Thesis (M.S.)--University of Michigan, 1989.

<p> Purpose: The purpose of this study is to explain the major barriers to medication access in rural seniors. How seniors access their prescription medications and make choices access helps to explain what seniors consider to be major barriers. This project has five goals: (1) describe what barriers rural seniors perceive that hinder access to their medicines and thus interfere with adherence to prescribed medication regimens; (2) understand what seniors perceive to be facilitators to accessing their prescriptions; (3) learn how or if social support networks play a role in helping rural seniors make decisions about how to use their resources to get their medications; (4) define the process that rural seniors use to move from potential access &mdash; the desire to get their medications, to revealed access &mdash; the actual ability to get their medications; and (5) describe what health care providers believe are the barriers that rural seniors face to getting their medicines. </p><p> Methods: I interviewed 19 low-income seniors in five towns in the San Luis Valley using semi-structured interviews, along with one pharmacist from each of seven pharmacies. A card study was conducted in nine clinics of the Valley Wide and Rio Grande systems. The interviews were coded using the grounded theory method. The card study survey was administered to primary care providers in eight clinics to gauge understanding of elderly patients' potential for barriers to access of medications. </p><p> Results: The primary finding is that poor structural health literacy (SHL) is the major barrier to access of medications, and to healthcare access generally. SHL is a factor in the more widely discussed barriers such as cost and transportation. </p><p> Discussion: SHL increases the chances that seniors will have access to healthcare by helping seniors learn how to take advantage of programs that enhance their ability to afford medications. Public Health agencies must work with community leaders to ensure that seniors are aware of their options for accessing medications, including financial and transportation options.</p>

<p> Understanding the relationships between human health, water, sanitation, and environmental health is a requirement to understanding the challenges that face researchers when it comes to addressing global health relating to water and sanitation. Access to improved water and sanitation is not only a precondition to health, but to all aspects of daily living. Target 7.C of the Millennium Development Goals (MDGs) addresses worldwide disparities in access to improved water and sanitation by calling for the reduction in <i> "half of the proportion of people without sustainable access to safe drinking water and sanitation by 2015".</i> Over 90% of the population of Costa Rica has access to improved water and sanitation, thus exceeding the water and sanitation targets for the Millennium Development Goals (MDGs). Despite having access to water and sanitation, little is known whether communities are only interested in access or if quality and quantity of water and sanitation systems are as equally as important. Target 7.c of the MDGs does not include water quality in the definition of safe water. Furthermore, the use of the words "safe" and "improved" in the target are often interchanged and can be misleading, especially when considering the impact of water quality on population health. In Costa Rica, households in the Nandamojo watershed have access to improved water and sanitation; it is unclear whether the drinking water is potable with respect to Costa Rican and the World Health Organization (WHO) water quality standards. The impact of leaking septic systems on human and environmental health is also unknown. </p><p> Illnesses associated with recreational water are an increasing public health problem, causing a great burden of disease in bathers every year. The global health impact of infectious diseases associated with recreational water exposure has been estimated at around three million disability-adjusted life years (DALYs) per year, resulting in an estimated economic loss of around twelve billion dollars per year. Fecal and chemical contamination of recreational water is a concern, especially in areas of non-point source pollution. Health-based water monitoring is often conducted in recreational waters as a tool for assessing risk. In Costa Rica, recreational water sampling is conducted at coastal beach areas only, neglecting other surface waters used by residents and tourists. Community perspectives regarding recreational water use and the associated risks are limited. Understanding these perspectives will enable public health professionals to better target community needs, such as education and to address the concerns of participating communities. </p><p> This dissertation was divided into three chapters. The first chapter explored community perceptions on improved water and sanitation, the second chapter assessed community water systems and the risk of acute diarrheal disease, and the third chapter captured community perceptions on recreational water use and the risk of waterborne illness. Methodologies for water sampling and analyses were used to assess water quality, while household interviews and focus groups were conducted to capture qualitative data. </p><p> Results from the first chapter showed participants had positive perceptions towards their improved water and sanitation systems. Household interviews revealed almost half of the respondents had concerns with water quality, while less than 25% did not think their septic tanks leaked or overflowed during rain events. Focus group discussions revealed common themes. Participants identified water quality, health, pipes, water scarcity, odors, insects, and overflow/infiltration of water and sanitation to be important issues. Participants revealed convenience, improved health and safety and the lack of odors to be themes directly related to customer satisfaction of improved water and sanitation. </p><p> Results from the second study revealed 57% of household samples had total coliform bacteria above the Costa Rican standard for safe drinking water exceeding the single standard limit of zero, while 61% failed the World Health Organization standard for fecal coliforms exceeding the single standard limit of zero. AGII was identified in 41 of the 378 household residents (11%). The odds ratio for AGII among household residents with a water sample positive for total coliforms was 1.88 (0.81-3.17). Fecal coliforms were statistically significant for those with AGII (OR = 3.19, 1.43-7.12). Regression modeling analyses revealed individuals with AGII and household drinking water positive for fecal coliforms to be statistically significant (OR = 3.01, 1.33 - 6.84), while other covariates (total coliforms, gender, treated water, and families) also had odds ratios greater than one, but were not significant. </p><p> Results from the third chapter indicated most respondents felt recreational water sources, such as streams and rivers were contaminated with human, animal, and chemical wastes. Focus group participants also stated they did not use inland waters for recreational purposes for these reasons. However, many did admit using marine water for recreational bathing and felt these areas were not contaminated. These beliefs did coincide with the water quality results from freshwater sources, but not marine sources. Fecal coliform contamination was widespread throughout the watershed in freshwater sources. Marine water samples failed the World Health Organization (WHO) and Costa Rican recreational water standards for fecal coliform and enterococci in 36% and 6% of the samples, respectively. </p><p> The overall results of this dissertation suggest that the definitions of improved water and sanitation have to include, at a minimum, water quality, water quantity, proper construction and containment of storage tanks, and oversight and maintenance of these systems. Given the challenges facing communities in the Nandamojo watershed regarding water and sanitation, it is essential for scientists, researchers, policy makers, water committees, health providers, and community members to design and implement strategies in water resource management and proper waste management. Communities and water committees would also be best served if they worked with government agencies to conduct concurrent testing of both recreational water and drinking water, especially since both them target many of the same parameters.</p>

Providing care services across several departments and care givers creates the complexity of the patient pathways, as it deals with different departments, policies, professionals, regulations and many more. One example of complex patient pathways (CPP) is one that exists in integrated care, which most literature relates to health and social care integration. The world population and demand for care services have increased. Therefore, necessary actions need to be taken in order to improve the services given to patients in maintaining their quality of life. As the complexity arises due to different needs of stakeholders, it creates many problems especially when it involves complex patient pathways (CPP). To reduce the problems, many researchers tried using several decision tools such as Discrete Event Simulation (DES), System Dynamic (SD), Markov Model and Tree Diagram. This also includes Direct Experimentation, one of techniques in Lean Thinking/Techniques, in their efforts to help simplify the system complexity and provide decision support tools. However, the CPP models were developed using a single tools which makes the models have some limitations and not capable in covering the entire needs and features of the CPP system. For example, lack of individual analysis, feedback loop as well as lack of experimentation prior to the real implementation. As a result, ineffective and inefficient decision making was made. The researcher also argues that by combining the DES and SD techniques, named the hybrid simulation, the CPP model would be enhanced and in turn will help to provide decision support tools and consequently, will reduce the problems in CPP to the minimum level. As there is no standard framework, a framework of a hybrid simulation for modelling the CPP system is proposed in this research. The researcher is much concerned with the framework development rather than the CPP model itself, as there is no standard model that can represent any type of CPP since it is different in term of its regulations, policies, governance and many more. The framework is developed based on several literatures, selected among developed framework/models that have used combinations of DES and SD techniques simultaneously, applied in a large system or in healthcare sectors. This is due to the condition of the CPP system which is a large healthcare system. The proposed framework is divided into three phases, which are Conceptual, Modelling and Models Communication Phase, and each phase is decomposed into several steps. To validate the suitability of the proposed framework that provides guidance in developing CPP models using hybrid simulation, the inductive research methodology will be used with the help of case studies as a research strategy. Two approaches are used to test the suitability of the framework – practical and theoretical. The practical approach involves developing a CPP model (within health and social care settings) assisted by the SD and DES simulation software which was based on several case studies in health and social care systems that used single modelling techniques. The theoretical approach involves applying several case studies within different care settings without developing the model. Four case studies with different areas and care settings have been selected and applied towards the framework. Based on suitability tests, the framework will be modified accordingly. As this framework provides guidance on how to develop CPP models using hybrid simulation, it is argued that it will be a benchmark to researchers and academicians, as well as decision and policy makers to develop a CPP model using hybrid simulation.

This thesis is concerned with the health-related effects of perspective-taking in response to a narrative health campaign. To begin, the thesis outlines the health promotion strategies currently in use (i.e., statistical vs. narrative), presents research discussing their relative effectiveness, and considers the potential for perspective-taking to influence the impact of narrative health campaigns (Chapter 1). The thesis then defines two types of perspective-taking, cognitive and emotional, and explores the processes underlying these (Chapter 2). Each type of perspective-taking is then considered in the context of the health promotion literature (Chapter 3). It was proposed that, whereas cognitive perspective-taking should have a relatively straightforward and positive effect on the impact of narrative health campaigns, the effects of emotional perspective-taking should be more variable. Seven studies were conducted to test this basic premise and identify mediators and moderators of the observed effects. In Chapter 4, two studies are presented that aim to establish the effects of perspective-taking on health-related outcomes (Studies 1 & 2). A broadly consistent pattern was observed across these studies: encouraging cognitive perspective-taking led to more positive health-related outcomes than did encouraging emotional perspective-taking. Having established the basic effect, two studies are presented in Chapter 5 that explore a potential mediator: perspective-takers’ self-efficacy concerning a health promoting behaviour (chlamydia testing: Studies 3 & 4). These studies found a consistent indirect effect of perspective-taking on intentions to get tested for chlamydia through self-efficacy: encouraging cognitive perspective-taking increased participants’ perceived self-efficacy relative to encouraging emotional perspective-taking, which in turn positively predicted intentions to get tested in the future. The three studies presented in Chapter 6 explore potential moderators of the effects of perspective-taking (Studies 5-7). Specifically, these studies test whether the relative effects of perspective-taking are moderated by features of the relationship between the perspective-taker and a target presented in a narrative health campaign. The broad pattern observed across these studies suggests that the perception of a shared categorisation (or social identity) between the perspective-taker and target moderates the effect of perspective-taking on health-related outcomes. Specifically, the final study, Study 7, demonstrated that encouraging cognitive perspective-taking in response to a narrative health campaign leads to more positive health-related effects than encouraging emotional perspective-taking when perspective-takers’ personal (unshared) identity is made salient; however, these effects are attenuated (and potentially even reversed) when a social (or shared) identity is made salient. Considered as a whole, the research presented in this thesis represents the first empirical examination of the relative health-related effects of different types of perspective-taking in response to a narrative health campaign. The research demonstrates that perspective-taking is an important factor in determining whether or not narrative health promotion campaigns are likely to be effective. However, it also makes clear that the processes through, and conditions under, which cognitive and emotional perspective-taking can help to ensure the effectiveness of narrative health campaigns are not yet fully understood. Nevertheless, the studies presented herein successfully identify several such conditions and mechanisms ready for further study. Theoretical and practical implications, alongside limitations and more specific suggestions for further research are discussed.

A research report submitted to the Schools of Public Health and Social Sciences, University of the Witwatersrand, Johannesburg, in partial fulfilment of the requirements for the award of the Degree of Masters of Arts in the Demography and Population Studies / Although life expectancy has increased in South Africa (RSA), compared with other middle-income countries, health status is poor most especially among the black majority. Coupled with this are the burdens of infectious and non-communicable diseases. RSA has also shown evidence of weak social cohesion through prevalent racial and gender discrimination, income inequalities, and violence. While previous studies on the health status of adults in RSA has only examined its association with other social determinants, the relationship of adult health status and social cohesion, unlike in developed countries, remains under researched in South Africa and other African countries. Using the collective efficacy theory by Sampson and colleagues (1997), this study adds the ‘African perspective’ to the ongoing debate about the health importance of social cohesion. It examined the relationship between social cohesion and the health status of adults in South Africa. The levels and patterns of health across social cohesion and other socio-demographic characteristics were also examined. DATA AND METHODS: Data was drawn from the 2012 South African Social Attitudes Survey, a survey implemented annually by the Human Sciences Research Council. Social cohesion was assessed by drawing from the five measurable items from the work of Sampson and colleagues (1997) which encompass trust, a sense of belonging, shared values and helpless in both cash and kind. These items were subjected to principal component factor analysis with Promax rotation. Cronbach’s alpha (α) for this scale is 0.84. Scores were divided into tertiles of low, medium and high social cohesion. A cumulative stepwise logistic regression model was fitted on a weighted sample of 22,605,550 adults in South Africa aged 18 years or older to examine the nexus between social cohesion and self-rated health status. Sub-group analysis examined if the observed relationship differed by race. The data was analysed using STATA software version 14. All model diagnostics showed that the model fits reasonably for the data. The interpretation of results was made using odds ratios (ORs), and a 95% confidence was used. RESULTS: More than half of adults (54%) in South Africa reported themselves to be in good health while only about 17% reported that they were in poor health. The percentage of adults reporting good health is higher among adults in the highest tertile of social cohesion (59%), compared to 53% among those in the lowest tertile. Controlling for other characteristics, regression analysis showed that adults in lowest tertile [OR:0.70, CI:0.516 - 0.965] and moderate tertile [OR:0.79, CI:0.589 - 1.055] of social cohesion were less likely to report moderate or good health compared to adults in the highest tertile of social cohesion, but the relationship was only statistically significant among adults in the lowest tertile of social cohesion. Sub-group analysis by race showed that among all the racial groups (excluding Indian or Asian adults), black African [OR:0.68, CI:0.472-0.989], coloured [OR:0.63, CI:0.305-1.309], and white [OR:0.67, CI:0.293 1.545] adults residing in the lowest tertile of social cohesion were less likely to be in moderate or good health compared to those in the highest tertile of social cohesion, but the relationship was only statistically significant among black Africans. CONCLUSION AND RECOMMENDATION: The findings from this study demonstrate that social cohesion among adults in South Africa, particularly among black Africans, is important for improvement in health. It is therefore important that the government of South Africa intensifies efforts aimed at increasing social cohesion among adults, particularly among black Africans. This could be achieved through public awareness on the health importance of social cohesion and the need for neighbours to share similar values, trust one another and be willing to help. This is especially important if significant progress is to be made in achieving the sustainable development goals to improve the health of adults in the country by 2030. / XL2018

This thesis investigated the health needs of economically disadvantaged mothers and children living in Grant County to determine if they were being met by the existing community health resources. The thesis had three main purposes: (1) to identify the health needs of economically disadvantaged mothers and children living in Grant County; (2) to assess the resources in Grant County which provide health instruction and, health services to mothers and children; and (3) to analyze the present health needs as they relate to resources available to economically disadvantaged mothers and children.Inquiry as to health needs of the mothers and children in the group was focused and limited to health care and instruction for expectant mothers during pregnancy, birth, and postpartum. tkbr the children, the need for regular health appraisals for early detection of defects was considered. The limitations of inquiry were designed. specifically to determine the need for initiating and implementing well child clinics, prenatal and postpartum clinics, and family planning clinics in Grant County for the economically disadvantaged mothers and children.Ball State UniversityMuncie, IN 47306

Due to the subjective nature of pain and the profound debilitating effects of pain for a growing number of people, there are many challenges to approaching and fully addressing its problems. The traditional biomedical model of health limits its treatment focus to the physical components of pain. Biomedicine provides useful and effective short-term relief of bodily symptoms, but usually cannot cure pain that persists in both mind and body over time. Because chronic pain is often accompanied with discomfort, depression, and other significant life impairments, health researchers have recently conceptualized more comprehensive models to address pain. In the bio-psycho-social-spiritual health model, chronic pain is assessed and treated in the context of a person’s overall quality of life, considering biological, psychological, social, and spiritual health conditions. This movement towards adopting integrative health care models can also provide patient guidance needed for developing inner resources to adapt to pain, as well as recover from and prevent disease. Self-compassion comes from a fertile field of inquiry emerging out of a wider conception of health that includes spirituality. The construct is based on three related components that can assist a person living with pain: (a) being kind to oneself while in pain or suffering, (b) perceiving difficult times as shared human experiences, and (c) holding painful thoughts and feelings with mindfulness, instead of over-identification. Measured using the Self-Compassion Scale, it demonstrates positive associations with a variety of health indicators. However, a direct relationship with chronic pain has not yet been examined. In applying recent research in quality of life (QoL) and self-compassion to a chronic pain patient population, the purpose of this study is twofold: (a) to produce a comprehensive assessment of bio-psycho-social-spiritual QoL conditions (b) to examine differences in QoL with the presence of self-compassion and determine its potential moderating effect on life impairments due to pain. From this project, the QoL conditions that are affected by chronic pain and the moderation effect of self-compassion will be understood better so that more effective treatment and prevention procedures can be developed for people living with pain from long-term disease conditions. / text

<p> The Accountable Care Organization (ACO) has been introduced in the US as a health system reform initiative with potential to achieve the immediate and long-term goals of improving population health, improving quality and producing greater value for the healthcare dollars spent. Over the past half-century, a number of health system reforms have been designed and implemented with these goals as the intended outcomes. These efforts have produced, at best, incremental learning, variable improvements in performance outcomes, and modest cost-savings. Early evaluations of the health, quality and cost outcomes from ACO sites suggest that the long-term effectiveness of the ACO care model faces obstacles similar to those that have impeded the long-term success of past health system reform efforts. The fundamental question of how to transform the existing construct of care delivery towards one of open collaboration, team-based care and active management of health and patient populations remains elusive (Institute of Medicine, 2012).</p><p> It is under these conditions that three independent but thematically linked investigations were conducted. The first investigation, a comparative policy analysis of US-based health system reform efforts found that transforming the construct of care delivery&mdash;how care is organized and how care is delivered are fundamentally social and relational processes that impact the outcomes of reform. These processes have been underexplored alongside other change levers in the health services research and practice communities to the detriment of healthcare organizations confronted by the need to transform the construct of care delivery as the healthcare environment transitions towards accountable care. </p><p> The second and third investigations were focused at the level of the healthcare organization and its members. The instrumental case of a large integrated delivery system transforming its disease management program for diabetes towards an ACO model was used to further examine the social and relational dynamics of health system reform. The second investigation, a qualitative analysis of the social-psychological dimensions of the change process, found that ACO characterization, Uncertainty, conceptual perceptions of the notion of accountability, and Electronic Health Record implementation influenced how the network of providers made sense of transformation towards accountable care and their perception of system readiness to engage in change and be successful. </p><p> The third investigation, an applied example, demonstrated how relational coordination and social network analysis can be used as complementary tools to inform the design and implementation of interventions intended to transform the construct of care delivery in support of the goals of health system reform. Measurement of the quality of team performance found weak relational coordination ties across each network and among the roles treating and managing diabetes in a network. Social Network Analysis (SNA) of relational coordination found differential pathways for leveraging roles structures within a network in support of change efforts. </p><p> Collectively, these investigations suggest that if ACOs are to achieve the short- and long-term goals of health system reform, the social and relational dynamics of change are important to incorporate and consider alongside of other health system reform change levers.</p>

<p> The federal government provides an uncapped reimbursement of state Medicaid spending. In theory, states can use the federal Medicaid funds as a replacement for state funds or the federal funds, which take the form of a matching grant that reduces the relative price of Medicaid, can increase (or stimulate) spending on Medicaid with state-raised tax revenue. In the first dissertation paper, <i> Subsidizing Medicaid Growth: The Impact of the Federal Reimbursement on State Medicaid Programs,</i> I use a state panel data set from 1992 to 2006 to assess the impact of the federal reimbursement on the size of state Medicaid programs. I find that a one point increase in a state's Medicaid reimbursement percentage increases state per capita Medicaid spending between $5 and $16 and increases the percentage of the state's population receiving Medicaid benefits by 0.04 percent to 0.29 percent. </p><p> The first paper also utilizes a case study that shows significant growth in Alaska's Medicaid program after its effective federal Medicaid reimbursement increased 50 percent between 1998 and 1999. The large growth in Alaska's Medicaid program after this increase provides evidence that states respond to large increases in the federal Medicaid subsidy in a stimulative manner by increasing spending with state-raised revenue. Overall, the results in the first paper are consistent with the hypothesis that decentralization in the form of intergovernmental matching grants increases the size of government. I also find that states with wealthier and more liberal populations tend to have larger Medicaid programs and that states with Democratic legislatures tend to have more Medicaid beneficiaries than states with Republican legislatures all else equal. </p><p> Since 2008, states have experienced significant budgetary pressure; in large part, because of rising Medicaid enrollment due to the recession and weak recovery. Between 2009 and 2011, many states enacted health care provider taxes as a way to bring in additional revenue through the federal Medicaid reimbursement. Provider taxes are generally supported by health care providers since states often give providers an implicit or explicit guarantee of a return of at least as much funding through higher payment rates or supplemental payments. In the second dissertation paper, <i>Impact of Hospital and Nursing Home Taxes on State Medicaid Spending,</i> I assess the impact of the two largest provider taxes, the hospital tax and the nursing home tax, on state Medicaid expenditures using a panel dataset of 42 states from between 2007 and 2011. I find significantly larger Medicaid spending growth for hospitals in states that added hospital taxes and significantly larger Medicaid spending growth for nursing homes in states that added nursing home taxes within the first two years of the enactment of the tax. I also find some evidence that states with hospital taxes were able to increase their total Medicaid spending more than states without hospital taxes during the economic downturn and initial recovery period. This paper also contains evidence that nursing home taxes diverted Medicaid spending from home and community based services to nursing homes. </p><p> In the third dissertation paper, <i>Statewide Health Impact of Tennessee's Medicaid Expansion,</i> I utilize a quasi-experimental approach to assess the impact of a large statewide public health insurance expansion on access to health care services, health care utilization, and health outcomes. In 1994, Tennessee expanded its state Medicaid program, called TennCare, by about ten percent of the state's population. Along with a major Medicaid expansion, Tennessee increased government subsidies for individuals to purchase health insurance coverage and emphasized managed care. Using a difference-in-difference methodology with Tennessee's neighboring states as controls, I found that TennCare's impact on utilization was mixed as blood pressure and cholesterol checks increased but regular physician check-ups decreased relative to the surrounding region. Surprisingly, both self-reported health and mortality rates were less favorable in Tennessee relative to the control states after TennCare. Ultimately, the evidence in this paper suggests that health reform built around a significant public insurance expansion is likely to result in minimal, if any, overall health gains measured in the entire population, at least in the short run. </p><p> The final dissertation section summarizes the findings from the three dissertation papers, discusses the economic efficiency of the uncapped federal Medicaid reimbursement and state provider taxes, and makes several predictions related to the Medicaid expansion in the Patient Protection and Affordable Care Act.</p>