Socioeconomically deprived women are at greater risk of adverse pregnancy outcomes. To counteract this, attention tends to focus around access (equality) of services. Yet access may not equate with the meaningfulness (equity) of services for women from different socioeconomic backgrounds. Without understanding equity we are not in a position to plan appropriate and equitable care. This study aimed to determine pregnant women's perceptions of the current antenatal provision and to determine if women from the extremes of socioeconomic background perceived their antenatal care differently. Longitudinal interviews were undertaken with multiple, comparative antenatal case studies between January 2007 and April 2009. Cases were primigravida women from ‘least deprived’ (n=9) and ‘most deprived’ (n=12) geographical areas as identified by the Scottish Index of Multiple Deprivation (SIMD 2006). The data were analysed using case study replication analysis. Analysis of categorical data from the sample groups indicated they were less diverse than might have been expected in terms of age and education. However in the key variables of housing tenure, potential income and socioeconomic status based on area of residence, the groups were indicative of the SIMD target populations. The preliminary analysis showed that the sample groups considered the initial General Practitioner contact to be less than adequate and the subsequent utility of antenatal education to be based on self perceived relevance. The substantive analysis showed little difference in access to antenatal services between the ‘least’ and ‘most’ deprived groups but perception of care differed. A key difference concerned the level of ‘engagement’ (defined as personalisation and active involvement in care, power and relationships and health literacy). Using these concepts, engagement was present in most of the ‘least deprived’ group and almost none of the ‘most deprived’ group. In comparison with women from affluent areas, more deprived women described less evidence of: personal connection to their own care; shared decision making; and perceived value in relation to the written educational aspects of antenatal care. In terms of the preliminary analysis, the results suggest that utility of educational material may need to be reviewed to ensure it is relevant to specific needs. Without this relevance, key information may be missed. The substantive analysis suggests that for women from socioeconomically deprived areas, access may be a less useful indicator than engagement when assessing quality of antenatal services. The lack of engagement perceived by those who are most deprived suggests that equity of service has yet to be attained for those who are most in need. Future research needs to be directed to the potential reasons that may undermine equity and engagement in women from lower socioeconomic areas.

In 2007, the Canadian Paediatric Society (CPS) released a guideline aimed at preventing complications of neonatal jaundice through universal screening and guidelines for follow-up and treatment. This thesis investigates the impact of implementation of the CPS guideline on health services utilization at a population level in Ontario. First, we surveyed all Ontario hospitals providing maternal-newborn services to determine if and when they had implemented universal bilirubin screening, and to gather information about the organization of services to provide follow-up and treatment, and about the factors that influenced screening implementation. Then we conducted two population-based cohort studies using linked administrative health data to evaluate the association between 1) the implementation of universal bilirubin screening and phototherapy use (during and following birth hospitalization) length of stay (LOS), jaundice-related emergency department (ED) visits and readmissions; and 2) universal bilirubin screening implementation and access to recommended follow-up care by socio-economic status (SES). By 2012, the majority of Ontario hospitals had implemented universal bilirubin screening. There is heterogeneity in how hospitals organize services, but a notable trend towards hospital-based post-discharge care. Screening was associated with an increase in phototherapy during hospitalization at birth (relative risk (RR) 1.32, 95% confidence interval (CI) 1.09-1.59), and a decrease in jaundice-related ED visits (RR 0.79, 95% CI 0.64-0.96), but no statistically significant difference in phototherapy after discharge, length of stay, or jaundice-related readmissions after accounting for pre-existing temporal trends in healthcare service use and other patient socio-demographic and hospital characteristics. Implementation of the universal bilirubin screening in Ontario was associated with a modest increase in rates of early follow-up (adjusted RR 1.11, CI 1.0014-1.22, p=0.0468), but most babies were not seen within the recommended timeframe. Babies of lowest SES were least likely to receive recommended follow-up, and disparities in follow-up increased following universal bilirubin screening implementation. En 2007, la Société canadienne de pédiatrie (SCP) a publié une directive visant à la prévention des complications de l'ictère néonatal par le dépistage universel et des lignes directrices pour le suivi et le traitement. Cette thèse étudie l'impact de la mise en œuvre de la directive SCP sur l'utilisation des services de santé à niveau de population de l'Ontario. Tout d'abord, nous avons interrogé tous les hôpitaux de l'Ontario offrant des services de santé maternelle-nouveau-né afin de déterminer si et quand ils avaient mis en œuvre le dépistage universel de la bilirubine, et à recueillir des informations sur l'organisation des services pour assurer un suivi et de traitement, et sur les facteurs qui ont influencé la mise en œuvre de dépistage. Ensuite, nous avons mené deux études de cohorte basée sur la population à partir de données administratives sur la santé pour évaluer 1 ) l'association entre la mise en œuvre du dépistage de la bilirubine universel et la photothérapie utilisation lors de l'hospitalisation à la naissance, la photothérapie après avoir sortie de l'hôpital, la durée du séjour, le service des urgences liées à la jaunisse et des réadmissions liées à la jaunisse; et 2 ) l'association entre la mise en œuvre du dépistage universel et l'accès aux soins de suivi recommandés et si cela différait entre les quintiles de statut socioéconomique. En 2012, la majorité des hôpitaux de l'Ontario a mis en œuvre le dépistage universel de la bilirubine. Il existe une hétérogénéité de la façon dont les hôpitaux organisent des services, mais une tendance notable vers les soins post-décharge en milieu hospitalier. Le dépistage a été associé à une augmentation de la photothérapie pendant l'hospitalisation à la naissance (risque relatif (RR) de 1,32, intervalle de confiance 95 % (IC 95 %) de 1,09 à 1,59), et une diminution des visites à l'urgence liées à la jaunisse (RR 0,79, IC 95 % 0,64 à 0,96), mais aucune différence statistiquement significative dans la photothérapie après la sortie , la durée du séjour , ou réadmissions liées jaunisse - après comptabilisation des tendances temporelles pré- existants dans l'utilisation des services de soins de santé et d'autres caractéristiques socio- démographiques des patients et caractéristiques de l'hôpital. La mise en œuvre de le dépistage universel en Ontario a été associée à une légère augmentation des taux de suivi précoce (RR ajusté 1,11; IC de 1,0014 à 1,22; p = 0,0468), mais la plupart des bébés n'ont pas été vues dans les délais recommandés. Les bébés de statut socioéconomique faibles étaient moins susceptibles de recevoir de soins de suivi recommandés et les disparités dans le suivi ont augmenté suite à la mise en œuvre du dépistage universel de la bilirubine.

Background: The purpose of this research was to examine how the Three Bridges Community Health Centre conceptualizes and addresses the issue of accessibility for gay men. This research explored the intersection and disjuncture of how accessibility for gay men is understood and practiced from multiple perspectives (staff and clients). It revealed perceived and real barriers and opportunities for gay men in accessing health services, and provides insight into the mechanisms Three Bridges Community Health Centre employs to provide comprehensive health care to a local population that is not easily identifiable. Methods: Case study is the central defining methodological feature of this research. This study applies both inductive and deductive approaches. The data are qualitative, derived from 14 semi-structured interviews, document analysis (25 documents with a total of 398 pages) and participant observation (approximately 33 hours). Analysis and interpretation of the data were accomplished through the various procedures and techniques associated with qualitative data analysis, including the use of a qualitative software package - NUD*IST 4.0. Results: The study revealed twelve main factors that facilitate (and obstruct) accessibility for gay men. They were developing a mission of accessibility for vulnerable populations; assessing gay men's health issues, barriers and needs; utilization of the clinic; delivery of appropriate programs and services; available providers with appropriate knowledge, attitudes and behaviour; cultural accessibility (e.g., gay-friendly environment, multiple languages); geographic accessibility (location); physical accessibility (architecture); financial accessibility (affordability); functional accessibility (convenience); awareness (marketing & publicity of services and location); and partners in accessibility (e.g., community, health authorities, government). Each section of this chapter details how Three Bridges addresses each of these elements (the strengths), the challenges (e.g., time, money and personnel) in addressing these issues, as well as suggestions for improving accessibility. These factors would also be relevant for any primary care setting about to embark upon an examination of how (well) it addresses access for gay men, and other vulnerable populations. Conclusions: Partnerships with community-based agencies and recruitment of queer staff are critical in creating cultural accessibility for queer people. Many of the challenges raised by staff need to be addressed at a policy, region-wide level. Cultural accessibility for queer people also needs to be addressed by other healthcare settings. / Education, Faculty of / Educational Studies (EDST), Department of / Graduate

The objective of this research was to determine if healthcare access disparities exist across race and gender in a publically funded safety-net healthcare system in Texas. Data were examined from a representative random sample of 1468 adults aged 18-64 who were patients in this safety-net system in July and August of 2000 and were analyzed using binary logistic regression and chi-square measures of significance. Major Findings: On measures of health status - overall health rating (p =.051), limited employment (p =.000), energy level (p =.001), and worry (p =.012) - Anglos reported the worst health; Mexican Americans, the best health; with African Americans intermediate. Mexican Americans were more likely to have never had health insurance, and to also have had insurance in the past year; Anglos were least likely to have ever had insurance (p =.015) or to have had insurance in the past year (p =.000). On use of EDs (p =.028), problems getting prescription medicines (p =.029), and foregoing other necessities of life to pay for healthcare, Mexican Americans were least disadvantaged with African Americans reporting greatest use of EDs among both men and women, and Anglos the most problems with prescription medicines and foregoing care, especially among women. Logistic regression revealed that health status was the strongest predictor of problems accessing healthcare in all groups; the poorer health status of safety-net patients, the more problems they had accessing care. Patterns of poor reported health status and greater problems accessing care among Anglos relative to other groups is discussed in terms of social drift and relative deprivation.

Thesis (M. Dev.) --University of Limpopo, 2013 / Section 27 of the Constitution of the Republic of South Africa, 1996 provides that everyone has a right to have access to health care. South Africa embraces the concept of universal health care coverage. Access to health care has four dimensions: geographic accessibility, availability, financial accessibility and acceptability. If there were barriers to access to health care, the stake-holders would be duty-bound to design interventions requisite to address those barriers. The aim of the study was to establish whether health care users enjoy the right to have access to health services at Ratshaatsha Community Health Centre (RCHC). The study used a combination of quantitative and qualitative research designs. While a questionnaire was used to collect quantitative data, focused group discussions and participant observations were employed to collect qualitative data. The following are the main findings of the study. Human rights instruments clearly spell out the indivisible and mutually supportive rights that persons have. There are barriers that often affect the rights to have access to health services at RCHC. For instance, the RCHC is not within a 25 km radius of some of the consumers of health care. The roads that link up the health care users and RCHC are in poor condition. The community is generally poverty-stricken. Many cannot afford, among others, the costs of basic needs, transport fares and opportunity costs. Travelling distance and time, scarce skills and lack of medication and equipment rank among demand-side and supply-side barriers to access to health care. Health care users often choose to consult churches and traditional healers. It is recommended that government should, among others, co-ordinate primary health care services in collaboration with churches and traditional healers; commission research into traditional health medicine and healing procedures and protocols of other health care providers; develop policy on cross-referral of patients; improve community participation; set minimum norms and standards for the delivery of alternative health care services; establish health care management guidelines for churches and traditional healers; integrate health care provisioning into IDPs; and provide health care in an integrated intergovernmental manner.

Orientador: Clea Adas Saliba Garbin / Banca: Ronald Jefferson Martins / Banca: Paula Caetano Araújo / Resumo: De acordo com o Instituto Brasileiro de Geografia e Estatística (IBGE), no Brasil, existem mais de 6,5 milhões de pessoas com deficiência visual, sendo 582 mil cegas e 6 milhões com baixa visão, segundo dados da fundação, com base no Censo 2010. Apesar da prevalência alta de deficiência visual, há pouca informação disponível sobre os cuidados de saúde bucal e as necessidades desses indivíduos. Nesse sentido, o objetivo deste trabalho foi avaliar a percepção e a condição de saúde bucal das pessoas com deficiência visual, bem como o acesso e a satisfação delas em relação aos serviços de saúde bucal. Trata-se de um estudo quantitativo, de caráter transversal, realizado com pessoas com deficiência visual de um Instituto para cegos. Foi utilizado um questionário semiestruturado com perguntas abertas e fechadas sobre o tema. As variáveis pesquisadas foram: gênero, tipo de deficiência visual, tempo dessa deficiência, condição socioeconômica, percepção (OHIP-14) e condição da saúde bucal (CPOD), acesso e satisfação em relação aos serviços de saúde bucal. A análise de dados foi descritiva, sob a forma de frequência relativa, absoluta e analítica. Foi realizada a comparação entre variáveis categóricas por meio dos testes Qui-quadrado, teste Exato de Fisher, com nível de significância de 5%. Entre os resultados desta pesquisa, pode-se notar que, do total de pesquisados (n=72), 65,3% eram do sexo masculino, com média de idade de 34,6 ± 20,8 anos; metade possuía cegueira total. Quando per... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: According to the Brazilian Institute of Geography and Statistics (IBGE), in Brazil, there are more than 6.5 million people with visual impairment, 582,000 blind and 6 million with low vision, according to the foundation's data, based on the Census 2010. Despite the high prevalence of visual impairment, there is little information available on oral health care and the needs of these individuals. In this sense, the objective of this study was to evaluate the perception and the oral health condition of people with visual impairment, as well as their access and satisfaction regarding oral health services. This is a cross-sectional, quantitative study of visually impaired people at an Institute for the Blind. A semi-structured questionnaire was used with open and closed questions on the subject. The variables studied were: gender, type of visual impairment, time of this deficiency, socioeconomic condition, perception (OHIP-14) and oral health condition (DMFT), access and satisfaction regarding oral health services. The data analysis was descriptive, in the form of relative, absolute and analytical frequency. The categorical variables were compared using the Chi-square test, Fisher's exact test, with a significance level of 5%. Among the results of this research, it can be noted that, of the total number of respondents (n = 72), 65.3% were males, with a mean age of 34.6 ± 20.8 years; half had total blindness. When asked about the need to go to the dentist, 66.7% answered affirmativ... (Complete abstract click electronic access below) / Mestre

Objectif : identifier de nouvelles formes d’organisation et adaptations à développer en soins primaires pour améliorer la prise en charge des personnes sans chez-soi (PSCS).Méthode : recherche mixte. une première phase a exploré les ressentis des médecins généralistes (MG) sur leur place dans la prise en charge des PSCS. La seconde phase a consisté à décrire, par une revue de la littérature, les principales composantes des programmes de soins primaires prenant en charge les PSCS, et identifier les plus pertinentes. La dernière phase a exploré le vécu et les représentations des PSCS vis-à-vis des soins premiers.Résultats : les médecins généralistes relevaient la complexité des prises en charge et le besoin d’une coordination médico-psycho-sociale renforcée. Dans la littérature, la quasi-totalité des programmes prenant en charge les personnes sans chez-soi privilégiaient cette approche pluridisciplinaire coordonnée. Les caractéristiques associées à des impacts positifs pour les PSCS étaient : la spécialisation dans leur prise en charge, l’accompagnement, les approches multidisciplinaires, l’implication d’infirmières dans la prise en charge, l’intégration de services d’aide sociale, et l’engagement dans la santé communautaire. Les entretiens auprès des PSCS ont relevé l’importance des attentes relationnelles : plus qu’une réponse médicale, ils souhaitent être écoutés, considérés et compris.Conclusion : les programmes de soins primaires souhaitant prendre en charge PSCS devraient privilégier une approche pluridisciplinaire et décloisonnée des soins de santé physique, mentale, et de la prise en charge sociale de ces patients, en privilégiant une approche centrée-patient. / Aim: to identify new forms of organization and adaptations to develop in primary care to improve the care of Homeless People (HP).Method: research by mixed methods. In the first phase we explored the views of general practitioners (GPs) about how they can provide care to HP. In the second phase we led a literature review, to describe the main characteristics of the primary care programs that take care of homeless people, and to identify which could be most relevant. In the third phase, we explored the experience and views of HP about primary care.Results: GPs expressed the need to develop medical and psychosocial approach with closer relation with social workers. In the litterature, almost all homelessness programs developed a multidisciplinary approach and / or offered co-located mental health, physical health and social services. Some characteristics were associated with significant positive outcomes: tailored primary care organizations, clinic orientation, multidisciplinary team-based models which included primary care physicians and clinic nurses, integration of social support, and engagement in the community’s health. The interviews with HP showed central relational expectations of HP for their general practitioner. More than a medical response, they expected to be listened to, considered and understood.Conclusion: Primary care programs that wish to better care for HP should develop a multidisciplinary, medico-psycho-social approach. The patient-centered approach appears warranted to improve the care experience of these patients.

This study operationalized the five dimensions of health care access in the context of contraceptive service provision and used this framework to examine access to contraceptive care at health department (HD) (Title X funded) and federally qualified health center (FQHC) (primarily non-Title X funded) clinics in South Carolina and Alabama. A cross-sectional survey was conducted in 2017/18 that assessed clinic-level characteristics, policies, and practices related to contraceptive provision. Provision of different contraceptive methods was examined between clinic types. Survey items were mapped to the dimensions of access and internal consistency for each scale was tested with Cronbach's alpha. Scores of access were developed and differences by clinic type were evaluated with an independent t-test. The overall response rate was 68.3% and the sample included 235 clinics. HDs (96.9%) were significantly more likely to provide IUDs and/or Impants on-site than FQHCs (37.4%) (P < 0.0001). Scales with the highest consistency were Availability: Clinical Policy (24 items) (alpha = 0.892) and Acceptability (43 items) (alpha = 0.834). HDs had higher access scores than FQHCs for the Availability: Clinical Policy scale (0.58, 95% CL 0.55, 0.61) vs (0.29, 95% CL 0.25, 0.33) and Affordability: Administrative Policy scale (0.86, 95% CL 0.83, 0.90) vs (0.47, 95% CL 0.41, 0.53). FQHCs had higher access scores than HDs for Affordability: Insurance Policy (0.78, 95% CL 0.72, 0.84) vs (0.56, 95% CL 0.53, 0.59). These findings highlight strengths and gaps in contraceptive care access. Future studies must examine the impact of each dimension of access on clinic-level contraceptive utilization.

Background: Guideline-concordant therapies for survivors of an acute coronary syndrome (ACS) hospitalization require healthcare access, something that millions of Americans lack. Methods and Results: Using data from a prospective cohort study of over 2,000 survivors of a hospitalization for an ACS in central Massachusetts and Georgia from 2011 to 2013, the first two aims of this thesis sought to identify the post-discharge consequences for survival and health status of having: 1) financial barriers to healthcare, 2) no usual source of care, and 3) transportation barriers. We found that patients lacking a usual source of care and having a transportation barrier were more likely to have died within two years following hospital discharge compared to those without such barriers. Also, patients with financial barriers to healthcare were more likely to experience clinically meaningful declines in physical and mental health-related quality of life over the six months after hospital discharge. The third aim sought to better understand factors influencing the success of care transitions home after an unplanned hospitalization through a qualitative study of 22 patients. Participants described how adequate healthcare access, particularly having insurance and transportation to clinical appointments, facilitated the receipt of follow-up care and adherence to treatments. Conclusions: Limitations in healthcare access may contribute to poorer survival, health-related quality of life, and survival. Additional research is needed to identify interventions to improve healthcare access and test whether improved access leads to better patient outcomes.

Background: Digital primary care is expanding rapidly in Sweden and access is unevenly distributed and affected by socioeconomic status (SES) and digital exclusion. The COVID-19 pandemic further highlighted this problem as digital care removes risk of infection. Research is lacking on digital visits by traditional health care providers (HCP) during the COVID-19 pandemic and a risk exists that socially vulnerable groups are multiple afflicted by the current situation and that health policy goals are not achieved. Objectives: To investigate the effect of the COVID-19 pandemic on digital visits by traditional HCP, the distribution of visits and correlations to SES in Malmö municipality. Method: Ecological retrospective observational cross-sectional study with comparisons between the years 2020 and 2021. Descriptive analysis of changes between the years and distribution of visits and logistic regression for the correlation to Care Need Index (CNI) as a proxy for SES. Results: Physical visits decreased more than digital visits increased. Privately operated HCP and HCP in areas with higher income better compensated the decrease of physical visits with digital visits. There were major differences between HCP in use of digital visits and high CNI and private operation negatively affected this. Conclusion: Among traditional HCP in Malmö municipality the COVID-19 pandemic may have increased digital visits and the access was unevenly distributed. This risks increased inequality in health and not achieving set health policy goals. Further studies and efforts are needed to achieve a digital primary care with equal access and patient’s autonomy, participation, and empowerment in focus. / <p>Betyg i Ladok 220617.</p>