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Traditionally, the compliance rates with preventive care services for members in the Medicaid Program are significantly lower than their peers enrolled in a commercial health insurance plan even when there are no financial costs for those services to Medicaid members. Start of life services which include prenatal care for pregnant mothers and well-child visits for newborns and infants are used to focus the research. Non-compliance, defined as not receiving recommended preventive services within the timeframe expected, has large financial and societal costs. Women who receive only the minimal prenatal care are at high risk for developing pregnancy complications and having negative birth outcomes while those that failed to receive prenatal care were three times more likely to have a low-birth weight infant. Within the first 6 months of life, children with incomplete visits are 60 percent more likely to visit the emergency room. They may have untreated development delays and disabilities, which occur in approximately 13 percent of children and are estimated to cost $417,000 in direct medical costs and indirect lost productivity per child. This thesis looks at motivational theories and economic incentives in practice in the health care industry to address the lack of compliance of services. It will analyze the problem from the perspective of how does a business, the State Medicaid Program or Medicaid Managed Care Organization (MCO), get a customer, the Medicaid population, to perform a specific behavior, receive preventive care services using motivational theories. / text

There are gaps in the UK knowledge base for understanding the implementation and evaluation of public health interventions which aim to improve the mental health and wellbeing of participants. In this thesis I examine the measurement of mental wellbeing and the implementation of health improvement interventions in a community setting and investigate the practicalities of their evaluation using a measure of mental wellbeing -- WEMWBS. Methods: Using a mixed methods approach I collected and analysed i) three cross sectional surveys of Coventry residents, ii) quasi-experimental before and after outcome evaluations of three CHIP projects, and iii) undertook semi-structured interviews with CHIP stakeholders. Data were integrated using a matrix technique. Results: A total of 8188 individuals (~40% response rate) completed valid survey questionnaires in 2010-2012, while 590 individuals (~88% response rate) completed valid before-after mental wellbeing outcome evaluations in 2011 and 2012 from three CHIP projects. Fifteen one-on-one interviews were completed. I found that health and lifestyle variables ‘sleep quality’ ‘physical activity’ and ‘fruit and vegetable consumption’ showed the strongest and most consistent patterns of association with levels of mental wellbeing measured using WEMWBS. CHIP projects demonstrated associations between the intervention and increases in mental wellbeing, some of which were both statistically significant and clinically meaningful. Some were sustained at three months. Interview findings showed that the difference between the plans and the observed implementation practices resulted in some of the projects struggling to cope with the evolving and changing needs of the programme, for example moving from outputs to outcomes, introducing mental wellbeing and changing concepts of health, and the work required to achieve partnership with the local authority). The effect on programme level outcomes and outcome measurement of these struggles was a reduction in the number and quality of valid evaluation returns from some of the projects in the programme and reduced staff capacity to deliver project objectives. The introduction of mental wellbeing as an outcome measure created a momentum of change for understanding complex health interventions and outcomes among stakeholders; it assisted those delivering the CHIP programme to understand the underlying health improvement rationale for their programme better. Through integrating quantitative datasets I provided a benchmark from which to make comparisons between population estimates of WEMWBS and observed evaluation findings. Integrating quantitative evaluation process challenges and qualitative insights from stakeholder interviews allowed for complex issues to be ‘untangled’. Interrelated mechanisms affected facilitators and barriers of programme planning, implementation, evaluation and sustainability. Integrating my quantitative and qualitative findings highlighted some clear health benefits from the projects but also highlighted a lack of congruence between the documented linear, unidirectional and unrealistic operational planning which I found in CHIP at a programme level, compared to practical implementation on the ground, which was nonlinear, complex and dynamic. Conclusion: Iterative, transitional stages of programme development could benefit implementation processes and potentially health outcomes, including mental wellbeing, in future public health practice. Further research in this area should explore the extent to which complex, collective, and adaptive operational planning can result in more successful public health improvement programmes.

Post-licensure surveillance of vaccine safety comprises of monitoring of adverse events, identification of those events that may be vaccine associated and, where necessary, controlled epidemiological studies to help assess causality. At the Health Protection Agency (HPA) in England a system for performing epidemiological studies using linked hospital episodes and immunisation data was established in the 1990s along with a new statistical approach called the self-controlled case-series (SCCS) for use on datasets which only include individuals with the adverse event of interest. In this thesis by published works I use seven publications from HPA studies addressing a variety of safety concerns to demonstrate the importance of such epidemiological studies and to form a framework which helps address the issues that need considering when doing vaccine safety studies. The seven studies are i) intussusception and oral polio vaccine, ii) measles-mumps rubella (MMR) vaccine and autism, iii) thimerosal in vaccines and neurodevelopment, iv) meningococcal group C conjugate vaccine and purpura/convulsions, v) diphtheria-tetanus-pertussis vaccines and various common and rare events, vi) pandemic influenza vaccine and Guillain-Barré syndrome, and finally vii) MMR vaccine and thrombocytopenic purpura (TP). These studies helped allay safety concerns or, in the case of MMR and TP quantify a true risk. The framework developed covers issues around defining the question, data sources and case-finding, study design and study implementation. In particular issues relevant to the use of the SCCS method are addressed such as ensuring independence of multiple events and bias due to vaccine contraindication. In conclusion the usefulness of epidemiological studies on vaccine safety and of the SCCS method has been demonstrated within a framework that can help with performing future studies.

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In this paper I will present my research about different kinds of social workers, and there way of looking at and working with adolescents alcohol use. To get my result, we interviewed eight social workers from four different organizations. The Interview participants were people working with adolescents on their spare time, and in the school environment. There were also participants representing social services and the police. The theory that we have chosen to apply to our thesis is systems theory. The results shows that professionals in Oskarshamn see that high school youth alcohol consumption generates large negative effects on the individual. One of the most complained of the impact of young girls drinking is so serious implications, as different forms of sexual exploitation. The result also shows that the preventive work is the focus of efforts to combat youth alcohol use.

<p>The aim of this project was to measure changes in dimension of the first three primary rugae and to evaluate tooth movement in the maxilla during orthodontic treatment in patients treated with and without premolar extractions.</p>

This study aims to analyse policy and political processes at multiple levels, and examine the consequences for Sexual and Reproductive Health (SRH) care development arising from the engagement of a participatory movement in Peru. I used Associations of Local Community of Health Administration (CLAS) as a core organisation for Peru’s major participatory model at local level. With policy makers, NGOs, health workers and (potential) service users, I explored factors that facilitated/prevented women’s participation in decision-making mechanisms and health practices. I employed a case study and multi-disciplinary approach at national, regional and local levels, focused upon women from multiple aspects in Andean Peru. I studied rural, periurban CLAS and non-CLAS models to compare across the case studies. I conducted semi-structured in-depth interviews with 116 respondents, unstructured observation, and documentary analysis in 2004. My analytical frameworks focused upon: ‘policy content’, ‘context’, ‘actors’, ‘process’, ‘patterns of participation’, and ‘outcomes and impacts’. Political, economic, legal and technical were identified which reflected the stagnant state of the development of SRH and CLAS policies. The central policy focuses on a narrow sense of SRH care, and neglects Reproductive Tract Infections (RTIs). Central government’s weak political leadership and stewardship to CLAS policies reflected that personal leadership (e.g. regional health directors) can define the destiny of regional CLAS development. Facilitating factors were led by NGOs and mixed factors were led by donors. CLAS appeared to create favourable conditions/environment for women’s participation in the community. Local respondents in the CLAS system understood the importance of participation to solve local problems compared to their non-CLAS system counterparts. Nevertheless, women in CLAS model had no influence on changes of SRH agenda, despite difficulties in the acquisition of contraceptives and effective RTIs medicines. The following actors must be incorporated into the decision-making and evaluation/feedback mechanisms in CLAS model to achieve more gender, age-gentle, and ethnically-sensitive Local Health Programmes and strengthen a rights- and trust-based approach: women’s Grassroots organisations, Defence Committees of Women’s Rights, Community Health Agents, Committees of Communal Development or Health (CODECOS)/(COSACOS), and traditional health providers. Alternative relationships (e.g. rapprochement) between CLAS and government authorities must be sought.

This research examines sexual health (SH) policies and experiences of youth, using the Maldives as a case study. Youth SH is a controversial and under-researched issue in The Maldives, an Islamic state where premarital sexual activity is a punishable offence. This thesis addresses the question: To what extent, and why is there a mismatch between official Maldivian SH policies, services and data and the lived experiences of youth in Maldives? It is a mixed methods study involving four research methods and sets of data: i) qualitative in-depth interviews (n=61) with youth aged 18-24 years from three sites within the Maldives; ii) key informant interviews (n=17) with policy actors and service providers; iii) a web-based quantitative survey of Maldivian youth (n=480); and iv) secondary analysis of the Maldives DHS 2009. There are four main findings from this research, three of which are substantive, and one of which is methodological. Sociocultural and religious factors heavily influenced policymaking, service provision and youth experiences. Contrary to most theocratic states, the SH policymaking process in the Maldives is shaped by policy actors and institutions whose strengths have more sociocultural basis than religious expertise. Whilst published official data and original secondary analyses of the MDHS suggest that premarital sexual activity among youth is very limited; this thesis finds extensive reporting of sexual activity. This contrast was also reflected in youth’s knowledge of STIs- where official data displayed a higher level of awareness than found through in-depth interviews and the web-based survey- and their experience of unwanted pregnancies and abortions, which appear to be under-reported in official data. Analyses of the web-based survey using the same questions as the DHS show significantly higher levels of reporting of sexual activity, showing a strong modality effect on survey response. Results from the web-based survey demonstrated that if sociocultural factors were removed from questionnaire design (e.g. censorship of certain issues) and administration (e.g., privacy and anonymity- difficult to achieve in small island communities typical of the Maldives); it is possible to improve response rates and quality of the data. Finally, this thesis highlights two key characteristics of the relationship between SH policy, services, data and youth experiences in the Maldives. Firstly, youth SH experiences appear to be disconnected from SH policies, services and data. Secondly, there is a mutually reinforcing relationship between official SH data and policies, where restrictive policies dictate the type and extent of data that may be collected, which then reinforce justifications for the current restrictive policies and limited services. Policy implications of this research include identifying and addressing the links between SH policymaking and religious and sociocultural factors, and addressing the subsequent effect on SH policy and services for youth.