The closure of the Manawatu Gorge in August 2011 caused a change in the travel time for patients living in the eastern area of the MidCentral Health District to their main hospital and health services located in Palmerston North. This presented an opportunity to study the effect a change in travel time and spatial access had on a population before and after such an event. This study used a retrospective cohort design, using routinely collected data from general practice, emergency department, hospital admissions and outpatient services. The investigation was completed using novel geospatial information systems methods to produce high fidelity data for analysis with free and open source software by developing and validating two new methods of improving geocoding data quality and a new travel time prediction model. Potential and realised spatial accessibility measures were calculated for 101,456 patients over 3.5 years while the gorge was both open and closed. Catchment sensitivity analysis and two-step floating catchment area using distance decays presented complimentary evidence of accessibility change during the Manawatu Gorge closure. Analysis of utilisation measures in both primary and secondary care were correlated with travel time. Utilisation of general practice services appeared to be negatively impacted by increased travel time when comparing realised accessibility in a control and intervention group during the gorge closure. It appeared as though other factors affected access to health services to a greater degree than an increase of up to fifteen minutes travel time.

Purpose: The scientific knowledge of how genes affect disease expression and evolution can facilitate more effective environmental and drug therapy interventions delivered by health care professionals. The purpose of this paper is to a) describe the role of genetic science in healthcare; b) explore genotype determinants for environmental and pharmacological interventions; c) and analyze ethical dilemmas, barriers to access, and allocation of resources based on genotype. Methods: A review of literature was conducted from the disciplines of nursing, medicine, psychology, and sociology using the CINAHL, Ebsco Host, Medline, and PsychINFO databases. The search was limited to peer reviewed, full text article in English that dated from 1987 to 2011. Inclusion criteria were articles describing environmental, pharmacologic, and nutritional influence on genetic expression. Forty-five articles on genetic intervention were chosen for further review, in addition to five book publications which met inclusion criteria. Many of the sources retrieved were obtained from the biomedical sciences and published in the last decade, owing to more recent innovations in genetic discovery. Results: Disease and treatment must be approached according to genetic profiles for effectiveness and to increase health outcomes. Several variations were found regarding response to pharmaceuticals, as well as environmental exposures, based on genotype. Conclusions: Health care has been practiced using a "universal protocol" approach; however, as the literature reveals, each individual genotype must be taken into account to provide optimal care.

Historicamente, no Brasil e no mundo, o setor saúde tem se relacionado de forma ambivalente com travestis e transexuais (TT) promovendo acesso ao processo transexualizador, por um lado, mas condicionando-o ao diagnóstico de Tanstorno de Identidade de Gênero (TIG), patologizando assim a experiência da diversidade de gênero. As medidas preventivas adotadas na década de 80 com a epidemia do HIV, também acentuaram o estigma sofrido por este grupo, segregando o acesso aos serviços de saúde especializados. Pesquisas revelam, no entanto, necessidades de saúde relacionadas, não apenas ao acesso às tecnologias mais especializadas, mas de forma integral, associadas às marcas de opressão sofridas por essa população, à necessidade de vínculo aos serviços de saúde e à possibilidade de desenvolver autonomia. No que diz respeito, especificamente, aos dados epidemiológicos, essa população apresenta altos índices de transtornos mentais, uso de substâncias, violência e uso indiscriminado de hormônio. Apontam, ainda, a invisibilidade no que se refere à Atenção Primária à Saúde (APS) e a população TT. A Política Nacional de Atenção à Saúde Integral da População Lésbicas, Gays, Bisexuais, Travestis e Transexuais (LGBTT) vem como resposta a estas necessidades de cuidado integral, indo além do estigma patologização. Em consonância com esta política, o presente estudo teve como objetivo geral: elaborar um manual de acolhimento à população travesti e transexual para a APS e objetivos específicos: caracterizar o perfil da população TT; identificar os motivos pelos quais o usuário usa ou deixa de usar a APS; identificar barreiras que dificultam o acesso da população à APS; propor estratégias de superação das barreiras de acesso da população TT à APS. O projeto de pesquisa foi submetido ao Comitê de Ética da Escola de Enfermagem da Universidade de São Paulo (EEUSP) e da Secretaria Municipal de Saúde de São Paulo (SMSSP), bem como à gestão do Centro de Cidadania LGBT (CCLGBT) Luiz Carlos Ruas. Método: trata-se de um estudo qualitativo exploratório que realizou entrevistas semiestruturadas na Unidade Básica de Saúde-Sé (UBS-Sé) e no CCLGBT-Luiz Carlos Ruas, ambos na região central de São Paulo. O conteúdo das entrevistas foi registrado e, posteriormente submetido à diversas leituras para análise temática de conteúdo segundo a proposta de Bardin (2006). Análise dos dados: foram identificadas categorias empíricas a partir do referencial teórico relativo ao acesso enquanto dispositivo transformador da realidade, segundo Abreu de Jesus (2006) e às barreiras no acesso aos serviços de saúde à população LGBTT (Albuquerque et. al, 2016).Com relação aos dados quantitativos estes foram organizados em uma planilha para a análise dos dados. Resultados: Foram entrevistadas vinte pessoas trans, entre elas, treze se identificaram como mulheres trans, uma como travesti e seis como homens trans. Com idade média de 33 anos, em sua maioria solteiros (80%), com baixo grau de escolaridade (40% da amostra, referiram ter ensino médio incompleto ou menor grau de escolaridade) e apenas 30% inseridos no mercado de trabalho formal, evidenciando o panorama de vulnerabilidades da população trans. Com relação às barreiras no acesso à APS foram identificadas barreiras tecnoassistenciais relacionadas: 1) ao paradigma heteronormativo e de gênero como equivalência de sexo na APS; 2) pouca oferta do cartão do SUS com nome social e não uso do nome social; 3) falta de uma escuta qualificada; além de barreiras relacionadas às: 4) implicações da transfobia no acesso do serviço de saúde; 5) educação permanente: desconhecimento dos fluxos e conceitos da rede da pessoa trans; e 6) Transfobia nos serviços da APS. A partir das barreiras identificadas foram elaboradas proposições de superação das mesmas que integraram o Manual de acolhimento de Transexuais e Travestis à Atenção Primária à Saúde. Dentre as propostas de superação com relação às barreiras tecnoassitencias: estratégias de uso correto do nome social, a superação de paradigmas biologizantes e a valorização da dimensão relacional do trabalho em saúde, como o uso de uma comunicação responsiva e do acolhimento. Com relação às barreiras associadas à educação permanente, destaca-se a necessidade de ampliar o conhecimento dos trabalhadores com relação às informações a respeito das características da população TT, tais como: conceitos básicos envolvidos na temática, suas principais demandas e fluxos de apoio na rede. Investindo em metodologias ativas de ensino que se pautem em um modelo de saúde ampliado, evidenciando a visão política transformadora do trabalho no SUS. A superação da transfobia nos serviços de saúde está relacionada à promoção de educação permanente neste contexto. Outros estudos poderão avaliar a compreensão e utilização do Manual pelos profissionais da APS e a satisfação das necessidades da população TT. / Historically, in Brazil and in the world, health has related itself in an ambivalent way with transsexuals and transvestites (TT). Understood as pathology and not as diversity and freedom of gender by international disease manuals, this diagnosis allows access to medical procedures for changes in sexual characteristics. In Brazil, health places attention on the TT population beginning at the HIV / AIDS epidemic in the 80\'s, increasing this group\'s stigma and segregation, limiting access to specialized services, marking the ambivalence of the health system. Research describe, however, health care needs that go beyond HIV and physical transformations desired by trans people: high rates of mental disorders, substance use, violence, and indiscriminate use of hormones. Research also point out the invisibility in relation to Primary Health Care (PHC). The National Policy for Attention to Comprehensive Health Care for the Lesbian, Gay, Bi-sexual, Transvestite, and Transsexual (LGBTT) Population comes as a response to these needs for comprehensive care, going beyond the stigma and pathologization of gender identity. In line with this policy, the present study had as general objective: develop a manual for embracing the transvestite and transsexual population in the PHC; and specific objectives: characterize the TT population\'s profile, identify the reasons why users use or not the PHC, identify barriers that hinder the population\'s access to the PHC, and propose strategies for overcoming the TT population\'s access barriers to the PHC. Method: this is a qualitative and exploratory study in which 20 semi-structured interviews were carried out in Sé\'s Basic Health Unit - (BHU) and in Center for LGBT Citizenship (CLGBTC), both in the downtown area of Sao Paulo. The empirical material was analyzed through thematic analysis. Results: Twenty trans people were interviewed, among them thirteen identified themselves as trans women, one as transvestite and six as trans men. With a mean age of 33 years, mostly unmarried (80%), with a low level of schooling (40% of the sample, reported having incomplete high school or lower education) and only 30% inserted in the formal job market, evidencing the panorama of vulnerabilities of the trans population. Technical-care barriers were identified related to: 1) the paradigm of hetero-normative and gender as sex equivalence in the PHC; 2) offer little of the SUS (Brazilian Public Health Care System) card with social name social printed and the non-use of the social name; 3) lack of qualified listening. In addition to the related barriers: 4) implications of transphobia in access to the health service; 5) permanent education: lack of knowledge of flows and concepts of the trans person\'s network; 6) Transphobia in the PHC services. Based on the barriers identified, proposals were made to overcome them, which integrated the \"Handbook on the reception of Transsexuals and Transvestites for Primary Health Care\". Among the proposals for overcoming in relation to the tecnoassitencias barriers: strategies of correct use of the social name, the overcoming of biologizing paradigms and the valorization of the relational dimension of health work, such as the use of a responsive and welcoming communication. Regarding the barriers associated with lifelong education, the need to broaden workers\' knowledge regarding information about the characteristics of the TT population, such as: basic concepts involved in the theme, its main demands and support flows in the public health system. Investing in active teaching methodologies that are based on an expanded health model, evidencing the transformative political vision of the SUS work. The overcoming of transphobia in the health services is related to the promotion of permanent education in this context. Other studies may assess the understanding and use of the Manual by PHC professionals and the satisfaction of the needs of the TT population. From the identified barriers, propositions for improvement of these were built, as well as the Embracing Transvestites and Transsexuals (TT) in Primary Health Care (PHC) Manual.

Abstract The aim of this thesis is to suggest a model to assist in the ability to judge access by private persons to Information Technology, IT, and to Public Information Sys-tems, PIS. It has its starting point in the Swedish Government´s endeavour to turn Sweden into the first information society for all. When the available statistics con-cerning the access to a PC and the Internet in Swedish homes are studied it is easy to think that this vision may soon be realised. Of course, access to the technical equipment is a fundamental condition in order to be able to use the Public Informa-tion Systems, but unfortunately, is not the only one. A number of studies have shown that it is not possible to equate possession and use. A number of access models or frameworks designed to judge whether or not a person has access to the ICTs do exist. However, it is my opinion that there is a de-ficiency in these models; they do not start out from the individual user´s prerequi-sites, but rather judge the external conditions available for possible access. Assisted by four empirical studies, interviews and questionnaires, a number of ac-cess barriers experienced by the users have been identified. The studies show that in addition to the technological hindrances, a series of more elusive ones also exist originating from prevailing norms and values in the environment the user lives in. The barriers are categorised into five groups; to have, to be able, to will, to may and to dare. Together these notions form the User Centred Access Model, UCAM, which is suggested for use in charting and communicating the necessary considera-tions that must be taken into account in the development of Public Information Sys-tems. KeywordsLanguage / PI - Publika Informationssystem

This thesis sheds light on differences in health insurance enrolment determinants and uptake barriers between urban and rural areas in the Jirapa district of Ghana. The National Health Insurance Scheme in Ghana has made significant progress in terms of enrolment, which has had a commensurate increase in utilization of health care services. However, there are challenges that pose a threat to the scheme’s transition to universal coverage; enrolment in the scheme has not progressed according to plan, and there are many barriers known to impede uptake of health care. Interestingly, these barriers vary in relation to locality, and rural residents appear to carry a disproportionate portion of the burden. A mixed method approach was employed to collect and analyse the data. On the basis of the primary qualitative and quantitative results, the thesis argues that the costs of enrolling and accessing health care is disproportionately higher for rural residents than it is their urban counterparts. It also highlights that the distribution of service benefits both in terms of the NHIS and health care in the Jirapa district favours urban residents. Lastly, the thesis found that whereas rural residents prefer health care provision to be social in nature, urban residents were more interested in the technical quality aspects of care. These findings suggest that rural residents are not benefitting from, or may not be accessing health services to the extent as their urban counterparts. Affordability, long distance to health facilities, availability and acceptability barriers were found to influence the resultant pro-urban distribution of the overall health care benefit.

Background: Approximately one in five women in the United States experience childhood sexual abuse or rape as an adult. Healthcare providers are often not equipped to address the long-term effects of sexual trauma and its impact on one's health. Research Question: How can healthcare providers lessen service barriers for SA survivors? Method: This qualitative study employed convenience sampling from clinics that offered family medicine, urgent care, gynecology, or obstetrics. Participants included 11 physicians, physician assistants, and nurses. A semi-structured interview guide was used to explore health providers' perspectives and current practice procedures regarding treatment for sexual assault survivors and the barriers they face in treating this population. Data analysis involved a constant comparative method for identifying, organizing, describing, analyzing, and reporting themes within the data set. Results: The findings indicated three key barriers to providing care for female SA survivors: 1) personal/professional discomfort in discussing the topic of SA, 2) lack of knowledge and training on trauma-informed care, and 3) lack of time spent with each patient. Discussion: Recommendations for healthcare providers include 1) universal trauma-informed care training to better serve and support sexual assault and other trauma survivors, 2) revision of intake forms to include questions on sexual trauma history, and 3) inclusive services such as spending extra time on procedures, talking gently with the patient, and providing resources for mental healthcare services. Implications: Sexual assault survivors are less likely to be triggered or retraumatized by trauma-informed healthcare providers. Thus, they do not avoid annual physicals, medical tests, or setting up appointments when not feeling well, thereby enhancing their health outcomes.

This thesis sheds light on differences in health insurance enrolment determinants and uptake barriers between urban and rural areas in the Jirapa district of Ghana. The National Health Insurance Scheme in Ghana has made significant progress in terms of enrolment, which has had a commensurate increase in utilization of health care services. However, there are challenges that pose a threat to the scheme’s transition to universal coverage; enrolment in the scheme has not progressed according to plan, and there are many barriers known to impede uptake of health care. Interestingly, these barriers vary in relation to locality, and rural residents appear to carry a disproportionate portion of the burden. A mixed method approach was employed to collect and analyse the data. On the basis of the primary qualitative and quantitative results, the thesis argues that the costs of enrolling and accessing health care is disproportionately higher for rural residents than it is their urban counterparts. It also highlights that the distribution of service benefits both in terms of the NHIS and health care in the Jirapa district favours urban residents. Lastly, the thesis found that whereas rural residents prefer health care provision to be social in nature, urban residents were more interested in the technical quality aspects of care. These findings suggest that rural residents are not benefitting from, or may not be accessing health services to the extent as their urban counterparts. Affordability, long distance to health facilities, availability and acceptability barriers were found to influence the resultant pro-urban distribution of the overall health care benefit. / Ghana Education Trust Fund (GETFund)

African American women tend to experience higher health disparities in cancer-related illness than any other female population in the United States. The purpose of this qualitative case study was to identify and examine access-related barriers that play a significant role in the decision-making process of this population when seeking breast cancer health services. The central research question explored the effect that barriers to health care have on African American women in the Southeastern region of the United States. Secondary research questions explored the role the Patient Protection and Affordable Care Act of 2010 has on improving access to affordable, quality breast cancer screening services for the sample population. A critical theory lens of racism and ethnicity provided conceptual framework for this case study. Significant findings identified barriers to accessing breast cancer related health services as personal, community, social, systemic, and institutional. Personal barriers identified were related to access, autonomy, and benefits of the Affordable Care Act. Social barriers corresponded to cultural, financial burden, funding, health conditions, insurance, role within the family self-discovery, and spirituality. Community barriers included access, advocacy, and autonomy. Systemic and institutional barriers consisted of doctor listening, doctor's rapport, doctor treatment, lack of trust, and benefits of the Affordable Care Act. Implications for social change included bringing awareness of the need to establish a Breast Cancer Resource Center in the region to engage this population in preventive measures, improve health outcome and reduce health disparities.

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