Le handicap est multifactoriel. Toutes ses composantes sont potentiellement sources d’obstacles et de désavantages. L’originalité de cette thèse est de tenir compte de la complexité de définition du handicap dans l’analyse du recours aux soins de santé primaires. L’objectif ultime des soins de santé primaires est une meilleure santé pour tous, passant par la réduction des exclusions et des inégalités sociales d’accès au système santé. Nous appréhendons le handicap de différentes manières jusqu’à intégrer les trois dimensions d’« une situation de handicap » (dimension fonctionnelle, dimension environnementale, et participation sociale) dans un même modèle explicatif. D’abord, nous analysons la dimension fonctionnelle en considérant les personnes handicapées comme physiquement limitées. Puis, nous investiguons la dimension environnementale par une étude chez les adultes vivant en institution. Enfin, nous adoptons une vision globale du handicap en intégrant simultanément toutes les dimensions par la mesure de capabilités latentes. Le modèle estimé s’approche d’une comparabilité inter-individus révélant, toutes choses égales par ailleurs, les niveaux sur lesquels agir pour pallier les inégalités. Les analyses suggèrent qu’un environnement favorable, sociétal et/ou socioéconomique, pourrait compenser les effets négatifs des limitations et des restrictions cognitives et physiques. Nous concluons sur plusieurs voies possibles afin d’améliorer le recours aux soins primaires : agir sur la dimension environnementale et sur la participation sociale. / Disability is multifactorial. All its components are potential sources of barriers and disadvantages. The originality of this thesis is to take into account the complexity of disability definition to analyze the use of primary health care. The ultimate goal of primary health care is better health for all, reducing exclusion and social inequalities in access to the health care system. We approach disability in different ways, ending with a model that includes the three dimensions of a “disability situation” (functional dimension, environmental dimension and social participation). First we analyze the functional dimension considering people with disabilities as physically limited. Then, we investigate the environmental dimension through analysis among adults living in institutions. Finally, we adopt a global vision of disability that integrates all the dimensions simultaneously through the measures of latent capabilities. The estimated model approximates a fundamental inter-individual comparability and reveals all things being equal, the levels on which to act to overcome inequalities. The analyses suggest that favorable environment, societal and/or socioeconomic could offset the negative impact of the limitations and cognitive and physical restrictions. We conclude on several possible waysto improve the use of primary care: acting on the environmental dimension and acting on social participation.

Cette thèse porte sur les difficultés d'accès aux soins dentaires dans le marché français semi-régulé. L'analyse cible la barrière financière d'accès aux soins dentaires et ainsi le rôle et le mécanisme de fixation des prix. La première partie permet de contextualiser la délivrance des soins dentaires en France et montre que la profession de chirurgiens-dentistes est particulièrement isolée dans le domaine sanitaire français. L'objet de la seconde partie est d'identifier les déterminants de l'accès aux soins dentaires. Nous montrons que le programme de prévention pour les enfants M'T'dents, entièrement gratuit, n'était utilisé que par les ménages les plus aisés et touchait peu les ménages défavorisés qui en ont le plus besoin. L'importance du support social dans l'accès aux soins est aussi affirmée dans notre seconde étude empirique. L'accès primaire aux soins dentaires des adultes présente la principale barrière d'accès. Une fois cette difficulté surmontée, les patients engagent le plus souvent les traitements suivants nécessaires, avec des niveaux de dépenses qui peuvent être importants même pour les moins aisés. À la suite de ces résultats, nous nous sommes intéressés spécifiquement au rôle du prix. Nous avons montré que plus le prix des prothèses dentaires était élevé, plus le renoncement à ces soins pour raisons financières était important. D'après nos travaux, l'intensité de la concurrence impacte négativement la fixation des prix contrairement à la solvabilité de la demande. Les prix entre concurrents sont aussi des compléments stratégiques. Ce sont autant de facteurs susceptibles d'être régulés pour lutter contre le renoncement aux soins dentaires et les inégalités sociales de santé qui en résultent. / This thesis concerns the difficulties to access dental care in the semi-regulated French market. The analysis targets the financial barrier of access to dental care and so the role and the mechanism of price setting. The first part gives the background of the French dental care delivery and shows that the profession of dental surgeons is particularly isolated in the French sanitary domain. In the second part we identify the decisive factors of the dental care access. We show that the free preventive program for the children Lov'Ur'Teeth was used only by the wealthiest and affected little the most disadvantaged households, which need it much more. The decisive impact of the social support in access to dental care is also a strong result in our second empirical study. The primary access to the dental treatment presents the main barrier of access. When people overcome this difficulty, they mostly continue the ensuing necessary treatments, that could be very expensive. Following these results, we focused in the role of the price. We showed that the more the prosthetic prices are high, the more is the renunciation for these cares. According to our works, the intensity of the competition impacts negatively the price setting, contrary to the demand's solvency. The prices between competitors are also strategic complements. That are many potential factors to be regulated to fight against the dental unmet need and the resulting social health inequalities.

The purpose of this quantitative study was to examine the interaction between parents’ own trauma and their assessment of their child’s functioning and its relationship to the parent’s belief that their child would benefit from mental health care services. The parents’ trauma experience was measured using the Adverse Childhood Experiences (ACEs) questionnaire and Trauma History Questionnaire (THQ), and the child’s functioning was measured using the Columbia Impairment Scale (CIS). It was hypothesized that the higher number of traumas a parent experienced was associated with a weaker relationship between a parent’s assessment of their child’s functional impairment and the likelihood a parent recognizes the benefit of mental health care services for their child. One hundred and eighty-four people participated in this study. Data were analyzed using multiple binary logistic regression, and no significant relationship was found between a parent’s assessment of their child’s functional impairment and that parent’s belief that their child would benefit from mental healthcare services. The parent’s childhood THQ score and age were found to have significant positive relationships with the parent’s belief that their child would benefit from mental healthcare services. The variable found to have the most significant positive relationship with the parent’s belief that their child would benefit from mental healthcare services was an educational or healthcare professional telling the parent that the child would benefit from mental health care services. Clinical implications, limitations, and future directions for research were addressed.

Of the 3.5 million persons infected with chronic HCV in the United States, the African American population is the largest racial group with chronic HCV. Disparities in access to care and treatment involve a complex set of individual, interpersonal, socioeconomic, and environmental factors that influence the course of HCV infection in the African American population, resulting in poorer outcomes and survival. Drawing upon both the theory of reasoned action and the theory of planned behavior, this study was conducted to determine whether the seeking of health care by HCV-positive African Americans and the responses of health care providers to HCV-positive African Americans had improved since 2008 following the introduction of new treatment options, as compared to other HCV-positive racial/ethnic groups, using secondary data analyses with survey datasets from the National Health and Nutrition Examination Survey, 2005-2012. Using chi-square test of difference and logistic regression analyses, the study did not identify a statistically significant relationship between health care seeking behavior and responses from health care providers for HCV-positive African Americans before (2005-2008) and after (2009-2012) the introduction of new treatment options as compared to other HCV-positive racial/ethnic groups. Given the ongoing development of new and improved drugs to treat HCV infection, further research might focus on the HCV-infected population as a whole to ascertain whether differences exist as compared to earlier therapies before 2013. This study may drive social change within the health care community by raising awareness of the risks of HCV infection resulting in less provider bias and the introduction of resources into the African American and underserved communities that will improve outcomes and reduce barriers to care.

Interprofessional education (IPE) is essential for enhancing students’ critical thinking skills and ability to integrate other professionals’ knowledge to ensure mutual respect and shared values for patient-centered care. The needs of medically underserved populations (MUPs) to receive behavioral health and nutritional care integrated with primary care services are significant. This research highlights the data outcomes from six offerings of a graduate IPE course on integrated health care. Funding from a Health Resources and Services Administration (HRSA) Behavioral Health Workforce and Education Training (BHWET) grant provided stipends for graduate social work and school counseling students in their final year of field working with MUPs in integrated care settings. Findings indicate significant increases in integrated care knowledge from pre- to post-course. Students reported appreciating the social justice framework of the course including food security and access to care. Students suggest that the course be required of all, not just stipend recipients. This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under Behavioral Health Workforce Education and Training Program Grant No. M01HP313900100. This information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the U.S. Government.

No description available.

No description available.

The Universal Declaration of Human Rights and Fundamental Freedoms and the International Covenant on Economic, Social and Cultural Rights state that everyone has the right to good health. According to the conventions, the states have obligations to prevent and combat disease, and if necessary, ensure that the conditions for treatment of the disease are appropriate (UDHR 1948, UNCESCR 1966). The broad wording in the conventions on the right to good health includes the right to care of substance use disorders. In the 1960ies the World Health Organization recommended, that people with such disorders should be seen as sick and that the legislation governing such care should be in accordance with special administrative legislations and not criminal legislation. The recommendation indicates WHO:s clear position that persons with substance use disorders primarily should be treated as persons suffering from disease and in need of care, and not primarily as disruptive individuals or criminals who should be disciplined or punished. This applies also to situations when treatment and care cannot be provided on a voluntary basis, but compulsorily. In Swedish context, the most commonly mentioned law in these cases is the social special legislation Law (1988: 870) on care of misusers, special provisions (LVM). Ever since the implementation of LVM in 1982, its legal position as well as application in institutional care has been subject of critical discussions within social work as well as in social science research. Such debate in the Nordic countries has until now mostly been marked by two important limitations. First, most comparisons are restricted to very few countries, e.g. four of the Nordic countries; secondly the notion of involuntary care is often limited to social legislation on compulsory care without taking criminal justice legislation or mental health legislation into account. The present dissertation studies legislations on compulsory commitment to care of persons with substance use problems (CCC), and compares these legislations from a larger number of countries, on global or European levels. This approach makes it possible to explore the great variation in CCC legislation between countries, i.e. type of law (criminal justice, mental health care and social or special legislation),  time limits (maximum duration) as well as levels of ambition, ethical grounds, criteria for admission, and adaption to human and civil rights.  In addition, the comparisons between many countries are used to investigate factors related to different national choices in legislations from country characteristics, e.g. historical and cultural background as well as economic and social conditions, including level and type of welfare distribution. Available datasets from different times permits trend analyses to investigate whether CCC or specific types of such are increasing or decreasing internationally.          Empirical materials: Article I is based on three reports from the WHO on existence of CCC legislation, before the millennium shift, in 90 countries and territories in all populated continents. Articles II and IV are based on own data collection from a survey in 38 European countries. Article III uses a combination of those data and additional information from country reports in scientific and institutional publications in three times of observation during more than 25 years, and including a total of 104 countries. Additional data for Articles I and II are information on various countries' characteristics obtained from different international databases.          Findings based on data from WHO reports at the eve of the millennium show that CCC legislation was very common in the world, since 82 per cent of the 90 countries and territories had such law. Special administrative (“civil”) legislation (mental health or social) was somewhat more prevalent (56 %), but CCC in criminal justice legislation was also frequent and present in half of the countries. The study shows that economically stronger countries in the western world and many of the former communist countries in Eastern Europe, the so-called "first and second worlds" in cold war rhetoric, more often had adapted to the recommendations made by WHO in the 1960ies, with CCC more often regulated in civil legislation. In the so-called "third world" countries, CCC in criminal justice legislation dominated. The new data collection from 38 European countries ten years later confirmed that legislation on CCC is very common, since 74 per cent of the explored countries have some type of legislation. The most common type was now CCC in criminal legislation (45%), although special administrative legislation (mental health or social) was almost equally common (37%). Special administrative legislation on CCC (both acute and rehabilitative), was more common in countries with historic experience of a strong influential temperance movement, and in countries with distribution of health and welfare more directed through the state, while countries with less direct government involvement in distribution of health and welfare and lacking former influence of a strong temperance movement more often had CCC in criminal justice legislation. During all the 25 years period from early 80ies up to 2009, it was more common for countries to have some type of law on CCC than not, although some reduction of CCC legislation is shown, especially during the last decade. But within countries having CCC, more cases are compulsorily committed and for longer time duration. This is related to a global shift from civil CCC to CCC in criminal justice legislation, directly in the opposite direction from what WHO recommended in the 60ies. Changes in CCC legislation are often preceded with national political debate on ethical considerations, and criticisms questioning the efficiency and content of the care provided. Such national debates are frequent with all types of CCC legislation, but ethical considerations seem to be far more common related to special administrative (civil) legislation. National legislations on CCC within Europe should conform to the human and civil rights stipulated in ECHR (1950). There seems, to be some limitations in the procedural rules that should protect persons with misuse or dependence problems from unlawful detentions, regardless type of law. The three types of law differ significantly in terms of criteria for CCC, i.e. the situations in which care may be ensured regardless of consent.        Conclusions: It is more common that societies have legislation on CCC, than not. This applies internationally – in all parts of the world as well as over time, for a period of 25 years, at least. Sweden’s legislative position is not internationally unique; on the contrary, it is quite common. Law on CCC tend to be introduced in times of drug epidemics or when drug-related problems are increasing in a society. Changes in CCC legislation are often preceded by national debates on ethics, content and benefits of such care. These findings here discussed may reflect different concurrent processes. A shift from welfare logic to a moral logic may be understood as more moralization, perhaps due to relative awaking of traditionalism related to religious movements in various parts of the world (Christian, Hindu, Muslim or other). But it may also be understood from more libertarianism that stresses both individual responsibility for one’s welfare and the state´s responsibility to discipline behaviours that inflict negatively on the lives of others. Possibly do these two tendencies work in conjunction to one another. At the same time, however, there is a stronger emphasis on care content within criminal justice CCC, especially in the Anglo-Saxon drug court system. Some shift within Civil CCC is also noticed, i.e. from social to mental health legislation. Thus drug abuse and dependence is increasingly more recognized and managed in the same way as other diseases, i.e. an increased normalization. Since social CCC has been more in focus of research and debates, this may also result in CCC turning into a more hidden praxis, which from ethical perspectives is problematic. The thesis shows that there are examples of focus on humanity and care in all three of the law types, but there are also examples of passive care, sometimes even inhumane and repressive, in all types. Thus, type of law cannot be said to in general correspond to a specific content of care. Although CCC can be delivered in accordance with human and civil rights, there is still a dissatisfying situation concerning the procedural rights that should ensure the misuser his/her rights to freedom from unlawful detention. The possibility to appeal to a higher instance is missing in about 20 percent of European CCC laws, although not differentiating one type of legislation from the others. A clear difference between the three law types concerns criteria that form the basis for who will be provided care according to the laws. This is of major importance for which persons of the needy who will receive care: addicted offenders, out-acting persons or the most vulnerable. The criteria for selecting these relate to the implicit ambitions of CCC – correction, protection, or for support to those in greatest need for care. The question is what ambition a society should have concerning care without consent in case of substance abuse and addiction problems. The trend that CCC according to special administrative legislation is declining and criminal legislation increases in the world should therefore be noticed.     Keywords: Alcohol, drugs, substance misuse, coercive care, compulsory commitment to care, involuntary care, mandatory care, legislation, human and civil rights, comparative analysis, prediction models, and trend analysis / <p>Vid tidpunkten för disputationen var följande delarbeten opublicerade: delarbete 4 inskickat.</p><p>At the time of the doctoral defence the following papers were unpublished: paper 4 submitted.</p>

Les patients atteints de mono-traumatisme à un membre doivent consulter un médecin de première ligne qui assurera la prise en charge initiale et référera au besoin le patient vers un orthopédiste. L‟objectif principal de cette étude est de décrire ce mécanisme de référence envers un Service d‟orthopédie affilié à un Centre de traumatologie Niveau 1. La collecte de données concernant l‟accès aux soins spécialisés et la qualité des soins primaires a été faite lors de la visite en orthopédie. Nous avons étudié 166 patients consécutifs référés en orthopédie sur une période de 4 mois. Avant leur référence en orthopédie, 23 % des patients ont dû consulter 2 médecins de première ligne ou plus pour leur blessure. Le temps entre la consultation en première ligne et la visite en orthopédie (68 heures) dépasse le temps compris entre le traumatisme et l‟accès au généraliste (21 heures). Parmi les cas jugés urgents, 36 % n‟ont pas été vus dans les temps recommandés. La qualité des soins de première ligne fut sous-optimale chez 49 % des patients concernant l‟analgésie, l‟immobilisation et/ou l‟aide à la marche. Les facteurs associés à une diminution d‟accès en orthopédie et/ou une qualité de soins inférieure sont : tabagisme, jeune âge, habiter loin de l‟hôpital, consulter initialement une clinique privée, avoir une blessure au membre inférieur ou des tissus mous et une faible sévérité de la blessure selon le patient. Ces résultats démontrent qu‟il faut mieux cibler l‟enseignement relié aux mono-traumatismes envers les médecins de première ligne afin d‟améliorer le système de référence. / Patients with isolated traumatic limb injuries usually consult primary care for first line treatment. The primary care physician will often refer the patient to an orthopaedic surgeon when needed. The research objective was to study the referral mechanism to an Orthopaedic Service in a Level 1 Trauma Center for patients with an isolated limb injury. Access to specialized care and quality of primary care are used to describe the referral mechanism. We studied 166 consecutives patients referred to orthopaedic surgery over a 4 months period. Before the orthopaedic visit, 23 % had seen 2 or more doctors for their injury. The time between the first primary care visit and the orthopaedic evaluation was greater (68 hours) then the interval between the injury and the visit with primary care (21 hours). Among the cases that were considered urgent, 36 % had not been seen within the recommended delay. Quality of initial care was judged sub optimal for 49 % of patients in terms of immobilization, analgesia and/or walking aids. Factors associated with decreased access or quality of care are: smoking, younger age, living far from the hospital, consulting first in a private clinic, lower limb or soft tissue injury and a patient‟s low self-perception of severity. These results underline the necessity of targeting primary care education and improving the referral mechanism for patients with isolated limb injuries.

Abstract The aim of the study was to describe and analyse access to care and factors relating to access to care theoretically and empirically. Access to care is a theoretical concept, analysed through waiting list lengths categorised by field of special health care. Public health services and related factors, access to care and the disparity between demand and supply are analysed within a theoretical framework. The study is divided into a theoretical and an empirical section. Access to care was studied through a mixed methods approach, based on a two-phase empiric material. The first phase is composed of focus group interviews (N=4). Interviewees were hospital district administrators and medical directors as well as chairpersons of the board and council or their representatives. The interviews were analysed by phenomenographic methods. The second phase is composed of waiting list data collected by THL (N=79) as well as population and prevalence data acquired from SOTKAnet (N=12) for 2008–2010. For 2009–2010, hospital district documents include financial statements (N=16), annual reports (N=23), annual statistics (N=6), personnel reports (N=21) and balance sheet books (N=6). The second phase were statistically analyzed. Results of the study on factors affecting access to care are divided into two themes: 1. challenges related to access to care from the hospital district’s perspective and 2. component factors of the realisation of access to care. Macro-level challenges related to access to care are legislation, politics, regulatory bodies, uniform grounds for non-urgent treatment, Current Care Guidelines recommendations and the connection between access to care, Current Care Guidelines recommendations, uniform grounds for non-urgent treatment, prioritisation and regulations. Meso-level challenges are operative decision-making and organisational operations models, resources, supply-based demand and the chain of treatment. Component factors of the realisation of access to care are the variance in waiting list lengths between different fields; the connection between waiting lists, the population and the hospital district; population size and its prevalence as well as resources and financial factors. / Tiivistelmä Tutkimuksen tarkoituksena oli kuvata ja analysoida hoitoon pääsyä ja siihen vaikuttavia tekijöitä teoreettisesti ja empiirisesti. Hoitoon pääsy on teoreettinen käsite, jota analysoidaan erikoisaloittaisten jonojen pituutena. Teoreettisessa viitekehyksessä tarkastellaan julkisen terveydenhuollon palveluja ja niihin vaikuttavia tekijöitä, hoitoon pääsyä sekä kysynnän ja tarjonnan epäsuhtaa. Tutkimus jakautuu teoreettiseen ja empiiriseen osaan. Hoitoon pääsyä tutkittiin mixed methods -menetelmällä kaksivaiheisen empiirisen aineiston pohjalta. Ensimmäinen vaihe koostui fokusryhmähaastatteluista (N=4). Haastateltavina olivat SHP:n johtajat ja johtajaylilääkärit sekä SHP:n ky:n valtuuston ja hallituksen puheenjohtajat tai heidän edustajansa. Haastattelut analysoitiin fenomenografisen menetelmän mukaisesti. Toinen vaihe koostui THL:n erikoisaloittaisista jonotiedoista (N=79) ja SOTKAnetistä saaduista väestö- ja sairastavuustiedoista (N=12) vuosilta 2008–2010. Aineistona vuosilta 2009–2010 käytettiin myös SHP:n dokumentteja, joita olivat tilinpäätökset (N=16), vuosi-/toimintakertomukset (N=23), vuositilastot (N=6), henkilöstökertomukset (N=21) ja tasekirjat (N=6). Toinen vaihe analysoitiin tilastollisesti. Tutkimustulokset hoitoon pääsyyn vaikuttavista tekijöistä jakaantuivat kahteen teemaan: 1. hoitoon pääsyn haasteisiin SHP:n näkökulmasta sekä 2. hoitoon pääsyn toteutumisen osatekijöihin. Hoitoon pääsyn haasteita makrotasolla olivat lainsäädäntö, politiikka, STM, THL ja EOA merkityksellisinä tahoina, yhtenäiset kiireettömän hoidon perusteet, Käypä hoito -suositukset sekä hoitoon pääsyn, Käypä hoito -suositusten, yhtenäisten kiireettömän hoidon perusteiden sekä priorisoinnin ja sääntelyn yhteys. Mesotason haasteita olivat operatiivinen päätöksenteko ja organisatoriset toimintamallit, resurssit, tarjontalähtöinen kysyntä ja hoitoketju. Hoitoon pääsyn toteutumisen osatekijöitä ovat erikoisaloittaisten jonojen pituuden vaihtelu, jonojen yhteys väestöön ja SHP:iin, väestön määrä ja sen sairastavuus sekä resurssit ja taloudelliset tekijät.