As Medicaid moves toward a system of managed care, Aid for Families with Dependent Children (AFDC) recipients often are assigned to an organization that assumes responsibility for managing their annual receipt of health care. This study reports the results of an investigation into the patterns of medical care utilization by AFDC recipients and their children under reformed Medicaid. The issues explored include whether or not medical care utilization patterns vary by race, and if there are identifiable factors that determine the utilization patterns of AFDC recipients and their children. We conclude that racial differences in medical care utilization do exist for AFDC recipients, but not for their children. Policy makers involved in reforming Medicaid should recognize that certain cohorts continue to exhibit undesirable medical care utilization patterns, and implement measures to rectify this situation.

A theoretical and an empirical investigation using Logit Analysis, Discriminant Analysis, (Hierarchical) Log-Linear models with factor interactions and Goodman's measures of optimal prediction and uncertainty within the framework of consumer choice theory to explain the usage of health-care facilities and the behavior of individual consumers and different population segments seeking medical care within the Danfa Community in Ghana, West Africa. Based upon the household objective of utility maximization and the set of constraints--income, wealth, time, information and health, the demand for medical care is estimated as a function of individual and system characteristics, i.e. those characteristics describing in broad terms the factors of the household's needs, perception, willingness to secure care, and ability to secure care (e.g. age, sex, education, ethnicity, type of disease, literacy, health condition, occupation and costs of medication, travel and consultation. The sources of treatment or the providers of medical care were classified into five categories: self, family, drug seller, herbalist, and clinic. Our empirical results indicate that an individual's decision to seek or purchase medical care is more likely to be based on individual characteristics such as the number of unhealthy days rather than on system characteristics such as prices or costs of medication, travel, etc. This study has also revealed that some segments of the Danfa population in Ghana are more likely to exhibit an increasing preference or avoidance for certain health care facilities than others or use health-care facilities in different ways by either purchasing more or less medical care than other consumer groups. In assessing the effects of changes in the levels of particular factors on health-care decisions, our empirical results indicate that there is a reduction in total medical outlays for some consumers if there is a rise in the number of unhealthy days or an increase in the cost indices of medication, travel, and consultation. Policy measures for improvement in the future, including the reduction of the number of unhealthy days and household medical care expenditures through preventive health care education, community-based health insurance schemes for various occupational groups, and improvement of access capabilities or income earning capabilities through the encouragement of proper organization of economic activities within the rural community have been recommended in this study.

Transgender and gender-nonconforming (TGNC) individuals in the United States experience significant marginalization due to stigma enacted at the structural, interpersonal, and individual levels. As a result, this population has reported increased behavioral and physical health needs, as well as unique barriers to healthcare. Moreover, TGNC individuals have reported greater experiences of childhood abuse compared to cisgender individuals. The cumulative experiences of stigma-related stressors and adverse childhood experiences put this population at risk for the development of mental and physical health problems, increasing need for health services. However, TGNC individuals have reported being denied medical care and postponing seeking care due to fear of discrimination, which may increase complications and severity of illness, and result in increased hospitalizations and healthcare costs. Utilizing the Andersen Behavioral Model of Health Services Use and Theory of Planned Behavior, the current study examined robust associations among stigma-related stressors, adverse childhood experiences, personal and physician-related enabling factors, mental, behavioral, and physical health needs, and healthcare utilization, intention, and delay among an online convenience sample of 109 TGNC adults in the United States. A series of multivariate and mediational analyses were conducted to determine the connections among predisposing factors, enabling resources, needs, health beliefs, and healthcare intention, delay, and behavior. Although predisposing factors were not directly associated with healthcare behavior, they were directly associated with healthcare delay. Moreover, mediation analyses indicated an indirect effect of victimization and adverse childhood events to decreased healthcare utilization and increased delay through mental health needs, internalized stigma, negative personal beliefs, perceived TGNC-inclusivity of healthcare providers, and finally, behavioral intention. Thus, the present study illuminated a possible cascade of detrimental effects that are initiated by stigma-related stress and adverse childhood experiences through enabling resources, needs, and beliefs, that ultimately are associated with healthcare utilization intent, behavior, and delay. These findings highlight the need to address both TGNC individuals’ timely use of care, and the quality of care they receive. It is imperative that future research takes a multi-level approach by creating and testing evidence-based interventions to improve both healthcare providers’ competency, as well as for TGNC individuals’ ability to coping with stressors.

This dissertation analyzes the effects of community violence on health care service utilization and access in Mexico. Given the widespread effects of violence, there is good reason to believe that health service delivery might be affected, but it is largely unknown. This study looks at potential channels through which violence may impact the supply and demand of health care services in Mexico, through qualitative and quantitative methods. It posits that violence can have heterogeneous effects on service utilization and provides a deeper exploration of factors that may have negative and positive effects on service utilization. Supply-side effects point towards deterring effects of violence in service utilization out of fear of travel and fear among medical staff to go to their workplaces or shortening the hours of operation out of fear of exposure. Mixed effects logistic regression models reveal demand-side effects through a significant increase in health care service utilization as violence increases possibly related to worsening health (e.g. through stress or other mechanisms), which may drive individuals to seek more services. In sensitivity analysis, increased primary care service utilization as a result of an increase in the homicide rate remains significant when predictors of service use such as having a chronic condition, insurance status and urban areas are included in the models. Qualitative findings also reveal an increased demand for mental health services at the primary care level as a result of increased community violence. Findings underscore the importance of access to outpatient services and mental health services at the primary care level in contexts of high violence. The significant increase in the use of outpatient service utilization point towards potentially protective behaviors driving the increase of use of services as violence increases. This analysis highlights the responsibility and need for providing safe access to medical services in contexts of violence that may translate to natural disasters or other man-made conflicts.

Chronic liver disease is an important disease which affects national healthy in Taiwan. Hepatitis B or C virus infection is strongly relative to chronic hepatitis, liver cirrhosis and hepatocellular carcinoma. However, the early effective treatment can decrease the progression of liver cirrhosis and hepatocellular carcinoma and increase the recovery rate. In order to promote the health care quality for the patients with hepatitis, Bureau of National Health Insurance (BNHI) implemented the ¡§Enhance Hepatitis B or C Health Care Program¡¨ in October of 2003. The new policy sets up the standard treatment models and pay medical costs to encourage the patients to participate this program and fit cost-effectiveness. Therefore, aims of the study are to estimate the effects of the new policy on health care utilization and expenditures for the patients with hepatitis B or C. The study used the database from Bureau of National Health Insurance (BNHI) in 2002 and 2004. The study sample is the patients with hepatitis B or C who enrolled the program from January to June in 2004. We compared the differences of health care utilization and expenditures with these statistics in 2002. Besides, we also analyzed the difference in the characteristics of the patients and hospitals. In health care utilization, we found that number of visits was increased but interval between visits was decreased. Total costs, costs of treatments, prescriptions, total claim amount, and averages of prescription costs in health care expenditures were all increased significantly after the new policy implemented. Otherwise, there were not different on health care utilization and expenditures between different gender and level of the hospitals. On the other hand, there were significantly correlation of ages and number of comorbility. It means that the patients¡¦ ages are older, and their number of visits and total costs are higher but interval between visits is shorter than younger. Furthermore, number of comorbility increases and then interval between visits become short. The new policy certainly affects the health care utilization and expenditures of patients with hepatitis B or C. Implementing the new program can encourage patients adopt treatment actively and physicians have standard treatment protocols to follow. Understanding the changes on health care utilization and expenditures can give a health care guideline of cost-effectiveness. In conclusion, the results can provide the information about payments on patients with hepatitis to BNHI and then use it to be a basis after the new program implemented. Moreover, other countries also can evaluate the implementation of the new policy based on our results.

The goal of this study is to identify factors which may be preventing use of an experimental health care program in the People's Republic of Benin. While previous surveys have focused more specifically on the impact of fees on use and demand, our aim to identify a wider range of factors. / There are two principle methods by which this can be done. One is to extract possible factors from a review of the relevant literature. The other is to carry out an exploratory, qualitative study in the field. We have used both these methods. / A qualitative study is a necessary prelude to a survey, since we initially have no specific idea about which factors to measure and investigate. The aim is to identify factors which may be relevant so that a subsequent survey, with a larger number of cases, could quantify and measure their influence and statistical significance.

Population aging in Canada is expected to result in a sharp increase in the use of health services by the aged. The purpose of this thesis, is to enhance the knowledge of the utilization of the health system by the elderly. For this, an analysis of the utilization of three health services was pursued, using data from two health surveys, and two general social surveys in a statistical examination; to describe age-use; identify the major determinants of utilization; and to discover the sources of change in use. The results show that the aged were the highest users of health services among all age groups. Use increased for some services, and decreased for others. Changes in how people were managed by the health system, and to a lesser extent a rise in disease prevalence, were the primary sources of variations in utilization. There was no conclusive evidence of the presence of supplier induced demand. Population aging was not a significant determinant of changes in health service use, but rather factors associated with the management of the elderly by the health system; this includes technological changes in medicine, and changes in treatment patterns.

Background: To curb the transmission of HIV/AIDS and other infectious diseases several studies indicate the need for improved access to medical care for injection drug users (IDUs) including those already linked to syringe exchange programs (SEPs). However, availability and access to services remains a problem for many IDUs. This study seeks to examine perceptions of medical care access among a pharmacy-based sample of IDUs, utilization of medical services among IDUs and, identify barriers to accessing health care services to help ensure that IDUs receive appropriate care when needed and reduce the transmission of diseases. Methods: Data was obtained from the Pharmacists As Resources Making Links to Community Services (PHARM-Link) study. Dependent variables: health care access to the same provider and receiving care a usual source, health care utilization of services including the emergency room, clinic, medical office, medical mobile unit and hospital; and health care barriers categorized as personal or structural. Independent variables were insurance status, homelessness in the prior six months, case management, drug treatment and socio-demographic characteristics such as age, sex, income, education and employment status. Descriptive statistics analysis and logistic regression were performed using SAS version 9.4 (2013) with significance set at p<0.05. Results: Our sample included 615 IDUs participating in the PHARM-Link study. Overall, IDUs accessed health services and having the same provider remained statistically higher among those with legal income above $5,000 OR: 1.60 (95% CI: 1.03- 2.48), the insured OR: 4.11 (95% CI: 2.48-6.79), and those with positive HIV status OR: 7.64 (95% CI: 3.18 – 18.36), while those who were homeless reported lower access to the same provider OR: 0.63 (95% CI: 0.43 – 0.92). Only the older age group OR: 2.85 (95% CI: 1.42-5.73) and the insured OR: 3.42 (95% CI: 1.81-6.46) remained significantly associated with more access to receiving health needs at the same location. Those with some college education had less frequent visits to the clinic OR: 0.59 (95% CI: 0.38-0.92) and medical office OR: 0.64 (95% CI: 0.41-0.99), while the homeless were more likely to visit the emergency room OR: 1.49 (95% CI: 1.06-2.11). Females were less likely to go to a mobile unit OR; 0.52 (95% CI: 0.33-0.83) and married people were more likely OR: 1.95 (95% CI: 0.28-0.91). Visit to the hospital were less likely among females OR: 0.54 (95% CI: 0.36-0.81) and among those with some college education OR: 0.63 (95% CI: 0.41-0.96). Those with legal income above $5,000 were less likely to have any personal barriers OR: 0.64 (95% CI: 0.45 – 0.92). Structural barriers remained more likely among those who were homeless OR: 1.62 (95% CI: 1.13-2.39), but less likely among those 44 years and older OR: 0.58 (95% CI: 0.40-0.85), the insured OR: 0.60 (95% CI: 0.38-0.94), those with positive HIV status OR: 0.53 (95% CI: 0.28-0.99), as well as Non-Hispanic Blacks OR: 0.47 (95% CI: 0.14-0.83) and Latinos OR: 0.47 (95% CI: 0.25-0.86). Conclusion: Our results suggest that most IDUs linked to care through pharmacy-based SEP programs established to expand health services and improve health, did access available health services. However, some continue to experience difficulties such as structural barriers among the homeless as well as few reported visits to the clinic, medical office and the hospital among the employed believed to have resources to pay for such services. These services may have been underutilized because the participants were unsatisfied with the services provided. Therefore, interventions should target structural barriers such as homelessness among IDUs as well as health insurance coverage to help increase access to and utilization of health services.

This study is an investigation of how experiences of discrimination, self-efficacy, and the associated outcome expectations influence health care utilization of young college students. The relationships tested were informed by Andersen’s Behavioral Model of Health Services Use (Andersen, 2008), the most widely used model to understand and predict health care utilization. Andersen proposed that health care utilization is influenced by predisposing (i.e., personal characteristics), enabling (i.e., income, insurance), and need (i.e., perception of illness) factors. However, his model has been criticized for not taking in consideration social factors and oversimplifying the role of ethnicity as a predictor (Bradley et al., 2002). The purpose of this study is to expand the explanatory power of Andersen’s model, by including psychosocial variables (e.g., discrimination, self-efficacy). One hundred and eighty-five students completed a 20 minute online survey, which included measures of experiences of discrimination, outcome expectations, self-efficacy, attitudes, and demographic variables. Results indicated that self-efficacy to communicate with physicians was a significant predictor of health care utilization, although experiences of discrimination were not. The effects of discrimination on health care utilization were further found to be mediated by self-efficacy to communicate with physicians. The present study's finding provided support for the inclusion of psychosocial variables (i.e., self-efficacy) in Andersen's model to increase its explanatory power.

This study is a part of a three stage pursuit to examine and to comprehend the relationship between the resources available, the apparent utilization patterns of those resources by the population being served, and the selected characteristics of the populations utilizing and not utilizing the prevailing medical care system. The first stage of the research involves the examination of the existing patterns of medical care utilization by socioeconomic status groups. Cross-national Comparison of Physician Utilization by the Socioeconomic Status Groups is the pilot research for the first stage and both modifies and develops the methodology for this type of research and also examines the physician utilization patterns of a population in well defined basic measurements — in this case the socioeconomic status index, the diagnosed disease, and the number of physician contacts. The comparison of the physician utilization patterns of socioeconomic status groups in respect to the prevailing medical care delivery system necessarily involves cross-area studies at least at regional level, but most likely cross-national comparisons as well. This study used already collected data, nevertheless, primary data, which had been collected and partly analysed in the World Health Organization/International Collaborative Study of Medical Care Utilization. The data came from twelve geographical areas, altogether from seven countries, and provided documented research material on the surveyed respondents' social characteristics, standard diagnostic procedures, and standard definitions of the interactions between the users and the prevailing medical care delivery systems. The social characteristics were used separately, but in a standardized way, in order to derive socioeconomic status groups in each area; the diseases distributions were examined in relationship to the socioeconomic status groups, and the physician utilization patterns were related to the socioeconomic status groups while controlling for the distributions of selected diseases, after which the study areas were compared to each other in terms of the exhibited relationships between the physician utilization and the socioeconomic status groups. The physician utilization patterns were found to vary only little from one area to another, however, consistently, to warrant the use of derived information for the second stage of the research. Physician utilizations were very weakly correlated to the socioeconomic status and these correlations were not substantially effected by the selection of the controlling disease, i.e., they were consistent. / Medicine, Faculty of / Population and Public Health (SPPH), School of / Graduate