Transportation is frequently cited as a barrier to health care, but rarely have researchers analyzed the problems in depth. The purpose of this study was to assess the role transportation plays in the utilization of preventive health care services among Medicaid recipients ages 0 - 20 in Texas. This preventive care is known as Early Periodic Screening and Diagnostic Testing (EPSDT), a comprehensive prevention and treatment program for Medicaid eligible children. Our computer assisted telephone interviewing based survey was administered to Medicaid recipients selected from a representative sample through a stratified sampling scheme. Binary logistic regression models were used to assess and predict factors associated with utilization of the Texas Medicaid Transportation Program (MTP) and utilization of EPSDT. We also used k-means cluster analysis to identify subgroups of Medicaid clients with particularly acute transportation barriers. Of the 1,214 Medicaid recipients interviewed, the overall odds of a Medicaid recipient being a MTP non-user was 0.94. For clients with automobile access, the probability increases to 0.98. Clients who experienced difficulties paying for gasoline decreased the overall odds to 0.86. When examining utilization of EPSDT, the overall probability of being a low utilizer was 0.59. Two factors, Spanish-speaking patients (0.21) and clients with more than one child at home (0.54) decreased the overall odds of being a low utilizer, while those with difficulty paying for gasoline increased the odds of being a low utilizer to 0.63. Increasing EPSDT utilization among the millions of Texas Medicaid recipients is an important policy objective. Because the Texas Medicaid population is large and diverse, no single approach to increasing utilization is likely to address all needs. The group concept provides a means to understand which Medicaid recipients do not access MTP services and those with low utilization rates. These groupings can be useful in targeting Medicaid clients with specific transportation difficulties. Instead of broad informational campaigns, policy makers should devise targeted strategies to promote the most appropriate types of assistance. In addition to expanding transportation options, policy makers should also examine the locations in which care is delivered, considering telemedicine, mobile health and school-based health clinics as options.

Advances in HIV care and treatment continue to prolong the lives of people diagnosed and living with HIV (PDLWH). The National HIV/AIDS Strategy mobilizes national, state, and local efforts toward ensuring equitable access to care, reducing disparities, and improving continuum of HIV care outcomes. A social/community-based factor that contributes to sub-optimal HIV outcomes for PDLWH – all of whom require regular visits to a medical facility – is access to accommodating, affordable, and acceptable HIV care providers. Employing case surveillance data to analyze relationships between social/community-based factors and HIV disease outcomes is an opportunity to identify underserved PDLWH. This analytic approach, linking individual case-level epidemiologic surveillance data with macro-level community measures, provides public health departments a more precise estimate of priority geographic zones and subpopulation clusters whereby limited public health resources can be directed for maximal impact and efficiency. This dissertation analyzed California HIV surveillance system (CHSS) data to characterize PDLWH in terms of residential census tract characteristics related to income, poverty, unemployment, vehicle access, population density, travel duration from residence to care facility, and access to care. The primary study population was 60,979 PDLWH as of 2014 who had recent, geocoded residential addresses collected in CHSS. Access to care was measured using a novel enhanced two-step floating catchment area (E2SFCA) method developed for this dissertation. We also assessed whether community characteristics, trip duration, and access to care were associated with suppressed viral load, an indicator of successful disease management. Several significant relationships were found between suppressed viral load and where people lived, how long they drove for care, and their E2SFCA-measured access to care. This analysis identifies new methods for state and local health jurisdictions to: investigate factors associated with HIV-specific health disparities, improve the capacity to direct resources for improving health outcomes for PDLWH, and enhance transmission prevention efforts.

The profession of law enforcement is an inherently stressful job. Although the physical stress of the job is often discussed, the mental health impact on officers is often ignored, resulting in poor mental health and increased risk for suicide. The purpose of the current study was to investigate factors related to the reluctance of law enforcement officers (LEOs) to seeking treatment, as well as to gain an understanding of the prevalence rates of disorders in a law enforcement population. Convenience sampling was used to recruit participants (N = 306) across a variety of agencies. Correlation, moderated regression analysis, and structural equation modeling (SEM) was used in order to model barriers to care among officers. Findings suggest that the presence of psychological disorders was not predictive of willingness to seek treatment. However, perceived stigma did predict lower willingness to seek treatment. General conclusions suggest that increasing unit cohesion and unit support may make a positive impact in decreasing stigma and increasing officers’ willingness to seek treatment.

HIV screening is recommended to destigmatize the condition, prevent partner transmission, and postpone AIDS progression. However, determinants associated with implementation of opt-out HIV screening are not well understood. The purpose of the study was to examine determinants that predicted odds of HIV screening for persons impacted by Hurricane Sandy, and how these factors differed according to demographic characteristics, geographical attributes, health-related quality of life score, access-to-care, and health insurance status. The social ecologic model provided the framework for this multilevel cross-sectional study that included New Jersey data from the Behavior Risk Factor Surveillance System. Bivariate chi-square, simple logistic regression, and adjusted multivariate and weighted logistic regression analyses were performed to estimate HIV screening odds. Findings indicated a significant odds ratio with access to care post- Hurricane Sandy and HIV screening (odds ratio = 1.74, 95% CI = 1.38-2.21). The positive social change implications may include assisting people to develop realistic plans for HIV screening, improving understanding of HIV screening determinants, and raising awareness of the risk factors related with access to medical care post-Hurricane Sandy.

Dental Caries is still considered one of the most prevalent chronic diseases that affect children in the US. Access to oral care problems could be due to the limited availability of services or unwillingness of people to seek services. As a proposed solution to those challenges, Atraumatic Restorative Technique (ART) was developed in the 1980s as an affordable, patient friendly caries management procedure that does not need extensive operator training or special skills. ART was originally developed to be conducted in field settings; however, after initial evidence of effectiveness, the World Health Organization (WHO) and the International Dental Federation (FDI) promoted the use of ART in modern clinical settings worldwide. In the US, the practice of ART is not believed to be widely used. This may be a result of little attention given to (ART) in dental education and advanced training. This dissertation is comprised of three separate studies that investigated the extent and the factors related to the didactic and clinical instruction on ART in US pre- and post-doctoral pediatric dentistry programs and the factors related to the willingness of pediatric dentists to use ART with their child patients. survey post-doctoral pediatric dentistry program directors and pre-doctoral pediatric dentistry program directors. In study III a different instrument was used to survey pediatric dentists in the US. The survey instruments were tested for content and face validity by cognitive analysis interviews and pilot testing. Using web-based survey methodology, two questionnaires were sent out in May 2010 to investigate self-reported use of ART in educational training institutes (study I and II) and in April 2011, a third questionnaire was sent to a random national sample of pediatric dentists (study III). Using a conjoint design, the third questionnaire asked pediatric dentists to rate their willingness to use ART for 9 patients' scenarios. Eighty eight percent of Pediatric Dentistry Residency programs and 66 % of pre-doctoral pediatric dentistry programs in the US provided clinical training on ART; however only 30% of post-doctoral programs and 14 % of pre-doctoral programs used ART "Very Often/ Often" as a caries management technique for their pediatric patients. Pediatric Dentistry residency programs and pre-doctoral pediatric dentistry programs used ART mainly in primary, anterior, single surface cavities and as an interim treatment. Attitudes toward ART alone and after controlling for other variables explained 35% of the level of training on ART in post- doctoral program and 23% in pre-doctoral pediatric dentistry programs. For study III, conjoint analysis showed that being very young and/or uncooperative were the most important reasons practitioners reported a higher likelihood of using ART. Although insurance coverage was the least important factor overall, not having any insurance was identified as an additional important factor in decisions to use ART. Collectively, our results suggest that that the use of ART is not widespread in the US. In addition, ART is viewed by some as a sub optimum treatment and needs to be modified to conform to the US standards of care. On the other hand, educators and pediatric dentists who had positive views of ART thought it could be a valuable treatment for very young, uncooperative children and children with no insurance.

Evidence suggests that employment for women can reduce poverty and inequality resulting in improved living standards. The garment industry is an important source of income for Indian women. This thesis tested the effects of garment work as an income source on women’s health-care utilization practices and decision-making in comparison to both agricultural labourers and general women in India. Cross-sectional data collected from India’s National Family Health Survey-3 were used to generate descriptive statistics. Statistical modeling was used to test the effect of garment work on a) barriers to health care services and b) decision-making abilities of Indian women. Results suggest garment workers are younger, more educated, urban, and wealthier, make more cash earnings, and have more access and control over their own money as compared to agricultural labourers. Results indicate female garment workers report facing fewer barriers to accessing health care services. As well, access to cash earnings increases their decision-making abilities.

This thesis explores the barriers to mental health care that new, racialized Canadians may face. Using a case study methodology, this project first reviews the literature on identified barriers to care. Several barriers are highlighted in this process including discrimination and racism, service use, language, awareness of services and knowledge of the Canadian healthcare system, socio-economic barriers, cultural beliefs, and stigma. Interviews were conducted with three new Canadians who identify as racialized to further existing knowledge on this topic. The interviews provided a forum for participants to speak to their experiences prior to immigrating to Canada, their experiences following immigration, and their pathway to mental health care. Participants described significant events which they believed to be factors in developing a mental health problem and as a result of this, their decision-making process in help-seeking. Using the categories from the literature as a framework, themes and sub-themes were developed to understand the experiences of the participants. Additional themes that were added included employment, coping with a mental health problem, and trauma. An in-depth, line by line analysis of the interview transcripts was conducted to provide a detailed depiction of each participant’s experience. Each participant interview was defined as a case and compared with the other interviews. This thesis concludes by summarizing the results and detailing the implications for social work practice. Implications include anti-oppressive practice, cultural competence, and self-awareness. Structural and clinical implications are also discussed. / Graduate

abstract: While women in higher income countries can expect to survive a diagnosis of breast cancer, women in lower- and middle-income countries such as Bangladesh have mortality rates near 50%, suggesting that there are significant barriers to care seeking for breast problems. Given limited literature on barriers to care among native, rural South Asian populations, this study thus sought to understand 1) the impacts of breast problems on women and their families, including the extent of abuse among women with breast problems, and 2) the barriers and facilitators of care for women with breast problems in rural Bangladesh. Sixty-three study participants (43 women and 20 men) were interviewed about their experiences. Interviewers elicited barriers to care, facilitators of care, and questions about the attitudes and behaviors of family and community members were in structured interviews. The study found that breast problems and their treatment put significant resource and emotional strains on the family. Furthermore, over a third of women in this study reported abuse of some kind, with emotional abuse, neglect, and abandonment being the most frequently reported. The study reinforced barriers to care identified in the literature for South Asian populations, but only a quarter of participants reported stigma of any kind. Lack of knowledge about breast cancer and inability to pay for care were the most frequently reported barriers, followed by access to care and fear of treatment. Facilitators of care among women who received a biopsy point to the importance of support by the husband and husband’s family, as well as the ability to identify economic support for and knowledge about care. This study contributes to the understanding of two overarching themes: structural violence and the value of women, as well as how these themes influence poor outcomes for women with breast cancer in rural Bangladesh. Suggestions for future studies and short and long-term interventions to address study findings are offered. / Dissertation/Thesis / Appendix E: Study Approval / Appendix B: Barriers to Care Table / Appendix H: Codebook / Appendix C: Study Instruments 1 / Appendix C: Study Instruments 2 / Doctoral Dissertation Anthropology 2016

Indiana University-Purdue University Indianapolis (IUPUI) / With an estimated 30.2 million diagnosed and undiagnosed cases among adults (and another 84 million at risk), diabetes mellitus is one of the most prevalent chronic conditions and a leading cause of mortality in the US. Diabetes self-management education and training (DSME/T) is a recognized standard of care and provides patients with the requisite knowledge and skills to properly manage the condition, improve long-term health outcomes, and reduce health care expenditures. Yet, DSME/T is greatly underutilized. Health insurance coverage that does not include benefits for DSME/T effectively imposes barriers to access for patients in need of the service. Many states have adopted laws and regulations requiring public and/or private insurers in their market to provide benefits for DSME/T; however, these requirements vary by state. It is unclear if these policies effectively improve access to DSME/T services. This dissertation seeks to rigorously assess the impact of state-mandated benefits and reimbursement provisions on access to DSME/T among adult patients with diabetes. The first analysis utilizes a unique combination of legal and programmatic data to quantify changes in the supply of DSME/T resources after the adoption of state-mandated benefits (potential access). The second analysis merges legal data with the Medical Expenditure Panel Survey (MEPS) from 2008 to 2016 to examine the impact of state mandates and reimbursement provisions on patient utilization of DSME/T (realized access). Lastly, the final analysis utilizes electronic health record data (2010-2016) from a safety net population to determine if patients’ evaluated need for DSME/T predicts the likelihood of receiving a DSME/T referral during a provider encounter (equitable access). Using novel data sources and a sophisticated policy analysis technique, this study provides a rigorous assessment of the impact of decades of state policies designed to improve access to care. / 2020-04-02

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