Autism spectrum disorder (ASD) is associated with a variety of physical, mental, and behavioral healthcare needs. However, parents of autistic children consistently report difficulty accessing necessary services, and no instrument has been validated to assess and quantify these barriers for autistic children. The current study aims to adapt and validate the Barriers to Care Questionnaire (BCQ), a pre-existing measure of barriers to healthcare for children with specific healthcare needs, for families of autistic children. The BCQ and theoretically related measures were collected from 242 parents (117 parents of autistic children, 125 parents of non-autistic children). Cronbach’s alpha statistics (ranging from 0.87 to 0.96 for BCQ subscales) provide evidence of reliability for the BCQ. The BCQ subscales were correlated with unmet treatment need, treatment experiences, and theoretically related variables at the child, parent, and family level, providing evidence of convergent validity. Correlations were of low magnitude with theoretically unrelated variables (parent personality and socially desirable responding), suggesting preliminary evidence of discriminant validity. Additionally, the BCQ subscales predicted a significant amount of variance in unmet need and treatment experiences over and above other predictors for autistic youth, indicating incremental validity. Parents of autistic children reported significantly more barriers to care across all subscales of the BCQ than parents of non-autistic children, and the highest average item score was on the “skills” subscale, which measures difficulties with navigating the healthcare system. Results support that the BCQ can be used among autistic youth, and suggest the critical need for family-centered supports and provider education in order to ameliorate barriers to healthcare for autistic children. / M.S. / Autism spectrum disorder (ASD) is related to many physical, mental, and behavioral healthcare needs. However, parents of autistic children state that it is often hard to receive healthcare when their child needs it. No questionnaire exists to measure barriers that make getting healthcare harder for autistic children. Our study adapted the Barriers to Care Questionnaire (BCQ) for families of autistic children. The BCQ and related questionnaires were filled out by 242 parents (117 parents of autistic children, 125 parents of non-autistic children). The BCQ reliably and consistently measured barriers to care in these groups. The BCQ subscales were associated with unmet treatment need, treatment experiences, and other related variables at the child, parent, and family level. The questionnaire was less strongly related to variables that we would not expect to be associated with barriers to care, like personality and social desirability. Also, the BCQ subscales predicted healthcare experiences even when accounting for other factors that might impact access to care. Parents of autistic children reported more barriers to care on all subscales of the BCQ than parents of non-autistic children, and the highest average item score was on the “skills” subscale, which measures difficulties with navigating the healthcare system. Results show that the BCQ can be used among autistic youth, and suggest the need for family-centered supports and provider education in order to improve barriers to healthcare for autistic children.

By examining barriers to care, health professionals can better understand what disparities exist between groups and who may be at greater risk for poor primary care. Researchers have highlighted the need for additional research that focuses on the extent of unmet needs for U.S. children with sickle cell disease (SCD). The purpose of this quantitative study was to compare the differences between parents who are in a SCD support group and those who are not. The theoretical framework of this study is based on the chronic care model and social support theory. A total of 128 parents of children with SCD completed the study survey. The sampling occurred by e-mail, phone, and face-to-face conversations. Selection criteria for potential participants in both groups were based on their children being diagnosed with SCD. Seventy-four participants (57.8%) were members of a SCD support group, and 54 participants (42.4%) were not members of a SCD support group. In this study, the independent variables were parents attending or not a SCD support group. The t test and MANCOVA was used to assessed the association between perceptions of barriers to care and support group status. However, statistical analysis showed no significant results. The null hypothesis was not rejected. Therefore, the positive social change implication is to further explore potential factors that may shape perceptions of barriers to care for those with SCD so that perceived barriers to care can be overcome.

Sjuksköterskans ansvar är att lindra lidande. Vårdverksamheten och vårdforskningens största utmaningar är att förstå hur lidande bäst kan lindras. Lidande som orsakas av vården kallas vårdlidande. Den systematiska litteraturstudiens syfte var att pröva Katie Erikssons teori om vårdlidande inom omvårdnad. En deduktiv ansats användes vid genomförandet av studien. Studien genererade tolv resultatartiklar som analyserades enligt Erikssons följande kategorier om vårdlidande kränkning av värdighet, fördömelse och straff, maktutövning och utebliven vård. De mest förekommande kategorierna som identifierades utifrån resultatet var kränkning av värdighet och utebliven vård. En ytterligare kategori som framkom benämdes vårdens prioriteringar. Den kan ses som en utveckling av Erikssons kategori utebliven vård. Resultatet bekräftade Erikssons teori om vårdlidande. Rekommendationer för klinisk verksamhet är att patienten ska få möjlighet att utvärdera vården i efterhand, för att skapa en medvetenhet hos vårdpersonalen kring patientens upplevelse. Vidare rekommenderas forskning om vårdens prioriteringar. / Nurses’ responsibility is to alleviate suffering. The main challenge for healthcare organisation and the science of caring and nursing is to understand how suffering could be alleviated. Suffering caused by care is called suffering related to care. The aim of the study was to test and imply Katie Erikssons theory about suffering related to care in nursing. The systematic review was performed with a deductive research method. Twelve articles was analysed according to Erikssons theory about suffering related to care. The theory includes three themes: violating the patients dignity, condemnation and punishment, exert of power and absence of care. The themes that occurred the most in the results were violating the patients’ dignity and absence of care. Another theme was developed through the results was healthcare priorities. The theory can be interpreted as a subtheme to absence of care. Erikssons theory was validated by the results of the study. One implication for clinical practice is to give the patients ability to evaluate their received healthcare. The purpose of the evaluation is to make the health care professionals aware of the patients’ experience. Further research about healthcare priorities are suggested.

Background: Regular access to dental services is a well-known factor in the oral health and development of children.1 As such, the United States federal government mandates each state to include dental services for children enrolled in Medicaid through the age of 21. Despite this mandate, the utilization rate of dental services among Medicaid enrolled children has remained remarkably low.2 In July 2005, Virginia implemented a sweeping Medicaid policy reform titled “Smiles for Children,” specifically aiming to increase Medicaid pediatric dental utilization rates. The purpose of this study aims to assess the effect of this 2005 policy reform on the utilization of dental services by children enrolled in Medicaid. Objective: The purpose of this study is to examine the impact of the 2005 Virginia Smiles for Children Medicaid policy reform on the utilization of dental services among Medicaid enrolled children. Methods: This was a retrospective cohort study of children (pre-reform n=559,820, post-reform n=690,538) enrolled in Virginia Medicaid from 2002 through 2008. Descriptive statistics and repeated measures multivariate logistic regressions were used to determine the relationship between enrollment (Pre- and Post-policy reform) and the utilization of dental services (1+ Dental Visits vs. No Dental Visits). Results: Descriptive analysis of the cohort found that 34% of pre-reform children had a dental visit while 44% of post-reform children. The logistic regression models revealed that children in the post reform period were 1.39 as likely to have had a dental visit. Stratifying for enrollment length reveals that as the length of exposure time to the post-reform policy increases, the odds of having a dental visit also increase as compared to the pre-reform period: for 31-36 months of enrollment the odds increase 1.54 times. Conclusions: Medicaid policy reform can significantly improve access to dental services for children and can therefore play an important role in promoting public health.

Medicaid expansion under the Affordable Care Act (ACA) facilitates access to care among vulnerable populations, but 21 states have not yet expanded the program. Tennessee’s Medicaid program experienced a dramatic Medicaid contraction when the program disenrolled approximately 170,000 nonelderly adults in 2005. Pre-ACA expansions were associated with better access to and utilization of healthcare services. However, little is known about the effect of these policy changes on improvement in health outcomes for women diagnosed with breast cancer, access to care for cancer survivors, and the effect of generosity and duration of expansion on access to care. This dissertation has three objectives. First, to assess the effects of the Tennesse’s Medicaid disenrollment on stage at diagnosis and delay in surgery for breast cancer among nonelderly women. Second, to compare access to care between cancer survivors living in non-expansion states and survivors living in expansion states. Third, to examine the effect of generosity and duration of the pre-ACA Medicaid expansions on access to and utilization of healthcare services. I use three different types of datasets: the 2002-2008 data from Tennessee Cancer Registry, the 2012 and 2013 Behavioral Risk Factor Surveillance System (BRFSS), and the 2012 Medical Expenditure Panel Survey (MEPS) data. I estimate difference-in-difference models and perform multiple logistic regression models to examine the impact of these policy changes on the different measurement outcomes. While many states are expanding Medicaid eligibility under the Affordable Care Act, there has been discussion among policymakers in some states about reducing eligibility under the Affordable Care Act once full federal funding expires. This study suggests that Medicaid disenrollment leads to later stage at diagnosis for breast cancer patients, indicating negative health impacts of contractions in Medicaid coverage. Prior to the passage of the Affordable Care Act, cancer survivors living in expansion states had better access to care than survivors living in non-expansion states. Failure to expand Medicaid could potentially leave many cancer survivors without access to routine care. The study informs policy makers that, relative to no expansion, moderate or generous expansion is associated with improvement in access to and utilization of healthcare services.

Former United States military members have consistently faced mental health concerns post discharge from the military. Some researchers have argued that the use of mental health services by veterans does not parallel the prevalence and need of such services (Hoge, Castro, Messer, McGurk, Cotting, & Koffman, 2004; Milliken, Auchterlonie, & Hoge, 2007; Vogt, 2011). Reasons why veterans do not access mental health care are varied and broad, however, they tend to be consistent with explanations rooted in the stigma of mental health care, and in the barriers that prevent the use of mental health care. The degree of the impact of factors contributing to stigma and barriers to mental health care is not fully understood. Particularly lacking from previous research is an examination of how the education received while in the military about mental health symptoms and treatment impacts the likelihood that a service member will access care. In the current study, I used theories of stigma and barriers to care outlined by Overton and Medina (2008) to examine the relationships among demographic characteristics, self-reported diagnoses of common mental health disorders that veterans experience, and likelihood of accessing mental health care based on the education received while in the military with self-reported levels of stigma and barriers to care in a sample of 355 former military service members from several branches. Multiple regression analyses were used to examine the relationships among these variables. Results revealed statistically significant relationships among gender, age, self-reported diagnosis of depression, the impact of education, and stigma. Results also revealed statistically significant relationships among employment and barriers to care. In addition, stigma was found to have significant relationships with the positive impact of education, and the likelihood of accessing care. Lastly, results revealed that when in the presence of the mediation variable impact of education, stigma was no longer associated with the likelihood veterans would access care post discharge.

The focus of this research was to: 1) study the perceptions of female students attending the university Student Health Center, concerning available services, 2) learn how they describe their decisions to obtain care, and 3) identify perceived barriers to reproductive health care and contraception. This exploratory study used a mixed-methods approach that included clinic public-space observations, interviews with health care providers and staff at Student Health Services (SHS), surveys distributed to clients of the campus clinic, and in-depth interviews to contextualize emergent themes. Topics addressed included sexual health behaviors and perceptions, influence of peers and partners, the propagation of health myths, and past experiences with SHS. Gathering practitioner perspectives on student barriers to care, goals of the clinic, and perceived health needs of the student community, allowed for measurement of incongruence between student and staff, thereby adding greater context to results. SHS sought recommendations in order to improve student's use of the Sexual Health and Gynecology clinic, increase accuracy of student's sexual health knowledge, and guide future clinic operations. SHS is now working with the College of Public Health to create improvement projects based on my results, including a peer education program. Research such as this can result in greater student awareness of available services, and more productive communication between patients and provide. Implications on the larger issues of gender and the search for health care, acceptance and knowledge of STI testing, and client comfort are addressed, and provide opportunity for future work in this area.

The overwhelming social norm for pregnant women in the U.S. is to receive prenatal care from an obstetrician and to give birth in a hospital setting. However, the incidence of midwifery care and out-of-hospital birth is increasing, particularly among White, non-Hispanic women. Florida has been considered a "model" state for home birth midwifery given legislative support that mandates coverage of all types of midwifery (e.g., Certified Professional Midwives and Certified Nurse-Midwives) care in all birth settings (e.g., hospital, home, birth center) and by all forms of insurance (e.g., commercial and Medicaid). Medicaid is the payer source for nearly half of the births in the United States and in Florida. However, Florida is one of only ten states where Certified Professional Midwives, who attend the vast majority of planned home births, are actively able to receive Medicaid reimbursement for home birth care. A key question then becomes, how is the system for Medicaid-funded home birth in Florida functioning? The central aim of this research was to better understand how Medicaid impacts the practice of and access to planned home birth in Florida. This was examined through quantitative analysis of Florida birth certificates as well as through qualitative data collection and analysis that sought to describe the experiences of women who had planned home birth while on Medicaid as well as the experiences of midwives that cared for these women. Findings are presented through the lens of Critical Medical Anthropology, which helps to interpret how and why home birth is systematically supported or threatened by legislation, policy, and practice at the level of the State of Florida, the federal-state Medicaid program, and the professional organizations in the United States involved in maternity care. Key findings demonstrate that the vast majority (87%) of planned home birth in Florida is attended by Certified Professional Midwives, and that while Florida Medicaid paid for 45% of all births between 2005 and 2010, only 31% of planned home births were paid for by Medicaid. However, after controlling for multiple factors (e.g., race/ethnicity, age, parity), in fact women who completed home (vs. hospital) birth were much more likely to be self-pay (AOR 10.1) or on Medicaid (AOR 4.6) compared to private, commercial insurance. Women interviewed for this study who received Medicaid for their home births overwhelmingly appreciated the "safety net" that Medicaid provided to them and the "relief" of knowing that if a hospital transfer was necessary it would be covered. However, they nearly universally stated that they would have found a way to pay for a home birth if they had not received Medicaid. Women felt that home birth with midwives provided them the greatest chance of having a "natural" birth in the environment most likely to maintain autonomy over decisions related to their pregnancy and birth. Several women experienced significant delays in enrolling in Medicaid, and found that the only providers who would provide care during "presumptive eligibility" were Licensed, Certified Professional Midwives. Midwives appreciated the steady, reliable payments Medicaid provided, despite that these were at about 30 to 40% of their rates charged to privately insured or self-pay clients. They felt that providing care to Medicaid funded women served as a form of social justice. They strongly disliked interfacing with Medicaid HMOs. Some midwives felt that the Florida legislation supported their practice, while others felt that it constrained their practice. Medicaid coverage of planned home birth in Florida now stands at a crossroads, given that Florida Medicaid has recently transitioned to a 100% managed care program (i.e., HMOs). These HMOs act as intermediaries between Medicaid providers and their reimbursements, as well as between Medicaid providers and recipients. The new relationships between providers, patients and the HMOs have shifted from that with a state agency to that with a private, for-profit industry. It remains to be seen whether home birth providers will enroll with Medicaid HMOs in order to continue providing care to pregnant women receiving Medicaid. Key policy recommendations therefore are to monitor women's access to pregnancy Medicaid, and specifically access to services mandated under Florida statute, including home birth and midwifery care. Furthermore, the creation of an integrated maternity care system that better supports transfers of care from the home to hospital setting is needed.

Learning to care and first encounter to care patients for male nursing students introduce a unique set of dilemmas to the predominantly female nursing educational process. The purpose of this study was to describe the experience male nursing students learning to care and first encounter care patients in their first nursing practice. A purposive sampling of seven male nursing students were interviewed by internet interview and analyzed by Qualitative content analysis. The results show that the Thai male nursing student stairway to confidence in nursing they start with feelings of stressfulness, developing sensitiveness, developing co—operation and developing strategies to care and encounter with patient. The results also seem to include gender specific questions on how to handle dilemmas in the predominantly female nursing education. These may reflect facilitators and barriers of developing a caring mind among male nursing students. Implication for nursing education and practice are presented and discussed.  In the clinical practice, the method of teaching was important to encourage, but also to gain additional knowledge and support peer groups as a suitable learning environment.

Despite the fact that the United States spends more per capita than any other nation on healthcare for its citizens, the quality of American health outcomes lags well behind every other developed country in the world. This paper proposes that it is no coincidence that the United States is also the only developed nation that does not guarantee the right comprehensive coverage of medical services for its citizens. Instead, we rely on a fee-for-service system which functionally denies quality health care to those without the means to pay for it. In this paper I document the experiences of various clients and staff of the Center, a torture survivor treatment and support agency, the majority of whose clients are or were refugees or political asylees, with the healthcare systems in the United States and elsewhere. I also analyze documented differences in the efficiency, efficacy, and levels of satisfaction with these foreign health care systems to that of the United States. The barriers to good quality health care experienced by the participants in this research are systemic, rather than individualistic, in nature. I therefore argue that the American ideology of health as a commodity to be bought and sold directly contributes to the inferior health outcomes of the United States health care delivery system, as compared to other nations whose ideology of health holds it to be a universal human right.