The aim of this thesis was to describe inequalities in the use of different health care services according to socioeconomic position (SEP) in Catalonia, Spain and Europe. In addition, we intended to assess whether the public coverage of the services, in particular dental health care, has an influence on the magnitude of inequalities in the use of such services. Finally, we aimed to determine the influence of population-based female cancer screening programmes on the prevalence of screening and on the extent of inequality. To accomplish these objectives four studies were carried out. The sources of information of the four studies were, respectively: several editions of the Catalan Health general practitioner (GP) services are equitable or manual classes use them to a greater extent. However, there are marked SEP inequalities in the use of outpatient specialist services, especially in dental care. Socioeconomic inequalities in use of dental care services exist throughout Europe, but they are larger in countries in which dental care is not covered at all by the public health care system than in countries in which dental care is partially covered. In Europe, socioeconomic inequalities in breast and cervical cancer screening are not found in countries with population-based screening programmes but they are found in those countries with only regional or pilot programmes and in those countries with opportunistic screening. / L'objectiu d'aquesta tesi era descriure les desigualtats en l'ús de diferents serveis sanitaris segons la posició socioeconòmica a Catalunya, Espanya i a Europa. A més a més, es volia avaluar si la cobertura pública dels serveis, en particular la dels serveis dentals, infuencia la magnitud de les desigualtats socioeconòmiques en l'ús d'aquests serveis. Finalment, es va voler determinar la influència dels programes poblacionals de cribratge dels càncers de mama i cèrvix en la prevalença de cribratge i en la magnitud de les desigualtats. Per tal d'assolir aquests objectius es van dur a terme 4 estudis. Les fonts d'informació d'aquests estudis van ser, respectivament: diferents edicions de l'Enquesta de Salut de Catalunya (ESCA), diferents edicions de l'Enquesta Nacional de Salut d'Espanya (ENS), l'Enquesta de Salut, Envelliment i Jubilació a Europa (SHARE) 2006 i dades dels països europeus que van participar a l'Enquesta Mundial de la Salut de l'OMS l'any 2002. Els dos primers estudis eren estudis de tendències mentre que els dos últims van ser transversals. En tots els estudis les desigualtats socioeconòmiques es van mesurar mitjançant índexos relatius (RII) i absoluts (SII) de desigualtat. Els resultats d'aquests estudis mostren que a Catalunya i a Espanya els serveis d'atenció primària són equitatius o fins i tot les persones de classes manuals en presenten una major proporció d'ús. Tanmateix, hi ha marcades desigualtats en visites a l'especialista, en especial en les visites al dentista. Les desigualtats socioeconòmiques en la utilització dels serveis dentals existeixen a tota Europa, però són més grans en aquells països on l'atenció dental no està coberta pel sistema públic de salut que en aquells països on aquesta està parcialment coberta. A Europa, no es troben desigualtats socioeconòmiques en el cribratge dels càncers de mama i cèrvix en aquells països amb programes poblacionals de cribratge, però sí que es troben en aquells països amb programes pilot o regionals o amb només cribratge oportunista.

Objective The aim of this study firstly, was to translate and test the validity and reliability of two diabetes-specific self-efficacy instruments (the Diabetes Management Self-Efficacy Scale; DMSES and the Perceived Therapeutic Efficacy Scale; PTES) in a Taiwanese population. The main aim of this study was then to develop an intervention based on self-efficacy theory that was appropriate for the Taiwanese population and to examine the effects of a self-efficacy enhancing intervention program (SEEIP). Background In Taiwan, the prevalence, mortality rate and healthcare cost of diabetes has dramatically increased. People with diabetes have low participation rates in performing self-care activities, with some two-thirds of diabetic patients not controlling their disease appropriately. Moreover, few studies in Taiwan have conducted randomised controlled trials or had improvement in patient self-care or self-management as their primary goal and no instruments that measure self-efficacy related to the management of diabetes (especially for outcome expectations) have yet been found and appropriately used to measure the effectiveness of self-management. Therefore, there is a particular need for research on self-efficacy enhancing intervention programs for people with type 2 diabetes. Design A convenience sample survey (n=230) was used in order to test the validity and reliability of C-DMSES and C-PTES in a Taiwanese population. Moreover, a randomised controlled trial (RCT) (n=145; the intervention group (72); the control group (73)) design was conducted in the main study with pre (baseline) and post-testing (undertaken at 3 months and 6 months following baseline collection). Intervention Both the control group and intervention group received the standard diabetic educational program in the outpatient clinic. The intervention group participants received the standard diabetic educational program and the following additional interventions: (1) viewed a 10-minute DVD (2) received a &quotDiabetes Self-Care" booklet (3) participated in four efficacy- enhancing counselling intervention sessions, and (4) participated in telephone follow-up. The self-efficacy model was adapted from Shortridge-Baggett & van der Bijl (1996). Diabetes self-management principles were used in program development and evaluation. Main outcome measures Instruments used in data collection included 1) Self-efficacy towards management of type 2 diabetes (as measured by the Chinese version of the Diabetes Management Self-Efficacy Scale; C-DMSES and the Chinese version of the Perceived Therapeutic Efficacy Scale; C-PTES); 2) self management behavior (as measured by the Summary of Diabetes Self-Care Activities; SDSCA); 3) health-related quality of life for diabetes (as measured by the Short Form-12; SF-12); 4) psychosocial well-being (as measured by the Medical Outcomes Study (MOS), Social Support Survey (SSS) tool and the Center for Epidemiology Studies Short Depression Scale; CES-D) and 5) health care utilisation (as measured by health care utilisation self report instrument). Data analysis Data were double-entered for verification using SPSS® statistical software. Study I: Descriptive statistics, regression analysis, Pearson's correlation, Cronbach's alpha-coefficients, factor analysis and Bland-Altman plots with 95% limits of agreement (LOA) were performed to evaluate validity and reliability of C-DMSES and C-PTES. Study II: Descriptive analysis was used to examine demographic variables and outcome variables. T-tests were used to analyse differences on continuous data between mean scores for the intervention and control groups. Categorical data were analysed using Chi-square statistics to test the significance of different proportions. To assess the group differences of dependent variable changes, repeated measures ANOVA/ ANCOVA were used. Results Study I: Convergent validity showed that C-DMSES correlated well with the validated measure of the General Self-Efficacy Scale (GSE) in measuring self-efficacy. Criterion-related validity showed that the C-DMSES was a significant predictor of the Summary of Diabetes Self-Care Activities (SDSCA) scores. Factor analysis supported the C-DMSES being composed of four subscales with good internal consistency (Cronbach's alpha=.77 to .93) and stability (ICC=.82). Similarly, significant criterion-related validity was demonstrated between the C-PTES and SDSCA scores. Convergent validity was confirmed as the C-PTES converged well with the GSE Scale in measuring self-efficacy. Construct validity of the C-PTES was confirmed through factor analysis and a single subscale formed. Internal consistency with a Cronbach's alpha was .95 and the test-retest reliability (ICC) was .77 and a Bland-Altman plot showed 97% of the subjects were within 2 standard deviations of the mean. Study II: The 3- and 6-month benefits of the intervention over usual care were increases in self-efficacy, outcome expectation, self-care activities, and social support. However, the results of the health-related quality of life and depression scores indicated that the change over time was not different in the two groups. A smaller proportion of the participants significantly in the intervention group, had been hospitalised and visited the emergency room than participants who were in the control group at the 6-month period. However, health-related quality of life and depression were not significantly increased in the intervention group at the 3- and 6-month compared to the control group. Conclusion Results of Study I support the psychometric properties of C-DMSES and C-PTES in providing a measure for self-efficacy specific to persons with type 2 diabetes in Taiwan. The main study revealed that the SEEIP for type 2 diabetes based on self-efficacy theory was culturally acceptable to Taiwanese people with diabetes and that the SEEIP was effective in the self-management of people with type 2 diabetes.

The aim of the study was to investigate the knowledge and utilisation of antenatal care (ANC) services by pregnant women at a clinic in Ekurhuleni. A quantitative, descriptive correlational study was carried out on 90 eligible pregnant women. Data were collected with a self-administered questionnaire and analysed with the help of a statistician using the Epi Info version 7 computer program. The results of the study indicate that most women initiated ANC later than the recommendations by the World Health Organization (WHO). Over half of the respondents had overall good knowledge of ANC, but lacked knowledge of medication and screening tests done during pregnancy, some danger signs during pregnancy and of exclusive breastfeeding. Factors that were identified as associated with late initiation of ANC were current employment status, number of children, transport costs to clinic and number of antenatal visits. / Department of Health Studies / M.A. (Public Health)

Text in English / Background: Children living in child-headed households have health needs that require treatment and care. Matsanjeni is one of the poorest socio-economic areas of Swaziland with the high number of children orphaned by HIV and AIDS who are often living without adequate family and social supports. These conditions are known for increasing people vulnerability to diseases and hindering access and utilization of health services. However, children living in child-headed households in Matsajeni community do attend the primary health care (PHC) services on regular basis. What influence the utilization of the above services by children living in child-headed households in the Matsanjeni community is not clear and well documented. Aim of the study: To explore and describe the views of children living in child-headed households in a rural community of Swaziland regarding factors influencing their utilization of PHC services. Design: A qualitative descriptive design was used to guide the study. Purposive sampling was used to select the most senior child from child-headed households in a rural community. Semi-structured individual face-to-face interviews were used to generate data. Data saturation was reached after twenty interviews. Thematic content analysis was used to analyse data. The researcher used Andersen behavioural model was to identify and organised the emerged themes. Ethical clearance was obtained from the Ethics Committees of the University of South Africa and the Ministry of Health of Swaziland. Results: Fear to develop a deadly disease, perceived seriousness of the condition, desire for compliance to medical treatment, and community support emerged as enablers of primary health care services utilisation among children living in child-headed households. While lack of money, ignorance, shortage of healthcare personnel, negative behaviour and attitude of health professionals, long waiting hours, unreliable transportation system, and long distance emerged as inhibitors of primary health care services utilisation among children living in child-headed households. Conclusion and recommendation: The results of this study add to our understanding factors that positively and negatively influence the utilisation of primary health care services among children living in child-headed households in rural communities. The findings suggest that the utilisation of primary health care services among children living in child-headed households is influenced by need for care-enabling resources-experience of care triad. Behavioural and social welfare interventions are needed to enhance the utilisation of primary health care services among this vulnerable section of the community in Swaziland. Recommendation for further research is also articulated. / Health Studies / M.A. (Public Health)

The aim of the study was to investigate the knowledge and utilisation of antenatal care (ANC) services by pregnant women at a clinic in Ekurhuleni. A quantitative, descriptive correlational study was carried out on 90 eligible pregnant women. Data were collected with a self-administered questionnaire and analysed with the help of a statistician using the Epi Info version 7 computer program. The results of the study indicate that most women initiated ANC later than the recommendations by the World Health Organization (WHO). Over half of the respondents had overall good knowledge of ANC, but lacked knowledge of medication and screening tests done during pregnancy, some danger signs during pregnancy and of exclusive breastfeeding. Factors that were identified as associated with late initiation of ANC were current employment status, number of children, transport costs to clinic and number of antenatal visits. / Department of Health Studies / M.A. (Public Health)

The purpose of the study is to determine the barriers to utilisation of antenatal care services among pregnant women in Omaheke Region - Namibia. A quantitative, cross-sectional descriptive research was followed, and a structured questionnaire was used to obtain information from study participants. One hundred and ten (110) women of child-bearing age between 18 to 49 years who visited Gobabis District Hospital in Omaheke Region for deliveries (full-term) or kept for postnatal care purposes were selected. A questionnaire with open-ended and closed-ended questions was designed using a Likert scale to gather information. SPSS software was used to generate descriptive statistics. Results indicated that the majority of respondents (39%) who attended antenatal care services, fell within the age range of 18-21 years. Participants demonstrated higher knowledge of the recommended number of antenatal care visits and of the importance of antenatal care services. Transport money and cost, long distances to health facilities, desirability, unplanned or unwanted pregnancy, and limited transportation options are the barriers that contribute to low utilisation of antenatal care services among pregnant women in Omaheke Region. Recommendations for deployment of more qualified midwives at rural antenatal clinics, building more antenatal care clinics in the region and creation of community awareness campaigns on the importance of antenatal care may increase the utilisation of antenatal care services in the Region. It is anticipated that this research will contribute to the promotion and utilisation of antenatal care services among pregnant women in Omaheke Region. / Health Studies / M. P. H.

Text in English / Background: Children living in child-headed households have health needs that require treatment and care. Matsanjeni is one of the poorest socio-economic areas of Swaziland with the high number of children orphaned by HIV and AIDS who are often living without adequate family and social supports. These conditions are known for increasing people vulnerability to diseases and hindering access and utilization of health services. However, children living in child-headed households in Matsajeni community do attend the primary health care (PHC) services on regular basis. What influence the utilization of the above services by children living in child-headed households in the Matsanjeni community is not clear and well documented. Aim of the study: To explore and describe the views of children living in child-headed households in a rural community of Swaziland regarding factors influencing their utilization of PHC services. Design: A qualitative descriptive design was used to guide the study. Purposive sampling was used to select the most senior child from child-headed households in a rural community. Semi-structured individual face-to-face interviews were used to generate data. Data saturation was reached after twenty interviews. Thematic content analysis was used to analyse data. The researcher used Andersen behavioural model was to identify and organised the emerged themes. Ethical clearance was obtained from the Ethics Committees of the University of South Africa and the Ministry of Health of Swaziland. Results: Fear to develop a deadly disease, perceived seriousness of the condition, desire for compliance to medical treatment, and community support emerged as enablers of primary health care services utilisation among children living in child-headed households. While lack of money, ignorance, shortage of healthcare personnel, negative behaviour and attitude of health professionals, long waiting hours, unreliable transportation system, and long distance emerged as inhibitors of primary health care services utilisation among children living in child-headed households. Conclusion and recommendation: The results of this study add to our understanding factors that positively and negatively influence the utilisation of primary health care services among children living in child-headed households in rural communities. The findings suggest that the utilisation of primary health care services among children living in child-headed households is influenced by need for care-enabling resources-experience of care triad. Behavioural and social welfare interventions are needed to enhance the utilisation of primary health care services among this vulnerable section of the community in Swaziland. Recommendation for further research is also articulated. / Health Studies / M.A. (Public Health)