The purpose of this dissertation was to examine patterns of antenatal stressful life events (SLEs) experienced by women in the United States (U.S.) and their association with postpartum depression (PPD). It further explored the role of women's state-level socio-economic status (SES) on PPD; the racial/ethnic dispartites in SLE-PPD relationship; and the role of provider communication on perinatal depression. Data from 2009–11 Pregnancy Risk Assessment Monitoring System (PRAMS) and SES indicators published by the Institute of Women’s Policy Research (IWPR) were used. Latent class analysis (LCA) was performed to identify unobserved class membership based on antenatal SLEs. Multilevel generalized linear mixed models examined whether state-level SES moderated the antenatal SLE-PPD relationship. Of 116,595 respondents to the PRAMS 2009-11, the sample size for our analyses ranged from 78% to 99%. The majority (64%) of participants were in low-stress class. The illness/death related-stress class (13%) had a high prevalence of severe illness (77%) and death (63%) of a family member or someone very close to them, while those in the multiple-stress (22%) class endorsed most other SLEs. Eleven percent had PPD; women who experienced all types of stressors, had the highest odds (adjusted odds ratio [aOR]: 5.43; 95% confidence interval [CI]: 5.36, 5.51) of PPD. The odds of PPD decreased with increasing state-level social/economic autonomy index (aOR: 0.75; 95% CI: 0.64, 0.88), with significant cross-level interaction between stressors and state-level SES. Among non-Hispanic blacks and non-Hispanic whites, husband/partner not wanting the pregnancy (aOR: 1.47; 95% CI: 1.14, 1.90) and drug/drinking problems of someone close (aOR: 1.37; 95% CI: 1.21, 1.55) were respectively associated with PPD. Provider communication was protective. That 1 out of every 5 and 1 out of every 8 women were in the high- and emotional-stress classes suggests that SLEs are common among pregnant women. Our results suggest that screening for antenatal SLEs might help identify women at risk for PPD. The finding that the odds of PPD decrease with increasing social/economic autonomy, could have policy implications and motivate efforts to improve these indices. This study also indicates the benefits of antenatal health care provider communication on perinatal depression.

A qualitative study of the experiences and observations of 4 art therapists and 2 program directors who facilitated Camp Suzanne, a week-long art-based therapeutic program for incarcerated mothers and their children in a federal prison in California. Research on psychotherapy, art therapy, and family therapy in prison environments, with a focus on parent-child dyads, Attachment Theory, and various techniques for creating sustainable therapy with separated family units, including tele-mental health and evidence-based military protocols, informed the interviews. The research participants were interviewed individually and created art regarding the subjects of Attachment Theory with incarcerated-mother-child dyads and longevity considerations for the program. Emergent themes in the data included the impact of art-making on attachment and a variety of observable attachment styles, as well as obstacles to both attachment and longevity of Camp Suzanne. Some of the obstacles addressed include systemic challenges, continuity of care, location concerns, external support (for facilitators and for incarcerated-mother-child dyads), as well as preparatory support (psychoeducation). Various implications of these obstacles are discussed.

La sclérose en plaques (SEP) est une maladie neuro-inflammatoire du système nerveux central. Les causes sont multifactorielles impliquant à la fois une prédisposition génétique et l'influence de facteurs environnementaux. Dans environ 85% des cas, les patients sont atteints de poussées correspondants à la survenue de signes neurologiques, suivis d'une phase de rémission partielle ou totale. De nombreux travaux avancent l'hypothèse selon laquelle le taux de poussées varie au gré des saisons, survenant plus fréquemment au printemps et en été. Cette fluctuation temporelle a soulevé la question de l'influence de paramètres dépendants de la saison tels que l'ensoleillement et le statut en vitamine D, le niveau de mélatonine ou encore la pollution atmosphérique. Etant donné cette variation de la pollution de l'air, nous avons cherché à explorer l'impact à court terme des particules fines (PM10), benzène (C6H6), dioxyde d'azote (NO2), monoxyde de carbone (CO) et de l'ozone troposphérique (O3), sur le risque de déclenchement de poussée, indépendamment des saisons "chaude" (1er avril au 30 septembre) et "froide" (1er octobre au 31 mars). Ce travail s'est appuyé sur les données de patients issus du réseau ville-hôpital alSacEP. Nous avons sélectionné 424 patients atteints de SEP à début rémittent et ayant connu un total de 1 783 poussées (2000-2009). Les niveaux journaliers de pollution, produits grâce au modèle physique déterministe ADMS-Urban, ont été modélisés sur une base horaire pour chaque IRIS de la communauté urbaine de Strasbourg par l'actuelle AASQUA ATMO Grand Est. De plus, une enquête individuelle menée dans le cadre de cette étude auprès de l'ensemble des patients (PT) a permis de collecter (par questionnaire téléphonique ou auto-questionnaire sur internet) des informations personnelles socio-économiques (SES) et du mode de vie pour 188 d'entre eux (PS). Enfin, le niveau SES des IRIS a été estimé à l’aide d’un indice de défaveur social - construit à partir des données du recensement de l’INSEE. Nous avons observé une influence saisonnière délétère à court terme de la pollution (3 jours précédant la poussée) sur le risque de poussée en PT, notamment de l'O3 en saison "chaude" et des PM10 et NO2 en saison "froide". Nos résultats suggèrent également que le contexte SES puisse exacerber ces associations, notamment chez les patients résidant dans les quartiers défavorisés lors d'exposition aux PM10, NO2, C6H6 et CO ("froide") et ceux résidant dans les quartiers favorisés et défavorisés lors de l'exposition à l'O3 ("chaude"). Enfin, nous avons observé chez la PS que le niveau d'éducation faible, le revenu familial moyen, la consommation de cigarette et le manque d'activité physique régulière sont les catégories SES et du mode de vie les plus associées avec le risque de poussée lors de l'exposition à la pollution de l'air. Ce travail montre la nécessité d'étudier les expositions environnementales au cours de la SEP selon une approche holistique intégrant des facteurs individuels et contextuels. / Multiple sclerosis (MS) is a neuro-inflammatory disease of the central nervous system (CNS). Causes are multifactorial enrolling both genetic predisposition and influence of environmental factors. In 85% of cases, patients experience relapse corresponding to the occurrence of neurologic signs, followed by a phase of partial or total remission. Several studies put forth the hypothesis that relapses rate varies across season, mainly occurring during spring and summer. This temporal fluctuation raised the question of season-dependent parameters influence such as sunlight exposure and vitamin D, melatonin level or ambient air pollution. Considering this variation of air pollution, we explored the short-term impact of fine particles (PM10), benzene (C6H6), nitrogen dioxide (NO2), carbon monoxide (CO) and ground-level ozone (O3), on the risk of relapse triggering, separately for "cold" (i.e., October-March) and "hot" (April-September) season. This work has drawn from data of patients provided by the alSacEP network. We included 424 patients affected with remitting MS onset who experienced 1,783 relapses over the 2000-2009 period. Daily level of air pollution was modeled through ADMS-Urban software at the census block scale of the Strasbourg metropolitan area (AASQA ATMO Grand Est). Furthermore, an individual survey was conducted among all the patients (PT) in order to collect individual socioeconomic (SES) and lifestyle features. Finally, the census block SES position was estimated using a composite deprivation index - created from the INSEE census data. A short-term (3 days preceding the relapse) seasonal adverse effect was observed in PT, in particular during exposure to O3 in "hot" season and PM10 and NO2 in "cold" season. Results also suggest that the SES context might exacerbate these associations, in particular among patients who were living in deprived neighborhood with exposure to PM10, NO2, C6H6 and CO ("cold) and those who were living in most well-of and deprived places with exposure to O3 ("hot"). Finally, we observed among Ps that low education level, average family income, smoking and lack of physical activity are more associated with the risk of relapse triggering when patients were exposed to air pollution. This work shows the need to investigate environmental exposure such as air pollution along the SEP course using a holistic approach integrating individual and contextual factors.

The determinants of health care use among rural, low-income mothers and their children were assessed using a multi-state, longitudinal data set, Rural Families Speak. The results indicate that rural mothers’ decisions regarding health care utilization for themselves and for their child can be best modeled using a simultaneous systems approach to negative binomial regression. Mothers’ visits to a health care provider increased with higher self-assessed depression scores, increased number of child’s doctor visits, greater numbers of total children in the household, greater numbers of chronic conditions, need for prenatal or post-partum care, development of a new medical condition, and having health insurance (Medicaid/equivalent and HMO/private). Child’s visits to a health care provider, on the other hand, increased with greater numbers of chronic conditions, development of a new medical condition, and increased mothers’ visits to a doctor. Child’s utilization of pediatric health care services decreased with higher levels of maternal depression, greater numbers of total children in the household, if the mother had HMO/private health care coverage, if the mother was pregnant, and if the mother was Latina/African American. Mother’s use of health care services decreased with her age, increased number of child’s chronic conditions, income as a percent of the federal poverty line, and if child had HMO/private health care insurance. The study expands the econometric techniques available for assessing maternal and pediatric health care use and the results contribute to an understanding of how rural, low-income mothers choose the level of health care services use for themselves and for their child. Additionally, the results would assist in formulating policies to reorient the type of health care services provided to this vulnerable population.

Background: Shifting the healthcare payment system from a volume-based to a value-based model has been a significant effort to improve the quality of care and reduce healthcare costs in the US. In 2018, Massachusetts Medicaid launched Accountable Care Organizations (ACOs) as part of the effort. Constructing, assessing, and risk-adjusting quality measures are integral parts of the reform process. Methods: Using data from the MassHealth Data Warehouse (2016-2019), we assessed the loss of community tenure (CTloss) as a potential quality measure for patients with bipolar, schizophrenia, or other psychotic disorders (BSP). We evaluated various statistical models for predicting CTloss using deviance, Akaike information criterion, Vuong test, squared correlation and observed vs. expected (O/E) ratios. We also used logistic regression to investigate risk factors that impacted medication nonadherence, another quality measure for patients with bipolar disorders (BD). Results: Mean CTloss was 12.1 (±31.0 SD) days in the study population; it varied greatly across ACOs. For risk adjustment modeling, we recommended the zero-inflated Poisson or doubly augmented beta model. The O/E ratio ranged from 0.4 to 1.2, suggesting variation in quality, after adjusting for differences in patient characteristics for which ACOs served as reflected in E. Almost half (47.7%) of BD patients were nonadherent to second-generation antipsychotics. Patient demographics, medical and mental comorbidities, receiving institutional services like those from the Department of Mental Health, homelessness, and neighborhood socioeconomic stress impacted medication nonadherence. Conclusions: Valid quality measures are essential to value-based payment. Heterogeneity implies the need for risk adjustment. The search for a model type is driven by the non-standard distribution of CTloss.

Childhood adversity is associated with numerous negative outcomes across multiple domains, including mental and physical health, interrelationships, and social functioning. Notably, research suggests that childhood adversity has a dose-response relationship with these outcomes; that is, greater numbers of adverse experiences in childhood are associated with worse outcomes. These outcomes overlap with many risk factors of homelessness. This study sought to address two questions: 1) Does a dose-response relationship exist between childhood adversity and chronic homelessness? 2) Does childhood adversity negatively predict the age at which homelessness first occurs? Adults experiencing homeless who are accessing homeless services in the Tri-Cities area of Northeast Tennessee responded to a brief instrument that includes measures of homeless chronicity, Adverse Childhood Experiences (ACEs), and age of onset of homelessness. Although relationships between ACEs and homeless chronicity was not observed, a relationship did emerge between number of ACEs and number of episodes and number of ACEs and age at initial onset of homelessness.

<p>All images in this document may not be produced without the expressed written consent of the author.</p> / <p>The innovative research method of “body mapping” was used in this study with geriatric inpatients receiving daily hæmodialysis therapy for end-stage renal disease at Toronto Rehabilitation Institute.</p> <p>Five people took part in this study; three participants completed all study phases. They created three body maps each and took part in one follow up, semi-structured interview to share their experiences of body mapping. Two themes were drawn from the data: (1) body mapping gives patients a voice to communicate their experiences in the dialysis unit; and (2) body mapping makes visible participants’ illness adjustment patterns, and levels of connection, or disconnection in the dialysis unit.</p> <p>Based on the ways body mapping benefitted participants in this study, it is reasonable to suggest that this visual communication tool could be useful in other research settings, and as a clinical tool to support patients’ attention to their bodies and their interactions with healthcare providers.</p> / Master of Arts (MA)

This research qualitatively explores the impacts of the Helen B. Landgarten Art therapy Clinic’s transition to art therapy telehealth services during the COVID-19 pandemic. The purpose of this research was to explore the efficacy of interventions and the clinical themes that emerged as a result of telehealth art therapy services delivered to marginalized communities through the Helen B. Landgarten Art Therapy Clinic. Data that was collected includes anonymous surveys from administrators, teachers, and caregivers of those receiving services and facilitators of services, semi-structured interviews with administrators, teachers, and caregivers of those receiving services, as well as a focus group with facilitators of services. Through the analysis of data several findings suggest that art therapy telehealth can provide a safe space for engagement in mental health and be more accessible to marginalized communities. These findings potentially open new doors for further inquiry into art therapy telehealth.

1. Unterschiedliche Definitionen der Gesundheit mit verschiedenen Betrachtungsweisen (WHO: Der Mensch eine biopsychosoziale Einheit. Schulmedizin: ohne klinischen und paraklinischen Befund mit Orientierung an kritikbedürftigen Referenzmittelwerten) führt bei Fachleuten, Behörden und Laien zu Verwirrungen, wenn es um die Beurteilung gesundheitlicher Schäden geht. 2. Es wurde die Aufgabe gestellt zu prüfen, welche der beiden Definitionen der Realität näher kommt. 3. Mittels der chronopsychobiologischen Regulationsdiagnostik, des Dreiphasenentspannungstests (Hecht und Balzer 2001), wurden unter dem Aspekt der beiden Gesundheitsdefinitionen drei Gruppen untersucht (je 40 Probanden). - klinisch Gesunde (klinisch Gesunde nach Schulmedizin ) - Gesunde nach Definition der WHO - Probanden mit nichtorganische Insomnie (ohne pathologische klinische und paraklinische Befunde) 4. Die mit den verwendeten Methoden gewonnenen Daten wiesen aus, dass zwischen den klinisch Gesunden und den Probanden mit nichtorganischer Insomnie weitgehend größere Ähnlichkeiten bestehen. Beide Gruppen zeigten aber zu der Gruppe der Gesunden nach WHO-Definition, welche die biopsychosoziale Einheit des Menschen berücksichtigt, noch hochsignifikante Unterschiede. Die Gruppe der klinisch Gesunden kann daher auf Grund unserer Ergebnisse nicht den Anspruch erheben, real gesund zu sein. 5. Mit der Bezugnahme auf die Internationale Klassifikation der Krankheiten (ICD 10F) haben die von uns untersuchten klinisch Gesunden und die nichtorganischen Insomniker eine mehr oder weniger stark ausgeprägte Symptomatik von psychischen Störungen. Dies müsste bei der Beurteilung von Schadstoff-, Lärm-, und EMF-Wirkungen auf den Menschen, wie auch bei den klinisch-pharmakoloischen Untersuchungen beachtet werden. Die in der Arbeit erzielten Ergebnisse bedürfen durch weitere Untersuchungen eine Fundierung. Sie signalisieren aber sowohl unter praktischen als auch unter theoretischen Aspekten einen dringenden Forschungsbedarf. / 1. Differing definitions of health using different criterea (WHO: The human being as a bio- psycho-social unit versus classical medicine: without clinical and paraclinical results based on suspect reference values) bring confusion to experts, authorities and laymen when assessing health damages. 2. The given task was to check which of the two definitions is closer to reality. 3. Using the chrono-psycho-biological diagnostic of regulation, the three-phase-relaxation test (Hecht and Balzer 2001), three groups were examined considering the aspects of the two health definitions (40 test subjects in the study group). - clinically healthy (clinically healthy per classical medicine definition) - healthy per definition of the WHO - test persons with non organic insomnia (i.e. no pathological or paraclinical findings) 4. The data gained from the employed methods revealed bigger similarities between clinically healthy persons and those with non organic insomnia. Both groups still showed highly significant differences to the group which fulfils the definition of the WHO regarding a human as a bio-psycho-social unit. As a result of this study, persons, though classified as "clinically healthy" might nevertheless not absolutely be healthy in reality. 5. In reference to the international classification of illnesses (ICD 10 F) the groups examined, both of clinically healthy and those with non organic insomnia, have more or less severe psychological symptoms. This should be taken into account when assessing the effects of pollution, noise, and EMF as well as clinical pharmacological studies. These present findings still need broader confirmation by further investigations. However, they clearly indicate, for practical and theoretical considerations, an urgent need for further research.

Given the general poor state of health care and the devastating effect of user fee, the National Health Insurance Scheme (NHIS) was instituted as a health financing policy with the main purpose to ensure universal access for all Nigerians. However, since NHIS became operational in 2005, only members of scheme are able to access health care both in the public and in private sectors, representing about 3% of Nigerian population. The thesis therefore examines the design and implementation policy of NHIS in Oyo state, Nigeria. Key design issues conceptual framework guides the analysis of data. The framework identifies three health interrelated financing functions namely revenue collection, risk pooling and purchasing. Data was collected from the NHIS officials, employees of the Health Maintenance Organisations (HMOs) and the Health Care Providers (HCPs) using key informant interview. In addition, in-depth interview and semi structure questionnaire were used to gather data from the enrolees and the nonenrolees. Empirical findings show that NHIS is fragmented given the existence of several programmes. In addition, there is no risk pooling neither redistribution of funds in the scheme. Revenue generated through contributions from the enrolees was not sufficient to fund health care services received by the beneficiaries because of the small percentage of the Nigerian population that the scheme covers. Further findings indicate that enrolled federal civil servants have not commenced monthly contribution to the NHIS. They pay 10% as co-pay in every consultation while federal government as an employer subsidised by 90%. Majority (76.8%) of the respondents agreed that they were financially protected from catastrophic spending. However, the overall benefit package was rated moderate because of exclusion of some priority and essential health care needs. Although above half (57%) of the respondents concurred that HMOs are accessible, in the overall, (47.6%) of the respondents were not satisfied with their services. In the case of the HCPs, majority (61.9%) of the respondents claimed that there is no excessive waiting time for consultation. Furthermore, (64.3%) rated their interpersonal relationship with the HCPs to be good. However, more than half of the respondents (54%) disagreed on availability of prescribed drugs in NHIS accredited health facilities. For the nonenrolees, findings show that most of the respondents (72.9%) were willing to enrol, but significant proportion (47.5%) indicated financial constraint as impediment to enrolment. / Sociology / D. Phil. (Sociology)