviços de saúde. Método. Estudo de corte transversal conduzido entre agosto de 2013 e maio de 2014 com amostra representativa da população com 20 anos ou mais, cadastrada na ESF da área urbana dos municípios de Coari e Tefé. Os desfechos \"Depressão maior\" e \"Utilização de Serviços de Saúde\" foram avaliados com a escala Patient Health Questionnaire-9 (PHQ-9) e questões sobre uso de serviços de atenção primária, urgência ou emergência e atenção médica especializada. Foram avaliadas as seguintes exposições: características demográficas e socioeconômicas, apoio social, eventos de vida estressantes, uso de tabaco e álcool, morbidades físicas e tratamento para transtornos mentais. As entrevistas foram realizadas no domicílio do participante. Regressão de Poisson foi utilizada para examinar a associação entre EDM e os fatores de exposição; os resultados foram apresentados como razão de prevalência, com os respectivos intervalos de confiança de 95% (IC 95%). Resultados. A prevalência geral de EDM foi 19,1% (IC 95% 17,2-21,1), sendo 22,2% (IC 95% 19,3-25,0) para mulheres e 16,0 (IC 95% 13,4-18,5) para homens. As prevalências de EDM em Coari e Tefé foram 18,3% (IC 95% 15,7-21,0) e 19,9% (IC 95% 17,2-22,7), respectivamente. Sexo feminino, ausência de apoio social de amigos/colegas, maior número de eventos de vida produtores de estresse e de morbidades físicas foram associados independentemente com depressão maior. Baixa escolaridade e baixa renda, uso de tabaco e uso de risco de álcool foram associados com depressão maior nas análises não ajustadas. EDM foi independentemente associado com a utilização dos três tipos de serviço de saúde investigados. Menos que 4,0% da população estudada recebiam algum tipo de tratamento relacionado à saúde mental. Conclusão. O Estado do Amazonas tem altos índices de desemprego, pobreza e baixa escolaridade, fatores de risco conhecidos para depressão. Uma parcela dos habitantes de Coari e Tefé apresentou indicadores de desvantagem social. Neste contexto, a alta prevalência de EDM encontrada no estudo, cerca de um em cada cinco adultos, não surpreende. As características individuais associadas com EDM nestes municípios são similares aos fatores de risco para depressão no Brasil e em outras partes do mundo. Apesar dos participantes com depressão utilizarem com maior frequência os serviços de saúde, apenas uma pequena proporção da população estudada recebia tratamento para transtornos mentais. Existe uma grande lacuna para o tratamento de depressão no Estado do Amazonas. Programas de tratamento que incluam identificação e tratamento de depressão no contexto da atenção primária devem ser desenvolvidos / Introduction. It is estimated that more than 350 million people of all ages have depression. In 2010, depression was the second leading cause of years lived with disability. Although there are effective treatments, the proportion of cases diagnosed and treated is low around the world, and even smaller in low and middle income countries. Objective. To estimate the prevalence of Major Depressive Episode (MDE) in the population aged 20 years or over enrolled in Brazil\'s Family Health Strategy (FHS) in two municipalities in the state of Amazonas: Coari and Tefé; to evaluate the association of MDE with the individuals\' characteristics; and to investigate the association of MDE with use of health services. Method. Cross-sectional study conducted between August 2013 and May 2014 with a representative sample of the population aged 20 or over enrolled in the FHS in the urban area of Coari and Tefé. The outcomes \"major depression\" and \"use of health services\" were assessed with the Patient Health Questionnaire-9 scale (PHQ-9) and questions about the use of primary care services, as well as emergency and specialized medical care. The following exposure variables were evaluated: demographic and socioeconomic characteristics, social support, stressful life events, use of tobacco and alcohol, physical morbidities and treatment for mental disorders. Interviews were carried out at the participants\' home. Poisson regression was used to examine the association between MDE and exposure factors; results are presented as prevalence ratios, with its respective 95% confidence interval (95% CI). Results. The overall prevalence of MDE was 19.1% (95% CI 17.2 - 21.1) and 22.2% (95% CI 19.3 - 25.0) for women and 16.0 (95% 13.4 - 18.5) for men. The prevalence of MDE in Coari and Tefé were 18.3% (95% CI 15.7 - 21.0) and 19.9% (95% CI 17.2 - 22.7), respectively. Being a woman, lack of social support from friends/colleagues, increased number of stressful life events and physical morbidity were independently associated with major depression. Lower formal education and income, tobacco use and risk use of alcohol were associated with MDE in unadjusted analysis. MDE was independently associated with use of three types of health care investigated. Less than 4.0% of the study population received any type of treatment related to mental health. Conclusion. The state of Amazonas has high rates of unemployment, poverty and low education achievement, known risk factors for depression. A portion of the inhabitants of Coari and Tefé presented indicators of social disadvantage. In this context, the high prevalence of MDE - about one in five adults - is not surprising. Individual characteristics associated with MDE in these municipalities are similar to risk factors for depression in Brazil and worldwide. Although participants with depression used health services frequently, only a small proportion of the study population received treatment for mental disorders. There is a large treatment gap for depression in the state of Amazonas. Treatment programs that include identification and treatment of depression in the context of primary health care should be developed

INTRODUÇÃO: O conceito de equidade enfatiza a diversidade como condição humana e propõe que a diferença seja tratada como princípio orientador das políticas públicas. O objetivo dessa investigação foi verificar a equidade na atenção à saúde de pessoas com indicativos de transtornos mentais comuns (TMC) na cidade de São Paulo. Foram analisadas a procura e utilização dos serviços de saúde, bem como o gasto com saúde no último mês de pessoas com indicativos de TMC, que referiram morbidade quinze dias precedentes à entrevista domiciliar, segundo características sociodemográficas e de condições de saúde. MÉTODOS: Foi realizado um estudo de corte transversal e utilizados os dados do Inquérito de Saúde no Município de São Paulo (ISA - Capital) de 2008. Foram selecionados sujeitos com 16 anos ou mais e com indicativos de transtornos mentais comuns; estes foram avaliados por meio do instrumento Self Reporting Questionnaire (SRQ-20). Foram analisados a procura e utilização de serviços de saúde, e o gasto com saúde no último mês, correlacionando com aspectos sociodemográficos e de condições de saúde. RESULTADOS: A procura pelo serviço de saúde foi menor entre as mulheres, maior na faixa etária dos 30 aos 44 anos e na faixa etária de 60 anos ou mais. A proporção de pessoas que procuraram pelo serviço e obtiveram atendimento foi elevada, o mesmo ocorreu para aquelas que procuraram por médico e foram atendidas por meio de consulta. A procura pelo SUS foi menor entre as pessoas de cor branca, de renda per capita elevada, com união estável e entre as pessoas com ensino superior. A cobertura pelo SUS foi menor para as pessoas das faixas etárias de 45 a 59 anos e de 60 anos ou mais, com renda per capita elevada, com Ensino Médio ou Técnico e Ensino Superior. As pessoas que gastaram mais com a saúde da família foram aquelas com idade igual ou superior a 60 anos, de cor branca, das faixas de renda per capita mais elevadas, com união estável e com Ensino Superior. Em relação à posse de plano de saúde, pessoas de cor branca, com renda per capita elevada e indivíduos com doença crônica apresentaram maiores chances de possuir este serviço. CONCLUSÕES: Foi observado, na população com indicativos de TMC, que não houve desigualdades no acesso e utilização dos serviços entre as pessoas que buscaram por ajuda diante de morbidade. Verificou-se que o SUS atende e cobre os gastos majoritariamente dos mais pobres, denotando uma cobertura desigual que favorece os mais necessitados, porém, considerando o fator idade, ficou explícita uma situação de iniquidade, pois foi constatado que o SUS oferece maior cobertura para a população mais jovem e não contempla as necessidades da população mais idosa. Além disso, verificou-se também uma demanda reprimida de pessoas que não acessaram o serviço, indicando barreiras que antecedem à busca / INTRODUCTION: The equity concept emphasizes diversity as a human condition and proposes this aspect as a guiding principle of the public policy. The objective of this investigation was to verify the equity in health care of people with signs of common mental disorders (CMD) in the city of São Paulo. We analyzed the demand and use of health services and the expenses on health in the last month of people with signs of CMD who reported morbidity 15 days before the home interview, according to socio-demographic characteristics and health conditions. METHODS: We developed a cross-sectional study and used the data from São Paulo\'s health survey (ISA - Capital) of 2008. We selected subjects with 16 years of age or older and with signs of common mental disorders; who were evaluated using the Self Reporting Questionnaire (SRQ-20). We analyzed the demand and the use of health services, and the health expenses in the last month, correlating them with sociodemographic and health condition aspects. RESULTS: The demand for health services was lower among women, higher in the age group from 30 to 44 years old and in the age group of 60 years old or more. The proportion of people who sought the service and were cared for was high, and the same thing happened to those who sought medical attention and had an appointment. The demand for SUS was lower among white people with high per capita income, married and among people with higher education degrees. The coverage of SUS was significantly lower for people aged between 45 and 59 years old and those aged 60 years old or more, with high per capita income, with high school, technical or college degree. The people who spent more on Family health were those with 60 years old or more, white, with high per capita income, married and with college degree. Regarding health care insurance ownership, white people with high per capita income and individuals with chronic diseases presented higher chances of owning a health care insurance. CONCLUSIONS: We observed, among people with signs of CMD, that there were no inequalities in the access and use of health services for those who sought for help faced with morbidity. We verified that SUS serves and covers the expenses mainly of the poorer, denoting an unequal coverage that favours the ones who need it the most, however, taking the age factor into account, a situation of inequity was explicit, since it was verified that SUS offers a wider coverage to the younger population and does not contemplate the needs of the elderly. In addition, there was also a repressed demand of people who could not access the health service, indicating barriers that precede the search

La présente thèse explore, à travers quatre papiers, la possibilité d’étendre le régime d’assurance maladie sociale (SHI) vers la couverture santé universelle (CSU) et ce en présence d’obstacles structurels économiques.Les effets moyens de deux traitements, les deux assurances MHI et MAS, sur l’utilisation des soins de santé (consultations externes et hospitalisations) sont estimés. L’actuel régime d’assurance sociale en Tunisie (SHI), malgré l’amélioration de l’utilisation des soins de santé procurée aux groupes couverts, reste incapable d’atteindre une couverture effective de tous les membres de la population vis-à-vis des services de soins dont ils ont besoin. L’atteinte de cet objectif requière une stratégie qui cible les ‘‘arbres’’ et non la ‘‘forêt’’.Le chapitre deux contourne les principaux obstacles à l’extension de la couverture par l’assurance maladie et propose une approche originale permettant de cibler les travailleurs informels et les individus en chômage. Une étude transversale d’évaluation contingente (CV) a été menée en Tunisie se proposant d’estimer les volontés d’adhésion et les consentements à payer (WTP) pour deux régimes obligatoires présentés hypothétiquement à l’adhésion. Les résultats confirment l’hypothèse selon laquelle la proposition d’une affiliation volontaire à un régime d’assurance obligatoire serait acceptée par la majorité des non couverts et que les WTP révélés pour cette affiliation seraient substantiels. Enfin, dans le chapitre trois, on insiste sur l'’importance de prendre en compte les attitudes protestataires en évaluant la progression vers la CSU. / This thesis explores, in a four paper format, the possibility of extending social health insurance (SHI) schemes towards Universal Health Coverage (UHC) in presence of structural economic obstacles.The average treatment effects of two insurance schemes, MHI and MAS, on the utilization of outpatient and inpatient healthcare are estimated. The current Tunisian SHI schemes, despite improving utilization of healthcare services, are nevertheless incapable of achieving effective coverage of the whole population for needed services. Attaining the latter goal requires a strategy that targets the “trees” not the “forest”.Chapter two gets around major challenges to extending health insurance coverage and proposes an original approach by targeting informal workers and unemployed. A cross-sectional Contingent valuation (CV) study was carried out in Tunisia dealing with willingness-to-join and pay for two mandatory health and pension insurance schemes.Results support the hypotheses that the proposition of a voluntary affiliation to mandatory insurance schemes can be accepted by the majority of non-covered and that the WTP stated are substantial.Finally in chapter three we focus on methodological aspects that influence the value of the WTP. Our empirical results show that the voluntary affiliation to the formal health insurance scheme could be a step towards achieving UHC in Tunisia. Overall, we highlight the importance of taking into account protest positions for the evaluation of progress towards UHC.