One of the most vulnerable groups in Swedish society today is single parent families, a group that has increased over the last thirty years in proportion to married and cohabiting parents. The aims of this thesis are to study inequality and inequity in health and health care utilization with regard to whether parents are single or couple (married/cohabiting), to investigate whether the concept of social capital may provide us with further understanding when analyzing inequality and inequity in health and to investigate how the mental health of single parent children may differ from couple parent children and to what extent this difference may be due to parental socio-economic and socio-demographic characteristics, including social capital. The results from the papers on which this thesis is based indicate that both single mothers and single fathers have poorer health than couple mothers and fathers. Single mothers also refrain from seeking medical care to a greater extent. The financial advantage of single fathers, in comparison with single mothers, might have an impact on their medical care utilization, since they seemingly seek and consume health care to an extent that matches their poorer health. Social capital has as robust an association with self-rated health as any traditional social determinant of health. Four parental characteristics were found to be independently associated with children’s mental health; being a single parent, ‘poor parental health’, limited social support and low levels of social capital. The uneven distribution of all investigated determinants of health, including social capital, gives us reason to conclude that our findings indeed raise concerns about equity. Action taken by society to enable single parents to increase their social capital might improve their and their children’s health. It may also be clearly stated that financial status has a major impact on both health and health care utilization. This particular characteristic is also rather accessible to alteration, for example through financial transfers between groups in society.

Abstract Objective: Readmission is a big part of health care expenditure and recent studies suggested that hospital readmissions can be applied as an important indicator of quality of care within health care system. Furthermore elderly population usually costs the large amount health care expenses and is the main group in readmission. Moreover readmission is usually attributed to chronic diseases. Nevertheless, evaluations of hospital readmissions under universal health care coverage areas were not well-studied in Taiwan. Therefore this study aims to explore the associations between initial hospitalizations and probability of hospital readmissions in details. Research method: Patients aged 65 or older with primary clinical diagnosis of asthma or COPD based on ICD-9-CM for hospital admissions and readmissions in Taiwan.National claims of these two diseases were collected and analyzed from year 2000 to 2004. Population-based descriptive analyses of related health care utilizations were estimated. Multivariate logistic regressions were conducted to predict the probability of hospital readmissions. Controlled variables included patient factors, medical institutions¡¦ characteristics, urbanizations, and air quality indicators. Result: Among asthma and COPD elderly patients, more health care utilizations were observed in the hospital readmissions than initial admissions. Multivariate logistic regressions indicated that age, gender, disease severity, hospital characteristics, and air quality were significant predictors of the probability of hospital readmission. Meanwhile, age, disease severity, and hospital characteristics also significantly affected the time interval between initial admission and readmission. In addition, longer length of stay in the initial admission will significantly shorten the time interval between initial admission and readmission (P<0.001). Conclusion: For Asthma and COPD elderly patients, longer length of stay in the initial admission will significantly shorten the time interval between initial admission and readmission and have higher probability of hospital readmission. This study provides the evidence of reducing the health care expenditure by controlling readmission rate. With more understandings of factors affecting hospital readmissions, we can improve the health care delivery and reduce unplanned readmissions in the future. Key words: Asthma, COPD, hospital readmission, health care utilization, length of stay, admission fees

White-Black disparities in disability in the older population are consistently reported in the literature, and are usually ascribed to differences in socio-economic, health, and cognitive status. However, the role of modifiable influences on disability, such as health and lifestyle behaviors or health care utilization on these differences is less clear. This dissertation examines: (1) longitudinal White-Black differences in disability and the potential contributions of distinct health behaviors to these differences; (2) White-Black differences in the effects of health care utilization on trajectories of disability; and (3) whether cognition mediates the effects of health behaviors on disability in Whites and in Blacks, independent of established confounders for these relationships. This dissertation uses longitudinal data from the Asset and Health Dynamics among the Oldest Old study (AHEAD). Trajectories of disability in basic (ADL) and instrumental (IADL) activities of daily living are fit using mixed effects models with time-varying predictors. The mediation effect is tested using a multilevel mediation model. Results indicate that health behaviors close the residual White-Black gap in IADL trajectories but not the residual gap in ADL trajectories. Physical activity participation and maintenance of a normal weight or overweight status resulted in lower ADL and IADL disability levels over time among Whites. None of the health behaviors influenced longitudinal trajectories of disability in Blacks. Short-stay nursing home and home health care utilization was associated with lower ADL and IADL disability levels over time among Blacks. Cognition mediated the effect of physical activity participation on ADL and cognitive IADL in Whites but not in Blacks. That is, physical activity participation had positive effects on ADL and IADL disability both directly, and indirectly through beneficial effects on cognition. Modifiable influences on disability, such as health and lifestyle behaviors and health care utilization should be targeted by intervention programs and regulatory policies in order to narrow or eliminate the White-Black disability disparities. Such interventions may represent effective avenues for achieving the goals of Healthy People 2010.

Background: A significant number of laryngeal cancer patients are diagnosed with advanced-stage disease. Since stage at diagnosis is an important prognostic factor, it is necessary to understand the characteristics of individuals at risk of being diagnosed at an advanced stage. Objectives: (1) Compare usual health care utilization between laryngeal cancer patients and the general population. (2) Evaluate the association between usual health care utilization and stage at diagnosis in laryngeal cancer. Methods: The study population included 1,702 laryngeal cancer patients diagnosed from 2005–2008, and 8,510 matched-controls from the general population. Demographic, clinical, and health administrative data from Ontario were used to measure usual health care utilization in a two-year period (i.e. frequency of encounters, continuity of care, primary care model enrolment, and preventive services use), stage at diagnosis, and covariates. Results: Laryngeal cancer patients had fewer health care encounters and a greater propensity for using preventive services than the general population. Comparisons of usual health care utilization among laryngeal cancer patients showed significant trends across Stage I–IV for the frequency of encounters (p=0.002), continuity of care (p=0.02), and preventive services use (p<0.0001). Stage I patients were less likely than Stage II–IV patients to have a low frequency of encounters (10%), low continuity of care (28%), and no preventive services use (28%). In adjusted multivariable analyses, low continuity of care was marginally associated with an increased risk of advanced-stage laryngeal cancer (RR [95% CI]: 1.17 [1.01, 1.34]). Stratification by subsite showed a marginally significant association between continuity of care and stage in glottic cancer (RR [95% CI]: 1.25 [0.98, 1.58]), but no association in supraglottic cancer (RR [95% CI]: 1.01 [0.89, 1.15]). Conclusions: Laryngeal cancer patients’ patterns of usual health care utilization differ from the general population. There was little evidence of an effect of usual health care use on the risk of advanced-stage laryngeal cancer in multivariable analyses adjusting for confounders. Multinomial regression may be needed to fully elucidate the effects of health care utilization across Stage I–IV. Understanding health care utilization among laryngeal cancer patients is important for improving early detection and warrants further research. / Thesis (Master, Community Health & Epidemiology) -- Queen's University, 2012-04-26 10:50:05.976

No description available.

Researchers examining issues of recent veterans of military conflicts in Iraq and Afghanistan have found evidence of psychological distress and difficulty adjusting to civilian life post-deployment. Changes in educational benefits offered to veterans will likely facilitate greater numbers of veterans to enter academia in the coming years. This survey of 49 college student veterans at a large Midwestern university was designed to reveal the frequency and intensity of psychological distress, PTSD and alcohol misuse. Relationships between these constructs and the constructs of social support, stigma and barriers to psychological care, life satisfaction, traumatic experiences, attitudes toward help seeking, and service utilization are reported. A history of mental health service utilization since military service was reported by many respondents. PTSD and alcohol misuse symptoms were reported by many college student veterans and incidence in this sample was greater than the incidence previously reported in the literature on veterans. Stigma was found to be negatively correlated with attitudes toward help seeking. Post deployment social support was found to be negatively associated with psychological distress and positively associated with service utilization. Implications and limitations of these findings are presented and future directions for research and intervention are discussed.

A equidade na utilização de cuidados de saúde deve ser considerada como questão central em qualquer política de saúde que pretenda contribuir para uma sociedade mais justa. Desse modo, o objetivo desta tese é analisar o desempenho da entrega de cuidados no Brasil em termos de equidade por meio de violações do princípio de equidade horizontal na utilização dos serviços de cuidados de saúde e da decomposição dos determinantes da desigualdade na utilização do cuidado relacionada à renda. A desigualdade na distribuição de cuidado médico pela renda é capturada por índices de iniquidade para a utilização de serviços de consultas médicas e internações hospitalares. Esses índices mostram se existem diferenças no uso de serviços de cuidados de saúde entre indivíduos com similares necessidades de saúde. Para explicar as causas da desigualdade, Wagstaff, van Doorslaer e Watanabe (2003) propõem que a medida do grau de desigualdade seja decomposta nas contribuições dos fatores explicativos do uso. A análise também considerou a perspectiva da desigualdade, o que permitiu observar não apenas desigualdades sociais mas também variações regionais na entrega de cuidados de saúde. Os resultados mostraram iniquidade horizontal pró-rico no uso de consultas médicas e pouca evidência de iniquidade no uso de internações. O padrão de iniquidade horizontal no uso se repetiu para todas as regiões, mas regiões menos desenvolvidas como, o Norte e o Nordeste, apresentaram maior grau de iniquidade. A decomposição da desigualdade mostra que contribuições de fatores de necessidades de saúde são principalmente pró-pobre, uma vez que pessoas mais pobres tendem a possuir maiores necessidades de cuidado. Por outro lado, as contribuições dos determinantes sociais foram bastante diversificadas. Renda e escolaridade contribuem para aumentar a distribuição pró-rico no uso de consultas e reduzir a contribuição pró-pobre no uso de internações hospitalares. A contribuição da condição de atividade foi, em geral, pró-pobre, podendo ser explicada pelo maior custo de oportunidade das pessoas ocupadas em procurar cuidados com a saúde. As contribuições dos plano de saúde e das desigualdades regionais são examinadas com maior atenção por serem alvo direto de políticas de saúde. Assim, contribuições pró-rico do plano de saúde e das desigualdades regionais poderiam ser reduzidas, por exemplo, por estratégias com foco em grupos de renda mais baixa e pela ampliação de recursos físicos e humanos das áreas menos desenvolvidas. / Equity in healthcare utilization should be considered as a basic issue at any health policy that you want to contribute to a fairer society. Thus, the aim of this thesis is to analyze the performance of medical care delivery in Brazil in terms of equity through violations of the horizontal equity principle of healthcare use and of the decomposition of the determinants of income-related inequality in the use of medical care. The inequality in the distribution of medical care by income is captured by inequity indices. This indices show if there are differences in the use of healthcare services among individuals with similar health needs. To explain the causes of the income-related inequality, Wagstaff, van Doorslaer, Watanabe (2003) proposed that the measure of the degree of inequality is decomposed into the determinants of use. The analysis also considered the regional perspective of inequality, which allowed us to observe not only social inequalities but also regional variations in the delivery of healthcare. The results find evidence horizontal inequity pro-rich in the utilization of doctor visits and little evidence de inequity in inpatient care use. The pattern of horizontal inequity in use is repeated for all regions, but less developed regions like the North and Northeast had a higher degree of iniquity. The decomposition of inequality shows that contributions of factors of health needs are mainly pro-poor, because poorer people tend to have greater care needs. On the other hand, the contributions of the social determinants were enough diverse. Income and education contributed to increase the pro-rich distribution of use of doctor visits and reduce the distribution pro-poor inpatient care. The contribution of status of activity was mostly pro-poor because probably economically active people have a higher cost of opportunity in seeking healthcare. The contributions from the health insurance and regional inequalities are examined more closely by being a direct target of health policy. Accordingly, contributions pro-rich of health insurance and of regional inequalities could be reduced, for example, by strategies focused on lower income groups and by the expansion of physical and human resources of less developed areas.

Identifying and communicating a disease diagnosis has historically been the center of the medical encounter. Recent advances in molecular biology and genetics have increased the amount of care devoted to disease screening and risk assessment. In this era of prevention, risk itself has become a ‘problem’ requiring intervention where once such problems were left unidentified. Treating risk as a diagnosis itself allows it be treated in a familiar manner, but marginalizes the patient experience. It is important to understand how adopting a biomedical view of risk and prevention influences participation in care and patient willingness to engage with the medical system, despite a lack of manifest disease. This is a critical gap in knowledge at a time when there is increased emphasis on preventive medicine. This dissertation contains three chapters that seek to characterize how identifying, labeling, and developing interventions for patients 'at risk' affects service provision and use. Study 1, Explanatory Models of Risk: The Role of Social Context in Breast Cancer Risk Perception and Decision-Making, sought to characterize explanatory models of risk among women at risk for developing breast cancer. Qualitative interviews demonstrated the importance of perceptions of risk and control in combination with elements of explanatory models and social context in their decision-making. Study 2, Associations between Breast Cancer Risk and General Health Service Use, considered the possibility that patterns of health service utilization may change following a medical finding that is often perceived as increased risk. Results showed a greater increase in the rate of outpatient visits and referrals in the year following a false positive mammogram, suggesting such utilization is driven by both patients and providers. Study 3, An Assessment of Patient Navigator Activities in Breast Cancer Patient Navigation Programs Using a Nine-Principle Framework, described similarities and differences in the execution of patient navigation programs designed to increase engagement in care among individuals who have been labeled as ‘at risk’ upon having an abnormal mammogram. Activities conducted by navigators where shown to vary according to the local context and population of women that they served.

Using data collected in 2007 for Addis Ababa Mortality Surveillance, the paper examines the effect of cause of death/type of illness on choice of health care in adults 12 years and above. The multinomial logit model using bootstrapped standard errors is used to investigate the relationship between dominant type of treatment and the covariates: cause of death, gender, age, education, occupation, ethnicity and religion. Availability of water, television and telephone in the household are used as a proxy for economic status. After controlling for duration of illness (exposure), type of illness, gender and marital status are significant. Those who die of HIV/TB and cancer behave similar in way they seek help, and have high likelihood of using traditional healers as the first point for help compared to those who died as a result of other illnesses. Thus the study concludes that cause of death; gender and marital status affect choice of health service.

Sickle cell disease (SCD) is the most common group of genetic, chronic hematologic disorders, and is characterized by chronic pain resulting from vaso-occlusive episodes. As such, youth with SCD utilize a disproportionately high amount of health care resources. Youth with frequent health care utilization (HCU) are at increased risk for psychosocial consequences, including disruptions in family functioning and decreased academic performance. While studies have separately examined HCU, family functioning, and academic achievement in this population, there is a dearth of research examining the association between these variables. The present study aimed to: (1) examine associations between family environment and patterns of HCU, (2) examine associations between patterns of HCU and academic achievement scores in math and reading, and (3) evaluate the indirect effect of family environment on academic achievement scores in math, as explained by patterns of HCU. This study included 41 youth with HbSS or HbS beta-thalassemia. Youth were administered the Woodcock-Johnson III Achievement, and caregivers completed the Family Environment Scale. Sociodemographic characteristics were collected, and medical history information was obtained via retrospective medical chart review. Overall, participants reported a more positive family environment, demonstrated less pain-related ED visits and hospital admissions, and obtained below average scores on academic achievement in math and reading. The present study did not provide evidence of associations between family environment, HCU, and academic achievement. Unique characteristics of the study sample, as well as clinical implications and next steps for future research are discussed.