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Background and Objectives: Recent immigrants experience unique challenges when accessing health services. Registered Nurses (RNs) working in primary health care (PHC) have the competencies and are well-positioned to facilitate healthcare access for immigrants. Aim: This study explored how PHC-RNs in Ontario support healthcare access and address barriers among recent immigrants. Methods: This study used a qualitative, interpretive descriptive approach and was informed by Levesque et al.’s (2013) access to care framework. Semi-structured interviews were conducted with 10 PHC RNs practising in Toronto, Ottawa-Gatineau, Hamilton, Kitchener-Cambridge-Waterloo, and London. Data were collected and analyzed concurrently using an inductive and deductive approach. Results: Findings show that PHC-RNs play instrumental roles in supporting recent immigrants through facilitating healthcare access across 9 dimensions of Levesque et al.’s (2013) access framework: (1) appropriateness, (2) availability and accommodation, (3) ability to perceive, (4) ability to engage, (5) ability to seek, (6) ability to reach, (7) affordability, (8) ability to pay, and (9) acceptability. RNs addressed significant challenges to health service access for recent immigrants, including language, geographical, and financial barriers. Several opportunities were identified to enhance the PHC RN clinical practice role to improve the delivery of PHC for recent immigrants, such as increasing organizational resources, utilizing their expertise and role beyond the PHC clinic, and promoting culturally appropriate care. Conclusions: PHC-RNs are key facilitators of healthcare access for recent immigrants by coordinating their care, educating, and connecting this population to services across the health system. However, there are opportunities to optimize nursing roles and more effectively utilize their scope of practice within interdisciplinary teams to promote the health of immigrants. / Thesis / Master of Science in Nursing (MSN)

By examining barriers to care, health professionals can better understand what disparities exist between groups and who may be at greater risk for poor primary care. Researchers have highlighted the need for additional research that focuses on the extent of unmet needs for U.S. children with sickle cell disease (SCD). The purpose of this quantitative study was to compare the differences between parents who are in a SCD support group and those who are not. The theoretical framework of this study is based on the chronic care model and social support theory. A total of 128 parents of children with SCD completed the study survey. The sampling occurred by e-mail, phone, and face-to-face conversations. Selection criteria for potential participants in both groups were based on their children being diagnosed with SCD. Seventy-four participants (57.8%) were members of a SCD support group, and 54 participants (42.4%) were not members of a SCD support group. In this study, the independent variables were parents attending or not a SCD support group. The t test and MANCOVA was used to assessed the association between perceptions of barriers to care and support group status. However, statistical analysis showed no significant results. The null hypothesis was not rejected. Therefore, the positive social change implication is to further explore potential factors that may shape perceptions of barriers to care for those with SCD so that perceived barriers to care can be overcome.

Bakgrund: Samsjuklighet förekommer ofta hos personer med psykisk sjukdom. Det är vanligt att de behöver hjälp inom den somatiska vården. Trots att psykisk sjukdom är utbrett i samhället är detta tillstånd fortfarande behäftat med stigma. En form av stigmatisering är diagnostisk överskuggning, vilket innebär att fysiska symptom felaktigt tolkas som symptom på den psykiska sjukdomen. Detta leder till underdiagnostisering och felbehandling. Stigma kan internaliseras och leda till självanklagelser och undvikande av kontakt med till exempel sjukvården. Syfte: Syftet var att undersöka hur personer med psykisk sjukdom upplever den somatiska sjukvården. Metod: En litteraturöversikt innehållande tolv vetenskapliga artiklar; tio kvalitativa samt två kvantitativa. Resultat: Fyra huvudteman utkristalliserades: ”Att inte bli tagen på allvar”, ”Längtan efter någon som lyssnar”, ”Självanklagelser och skam” samt ”Upplevelser av barriärer”. Diskussion: Resultatet diskuterades mot Erikssons omvårdnadsteori och Nordenfelts teori om värdighet samt mot konsensusbegreppen människa, hälsa och miljö. Det mest framträdande temat var upplevelsen av att inte bli tagen på allvar. Patienterna kände att vårdpersonalen viftade bort deras upplevelser och tolkade att de fysiska symptomen gick att härleda till den psykiska sjukdomen. Detta är exempel på stigma i handling, en företeelse som bidrar till minskad värdighet och vårdlidande hos patienten. / Background: Medical comorbidity is common in people with mental illness. There is still a strong stigma attached to mental illness. One of these could be diagnostic shadowing, a process where health professionals wrongly presume that physical symptoms are consequences of the patient´s mental illness. Diagnostic overshadowing can lead to underdiagnosis and mistreatment of the physical condition. Stigma and self-discrimination could also prevent people with mental illness from seeking treatment. Aim: The aim was to investigate how people with mental illness experience somatic health care. Method: A literature review was conducted which included twelve articles: ten with qualitative design and two with quantitative design. Results: Four main themes emerged: "Experience of not being taken seriously", "Longing for someone who listens", "Self-discrimination and shame" and "Experiences of barriers". Discussion: The results was discussed in relation to Eriksson's nursing theory, Nordenfelt theory of dignity and the consensus concepts of person, health and environment. The most distinct and common theme was the experience of not being taken seriously. The health professionals did not listen to the patients and assumed that the physical symptoms were consequences of the mental illness. This is stigma in action and it contributes to suffering and affects the patient’s sense of dignity.

Le vieillissement de la population associé à un nombre croissant de cancers constituent une réalité épidémiologique qui soulève des interrogations sur l’accès aux soins et le pronosticdes sujets âgés avec un cancer, pour lesquels des disparités ont été mises en évidence. Toutefois, les études présentent plusieurs limites dont l’absence de facteurs spécifiques aux personnes âgées (PA). L’objectif de ce travail était d’étudier les déterminants sociodémographiques, socioéconomiques et cliniques de l’accès aux soins (stade de cancer, traitement) et du pronostic (déclin fonctionnel, survie) chez des PA atteintes d’un cancer. Les travaux ont été réalisés à partir de données issues de registres de cancers et de troiscohortes de PA en Gironde (486 patients de 65 ans et plus, période 2005-14). Les cohortes ont permis de disposer de données telles que le niveau d’éducation, le revenu, la prise demédicaments, la dépendance ou la démence. Selon l’objectif (accès/pronostic), nous avons utilisé différentes méthodes pour prendre en compte le type de données et de critères (régression logistique, modèles multiniveaux, modèles multi-état et de Cox). Notre population était composée pour plus de la moitié de PA de 80 ans et plus, de sexe masculin et ayant un niveau d’éducation supérieur au niveau primaire. Nous nous sommes d’abord intéressés aux déterminants de l’accès aux soins. Aucun déterminant d’un stade avancé de cancer au diagnostic n’a pu être mis en évidence, un niveau d’éducation faible était proche de la significativité pour les cancers avec un stade avancé (p=0,0671). Pour l’accès à un traitement du cancer, nous avons mis en évidence qu’un stade avancé (p=0,003) et la présence d’une démence (p=0,0109) étaient associés à un risque plus faible de recevoir un traitement. Nous avons ensuite étudié les déterminants du pronostic. Les sujets les plus âgés présentaient toujours un risque plus élevé de déclin fonctionnel (p<0,005), quel que soit le critère analysé. Les sujets ayant un faible niveau d’éducation (p=0,027), prenant plus de six médicaments par jour (p=0,047), présentant une démence (p<0,001) ou diagnostiqués à un stade avancé (p<0,001) avaient une probabilité de déclin fonctionnel plus importante, les résultats variant selon le critère. Enfin, à 12, 24 et 36 mois, la probabilité de survie globale était respectivement de 66, 57 et 48%. Le risque de décès était plus élevé chez les hommes (p=0,019), diagnostiqués à un stade avancé de cancer (p<0,001) et sans traitement du cancer (p<0,001), mais aussi chez les fumeurs (actuels et anciens) (p=0,019) et les PA dépendantes (p<0,001). En sus de déterminants classiques de l’accès aux soins ou du pronostic des cancers, nous avons mis en évidence pour les PA, le rôle des déficits cognitifs pour l’accès à un traitement ou sur le pronostic fonctionnel et celui de la dépendance sur la survie. Chez les PA avec un cancer, les facteurs spécifiques aux PA semblent donc essentiels à analyser. L’analyse des liens de causalité entre les déterminants de santé reste un sujet particulièrement intéressant dans cette population de PA comme pour les patients avec un cancer. / The growing incidence of cancer associated to an aging population represents an epidemiologic reality that requires questioning access to care and prognosis in elderly with cancer, for which disparities have been highlighted. However, generally speaking, studies are limited in that they overlook geriatric-specific factors. The aim of this work was to study sociodemographic, socioeconomic and clinical determinants of access to care (cancer stage, cancer treatment) and prognosis (functional decline, survival) in elderly cancer patients. This research project has relied on data from cancer registries and three elderly cohort studies in the French department of Gironde (486 patients aged 65 and over from 2005 to 2014). The cohorts provided data such as education level, income, medication, dependency and dementia. Depending on the aim, we used different statistical methods to analyze different types of data and outcomes (logistic regression, multi-level model, multi-state model, Cox model). More than half of our population was aged 80 and over, male and had high education degrees. First, we studied determinants of access to care. No determinant of advance stage at diagnosis was found, but low education was close to significance for advanced stage (p=0.067). Concerning cancer treatment administration, advanced stage at diagnosis (p=0.003) and diagnosis of dementia (p=0.011) were associated with a lower risk of treatment administration. Second, we studied determinants of prognosis. Older old had higher risk of functional decline (p<0.001), regardless of the outcome. Subjects with low education (p=0.027), taking more than six daily drugs (0.047), presenting diagnosed dementia (p<0.001) or those with advanced cancer stage at diagnosis had higher risk of functional decline, results depending on outcome. At last, overall survival at 12, 24 and 36 months was 66, 55 and 48%, respectively. Risk of death was higher in men (p=0.019), in patients with advanced stage at diagnosis (p<0.001) or without treatment (p<0.001) in current and former smokers (p=0.019) and in dependent elderly patients (p<0.001). In addition to classical determinants of access to care and prognosis in cancer, we demonstrated the impact of cognitive impairment on treatment administration or functional prognosis, and that of dependency on survival. . It appears essential to consider geriatric specific factors in studies on the elderly with cancer population. The causality between health determinants is particularly interesting in the elderly as well as in the cancer populations.

The purpose of this study was to determine the awareness and attitudes of dental hygienists in Ohio regarding the Advanced Dental Hygiene Practitioner (ADHP) as an occupation proposed by the American Dental Hygienists’ Association and to determine whether the ADHP could be a viable career option for Ohio dental hygienists. I developed a survey to assess dental hygienists’ awareness, attitudes, and their views regarding the new mid-level dental provider. The study was limited to licensed dental hygienists in Ohio. The study included a simple random sample of 400 of the 4100 dental hygienists in Ohio obtained by a systematic approach, a random start and selection of subjects at a constant interval. The method of data collection was electronic surveys. Fifty-four dental hygienists (13% of the sample) participated in the study. The results show that most of those responding were aware of the ADHP. Also, their attitude regarding the new mid-level dental provider was positive. Attitudes varied more when the respondents provided data on the adoption of legislation for the new provider. There was no consensus among respondents regarding the ADHP as a viable career option. More robust research is needed on the viability of the ADHP in Ohio.

This thesis evaluates the cost-effectiveness of eight policies expanding human immunodeficiency virus (HIV) testing in South Africa. All policies entail provider-initiated test offers for primary healthcare users and one of two options across three policy components: (i) consent method, opt-in or opt-out; (ii) test protocol, rapid only or rapid plus acute infection testing; and (iii) linkage-to-care, standard or enhanced. This thesis highlights four methodological issues. First is the challenge of conducting a population-level analysis, projecting the cost-effectiveness of expanded testing for each member of South Africa’s adult African population. To this end, I conducted a retrospective, descriptive study to measure current population-level testing rates and epidemic descriptors in an African community near Cape Town, South Africa. Second, the effects of testing expansion on current testing uptake were estimated by distinguishing testing in the study community likely to cease after testing expansion (baseline testing) from that likely to continue (background testing). Third, because testing alone is an outcome of less interest than health benefits following treatment, study community linkage-to-care probabilities were estimated and models utilized to estimate the efficacy of treatment. Fourth, the methods to convert the study community testing data into inputs for these models’ parameters are outlined. The enhanced linkage-to-care policies proved the most cost-effective, with opt-in testing and a rapid-only test protocol the least expensive cost-effective option at $848 per life year gained (LYG). Adding an opt-out consent method or acute infection test protocol to this policy increased the LYGs, but at higher cost-effectiveness ratios.

Despite (national) strategies/frameworks for care at the end of life, many patients do not die at their preferred location or under the form of care desired. This cross-country comparison study analyzed system-level characteristics - such as legislation, regulation and financing - that might influence service delivery in the care for terminally ill adults and their implications for outcomes and costs. Drawing on triangulated data from Canada, England, Germany and the United States of America and taking a 'most similar – most different' perspective, it was hypothesized that system-level factors might impede the broader use of (integrated) models of hospice and palliative care/the system-wide adoption of best practices. An embedded case study examined resource utilization and costs of shared care and its role as a potential best practice avenue. While similar with regard to leading causes of death, patient needs and potential avenues to care, different service models were employed – including hospice and palliative care. Generally offered alongside standard care along the disease continuum and across settings - and featuring common elements like physical, psycho-social and spiritual care - outcomes (e.g., access, utilization) varied. Legislative (e.g., jurisdictional), regulatory (including education and training) and financial issues were identified as barriers, as were public knowledge and perception ('giving up hope') challenges. Advance care planning, dedicated and stable funding, population aging and standards of practice/guidelines to care were seen as facilitators. Successful policy implementation requires concerted action to align system-level characteristics – with each alone being essential but not sufficient. Policies need to be monitored and fine-tuned, with a caveat toward their transferability between jurisdictions. The analysis of the shared-care approach in the rural Niagara-West setting revealed effective and efficient home-based hospice and palliative care – on par with per diem funding for long-term care homes and lower than average alternate level of care and hospital costs in Ontario, and in line with the Medicare Hospice Benefits in the United States of America. The thesis results provide a base for further analyses across jurisdictions and settings and might assist decision makers in the allocation of resources to meet the complex needs of hospice and palliative care populations.

Despite (national) strategies/frameworks for care at the end of life, many patients do not die at their preferred location or under the form of care desired. This cross-country comparison study analyzed system-level characteristics - such as legislation, regulation and financing - that might influence service delivery in the care for terminally ill adults and their implications for outcomes and costs. Drawing on triangulated data from Canada, England, Germany and the United States of America and taking a 'most similar – most different' perspective, it was hypothesized that system-level factors might impede the broader use of (integrated) models of hospice and palliative care/the system-wide adoption of best practices. An embedded case study examined resource utilization and costs of shared care and its role as a potential best practice avenue. While similar with regard to leading causes of death, patient needs and potential avenues to care, different service models were employed – including hospice and palliative care. Generally offered alongside standard care along the disease continuum and across settings - and featuring common elements like physical, psycho-social and spiritual care - outcomes (e.g., access, utilization) varied. Legislative (e.g., jurisdictional), regulatory (including education and training) and financial issues were identified as barriers, as were public knowledge and perception ('giving up hope') challenges. Advance care planning, dedicated and stable funding, population aging and standards of practice/guidelines to care were seen as facilitators. Successful policy implementation requires concerted action to align system-level characteristics – with each alone being essential but not sufficient. Policies need to be monitored and fine-tuned, with a caveat toward their transferability between jurisdictions. The analysis of the shared-care approach in the rural Niagara-West setting revealed effective and efficient home-based hospice and palliative care – on par with per diem funding for long-term care homes and lower than average alternate level of care and hospital costs in Ontario, and in line with the Medicare Hospice Benefits in the United States of America. The thesis results provide a base for further analyses across jurisdictions and settings and might assist decision makers in the allocation of resources to meet the complex needs of hospice and palliative care populations.

Ce travail décrit les trajectoires des adolescents qui sont amenés à être suivis en psychiatrie parce qu'ils refusent d'aller à l'école en France. Il se propose ainsi d’employer une démarche sociologique de théorie ancrée (Grounded Theory) afin de répondre à une question de santé publique. En 1991, on estimait que les enfants et adolescents refusant d'aller à l'école représentaient 5% des consultations de pédopsychiatrie en France. Depuis 25 ans, il demeure pourtant difficile de quantifier ce phénomène et son évolution, notamment parce que le refus scolaire ne correspond à aucune catégorie de maladie mentale. L'enjeu sociétal et économique est toutefois considérable. Les associations de parents alertent sur le coût élevé de la déscolarisation, la 'phobie scolaire' rencontre un écho médiatique constant, et les jeunes qui achèvent leurs études sans obtenir de diplôme ont un taux de chômage supérieur à la moyenne pour leur tranche d'âge. De plus, une littérature psychiatrique internationale considérable sur le refus scolaire s’adosse à de nombreuses institutions de soin dédiées à la rescolarisation (consultations et hôpitaux de jours) et de manifestations professionnelles à ce sujet. Dans un contexte de contraintes budgétaires du sanitaire et de crise du système éducatif français, la gestion par le champ médical du refus scolaire pose question. Premièrement, une analyse socio-historique de la littérature médicale internationale entre 1941 et 2018 décrit comment le problème du « refus scolaire » s’est développé dans le discours scientifique selon les deux courants distincts de la phobie scolaire (school phobia) et du refus scolaire (school refusal) ; et tend actuellement à s’élargir vers une problématisation médicale de toute absence scolaire. La deuxième et la troisième partie de ce travail explorent les processus décisionnels qui sous-tendent la médicalisation du refus scolaire à l’échelle individuelle. En effet, le diagnostic psychiatrique intervient relativement tard, à l’issue d’une carrière débutée au sein de l’institution scolaire et de la famille. Comment un jeune en vient-il à être désigné par la catégorie de 'phobie scolaire'? Cette approche interactionniste se fonde sur plus de 100 entretiens réalisés auprès de familles et de professionnels de l’école et analyse le travail produit par le jeune et par les acteurs qui l’entourent. On décrit comment les professionnels de l’école repèrent et qualifient ses difficultés de fonctionnement scolaire. Quatre styles de gestion du problème émergent au sein de l’école, selon le degré d’extériorisation du problème hors du champ scolaire, l’usage des pratiques de care et les modes relationnels avec les autres acteurs. Une analyse dite des « carrières » retrace la trajectoire d’adolescents déscolarisés, de l'école à l'hôpital, en partant du récit des jeunes et de leurs parents. Si les enquêtés présentent le refus scolaire comme une prise de décision brutale, celle-ci vient interrompre un processus de longue durée notamment caractérisé par un épuisement lié au travail de représentation de soi en société. Après la décision de refus scolaire, sont analysés le récit de la transformation de soi, le remaniement des relations aux autres (parents, camarades, enseignants, soignants), la déconstruction et la construction de certaines modalités de socialisation. / School refusal is an increasingly common motive for consultation in child psychiatry. According to the psychiatrists, situations leading to school refusal are extremely diverse, from anxiety feelings in the classroom to truancy, and may lead children to miss school occasionally or to give up their studies. This sociological study, uses the grounded theory to describe the career of teenagers who receive psychiatric care in France because they refuse to go to school. More than 100 in-depth interviews with teenagers, parents and school professionals allow to describe their careers from the school to the psychiatric care. First, we provide a socio-history of the medicalization of school absenteeism through the construction of medical categories (school phobia, school refusal, school attendance problems), based on a review of the international psychiatric literature from 1941 to 2018. Second, teachers discourse on school refusal, their daily management of student who refuse school and their involvement in the medicalization of the absenteeism of some pupils is analyzed. Four styles of management are described among school professionals. Third, the narratives of teenagers and of their parents are analyzed. If school refusal appears as an immediate shift, it answers to a process of long duration. For some students, struggling to attend school from day to day required a consuming work: the presentation of self in public places and emotional work towards peers. After refusing school, students ‘illness’ narratives describe their career in deconstructing and reconstructing their socialization and self.