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Home and community participation is measured by a multitude of determinant factors based within the context of a health system. Three studies were completed to understand relationships between environment and personal factors with service utilization and outcomes of participation among children with disabilities. In the first study, a scoping review was completed to identify factors that influenced rehabilitation service utilization among Canadian children with disabilities. Key findings of this review indicated higher rates of service utilization are associated to younger age, males and those with lower cognitive or motor functioning. Occupational therapists, physiotherapists and speech-language pathologists were the most commonly utilized disciplines. Higher perceptions of service satisfaction related to increased presence of family-centered practices. Areas requiring further research include family needs, barriers, personal health practices and participation outcomes. Based on the findings of this review, a survey was created to administer to parents using a large children’s rehabilitation treatment centre in Ontario. Findings from the survey conducted with 279 parents are reported in the second study by providing a descriptive profile of families and children using geographically-based rehabilitation services. Families using the centre typically have younger aged children, with more boys than girls, and a large proportion use the centre for speech services. Complexity scores correlated significantly and positively with service need and service utilization, indicating children with lower functioning desired and received more rehabilitation services. Age, sex, and diagnosis did not predict total time in therapy, but complexity was a significant predictor of total time in therapy. Participation frequency scores showed weaker relationships to complexity in comparison to participation involvement scores. The final study explored the relationship between environmental and personal factors of service utilization and participation using structural equation modeling. Predictors of participation include child’s age, environmental barriers, complexity, and mother’s participation. Findings support that exploring children’s complexity and promoting mother’s participation by removing environmental barriers and modifying inaccessible structures are important to examine from a young age. / Dissertation / Doctor of Philosophy (PhD) / This study examines the relationship between factors of service utilization and participation outcomes for children with disabilities. Currently, there is little knowledge pertaining to the characteristics of children receiving rehabilitation services and the influence of these services on health outcomes. Such information is vital to understand how health conditions, service utilization, service planning, and service satisfaction differ across children with disabilities. Use of health services (type and number of rehabilitation services used, duration of services), environmental barriers, maternal leisure practices, and socioeconomic factors are examined with consideration to the child’s diagnosis and complexity in relation to scores of participation. This is the only study in Canada so far to comprehensively explore relationships between rehabilitation utilization and participation. The study informs health care providers and researchers about patterns and variations in children’s needs that can be utilized to improve service quality and plan services, as well as to understand participation patterns.

Obstructive sleep apnea (OSA) is underrecognized. Between 10% and 69% of preoperative patients have undiagnosed OSA. To reduce the risk of peri-operative complications related to undiagnosed OSA, patients planned to undergo bariatric surgery are screened for OSA. To understand the OSA detection rate with screening practices, the prevalence of OSA within patients who underwent publicly funded bariatric surgery in Ontario between 2010 and 2016 was measured. Secondly, to understand the effect of OSA screening practices on perioperative and longer-term health care costs, health care utilization and costs were compared between patients with OSA and matched patients without OSA in the 30 days post-bariatric surgery, as well as in the 1 year post-bariatric surgery. The Ontario Bariatric Registry (OBR) linked to the ICES health administrative databases were used. A diagnosis of OSA was identified if recorded in the OBR at time of initial bariatric consultation, or if recorded in ICES databases from the bariatric surgery admission records. Costs were calculated based on the “Guidelines on Person-Level Costing Using Administrative Databases in Ontario” using ICES costing algorithms. The overall prevalence of OSA was 47% (95% CI 46% to 47%). Total health care costs per patient, in the 30-day post-operative period, were 1% lower (95% CI 1% to 1%, p < 0.001) in patients with OSA compared to matched patients without OSA. Similarly, at 1 year postbariatric surgery, total health care costs per patient, were 1% lower (95% CI 1% to 1%, p < 0.001) in patients with OSA compared to matched patients without OSA. At 30 days and 1 year, this difference was driven by lower hospitalization-related costs. OSA screening practices at surgical centers in our network led to similar rates of OSA detection as reported in the literature. However, the literature suggests that screening practices lead to missed OSA diagnoses. Further study is required to understand the reduced post-bariatric surgery costs in patients with OSA compared to matched controls without OSA; and, we postulate that missed OSA diagnoses may be a contributor. / Thesis / Master of Science (MSc) / Obstructive sleep apnea (OSA) is underrecognized and a good proportion of patients with OSA are undiagnosed. To reduce the risk of peri-operative complications related to undiagnosed OSA, patients planned to undergo bariatric surgery are screened for OSA. To understand the performance of OSA screening practices, using a province-wide registry, the proportion of patients diagnosed with OSA within patients who underwent publicly-funded bariatric surgery in Ontario between 2010 and 2016 was measured at 47%. Furthermore, to understand the effect of OSA screening practices on peri-operative costs and longer-term health care costs, health care utilization and costs were compared between patients with OSA and matched patients without OSA in the 30 days and 1 year post-bariatric surgery. Total health care costs per patient were 1% lower in patients with OSA compared to patients without OSA, and this difference was driven by lower hospitalization-related costs.

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Background: Non-communicable diseases (NCDs) are the leading causes of morbidity and mortality among adults in Vietnam. Little is known about the magnitude of socioeconomic inequalities in NCDs and other NCD-related factors in urban areas, in particular among the poor living in slum areas. Understanding these disparities are essential in contributing to the knowledge, needed to reduce inequalities and close the related health gaps burdening the disadvantaged populations in urban areas.  Objective: To examine the burden and health system responsiveness to NCDs in Hanoi, Vietnam and investigate the role of socioeconomic inequalities in their prevalence, subsequent healthcare utilization and related impoverishment due to health expenditures.  Methods: A cross-sectional study was conducted among 3,736 individuals aged 15 years and over who lived in 1211 randomly selected households in 2013 in urban Hanoi, Vietnam. The study collected information on household’s characteristics, household expenditures, and household member information. A qualitative approach was implemented to explore the responsiveness of commune health stations to the increasing burden of NCDs in urban Hanoi. In-depth interview approach was conducted among health staff involved in NCD tasks at four commune health stations in urban Hanoi. Furthermore, NCD managers at relevance district, provincial and national levels were interviewed.  Results: The prevalence of self-reported NCDs was significantly higher among individuals in non-slum areas (11.6%) than those in slum areas (7.9%). However, the prevalence of self-reported NCDs concentrated among the poor in both slum and non-slum areas. In slum areas, the poor needed more health care services, but the rich consumed more health care services. Among households with at least one household member reporting diagnosis of NCDs, the proportion of household facing catastrophic health expenditure and impoverishment were the greater in slum areas than in non-slum areas. Poor households in slum areas were more likely to face catastrophic health expenditure and impoverishment. The poor in non-slum areas were also more likely to face impoverishment if their household members experienced NCDs. Health system responses to NCDs at commune health stations in urban Hanoi were weak, characterized by the lack of health information, inadequate human resources, poor financing, inadequate quality and quantity of services, lack of essential medicines. The commune health stations were not prepared to respond to the rising prevalence of NCDs in urban Hanoi.  Conclusion: This thesis shows the existence of socioeconomic inequalities in the prevalence of self-reported NCDs in both non-slum and slum areas in urban Hanoi. NCDs associated with the inequalities in health care utilization, catastrophic health expenditure and impoverishment, particular in slum areas. Appropriate interventions should focus more on specific population groups to reduce the socioeconomic inequalities in the NCD prevalence and health care utilization related to NCDs to prevent catastrophic health expenditure and impoverishment among the households of NCD patients.  The functions of commune health stations in the urban setting should be strengthened through the development of NCDs service packages covered by the health insurance.

The aim of this thesis was to investigate in a (RCT) the effect of support group intervention in women with primary breast cancer in the short term, and with a long-term follow-up. Women with primary breast cancer were randomized between April 2002 and November 2007 and stratified according to adjuvant treatment with chemotherapy. Of 382 eligible patients, 191+191 patients were randomized to intervention and control groups respectively. Control patients were subjected to standard follow-up procedures. Patients in the intervention group received support intervention at the Foundation of Lustgården Mälardalen during one week followed by four days of follow-up two months later. Patients in intervention and control groups filled in questionnaires at baseline, after 2, 6 and 12 months and in the long-term follow-up after a mean of 6.5 years. In paper I, we studied the effect of the intervention on anxiety and depression measured by the HAD scale and we could show that a significantly lower proportion of women in the intervention group had high anxiety scores compared with women in the control group after 12 months; however, the proportion of women with high depression scores were unaffected. In paper II, we studied the effect of the intervention on fatigue and health-related quality of life (HRQoL) measured by the Norwegian version of the fatigue questionnaire (FQ) and EORTC-QLQ 30 and BR 23.We could not demonstrate any significant effect of the intervention. In paper III, we studied the effect of the intervention on sick-leave, healthcare utilization and the effect of the intervention in economic terms. We used a specially formulated questionnaire. There was a trend towards longer sick leave and more health-care utilization in the intervention group. The difference in total costs was statistically significantly higher in the intervention group after 12 months (p= 0.0036). In paper IV, we studied the long-term effects of the support intervention on anxiety, depression, fatigue and HRQoL. We could show a significant effect of the intervention on cognitive function, body image, future perspective and fatigue, the largest effect was seen among women who received chemotherapy; however, no effects on anxiety and depression were demonstrated.

Abstract Recent studies in adults have shown that musculoskeletal (MS) pains are often experienced at several body sites. The number of pain sites has been shown to be proportional to poor health outcomes, such as functional ability and health-related quality of life (HRQoL). This study investigated the occurrence and persistence of MS pain in multiple locations, determinants of multiple-site pain, and the impact of multiple-site pain on HRQoL and health care use among adolescents aged 16 to 19. The data were based on three inquiries that were administered to the adolescents of the Northern Finland Birth Cohort 1986. MS pain was common and often occurred at multiple sites. Moreover, the majority of adolescents with multiple-site pain at 16 reported multiple-site pain also at 18. Multiple-site MS pains were strongly associated with psychosocial complaints, but also with high physical activity level, long sitting time, short sleeping time, smoking, and overweight. Emotional problems, behavioral problems, and high sitting time among males, and emotional problems, high physical activity level, short sleeping time, and smoking among females were predictive factors for the persistence of multiple-site pain. The likelihood of reduced HRQoL increased according to the number of MS pain sites. A trend toward an increase in health care use with the number of pain sites was also observed. Reporting pain in multiple sites in adolescence may have both peripheral (tissue origin) and central (pain experience) causes. As multiple-site pain in adolescence may predict subsequent MS morbidity, the adolescents who are at highest risk and also at the highest need of health promotion should be identified in further studies. / Tiivistelmä Aikuisväestössä tehtyjen tutkimusten perusteella tuki- ja liikuntaelimistön kivut esiintyvät tavallisesti usealla kehon alueella samanaikaisesti. Monikipuisuudella näyttää olevan epäedullisia vaikutuksia useisiin terveyteen liittyviin ilmiöihin kuten toiminta- ja työkykyyn sekä elämänlaatuun. Tässä tutkimuksessa tarkasteltiin monipaikkaisen tuki- ja liikuntaelinkivun esiintyvyyttä, pysyvyyttä ja riskitekijöitä sekä sen vaikutusta terveyteen liittyvään elämänlaatuun ja terveyspalvelujen käyttöön 16–19 –vuotiailla nuorilla. Tutkimuksen aineisto perustui kolmeen kyselyyn, jotka lähetettiin Pohjois-Suomen syntymäkohortti 1986:n nuorille. Tuki- ja liikuntaelinkipu oli yleistä ja esiintyi tavallisimmin usealla kehon alueella. Suurin osa nuorista, jotka raportoivat monen paikan kipua 16-vuotiaana, raportoivat sitä myös 18-vuotiaana. Monen kehon alueen tuki- ja liikuntaelinkipu yhdistyi voimakkaasti psykososiaalisiin tekijöihin, mutta myös korkeaan liikunta-aktiivisuuteen, runsaaseen istumiseen, vähäiseen uneen, tupakointiin ja ylipainoon. Käyttäytymisen- ja tunne-elämän häiriöt sekä runsas istuminen pojilla, ja tunne-elämän häiriöt, korkea liikunnallinen aktiivisuus, vähäinen uni sekä tupakointi tytöillä ennustivat monen kehon alueen kivun pysyvyyttä. Todennäköisyys heikentyneeseen terveyteen liittyvään elämänlaatuun lisääntyi suhteessa kipualueiden määrään. Myös terveyspalvelujen käytön ja kipualueiden lukumäärän välillä havaittiin yhteys. Monen paikan tuki- ja liikuntaelinkipua selittänevät sekä kudostasoiset että keskushermostolliset syyt. Koska laaja-alainen kipuoireilu nuoruudessa voi ennustaa myöhempiä tuki- ja liikuntaelinongelmia, riskiryhmiä ja samalla eniten terveyden edistämistä tarvitsevia nuoria tulisi pyrkiä jatkossa tarkemmin tunnistamaan.

There are currently no effective methods for treating and preventing chronic pain. The aim of this thesis was to study prognostic factors for health care utilization, and the long-term outcomes of tailored behavioral medicine treatment for patients with musculoskeletal pain. Another aim was to increase knowledge about physical therapists’ assessment and analysis of patients’ pain conditions and to investigate the potential of subgrouping patients based on prognostic factors. Methods: In Study I, a prospective population-based cohort was followed over 21 years. Data from three measure points were analyzed: 1995 (n=2425), 2007 (n=1582) and 2016 (n=1184). Study II was a 10-year follow-up of randomized controlled trial (n=97), comparing tailored behavioral medicine treatment and exercise-based physical therapy. In Study III, a descriptive and explorative design was applied, using data from video-recordings of 12 physical therapists. In study IV, assignment to three subgroups based on the Örebro Musculoskeletal Pain Screening Questionnaire was validated against reference instruments, and the stability between two points of measurement was investigated in patients (n=40) who were seeking primary health care due to musculoskeletal pain. Results: Chronic pain, female gender and high age predict high health care utilization over 21 years, and a trajectory of stable high health care utilization over the entire period. The differences between groups in favor for tailored behavioral medicine treatment reported at post-treatment and after two years, were not maintained at the 10-year follow-up. A majority of the physical therapists assessed factors for poor prognosis. The analyses were mainly based on biomedical assessments and none of the physical therapists included behavioral factors. Subgroup assignment according to the Örebro Musculoskeletal Pain Screening Questionnaire appears to be valid and stable over time. Conclusion: Prognostic factors such as chronic pain and female gender need to be considered when allocating health care resources and planning treatment to improve long-term outcomes. The treatment should also be tailored based on individual functional behavioral analyses of key behaviors and on patient´s biomedical and psychosocial condition, including strategies for maintenance of behavioral changes. Evidence-based methods for integrating behavioral medicine treatment into physical therapy need to be further evaluated and improved.

This dissertation examined health care utilization patterns across conventional health care (CHC), complementary and alternative medicine (CAM), and public health care (PHC) systems among Canadians aged fifty and older. I argued that utilization research is currently limited by a primary focus on discrete use of health care services, largely within the CHC system (i.e., medical doctors, specialists, hospitals). However substantial growth in use of CAM and PHC, particularly among late middle-age cohorts, suggests the need to widen the research lens from discretionary service use within health care systems to include medical pluralism or use across health care systems. To address the lack of research on medical pluralism and the need for a comprehensive overview of service use, I used two different strategies to create discrete patterns of service use and non-use. To frame the predictors of these patterns, a medical pluralism paradigm was proposed, which suggests that there are distinct social location and health characteristics that may explain use across health care systems. Five hypotheses were tested using data pooled from two cycles of the Canadian Community Health Survey (Cycles 2.1 [2003] and 3.1 [2005]) to create an overall sample (n=117,824). Results from the deductive (variable oriented) and inductive (person centred) strategies were compared. Differences in both the number and form of patterns are apparent. Across both strategies, the most common pattern is dual use of CHC (medical visits, specialist visits) and PHC (flu shots, sex-specific screening) but not CAM (chiropractors, other CAM providers). Consistent with the literature, women use more types of services overall than do men. The gender effect is significantly mediated by age: older men are less likely to use services across the three health care systems than older women. Strong evidence for a socioeconomic gradient in medical pluralism is also found. Higher levels of income and education increase the likelihood of using services across the three health care systems compared to low and middle levels of both income and education. The relationship between race and health service use was much less significant. Long-term immigrants demonstrate tri-use patterns close to those of Canadian born individuals; however, service differentials remain even after controlling for health needs, in favour of native-born Canadians. Medical pluralism is also associated with health related-need as support was found for both illness and wellness care. Lastly, regional differences point to a greater likelihood of medical pluralism in western Canada, but not always in urban areas. In future, a longitudinal examination of medical pluralism is necessary and would help establish the sequencing of services and how services are used in relation to the disablement process. Health policy would thus benefit from insight into the extent of service duplication for specific conditions and clarify the role of medical doctors in referral processes. / Graduate