Active asthma and asthma-related health care utilization are higher among adult females than they are among adult males in Puerto Rico. The purpose of this study was to examine the determinants of the risk of active asthma and associated health care utilization and asthma control among women in Puerto Rico. Guided by the Andersen behavioral model, the study included data from the Asthma Call-Back Survey (ACBS) during 2011 and 2012 in Puerto Rico. The associations between active asthma and behavioral, demographic, and environmental factors were assessed using logistic regression. The relationship between asthma-related health care utilization and predisposing, enabling, and need factors was examined using multiple linear regression. The association between achieved level of asthma control and asthma-related healthcare utilization was investigated using multinomial logistic regression. Results of the logistic regression indicated that being out of work, being in a middle income category, and being obese significantly increased the odds of active asthma. Being self-employed and being in the income category of $15,000-$25,000 significantly predicted the frequency of emergency room visits (ERVs). Results of the multinomial logistic regression indicated that physician urgent visit and ERV were significantly associated with poorly controlled asthma symptoms. The positive social change implication of these findings is that the identified risk factors can be used to develop asthma management plans to prevent and control asthma attacks in at-risk populations and reduce asthma-related health care utilization cost

Background: Pregnancy induced hypertension (PIH) is the leading cause of maternal mortality and a major contributor to preterm birth and neonatal mortality. Literature suggests that several modifiable psychosocial and health behavioral factors may play significant roles in the development of PIH. However, interrelationships among these factors and their collective impact on PIH are not well understood. Objectives: This study aims to: 1) Examine the relationship between pre-pregnancy physical activity and risk of PIH, 2) Determine the association between prepregnancy depression and PIH and the role of race/ethnicity in this association, 3) Evaluate the association between intimate partner violence (IPV) in women before and/or during pregnancy and PIH, and the role of utilization of prenatal care (PNC) as a mediator in this association. Methods: This study utilized the national Pregnancy Risk Assessment Monitoring System survey data (years 2009-2015). The outcome variable PIH was defined as a dichotomized variable (Yes; No) utilizing a birth certificate variable data. Domain-adjusted multiple logistic regression, multiple logistic regression with stratification, and structural equation modeling analyses were used to investigate the study aims. Results: No significant reduced risk of PIH was observed in women who were physically active prior to pregnancy compared to sedentary women. However, women with prepregnancy depression were more likely to have PIH compared to women without prepregnancy depression and this association was significant for non-Hispanic White women when stratified by race/ethnicity. Further, PNC utilization was a significant mediator in the association between IPV before and/or during pregnancy and PIH. However, IPV had no direct or total effect on PIH in this study. Conclusions: Public health professionals and health care providers should be aware of the relationships between prepregnancy depression, race/ethnicity, IPV, and prenatal care utilization, and PIH, and utilize the information in risk profiling, screening, early detection and intervention in women at risk of PIH.

<p>A randomized intervention study, with the aim to compare the effects of individual psychosocial support provided by (1) oncology nurses specially trained in psychological techniques (INS), or (2) psychologists (IPS), to (3) standard care (SC). Breast cancer patients, living in Uppsala County, and about to start adjuvant treatment at the Department of Oncology, Uppsala, were consecutively included between 1998 and 2000. The patients were assessed seven times during two years by self-administered questionnaires. Study I revealed positive effects of both INS and IPS as compared to SC on global quality of life, side effects, and post-traumatic distress. A lower proportion of patients in the intervention groups had psychosocial support provided in routine care compared with the SC group. In study II the patients reported being highly satisfied with the intervention, irrespective of profession providing the support. However, patients in the INS group reported higher levels of benefit regarding disease-related problems than those in the IPS group. In study III total Health Care costs were lower in the intervention groups and since a gain in quality-adjusted life years (QALY) was seen (mean .1 QALY), the interventions dominated. The costs for the interventions were 44 291- 48 978 SEK. In study IV, daily reporting of anxiety, depression and activity on Visual Analogue Scales (VAS) were completed during two weeks before and after the Hospital Anxiety and Depression Scale (HADS) assessments. A point assessment with the HADS captured the situation better than four weeks assessment on three VAS in the diary. The HADS was considered preferable to the diary. The conclusion is that psychosocial support is beneficial for breast cancer patients and that the intervention delivered by nurses was as effective as that given by psychologists. The costs for the interventions were limited.</p>

A randomized intervention study, with the aim to compare the effects of individual psychosocial support provided by (1) oncology nurses specially trained in psychological techniques (INS), or (2) psychologists (IPS), to (3) standard care (SC). Breast cancer patients, living in Uppsala County, and about to start adjuvant treatment at the Department of Oncology, Uppsala, were consecutively included between 1998 and 2000. The patients were assessed seven times during two years by self-administered questionnaires. Study I revealed positive effects of both INS and IPS as compared to SC on global quality of life, side effects, and post-traumatic distress. A lower proportion of patients in the intervention groups had psychosocial support provided in routine care compared with the SC group. In study II the patients reported being highly satisfied with the intervention, irrespective of profession providing the support. However, patients in the INS group reported higher levels of benefit regarding disease-related problems than those in the IPS group. In study III total Health Care costs were lower in the intervention groups and since a gain in quality-adjusted life years (QALY) was seen (mean .1 QALY), the interventions dominated. The costs for the interventions were 44 291- 48 978 SEK. In study IV, daily reporting of anxiety, depression and activity on Visual Analogue Scales (VAS) were completed during two weeks before and after the Hospital Anxiety and Depression Scale (HADS) assessments. A point assessment with the HADS captured the situation better than four weeks assessment on three VAS in the diary. The HADS was considered preferable to the diary. The conclusion is that psychosocial support is beneficial for breast cancer patients and that the intervention delivered by nurses was as effective as that given by psychologists. The costs for the interventions were limited.

published_or_final_version / abstract / toc / Dentistry / Doctoral / Doctor of Philosophy

One of the most important factors in accessing dental care is having dental insurance. For people with low incomes, Medicaid is the main source of health insurance. Medi-Cal is California’s Medicaid program. Adult dental services were mostly eliminated in Medi-Cal in 2009 due to the economic downturn and partially restored in 2014. The objective of this study is to evaluate the effect of change in Medi-Cal dental coverage, specifically the partial restoration of adult dental coverage in 2014, on dental care utilization among Medi-Cal beneficiaries. The partial restoration significantly increased the utilization rates in dental clinics from 2014 to 2017 (22% in 2017 vs. 12% in 2013) for the overall population. However, the magnitude of increase differs in different age groups and ethnic groups. More statistically significant findings show greater utilization rates among beneficiaries of 19-64 than 65-74 and 75+ years old. Also, more significant findings show lower utilization among Black than White, Hispanic or Asian beneficiaries. The partial restoration significantly reduced the dental related ER visits among Medi-Cal beneficiaries from 2015 to 2017. However, the reduction is largely seen in beneficiaries of 19-64 years old in the ethnic groups of White and Black with reductions of 20 and 15 visits per 1,000 enrollees respectively in 2017 comparing to 2013. The dental related ER visits were lower for Hispanics and Asians, and remained very low among those 65 years old and above. In addition, the partial restoration resulted in increases in participation of dental care providers in the Medi-Cal program.

Indiana University-Purdue University Indianapolis (IUPUI) / Transgender women have the highest HIV prevalence rates of all gender and sexual minorities, yet are less likely to enter and be retained in HIV care. As a result, they are at high risk for HIV-related morbidity and mortality. This study aimed to describe the illness career of transgender women living with HIV and to describe how interactions with health care providers and important others influenced their illness trajectory. The findings are a theoretical model that includes four stages: Having the world come crashing down, shutting out the world, living in a dark world, and reconstructing the world. Relationships within the social network (family, friends, and romantic partners) and the network of health care providers provided the context of the women's illness careers. Pivotal moments marked movement from one phase to the next. Having the World Crashing Down was the first stage that occurred when the participants were diagnosed with HIV. They felt that their lives as they knew them had been destroyed. They indicated that the "whole world just shattered" the moment they found out they had HIV. Shutting Out the World occurred next. During this stage, many participants experienced withdrawal, denial, social isolation and loneliness. As they struggled with their diagnosis, they often avoided HIV care and avoided contact with important others. During the third stage, Living in a Dark World, participants descended into a dark phase of self-destructive life and health-threatening behaviors following their diagnosis. During the fourth stage, Reconstructing the World, participants began to reestablish themselves in the world and found new ways to reengage with important others and resume meaningful life activities. Findings confirm that the illness careers of HIV-positive transgender women are influenced by the social context of the health care setting and interactions with health care providers and important others.

Objective: The aim of this study was to investigate the longitudinal impact of depressive symptoms on utilization of healthcare in terms of GP visits as well as specialist visits and hospital admission in late life among community-dwelling individuals. Methods: Longitudinal data (baseline and follow-up) were derived from the German multicentre, prospective cohort study “Late-life depression in primary care: needs, health care utilization and costs” study (AgeMooDe). At baseline, n = 1,230 patients aged 75 years and older were recruited from primary care practices. Main outcomes of interest were use of health care services: the number of GP visits, the number ofmedical specialist visits, and hospital admission. We used the Geriatric Depression Scale (GDS-15) to measure depression. Outcomes were analyzed with multilevel random intercept negative binominal regression and logistic random-effects models. Results: At baseline (n = 1,191), mean age was 80.7 (SD 4.6) years, 62.9% were female, and 196 individuals (16.5%) had depression (GDS-15 6). Our longitudinal analyses indicated that older individuals with more depressive symptoms visited their GP more often (IRR=1.03; CI [1.01-1.04], p < 0.001), were visiting medical specialists more frequently (IRR=1.03; CI [1.01-1.04], p < 0.01), and had higher odds of being hospitalized (OR=1.08; CI [1.02-1.13], p < 0.01). Conclusions: Based on this large longitudinal study we showed that, after adjustment for important covariates, older individuals with more depressive symptoms had higher health care utilization over time. They visited their GP and specialists more frequently and they had higher odds of being hospitalized. This may suggest that higher utilization of specialist care and increased likelihood of being hospitalized may be also attributable to unspecific symptoms or symptoms that are elevated through depressive symptoms

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