Glioblastoma multiforme (GBM) is a destructive brain cancer that results in death 12 to 15 months after diagnosis. The purpose of this retrospective study was to determine if variations in tumor size at diagnosis, treatment options, and survival rate occur in GBM patients living in urban and rural areas of the United States. Using the behavior model of health services as the theoretical framework, this study used secondary data sets of GBM cases reported from 1988 to 2011 from the Surveillance, Epidemiology, and End Results program. Tumor size was measured in millimeters; treatment was evaluated by ascertaining the number of GBM patients who had surgical resection of their tumors, radiation, and chemotherapy; and survival rate was evaluated using Cox Regression analysis. With a sample size of 33,202 cases, data were examined using descriptive and multivariable analyses with SPSS. Results showed statistically significant differences in tumor size at diagnosis in rural patients compared to urban patients (p = 0.0085; p = 0.018), more urban patients were treated with radiation compared to rural patients (p < 0.001), and rural patients had poorer survival rates than urban patients (p < 0.001). Finally, when controlling for region, race, age, gender, education, and income, longer survival time was associated with urban status, female cases, and higher family income (p < 0.0001), and greater age was associated with reduced survival time (p < 0.0001). Study results could promote positive social change by identifying predictive variables associated with health outcomes of GBM patients. It may also educate providers on the risk of rurality of patients diagnosed with GBM, and inform lawmakers responsible for the creation of healthcare policy and the equitable allocation of healthcare resources.

Mental health professionals (MHPs) play a pivotal role in enhancing treatment outcomes for drug-using populations and minimizing their harm to the public. In response to a gap in the literature, this study sought to (a) assess MHPs' attitudes about the use and abuse of substances and their perception of their role in tackling substance abuse and related disorders in Nigeria, (b) identify predictors of perception, and (c) explore regional variations in attitude. Based on the validated drug and drug users' problems perception questionnaire and the substance abuse attitude survey, a cross-sectional survey was conducted in a randomized sample of 292 MHPs practicing in neuropsychiatric hospitals and in the mental health departments of teaching hospitals from 4 geopolitical zones of Nigeria. A response rate of 81.1% was achieved. MHPs' attitude about substance use tended towards the non-permissive, stereotypical, and moralistic spectrum, and its role perception was distinctly defined. Educational attainment (O.R = 0.50, p = 0.030), work-motivation (O.R = 0.55, p < 0.0001), and role-support (O.R = 1.48, p < 0.0001) significantly predicted MHPs' role perception. The Kruskal-Wallis test showed that there were significant regional variations in the attitudes of multidisciplinary MHPs, H (3) 18.727, p < 0.0001. Step-down follow up analysis revealed that the distribution of attitude total score vary significantly between the south-southern and southwestern region (p< 0.001), the northeastern and southeastern region of the country (p < 0.028). To foster the rehabilitation of this population and its reintegration into mainstream society, a holistic approach toward the standardization of drug treatment is needed. It should take into account the cultural, religious, and ethnic differences predominating in different regions.

Textile manufacture in England had always employed a high proportion of women and this continued to be the case during the period 1760-1850. However, these industries underwent dramatic changes in both the nature and location of production, and women’s employment opportunities altered. Whilst in some cases technological advances reduced the strength required to perform a given process, making women more attractive to employers, this was not always the case. Urbanisation and factory production increased trade union influence, which often acted to the detriment of women’s access to well-paid occupations. The long standardised hours worked away from the home typically required of factory workers made it harder for women to combine textile work with the mothering and domestic responsibilities expected of them. As well as making it harder for women to work throughout their life, this discouraged investment in human capital of females by both themselves and their parents. Ideological resistance to women’s work outside of the home increased as the Industrial Revolution progressed. The more formalised work hierarchy created by factory production meant that resistance to female authority became increasingly important for denying women access to the best paid occupations. Ideology was not merely a response to material factors, but helped determine decisions made by economic actors. This thesis draws on a number of parliamentary reports over the period 1802-67. Not only do these reports provide a wealth of qualitative information, they also contain quantitative information which enables me to track male and female factory earnings over the life-cycle, by region and industry. The information in the parliamentary reports is used in conjunction with business records of various firms, covering both domestic and factory workers, as well as the writings of numerous contemporary observers.

Innerhalb von Deutschland gibt es erhebliche Unterschiede in der kardiovaskulären Mortalität mit einer erhöhten Mortalität in den ostdeutschen im Vergleich zu den westdeutschen Bundesländern. Das Risiko, an einer koronaren Herzkrankheit oder einem Schlaganfall zu sterben, ist in Ostdeutschland etwa 50% höher als in Westdeutschland. Damit hat sich das Risikoverhältnis seit der Wiedervereinigung insgesamt wenig verändert, obwohl sowohl in Ost- als auch in Westdeutschland die kardiovaskuläre Mortalität abgenommen hat. Mögliche Ursachen für die regionale Variation sind Unterschiede bei kardiovaskulären Risikofaktoren, soziodemographischen Faktoren, Lebensstilfaktoren, Umwelteinflüssen und in der medizinischen Versorgung. In ganz Deutschland wird ein hoher Prozentsatz von Patienten mit kardiovaskulären Erkrankungen nicht entsprechend den aktuellen Leitlinien europäischer Fachgesellschaften behandelt. Eine inadäquate Einstellung von Risikofaktoren kann neben einer erhöhten Morbidität auch über den Verlust an Produktivität zu hohen indirekten Kosten für die Gesellschaft führen, ebenso wie zu einer Einschränkung der Lebensqualität für die Patienten. Neben einer adäquaten Prävention ist auch das „richtige“ Verhalten bei Auftreten von kardiovaskulären Symptomen wesentlich (Notrufnummer „112“), da sich ein hoher Prozentsatz der Todesfälle bereits vor Erreichen des Krankenhauses ereignet. Insgesamt zeigt sich eine deutliche Diskrepanz zwischen den Ergebnissen der klinischen Forschung und der Versorgungssituation im Alltag. Um längerfristig die Versorgung der Patienten zu verbessern, sind gezielte Interventionen erforderlich, um die Einhaltung der Leitlinien durch die Ärzte zu fördern und die Compliance der Patienten mit Lebensstilmaßnahmen und medikamentöser Therapie zu verbessern. Längerfristige Ziele sind die Verringerung der Kluft in der kardiovaskulären Mortalität zwischen Ost- und Westdeutschland und eine weitere Reduktion der Mortalität durch eine verbesserte Prävention. / Within Germany, there is a considerable regional variation in cardiovascular mortality with an increased mortality in the East compared to the West. The relative risk of cardiovascular death due to coronary heart disease or stroke is about 50% higher in East compared to West Germany. Despite an overall decrease in cardiovascular mortality in both East and West Germany, the risk ratio has remained largely constant since reunification. Possible explanations for the regional variation include differences in cardiovascular risk factors, socio-demographic factors, lifestyle, environmental conditions, and medical care. In addition, a high percentage of patients with cardiovascular diseases in Germany are not treated according to current international guidelines. Apart from an increased morbidity, inadequate treatment of risk factors may lead to a high amount of indirect costs due to productivity loss. Also, health-related quality of life is reduced in patients with cardiovascular diseases. As a high percentage of cardiovascular deaths occur prior to the arrival at the hospital, it is also important to educate people at risk about an appropriate help seeking behaviour in the case of an acute event (e. g. emergency number “112”). To conclude, research results are not sufficiently translated into routine medical care. Interventions are, therefore, needed to improve both compliance of physicians with current guidelines and compliance of patients with lifestyle measures and medication. In the long term, the gap in cardiovascular mortality between East and West Germany should be narrowed and preventive measures should be improved to further reduce cardiovascular mortality in Germany

Objectives. The first aim was to examine the effects of secondary prevention with a focus on determinants in the risk of recurrent coronary heart disease (CHD). The second aim was to analyse the effects of a cognitive behavioural therapy (CBT) intervention on the risk of recurrent cardiovascular disease (CVD) and to investigate the psychosocial situation of CHD patients. Material and methods. Papers I and II were based on the Swedish Acute Myocardial Infarction Statistics Register, 1969 to 2001: 775,901 events in 589,341 subjects. Papers III and IV were based on The Secondary Prevention in Uppsala Primary Care project (SUPRIM), a randomized controlled clinical trial in 362 CHD patients. Results. The risk of a recurrent acute myocardial infarction (AMI) event was highly dependent on time from the previous event, with the greatest risk immediately after an AMI event. In addition, sex, age, and AMI number influenced the general risk level. Furthermore, there has been a major decline in recurrence risk over 30 years, and there were considerable geographical differences in risk, best explained by residential area population density, with a high recurrent AMI risk in areas with the lowest and the highest population densities, and the lowest risk in areas with moderate population density. Disease status and sex were determinants of psychological well-being the first year after a CHD event. Sex seemed to be the stronger determinant. The CBT intervention focused on stress management during one year in patients with CHD.  There was significantly improved outcome in the intervention group on recurrent CVD and recurrent AMI during a 9 year follow up. A dose-response relationship was demonstrated between attendance rate at intervention group meetings and outcome, the higher the attendance rate the better the outcome. Conclusions. The risk of a recurrent AMI event was dependent on time from the previous event, with major improvement seen in recent decades. Regional differences were best explained by population density. Female CHD patients were at high risk concerning well-being after a coronary event, which deserves special attention. The CBT intervention for CHD patients improved outcomes concerning the risk of recurrent CVD and AMI events.

The current diploma thesis examines Czech listeners' perception of various accents of English from the points of view of comprehensibility, pleasantness, socioeconomic status, and model suitability. The main aim of the study is to contribute to the discussion on how accent variation within the Anglophone world is perceived by non-native speakers, and what aspects influence their evaluations of the accents. The theoretical part of the thesis defines several terms related to the domain, describes selected pronunciation varieties of English, and summarizes research which has focused on native accents of English in the perception of non-native speakers. The research part of the thesis consists of a study, in which 39 Czech students from two types of schools evaluated six accents of English and provided information about their experience with English and Anglophone cultures. The results showed that standard varieties are favoured by the students in all four respects, but also that students' evaluations, especially for pleasantness, may be affected by their relations to the Anglophone world. Key words: Native Accent, Regional Variation, L2 learner, Comprehensibility, Socioeconomic Status, Pronunciation Model, Standard

Abstract Monitoring regional variation in the survival of cancer patients is an important tool for assessing realisation of regional equity in cancer care. When regions are small or sparsely populated, the random component in the total variation across the regions becomes prominent. The broad aim of this doctoral thesis is to develop methods for assessing regional variation in the cause-specific and relative survival of cancer patients in a country and for quantifying the public health impact of the regional variation in the presence of competing hazards of death using summary measures that are interpretable also for policy-makers and other stakeholders. Methods for summarising the survival of a patient population with incomplete follow-up in terms of the mean and median survival times are proposed. A cure fraction model with two sets of random effects for regional variation is fitted to cause-specific survival data in a Bayesian framework using Markov chain Monte Carlo simulation. This hierarchical model is extended to the estimation of relative survival where the expected survival is estimated by region and considered as a random quantity. The public health impact of regional variation is quantified by the extra survival time and the number of avoidable deaths that would be gained if the patients achieved the most favourable level of relative survival. The methods proposed were applied to real data sets from the Finnish Cancer Registry. Estimates of the mean and the median survival times of colon and thyroid cancer patients, respectively, were corrected for the bias that was caused by the inherent selection of patients during the period of diagnosis with respect to their age at diagnosis. The cure fraction model allowed estimation of regional variation in cause-specific and relative survival of breast and colon cancer patients, respectively, with a parsimonious number of parameters yielding reasonable estimates also for sparsely populated hospital districts. / Tiivistelmä Syöpäpotilaiden elossaolon alueellisen vaihtelun seuraaminen on tärkeää arvioitaessa syövänhoidon oikeudenmukaista jakautumista alueittain. Kun alueet ovat pieniä tai harvaan asuttuja, alueellisen kokonaisvaihtelun satunnainen osa kasvaa merkittäväksi. Tämän väitöstutkimuksen tavoitteena on kehittää menetelmiä, joilla pystytään arvioimaan maan sisäistä alueellista vaihtelua lisäkuolleisuudessa, jonka itse syöpä potilaille aiheuttaa, ja tiivistämään alueellisen vaihtelun kansanterveydellinen merkitys mittalukuihin, jotka ottavat kilpailevan kuolleisuuden huomioon ja ovat myös päättäjien tulkittavissa. Ehdotetuilla menetelmillä voidaan potilaiden ennustetta kuvailla käyttäen elossaolo-ajan keskiarvoa ja mediaania, vaikka potilaiden seuruu olisi keskeneräinen. Potilaiden syykohtaiselle kuolleisuudelle sovitetaan bayesiläisittäin MCMC-simulaatiota hyödyntäen malli, jossa parantuneiden potilaiden osuuden kuvaamisen lisäksi alueellinen vaihtelu esitetään kahden satunnaisefektijoukon avulla. Tämä hierarkkinen malli laajennetaan suhteellisen elossaolon estimointiin, jossa potilaiden odotettu elossaolo estimoidaan alueittain ja siihen liittyvä satunnaisvaihtelu otetaan huomioon. Alueellisen vaihtelun kansanterveydellistä merkitystä mitataan elossaoloajan keskimääräisellä pidentymällä sekä vältettävien kuolemien lukumäärällä, jotka voitaisiin saavuttaa, mikäli suotuisin suhteellisen elossaolon taso saavutettaisiin kaikilla alueilla. Kehitettyjä menetelmiä käytettiin Suomen Syöpärekisterin aineistojen analysointiin. Paksusuoli- ja kilpirauhassyöpäpotilaiden elinaikojen keskiarvojen ja mediaanien estimaatit oikaistiin harhasta, joka aiheutui potilaiden luontaisesta valikoitumisesta diagnosointijakson aikana iän suhteen. Parantuneiden osuuden satunnaisefektimalli mahdollisti rintasyöpäpotilaiden syykohtaisen kuolleisuuden ja paksusuolisyöpäpotilaiden suhteellisen elossaolon kuvaamisen vähäisellä määrällä parametreja ja antoi järkeenkäyvät estimaatit myös harvaan asutuille sairaanhoitopiireille.

In this study I explore how intergenerational social mobility varies between subnational regions across Europe and whether any contextual factors are associated with levels of mobility. Support is found for subnational variation in class and occupational rank mobility within 24 European countries using the European Social Survey. Two theoretical frameworks are applied, the industrialization thesis (more economic development leads to more mobility) and an inequality framework (more inequality leads to less mobility). A bivariate association is shown between higher levels of economic development and higher levels of mobility on a regional level. Support for the inequality framework is seen in that a higher at-risk-of-poverty-rate is associated with lower levels of absolute class mobility, which was found to be a result of within-country variation. Between-country variation is seen concerning the association between both lower rates of absolute class mobility and higher rates of people living in low work intensity-households and severe material deprivation. Further, a higher rate of workers in the primary sector is found to be associated with lower mobility rates. In conclusion, this study shows that local economic factors, and not only national, contribute to explaining variation in intergenerational mobility.

No description available.

Because of evidence of regional variation in health and healthcare use, this thesis used health equity and access to care theory to examine regional differences in access to primary care, using survey- as well as secondary data in four empirical studies. First, a systematic literature review was used to categorize forms and reasons for regional healthcare shortages and access barriers, with a particular focus on rural areas. After information extraction from the selected studies and a thematic content analysis, the forms and causes identified in the literature were grouped and discussed. Following the literature-based review of these thematic foundations, a study was then designed to evaluate patient-reported access to primary care in exemplary German regions and assess empirical differences in rural vs. urban populations. This allowed the importance to patients of different access dimensions to be evaluated. For a subgroup of study participants with multidisciplinary care needs, care coordination failures and the supportive role of the general practitioner as a primary point of access was investigated. Finally, regional factors that are associated with variations in need, health, and utilisation beyond individual health determinants were identified, and placed on different regional framework conditions. These health-related factors were summarised in a regional deprivation measure and small-scale regions in Germany were differentiated by their regional deprivation by the main dimensions (material, social, ecological). Finally, their association to regional health outcomes were cross-sectionally estimated. To reduce unwarranted access variation, while also taking the patient perspective (by region) into account, the thesis concludes with a chapter on implications. Here, concepts for regional and multidimensional access monitoring, as well as further regulatory measures in capacity and distribution planning of primary care, are discussed.:Content Tables ........................................................................................................................... V Figures ....................................................................................................................... VI Abbreviations ........................................................................................................... VII 1. Background and research objectives .................................................................. 9 1.1. Health equity and access to health care ........................................................ 10 1.2. Regional variation as a contradiction to the equity principle ....................... 16 1.3. Reducing unwarranted regional variation in health care .............................. 20 1.4. Research objectives and thesis structure ...................................................... 24 References ............................................................................................................... 28 Legal sources .......................................................................................................... 33 2. Rural health care shortages and access barriers ............................................. 34 3. Regional access and satisfaction with primary care........................................ 35 Appendix 3 .............................................................................................................. 36 4. Access to primary care and outpatient care coordination .............................. 48 4.1. Introduction .................................................................................................. 49 4.2. Background ................................................................................................... 51 4.2.1. The patient perspective of care coordination ......................................... 51 4.2.2. Coordinating mechanisms ..................................................................... 52 4.3. Methods ........................................................................................................ 55 4.3.1. Data collection and sample .................................................................... 55 4.3.2. Measures ................................................................................................ 55 4.3.3. Data analysis .......................................................................................... 58 4.4. Results .......................................................................................................... 59 4.5. Discussion and limitations ............................................................................ 62 4.6. Implications .................................................................................................. 65 References ............................................................................................................... 69 Appendix 4 .............................................................................................................. 73 5. Area deprivation and its impact on health ....................................................... 76 6. Summary of implications ................................................................................... 77 6.1. Establishing a framework to assess primary care access and performance .. 77 6.2. Strengthening patient involvement in health care structure planning .......... 81 6.3. Strengthening access to GPs as outpatient care coordinators ....................... 84 6.4. Including regional deprivation factors in health care structure planning ..... 86 References ............................................................................................................... 90