Rozprawy doktorskie na temat „Health service utilisation”

Introduction Self-rated health (SRH) is a widely used indicator of health service utilisation and reflects self-perceived objective health condition. Poorer non-comparative SRH was shown to be related to higher inpatient and outpatient utilisation in Western and elderly populations. Little is known about how healthcare utilisation relates to SRH in non-Western settings, such as Hong Kong and in adult populations. The association of age- and time- comparative SRH with healthcare utilisation is also unclear. This study aimed to assess the association of three types of SRH (non-, age- and time- comparative SRH) with inpatient and outpatient utilisation in Hong Kong‟s general populaion. Methods Data were derived from 2011 Thematic Household Survey (THS), covering 23,892 non-institutional residents aged 20 and above. The study adopts Andersen‟s Behavioral Model of Health Service Use for the analytical framework. Healthcare utilisation was measured by inpatient use during the past year and outpatient use (including General Outpatient Clinic (GOPC) and Specialist Outpatient Clinic (SOPC)) during the past month, in terms of ever-use and the amount of use (bed-days and number of outpatient visits). SRH was measured with a 5-point Likert Scale: non-comparative SRH from “Excellent” to “Poor”; age- and time- comparative from “much worse” to “much better”. Logistic regression and zero-truncated negative binomial/ Poisson regression were applied to examine the association of SRH and chronic diseases with healthcare utilisation in the public and private sector separately as per the Andersen behavioral model. Results “Fair/ poor” non-comparative SRH was associated with higher inpatient and outpatient utilisation. The association was not significant for hospital bed-days. Similarly, age-comparative SRH was associated with inpatient (except private bed-days) and outpatient utilisation (except the number of SOPC visits). “Worse/ much worse” time-comparative SRH was associated with higher healthcare utilisation, but the relationship was less clear for private hospitalisation. The presence of cancer, cardiovascular diseases, diabetes, lower respiratory diseases, and musculoskeletal diseases were associated with higher healthcare utilisation, with stronger association observed for ever-use than the amount of use. The relationships between musculoskeletal diseases and inpatient utilisation, between cardiovascular diseases and diabetes and the number of private outpatient visits, and between lower respiratory diseases and GOPC utillisation were not significant. Conclusions The present study suggests SRH to be a useful health indicator of health service utilisation. All three SRH measures were associated with health service utilisation and no marked differences were observed between different measures. Poorer SRH were strongly related to higher public inpatient utilisation, with stronger association observed for ever hospitalisation than bed-days. Poorer SRH measures were also related to higher outpatient uilisation in both sectors during the past month. All the selected chronic conditions were related to increased healthcare use. The associations were less clear for hospital bed-days and the private sector. Future studies should focus on the predictive validity of SRH on future healthcare utilisation.
published_or_final_version
Public Health
Master
Master of Philosophy

This thesis follows the paper-based format and papers one and two have been prepared for submission to Attachment and Human Development and the British Journal of Clinical Psychology, respectively. The relevant submission guidelines are included in the appendices (Appendix A and B).Attachment theory (Bowlby, 1977a) has prompted a wealth of empirical research in its contribution to adult attachment patterns and subsequent psychopathology in mental health (Holmes, 2001; Wallin, 2007). More recently, attachment theory has been proposed as a suitable framework by which to inform the organisation, design and delivery of mental health services (Goodwin, 2003; Seager et al., 2007) but it is unclear what this would look like in practice. Adopting an attachment-informed service model has key implications for individual and service outcomes and the two papers presented in this thesis aim to contribute to research in this area, followed by a critical review of the research, its relevance and future implications. Paper one is a narrative overview of the literature discussing the practice implications of services adopting an attachment-informed framework, and describes how this might be conceptualised in front-line service delivery. Articles reviewed described the influence of attachment theory in predominantly inpatient, secure forensic and/or psychiatric rehabilitation services, and its application within more generic community mental health services was explored. Paper two aimed to investigate the importance of individual attachment and service attachment to client psychopathology, quality of life, service utilisation and service costs in community-based mental health services. The final section, the Critical Review, critiqued the literature review and aimed to place the research within a wider context. This section considers the findings from the research and the limitations of the study, while also highlighting important issues for services, with implications for clinical practice and future research.

This study was undertaken with the aim to develop improved measures of health service utilisation (HSU) and direct medical costs following an index injury, utilising large scale datasets linked via anonymous patient identifiers. A cohort of anonymous injury patients resident in Swansea and attending an emergency department (ED) or admitted to hospital between 01/04/2005 and 31/03/2007 were identified and tracked as they progressed through various treatment stages following their index injury, incorporating ED attendances, inpatient stay and outpatient contacts. To determine the extent of the subsequent HSU and direct medical costs associated with the index injury a unique model was developed whereby the numbers, lengths and treatment costs of health service contacts observed amongst the cohort of injured individuals during the follow-up period were compared with the equivalent figures expected in the absence of an injury. On average each index injury was found to lead to an excess of 0.12 (95% Cl 0.11, 0.13) ED attendances, 0.07 (95% Cl 0.06, 0.08) inpatient admissions, 1.00 (95% Cl 0.78, 1.23) inpatient bed days and 0.55 (95% Cl 0.52, 0.58) outpatient contacts being estimated over the follow-up period. Moreover, every index injury resulted in mean excess ED, inpatient and outpatient treatment costs of £12.05 (95% Cl £11.05, £13.05), £492.43 (95% Cl £415.66, £569.21) and £73.30 (95% Cl £68.44, £78.17), respectively, equating to a combined figure of £577.79 (95% Cl £500.32, £655.26). Across the entire injured cohort this amounts to an overall excess direct medical cost total of £17.6 million being incurred, with the equivalent figure for the whole of Wales potentially being as high as £306.4 million. Together with signifying the magnitude of the HSU and direct medical costs resulting from injury, this study has introduced and implemented improved methods for estimating these outcome measures based on the use of anonymous patient record linkage.

The closure of the Manawatu Gorge in August 2011 caused a change in the travel time for patients living in the eastern area of the MidCentral Health District to their main hospital and health services located in Palmerston North. This presented an opportunity to study the effect a change in travel time and spatial access had on a population before and after such an event. This study used a retrospective cohort design, using routinely collected data from general practice, emergency department, hospital admissions and outpatient services. The investigation was completed using novel geospatial information systems methods to produce high fidelity data for analysis with free and open source software by developing and validating two new methods of improving geocoding data quality and a new travel time prediction model. Potential and realised spatial accessibility measures were calculated for 101,456 patients over 3.5 years while the gorge was both open and closed. Catchment sensitivity analysis and two-step floating catchment area using distance decays presented complimentary evidence of accessibility change during the Manawatu Gorge closure. Analysis of utilisation measures in both primary and secondary care were correlated with travel time. Utilisation of general practice services appeared to be negatively impacted by increased travel time when comparing realised accessibility in a control and intervention group during the gorge closure. It appeared as though other factors affected access to health services to a greater degree than an increase of up to fifteen minutes travel time.

Achievement of Universal Health Coverage (UHC) is a desirable goal for all countries. Complementary public and private services are essential. This study examined factors that influence consumer choice for private and public health care services in Vietnam. Thirty senior healthcare professionals were interviewed and secondary data on over 35,000 episodes of healthcare gathered during national health surveys in households were analyzed. For Vietnam and similar low and middle-income countries to achieve UHC, it is necessary to overcome incomplete social health insurance coverage, variable quality of private and public health services, unregulated quality in advertising and inefficient competition between sectors.

Background: Time utilisation among primary care professionals has been affected by structural changes and reorganisation performed in Swedish primary care over several decades. The work situation is complex with a heavy administrative work load. The overall aim with this thesis was to describe time utilisation among staff in Swedish primary care and to investigate associations with perceived psychosocial work environment and legitimacy of work tasks. Methods: A multicentre, descriptive, cross-sectional study design was used including all staff categories in primary care i.e. registered nurses, primary care physicians, care administrators, nurse assistants and allied professionals (physiotherapists, occupational therapists, psychologists, counsellors, dieticians and chiropodists) at eleven primary care centres located in southeast Sweden. The data collection consisted of a questionnaire including a subjective estimate of workload, the Bern Illegitimate Tasks Scale (BITS) and the Copenhagen Psychosocial Questionnaire (COPSOQ). Also, a time study was performed, where the participants reported their work time based on three main categories; direct patient work tasks, indirect patient work tasks and other work tasks, each with a number of subcategories. The participants reported time spent on different work tasks, day by day during two separate weeks. Response rates were 75% for the questionnaire and 79% for the time study. Results: In paper I the time study revealed that health professionals at the primary care centres spent 37% of their work time with direct patient work tasks. All professions estimated a higher proportion of time spent directly with patients than they reported in the time study. Physicians scored highest on the psychosocial scales of quantitative demands, stress and role conflicts. The proportion of administrative work tasks was associated with role conflicts, the more administration the more role conflicts. Findings in paper II were that more than a quarter of physicians scored above the cut-off value for BITS regarding unnecessary work tasks, which was significantly more than the proportion observed in all other professions in the survey. Across all staff groups, a perception of having to perform illegitimate work tasks was associated with experiencing negative psychosocial work environment and with high proportion of administrative-related work tasks. Conclusions: Swedish primary care staff spend a limited proportion of their work time directly with patients and primary care physicians perceive the psychosocial work environment in negative terms to a greater extent than all other staff members. Allocation of work tasks has an influence on the perceived psychosocial work environment. The perception of having a large number of illegitimate work tasks affects the psychosocial work environment negatively, which might influence the perception the staff have of their professional roles. Perception of high proportion of unreasonable work tasks is associated with a high proportion of non-patient-related administration. This thesis illuminates the importance of decision makers thoroughly considering the distribution and allocation of non-patient related work tasks among staff in primary care, in order to achieve efficient use of personnel resources and favourable working conditions. Hopefully, the results of this study will contribute to further development of primary care so that medical competence will benefit patients as much as possible.
Bakgrund: Under de senaste decennierna har det i svensk primärvård varit omfattande omorganisationer, vilket har påverkat arbetstidens innehåll. Arbetssituationen är komplex och omfattningen av administration har ökat. Det övergripande syftet med föreliggande studie var att beskriva arbetstidens innehåll bland personal i svensk primärvård och att undersöka samband mellan upplevd psykosocial arbetsmiljö och arbetsuppgifternas legitimitet. Metod: Studien har genomförts som en deskriptiv multicenterstudie med tvärsnittsdesign och inkluderade sjuksköterskor, läkare, vårdadministratörer, undersköterskor och övriga professioner (fysioterapeuter, arbetsterapeuter, psykologer, kuratorer, dietister och fotvårdsspecialister) vid elva vårdcentraler i sydöstra Sverige. Studien inleddes med att deltagarna ombads att besvara ett frågeformulär vars första del bestod av en skattning av hur arbetsuppgifterna var fördelade. Frågeformuläret innehöll också frågor om illegitima arbetsuppgifter; Bern Illegitimate Tasks Scale (BITS) och psykosocial arbetsmiljö; Copenhagen Psychosocial Questionnaire (COPSOQ). Därefter gjordes en tidsstudie där deltagarna fick registrera tidsåtgången för olika arbetsuppgifter, varje dag under två separata veckor. Arbetsuppgifterna delades upp i tre huvudkategorier; direkt patientarbete, indirekt patientarbete och övrigt arbete. Varje huvudkategori hade flera underkategorier. Svarsfrekvensen var 75% för frågeformuläret och 79% för tidsstudien. Resultat: Resultatet från delarbete I visar att personal i primärvård ägnade 37% av arbetstiden direkt med patienter. Alla professioner skattade den direkta patienttiden till större andel än vad tidsstudien visade. Läkare upplevde sämst psykosocial arbetsmiljö avseende kvantitativa krav, stress och rollkonflikter. Det förelåg ett samband mellan andelen administrativa arbetsuppgifter och rollkonflikter, ju mer administration desto mer rollkonflikter. I delstudie II visade resultatet att mer än en fjärdedel av läkarna upplevde en hög nivå av illegitima arbetsuppgifter avseende onödiga arbetsuppgifter, vilket var signifikant mer jämfört med andra professioner. För personalgruppen som helhet framträdde ett samband mellan upplevelsen av att ha mycket illegitima arbetsuppgifter och upplevelse av negativ psykosocial arbetsmiljö samt med hög andel administrationsrelaterade arbetsuppgifter. Konklusion: Personal i primärvård ägnar en begränsad andel av arbetstiden åt direkt patientarbete och läkare upplever sämre psykosocial arbetsmiljö än övriga professioner. Arbetstidens fördelning mellan olika arbetsuppgifter påverkar den psykosociala arbetsmiljön. Upplevelsen av att utföra en stor andel illegitima arbetsuppgifter påverkar den psykosociala arbetsmiljön negativt, vilket kan ha inverkan på hur personalen uppfattar sin professionella roll. Upplevelsen av att ha mycket oskäliga arbetsuppgifter har samband med hög andel icke patientrelaterad administration. Avhandlingen belyser vikten av att beslutsfattare noga överväger fördelningen av icke patientrelaterade arbetsuppgifter bland personal i primärvård, för att möjliggöra effektiv användning av personalresurserna och för att främja goda arbetsförhållanden. Förhoppningen är också att studiens resultat ska bidra till fortsatt utveckling av primärvården så att den medicinska kompetensen kommer patienterna till nytta i så stor omfattning som möjligt.

Health is determined by the past as well as the present; the health status of indigenous peoples has been strongly influnced by the experience of colonisation and their subsequent efforts to participate as minorities in contemporary society while retaining their own ethnic and cultural identities. Colonial journays may have led to innovation and adaptation for Maori, but they have also created pain and suffering from which full recovery has yet to be felt (Durie, 2001). The oral health area can be described as having considerable and unacceptable disparities between Maori and non-Maori (Broughton 1995; Thomson, Ayers and Broughton 2003). Few reports have been conducted concerning Maori and patterns of oral health service utilisation, however a lower service utilisation among Maori than non-Maori has been noted (TPK 1996; Broughton and Koopu 1996). Overall, Maori oral health is largely unknown due to a paucity of appropriate research. This research aims to provide new information by describing Maori oral health outcomes over the life course, within a Kaupapa Maori Research (KMR) methodology. In general, the basic tenets presented for KMR are: (1) to prioritise Maori - from the margin to the centre; (2) to be Maori controlled - by Maori, for Maori; (3) to reject �victim-blame� theories; and (4) to be a step towards action and change in order to improve Maori oral health outcomes. The aims of this research are to: 1. Describe the occurrence of caris at ages 5, 15, 18 and 26 and periodontal disease at age 26 years for Maori. 2. Describe self-reported oral health, self-reported dental aesthetics and oral health service utilisation among Maori at ages 5, 15, 18 and 26. 3. Compare the above oral health characteristics between Maori and non-Maori . 4. Investigate the determinants of any differences in oral health outcomes between Māori and non-Maori using a KMR methodology. The investigation involves a secondary analysis of data from the Dunedin multidisciplinary Health and Development study (DMHDS). The existing data-set was statistically analysed using SPSS (SPSS Inc, Chicago, USA). Descriptive statistics were generated. The levels of statistical significance were set at P< 0.05. Chi-square tests were used to compare proportions and independent sample t-tests or ANOVA were used for comparing means. A summary of the Maori/non-Maori analysis shows that, for a cohort of New Zealanders followed over their life-course, the oral health features of caries prevalence, caries severity, and periodonal disease prevalence are higher among Maori compared to non-Maori. In particular, it appears that while Maori females did not always have the highest prevalence of dental caries, this group most often had a higher dmfs/DMFS for dental caries, compared to non-Maori. As adolescents and adults, self-reported results of oral health and dental appearance indicate that Maori males were more likely to report below average oral health and below average dental appearance, when compared to non-Maori. However, at age 26, non-Maori males made up the highest proportion of episodic users of oral health services. This study has a number of health implications: these relate specifically to the management of dental caries, the access to oral health services, and Maori oral health and the elimination of disparities. These are multi-levelled and have implications for health services across the continuum of care from child to adult services; they also have public health implications that involve preventive measures and the broader determinants of health; and involve KMR principles than can be applied to oral health interventions and dental health research in general. Dental diseases and oral health outcomes, such as dental anxiety and episodic use of services, are a common problem in a cohort of New Zealanders with results demonstrating ethnic disparities between Maori and on-Maori. As an area of dentistry that has had very little research in New Zealand, the findings of this study provide important information with which to help plan for population needs. The KMR approach prioritises Maori and specifically seeks to address Maori oral health needs and the elimination of disparities in oral health outcomes. While the issues that are raised may be seen as the more difficult to address, they are also more likely to achieve oral health gains for Maori and contribute to the elimination of disparities.

Cancer prevalence is an important epidemiological measure of the disease burden. It is defined as the number of people in a given population who are alive at a specified point in time (the index date) and who have previously been diagnosed with cancer. It may be expressed as either a count or as a proportion of the population. Members of the prevalent population are known as 'cancer survivors' and the time spent as such is known as 'cancer survivorship'. Complete prevalence includes all survivors regardless of when they were diagnosed, whereas N-year limited duration prevalence includes only those who have received at least one cancer diagnosis in the N years prior to the index date. In the United Kingdom (UK), addressing the needs of cancer survivors is a high priority for the Department of Health, as well as for voluntary sector organisations, and the need for further research into cancer survivorship has been highlighted. Despite this, in recent years little study has focused on cancer prevalence in the UK. The aims in preparing this thesis were to provide up-to-date estimates of cancer prevalence in the UK, to describe levels of acute health service utilisation among cancer survivors in different temporal phases of survivorship and to provide projections of future cancer prevalence. National cancer registry data for the UK were analysed, together with National Health Service hospital activity data for England. It was found that there are currently around two million cancer survivors in the UK, a figure far higher than previously thought. Levels of acute in-patient health service utilisation were, however, generally low among cancer survivors who had survived at least five years and who were not in the final year of their life. A discrete time model for projecting cancer prevalence was derived and used to project cancer prevalence in the UK from 2009 to 2040 under various different scenarios of future cancer incidence and survival. It was shown that in the coming decades cancer prevalence is likely to increase substantially. This thesis contains a detailed description of cancer prevalence and aspects of cancer survivorship in the UK which highlights the need for adequate planning to meet the many and varied needs of those diagnosed with cancer.

Thesis (MTech (Information Technology))--Cape Peninsula University of Technology, 2012.
This research is an attempt to investigate the utilisation of Information Communication Technology (ICT) in Healthcare to support the flow of HIV/AIDS patient’s general information in public and private sector. Furthermore, the research examines the detail flow of database information for healthcare service delivery to patients, in particular HIV/AIDS patients, in Khayelitsha Township. Finally, the research will detail the types of technologies currently being utilised to transfer this information, technology utilised for capturing or data collection profile of the patient. The research study data collecting was done in 2009 in mostly private and public healthcare centre in Khayelitsha township. First, the study will concentrate on general utilisation of ICT in healthcare service delivery and flow of information for public and private sector healthcare centres. Additionally, the research also looks at NGOs such as HIV/AIDS Unit in Cape Peninsula University of Technology (CPUT) and Treament Action Campaign (TAC) to find out what ICT equipment is being utilised to transfer this information to adult people to inform and make them to be aware of HIV/AIDS and improve healthcare service delivery to patients and particularly to HIV/AIDS patients. Taking NGO’s such as TAC and CPUT HIV/AIDS Unit that are well informed about HIV/AIDS, nationally and internationally will make our research results to be more precise. The research will also look at the utilisation of ICT in flow of information at healthcare centre such as communication between healthcare providers such as receptionist/clerk, nurses, doctors and medical researchers since they are the first people who deal with HIV/AIDS patient cases when they come for healthcare provision.

Master of Public Health - MPH
Background: The Western Cape's Comprehensive Service Plan (CSP) is committed to "treating the right patient at the right level right, with the right skills and at the right cost" (Page 1, Tygerberg Hospital Annual Report, 2007). Occupational therapy (OT) Managers in the Metro District, Western Cape Province are in the process of aligning the OT services to the new CSP document. A major problem is the high default rate (non attendance) and irregular attendance (patient attends but skips sessions) amongst paediatric out-patients. In order to properly improve the OT paediatric services, it is vital for the OT managers to know the reasons for the poor utilisation of the OT services at the paediatric out-patient units. Purpose of study: The irregular attendance and high default rates (where patients stop attending the OT sessions completely) among children are a major problem at three OT out-patient units in Cape Town, Western Cape Province. The occupational therapists who work at these units are adamant that this impacts negatively on the child's progress. This study sought to explore the factors influencing the utilisation of the OT service in these three OT paediatric out-patient units in the hope of providing relevant information to the OT managers of these units in order to rethink the current service and make appropriate changes to improve adherence and treatment progress. Study design: This was an exploratory study using qualitative research methods. In-depth interviews were conducted with ten parents of children who have to attend the OT out-patient services. One group discussion was conducted with the occupational therapists that provide the services at the out-patient units. Sampling: Purposive sampling methods were employed to select four occupational therapists (at least one from each unit) and ten parents (at least three from each unit, with at least two who attended poorly and one that attended regularly). Analysis: Thematic analysis was used to interpret the data. The data was coded and categorised according to themes that emerged during data analysis. Results: The results of this study revealed that the factors that impact the utilisation of the OT service at the three OT units is complex. Factors that influenced the utilisation of the OT services in this study were related to the OT service such as staff attitude, relationship between the occupational therapist and the mothers as well as their child, communication between the mother and the occupational therapist, treatment progress, parent involvement in the OT programme and access to the OT service. Other factors such as the mothers' perception of the severity of the child's health condition, family support, work factors and family support were important factors related to the mother. The findings also revealed that environmental factors namely stigma, discrimination and travelling to the OT units impacted utilisation of the OT service. The participants made recommendations on how to improve the service. Conclusion: This study describes the complexity of what impacted the utilisation of the OT services and how closely interlinked these different factors are. It is evident from the findings of this study that a comprehensive, client centred approach is required to properly deal with the factors that negatively impact the utilisation of this service. Recommendations: A multi-faceted approach is required. Important issues to address are the shortage of occupational therapists across the levels of health care in the Western Cape Province; improving on the client centred approach in OT intervention programmes; advancing advocacy against stigma and discrimination against children with disabilities; and making public transport more accessible to children and their mothers.

As significant investments and efforts have been made to strengthen HIV prevention and care service provisions throughout sub-Saharan Africa, approaches to monitoring uptake of these services have grown in importance. Global HIV/AIDS organisations use routinely updated estimates of the UNAIDS 90-90-90 targets, which state by 2020, 90% of all people living with HIV (PLHIV) should be diagnosed, 90% of diagnosed PLHIV should be receiving treatment, and 90% of PLHIV receiving treatment should achieve viral suppression. Currently, estimates of these targets in sub-Saharan Africa use population based demographic and HIV serological surveillance systems, which comprehensively measure vital events and HIV status but rely on self-reports of health service use. In contrast, most analyses of health service use are limited to patients already diagnosed and enrolled into clinical care and lack a population perspective. This thesis aims to augment existing computer software towards a novel approach to record linkage - termed point-of-contact interactive record linkage (PIRL) - and produce an infrastructure of linked surveillance data and medical records from clinics located within a surveillance area in northwest Tanzania. The linked data are then used to investigate methodological and substantive research questions. Paper A details the PIRL software that was used to collect the data for this thesis. Paper B reviews the data created by PIRL and reports record linkage statistics, including match percentages and attributes associated with (un)successful linkage. A subset of personal identifiers was found to drive the success of the probabilistic linkage algorithm, and PIRL was shown to outperform a fully automated linkage approach. Paper C provides original evidence measuring bias and precision in analyses of linked data with substantial linkage errors. Paper D critiques the estimation of the first 90-90-90 target and shows that current guidelines may underestimate the percentage diagnosed by a relative factor of between 10% and 20%. Finally, Paper E determines that while HIV serological surveillance has increased testing coverage, PLHIV who were diagnosed for HIV in a facility-based clinic were statistically significantly more likely to register for HIV care than those diagnosed at village-level temporary clinics during a surveillance round. Once individuals were in care, there was no evidence of any further delays to treatment initiation by testing modality. The collective findings of this thesis demonstrate the feasibility of PIRL to link community and medical records and use the linked data to measure patterns of HIV service use in a population.

Older adults have high rates of chronic diseases, leaving them more vulnerable to associated mental health declines. Nevertheless, the intentions of older adults with chronic diseases to seek help from mental health support systems are low. Couched in the Theory of Planned Behaviour (TPB), this thesis aimed to 1) identify antecedents to help-seeking for mental health problems in older adults with chronic diseases, and 2) to design, develop and test a behaviour change intervention, promoting mental health help-seeking among older adults with chronic diseases in Australia. An overview of this thesis is presented in Chapter 1. A literature review on the relationship between mental health problems, chronic diseases, and help-seeking in older adulthood is then provided (Chapter 2). A scoping review was conducted, which mapped 49 articles that applied the TPB to mental health help-seeking in adults aged >18 years (Chapter 3). A considerable evidence base was found on the TPB for predicting mental health help-seeking intentions, and to a lesser extent behaviour. A survey instrument, to measure mental health help-seeking intentions among older adults (MHHS-OA), was developed and piloted with a sample of 54 adults aged 65 to 94 years living in metropolitan Perth, Western Australia (Chapter 4). The MHHS-OA demonstrated acceptable reliability and validity for measuring the TPB constructs of attitudes, subjective norms, and behavioural intention (Cronbach alphas .64 to .82). Modifications were made to improve the measurement of perceived behavioural control. The modified MHHS-OA was utilised in a cross-sectional study with 108 adults aged 65 to 93 years, living in metropolitan Perth, diagnosed with cardiovascular diseases, respiratory diseases, and/or type 2 diabetes (Chapter 5 and 6). The cross-sectional study sought to identify factors associated with intentions to seeking help, and barriers to seeking help, among older adults with chronic diseases. Using multiple linear regressions, the TPB was found to be a suitable model for understanding mental health help-seeking intentions in older adults with chronic diseases, accounting for 69.7% of the variance in intentions (Chapter 5). Attitudes and perceived behavioural control had the strongest association with help-seeking intentions, followed by subjective norms. Two common barriers to help-seeking were identified: ‘wondering whether the mental health problem is significant enough to warrant treatment’ (endorsed by 51.9% of participants), and ‘not having a regular primary health care provider to speak with’ (endorsed by 39.6% of participants). Multiple linear regressions revealed past use of mental health services had the strongest association with both barriers; past help-seeking behaviour was associated with less endorsement of barriers to help-seeking (Chapter 6). Identifying factors associated with intentions to seek help (attitudes, perceived behavioural control, and subjective norms), and barriers to seeking help, the first aim of this thesis was achieved. To achieve the second aim of this thesis, an intervention aimed at promoting mental health help-seeking was developed and tested in a pilot randomised controlled trial (RCT) (Chapter 7). The intervention was designed to address the antecedents to help-seeking that were identified (Chapters 5 and 6). Nine stakeholders were interviewed to inform the design and development of the intervention and 241 adults aged 66 to 90 years were randomised to receive the intervention or control materials. The intervention consisted of a TPB-based brochure, aimed at promoting mental health help-seeking. Results indicated the intervention is an acceptable and feasible method for improving mental health help-seeking in older adults with and without chronic diseases. Repeated measures ANOVAs, regarding the effectiveness of the intervention, indicated the intervention is effective in improving attitudes and intentions towards seeking help for mental health problems. Finally, Chapter 8 summarises, concludes, and proposes future research directions. This thesis helps to delineate factors associated with intentions as well as barriers to help-seeking and provides researchers and health professionals with an empirically based intervention aimed at increasing the likelihood of help-seeking intentions and behaviour among older adults with chronic diseases.

Développer une utilisation efficace des Systèmes d’Information (SI) de santé devient un impératif pour le secteur des soins de longue durée qui fait face à des enjeux de qualité et de productivité dans un contexte sous tension, lié au vieillissement de la population Européenne. Malgré l’intérêt croissant pour la phase de post-adoption des systèmes d’information, celle-ci reste largement inexplorée. Partant de ce constat, cette thèse se concentre sur les utilisations exploitantes et exploratoire des SI dans le secteur de la santé, deux utilisations considérées comme clé dans la phase de post-adoption et visant à obtenir des bénéfices du SI et à accroitre sa performance. Un premier essai définit et restructure notre compréhension des utilisations exploitantes et exploratoires, leurs antécédents et impacts sur la performance des utilisateurs. Les essais suivants analysent les dynamiques liants ces deux types d’utilisations dans le secteur des soins de longue durée et le rôle de l’environnement et plus particulièrement du stress lié à la technologie sur ces dernières. Les résultats mettent en évidence l’importance d’étudier conjointement les utilisations exploitante et exploratoire. Ils montrent la façon dont les utilisateurs alternent entre ces deux utilisations ainsi que la façon dont les contraintes liées à l’environnement tendent à enfermer les utilisateurs dans un usage exploitant. Cependant ils révèlent également que des solutions existent pour sortir de cette trappe d’exploitation. Enfin, ils soulignent le rôle ambivalent du SI lui-même, et plus particulièrement du stress lié à la technologie sur l’utilisation exploitante et exploratoire du logiciel de soin
Developing Health Information Systems (HIS) effective use becomes an imperative for the long-term health care sector, which is facing quality and productivity concerns, in a context under pressure, linked to European population ageing. Despite growing interest for the Information Systems’ (IS) post-adoption stage, this one stills largely unexplored compared to the implementation and adoption stages. Tackling this issue, this dissertation focuses on IS exploitative and exploratory uses in the healthcare sector, two kind of uses considered as key to reach benefits from IS and increase performance in the post-adoption stage. A first essay defines and conceptualizes our understanding of exploitative and exploratory uses, their antecedents and outcomes on users’ performance. Following essays analyze the dynamics behind these two use behaviors in the long term health care sector, as well as the role of the environment, and of the stress related to the technology, on these former. Results highlight the importance of studying exploitative and exploratory uses together. Thus, our findings show the way in which users switch between these two use behaviors as well as the way in which constraints related to the environment tend to lock users in exploitative use. Nevertheless, these findings also unveil solutions to get out of this exploitation trap. Finally, they highlight the ambivalent role of the system itself, and more specifically of the stress related to the technology on HIS exploitative and exploratory uses

RESUME

La Trypanosomiase Humaine Africaine (THA) appelée également « maladie du sommeil» est une maladie parasitaire provoquée par un protozoaire du genre Trypanosoma dont deux sous-espèces (T. brucei gambiense et T. brucei rhodesiense) sont pathogènes à l’homme. La stratégie de lutte contre cette maladie est essentiellement basée sur le dépistage précoce et le traitement des malades, complété avec le contrôle du vecteur. Cependant, l’utilisation du service de dépistage de la THA par les communautés exposées représente un défi majeur. L’adhésion aux campagnes de dépistage actif avec des équipes mobiles spécialisées était en-dessous de 50% dans certains villages endémiques fin des années nonante. De surcroît, l’utilisation des services de santé fixes en RDC est si faible que ceci compromet le dépistage passif dans les formations sanitaires fixes. Notre hypothèse est que cette faible utilisation des services de santé pourrait elle-même être due à un problème d’acceptabilité du dépistage et traitement de la THA par les communautés vivant dans les zones de transmission de la THA. Tout ceci compromet l’élimination de la THA comme problème de santé publique, un but que s’est fixé la communauté internationale d’ici 2020.

Ce travail a comme objectif d’explorer cette dimension socioculturelle de la maladie qui est souvent négligée dans le contrôle de la THA et générer une meilleure connaissance de ces aspects.

Nous avons réalisé cinq études en total pour adresser la question de la sous-utilisation des services de dépistage et traitement de la THA par les communautés et sa relation avec l’acceptabilité des services. Nous avons d’abord développé une première étude qui évalue les résultats du traitement de la THA en analysant rétrospectivement les données de routine du programme de contrôle de la THA pour l’année 2006 à 2008. Ensuite, nous avons réalisé trois études qualitatives par focus group (groupe focalisé) et entretiens individuels pour documenter la dimension socioculturelle de la lutte contre la THA. D’abord une étude qui a exploré les perceptions sur la THA dans la communauté, suivi par une étude qui explore les perceptions sur le traitement de la THA et une autre qui se concentre sur les pratiques diagnostics des professionnels de santé face à un syndrome neurologique en contexte de ressources limitées.

Une cinquième étude combine une enquête-ménage avec des focus groups et des entretiens individuels pour explorer les perceptions de la communauté sur la santé en général et les services de santé.

Nous avons comparé les obstacles à l’utilisation des services de dépistage et traitement de la THA identifiés dans ce travail avec les messages de sensibilisation sur la THA utilisés au programme de contrôle de la THA en RDC et nous avons développé des recommandations stratégiques.

L’évaluation des indicateurs de performances sur l’issue de traitement montre que le taux de suivi post-thérapeutique est faible dans son ensemble :25 % pour le premier suivi de six mois et moins d’un pourcent des patients revient pour la dernière visite de contrôle au mois 24. Nous avons aussi observé dans cette étude un taux d’échec au mélarsoprol et à la pentamidine respectivement de 30% et de 22 % au Kasaï Oriental qui sont cependant difficilement interprétables, car le dénominateur est incomplet. Comme très peu de patients reviennent au contrôle post-thérapeutique, cette proportion est probablement biaisée vers ceux qui sont en échec de traitement.

L’étude de perception de la THA montre que la maladie est bien connue dans les communautés vivant dans les zones à risque. Par contre, plusieurs obstacles au dépistage et traitement de la THA ont été identifiés. Les plus importants sont :la toxicité des médicaments de la THA, les obstacles financiers, l’inadéquation entre le programme de dépistage des équipes mobiles et les occupations des communautés, les interdits qui accompagnent le traitement de la THA, le manque de confidentialité et la peur de la ponction lombaire.

L’étude sur la perception du traitement de la THA a montré que le mélarsoprol est perçu comme un médicament toxique et est surnommé « médicament des interdits ». Par contre, le régime NECT est perçu comme un nouveau médicament moins toxique qui a rendu les interdits liés au mélarsoprol obsolètes sauf un seul, celui de ne pas avoir de rapport sexuel pendant la période de traitement et de suivi post thérapeutique qui est de 6 mois. Les interdits ont été instaurés de manière empirique par les professionnels de santé et les communautés pour mitiger les effets indésirables du mélarsoprol. Leur violation pourrait entrainer des conséquences graves et mortelles. Ces interdits sont fortement ancrés dans les croyances de la communauté et constituent aujourd’hui un obstacle au dépistage et traitement.

L’étude sur les pratiques diagnostiques des professionnels de santé en matière de syndrome neurologique en contexte de ressources limitées a montré qu’en zone rurale le diagnostic est principalement clinique. Les obstacles perçus au diagnostic de confirmation sont essentiellement d’ordre financier puisque le patient doit tout financer de sa poche. Autres obstacles évoqués sont le manque d’outils de diagnostic et la perception de la communauté qui voit le clinicien comme un devin (petit dieu) ou oracle capable de « deviner » directement la maladie sans passer par un processus diagnostique de laboratoire.

L’étude sur les perceptions de la santé et des services de santé a montré que les capacités de travailler (82%) et les capacités de se mouvoir (66%) sont les signes de bonne santé les plus perçus. 90% des responsables des ménages perçoivent positivement la santé de leur ménage. Les opinions sur le service de santé sont partagées.

Les études présentées dans ce travail ont généré des nouvelles connaissances sur la dimension socioculturelle de la THA. L’analyse des messages de sensibilisation sur la THA utilisés par le programme de contrôle de la THA en RDC en termes de comparaison avec les obstacles au dépistage et traitement de la THA identifiés dans ce travail montre que ces aspects socioculturels bien qu’étant des véritables goulots d’étranglements dans la dynamique de la lutte contre la THA ne sont pas bien ciblés par la communication sur la THA.

Les perspectives des communautés exposées au risque de la THA doivent être adressées par un dialogue continu entre professionnels de santé et communautés adapté aux réalités locales. Ainsi il sera possible d’améliorer de manière opérationnelle les stratégies d’information, éducation et communication, et de façon plus large, le dépistage et traitement de la THA en intégrant la dimension socioculturelle de la THA dans la politique de lutte contre la THA.

SUMMARY

Human African Trypanosomiasis (HAT), also known as “sleeping sickness” is a parasitic disease caused by protozoa of the species Trypanosoma. There are two types that infect humans, Trypanosoma brucei gambiense and Trypanosoma brucei rhodesiense. The strategy used to control sleeping sickness consists of early case detection and treatment of patients, together with vector control. Meanwhile, utilization/access to HAT screening by the affected communities remains a major challenge. Adherence to active screening programs with mobile units was below 50% in certain endemic villages end of the 90’s. Moreover, utilization of fixed health facilities in DRC is so low that it compromises passive case finding. Our hypothesis is that this low utilization of health services is caused by a problem of acceptance of case detection and treatment of HAT by the communities living in the HAT transmission zones. This compromises the target of the international community to eliminate HAT as a public health problem by 2020. This thesis wants to explore and tries to generate more knowledge on the socio-cultural aspect that is often neglected in the control of HAT.

We conducted five studies to address the lack of community participation in HAT screening and treatment activities and the relation with acceptance of these services.

The first study evaluated the results of HAT treatment by retrospectively analyzing data of the routine HAT control program for the period 2006-2008.

Afterwards we performed three qualitative studies consisting of focus group discussions and individual interviews to document the socio-cultural dimension of the fight against HAT. The first study explored the community perceptions regarding sleeping sickness. The second study explored the perceptions regarding HAT treatment and a third study focused on diagnostic practices of health professionals in low-resource settings facing a neurological syndrome.

The fifth study consists of a household survey, focus group discussions and individual interviews to explore community perception regarding health in general and health services. We compared the identified barriers to screening and treatment of HAT with awareness messages on sleeping sickness used by the HAT control program in DRC and we developed strategic recommendations. The evaluation of performance indicators for treatment showed that compliance with post-treatment follow-up is very poor: 25% for the first post-treatment follow-up examination at six months and less than 1% of the patients returns for the final examination at 24 months. In this study we also observed a treatment failure rate of respectively 30% and 22% for melarsoprol and pentamidine in Kasai-Oriental. However, these date are difficult to interpret because of an incomplete denominator. As only few patients return for follow-up visits, this proportion is probably biased towards those in treatment failure.

The study on the perception of sleeping sickness shows that the disease is well known amongst the communities living in the endemic areas. However, several screening and treatment barriers were identified. The most important are: drug toxicity, financial barriers, the incompatibility between the itineraries of the mobile screening teams and the local communities’ activities, the prohibitions related to HAT treatment, lack of confidentiality and fear of lumbar punctures. The study on the perceptions regarding HAT treatment show that melarsoprol is perceived as a toxic drug and is nicknamed the ‘taboo drug’. On the other hand the NECT regime is perceived as the new drug that is less toxic and that has abolished all the taboos of melarsoprol with the important exception of sexual intercourse during the treatment period and the post-treatment follow-up period of six months.

The prohibitions have been established empirically by healthcare providers and communities to mitigate the side effects of the melarsoprol regimen. Violating these restrictions is believed to cause severe and sometimes mortal complications. Communities adhere strictly to these prohibitions and this constitutes a barrier for HAT screening and treatment.

The study focusing on diagnostic work-up of neurological syndromes in low-resource settings by health care providers has shown that in rural areas diagnosis is usually clinical. Barriers to confirmation of diagnosis are mainly related to the purchasing power of the patient. Other reported barriers are a lack of diagnostic tools and the communities’ perceptions associated with the care provider. Clinicians are perceived as diviners being able to directly identify the cause of the illness without using laboratory tests. The study regarding the perceptions on health and health services has shown that ability to work (82%) and ability to move (66%) are the most perceived signs of good health. 90% of the household responsibles positively perceive the health of their family. The opinions on the health services are divided.

The studies presented in this thesis have generated new insights on the socio-cultural dimension of HAT. The analysis of the awareness messages on HAT in DRC compared with the reported HAT screening and treatment barriers have shown that

although these sociocultural aspects are real bottlenecks in the dynamic of the fight against HAT, they are not targeted by the communication on HAT.

The prospects for communities at risk of HAT should be addressed through continuous dialogue between health professionals and communities adapted to local realities.

It will thus be possible to operationally improve the information strategies, education and communication, and more broadly, screening and treatment of HAT by integrating the socio-cultural dimension in the fighting policy against sleeping sickness.

Doctorat en Sciences
info:eu-repo/semantics/nonPublished

The number of cancer survivors is increasing. Knowledge gaps exist regarding the health of survivors and their use of services, particularly survivors with long-term effects of the disease and treatment, including late effects. This PhD study comprised (i) a systematic review of health service utilisation by cancer survivors; (ii) a population-based comparative survey of the health status and service utilisation of cancer survivors and a matched General Practice population; (iii) an overview of reviews of late effects; (iv) a comparative analysis of cancer survivors with self-reported late effects and survivors without late effects in terms of their health status and services utilisation patterns and; (v) a qualitative study of the narrative of cancer survivors with late • effects. The health service utilisation review identified that increasing age was associated with less care and increased hospitalisations. Improved care receipt was dependent on type and frequency of physician contact which facilitated health service use. Survivors were generally higher service users and received more care than the general population- this finding concurs with results of the survey. Survivors also had significantly poorer health than the general population. The presence of co-morbidities was associated with less service receipt, though the survey found that survivors with late effects were high users of care and experienced poorer health than their counterparts without late effects. There was general I SUMMARY 2 - PAGE 3 - agreement that physical late effects tend to emerge some time post-treatment, but there was -- less agreement regarding the onset of psychological late effects. Late effects impacted on many aspects of survivors' lives and were managed in many ways. The main emergent themes from the qualitative analysis were: sense-making, social comparisons and psychology of the individual. Care recommendations and implementation of preventive care plans would facilitate receipt of appropriate care and improve health for survivors including those with late effects.

The Government of Malawi has entered into agreements with Christian health association of Malawi (CHAM) health care facilities in order to exempt their catchment populations from paying user fees. These agreements are called service level agreements (SLAs). Government in turn reimburses the CHAM health care facilities for the health services that they provide. The agreements started in 2006 with 28 out of 166 CHAM health care facilities and increased to 68 in 2010. The aim of the exemption policy is to guarantee universal access to a basic package of health care services. Although the agreements were designed to cover every health service in the basic health care package, only maternal and neonatal health services are included due to limited resources. The main objective of this thesis was to evaluate the impact of the health care financing change on health care utilisation and health. The specific objectives were as follows: first, to examine whether health care facility visits for maternal health care changed due to user fee exemption; second, to evaluate whether user fee exemption affected the choice of the health care provider where women living in the catchment areas of CHAM health care facilities with user fee exemption sought maternal health care; third, to analyse the effect of user fee exemption on birth weight and; fourth, to explore and apply novel methods in the evaluation of user fee exemption. The gradual uptake of service level agreements by CHAM health care facilities provided a natural experiment with treated and control health care facilities. An additional control group comprised of other demographic groups apart from pregnant women and neonates at CHAM health care facilities with service level agreements. In household survey data, individuals were assigned to treatment and control groups based on their proximity to either a CHAM health care facility with SLA or a CHAM health care facility without SLA. This proffered the unique opportunity to estimate the effect of a single treatment on multiple outcomes. The difference-in-differences (DiD) approach was used to obtain causal effects of user fee exemption. It was implemented in the context of fixed effects, switching regression and multinomial logit models across different chapters. Health care facility level panel data for utmost 146 health care facilities for a maximum of 8 years, 2003-2010, were used. The data were obtained from the Malawi health management xiii information system (HMIS). Linked survey data were also used. Malawi demographic and survey data for 2004 and 2010 were linked to health care facility data and then merged. Analyses that utilised health care facility data showed that user fee exemption had led to increases in first antenatal care visits in the first trimester, first antenatal care visits in any trimester, average antenatal care visits and deliveries at CHAM health care facilities with SLAs. Results from survey data showed that the probability of using a CHAM health care facility with user fee exemption for antenatal care increased, the probability of using home antenatal care declined and the probability of not using antenatal care also declined due to user fee exemption. The probability of delivering at a CHAM health care facility with SLA also increased while the probability of delivering at home declined. User fee exemption did not affect the choice of where to go for postpartum care. Results of the effect of user fee exemption on birth weight were not reported because of potential endogeneity bias arising from lack of instrumental variables for antenatal care. The key policy messages from this thesis are that the user fee exemption policy is an important intervention for increasing the utilisation of maternal health care and needs to be extended to as many CHAM health care facilities as necessary. User fee exemption is not enough, however. Other factors such as education of the woman and her husband/partner, wealth status and cultural factors are also important. This thesis has contributed to the body of knowledge in the following ways. First, it has generated evidence on the impact of user fee exemption on maternal health care utilisation and birth weight in Malawi. Second, with respect to maternal health care utilisation, the thesis has looked at variables that capture the whole maternal health care process from early pregnancy to postpartum care and in a policy relevant way. Third, the thesis has evaluated the effect of user fee exemption on a variable that have not been looked at before, first antenatal care visits in the first trimester. Fourth, the thesis has examined the effect of a single treatment on multiple outcomes in a methodologically unique way. Treatment effects, which were the changes in the probabilities of using different alternatives summed up to zero, thus showing where any increase in the probability of using the outcome of interest came from. Fifth, this thesis is first to use disequilibrium theory of demand and supply in health economics. Application of this theory entailed using switching regression models with unknown sample separation, a seldom used estimation method in health economics. This was an important contribution to the methods xiv of analysing aggregate health care utilisation. Sixth, the STATA program that was written for the estimation of the disequilibrium models was itself a very important contribution to the methods for estimating aggregate supply and demand.

The aim of the present thesis is to evaluate the effects of an Intensified Primary Health Care (IPHC) intervention on GPs' and home care nurses' possibilities to monitor and support cancer patients, and on cancer patients utilisation of medical services. A further aim is to identify determinants of cancer patients' utilisation of such services. A total of 485 patients newly diagnosed with breast, colorectal, gastric or prostate cancer were randomised to the intervention or to a control group. The follow-up period was 24 months for all patients.

Patients randomised to the IPHC were referred to the home care nurse. The home care nurse and the GP received copies of the medical record each time the patient was discharged from hospital after a period of in-patient care, or had visited a specialist out-patient clinic. In addition to this, recurrent education and supervision in cancer care were arranged.

The IPHC resulted in a marked increase of home care nurse follow-up contacts. The majority of control patients (74%) reported no such contacts, while 89% of IPHC patients reported this. High age (=80 yr) was the strongest predictor within the IPHC group for reporting a continuing home care nurse contact. Furthermore, the IPHC increased GPs' knowledge about patients' disease and treatments, and appeared to facilitate their possibilities to support the patients. The IPHC reduced the utilisation of specialist care among elderly cancer patients. The number of days of hospitalisation for older patients (=70 yr) randomised to the IPHC were 393 less than for older control patients during the 3 first months after inclusion. Regression analyses defined diagnosis, extensive treatment, comorbidity, low functional status, pain and socio-economic factors as predictors of a high utilisation of medical services.

Background: Maternal mortality and morbidity still pose a significant challenge in Sudan, where no significant improvements in maternal health have been achieved despite the focus on the Millennium Development Goals. Under-utilisation is a major public health concern even though Sudan is among the African countries that have registered poor maternal and child health. Health services in Sudan are generally limited and with poor quality and disparate access. Therefore, there is a need for better understanding of the barriers to the provision and utilisation of maternal health services in order to improve the health and survival of Sudanese mothers. Objectives: This study sought to assess the maternal health system functions and influences on utilisation as well as the social, cultural, and women’s characteristics that may constitute barriers to utilisation. Methodology: The study used an explanatory sequential mixed-methods design. A comprehensive analysis was conducted using several quantitative and qualitative data sets, guided by a new framework, the Maternal Health System Performance framework (MHSP) developed as part of this work in order to assess both the three objectives and four functions of the health system on both macro and micro levels. Findings: The study findings provide clear evidence that the Sudan health system is not currently capable of achieving an adequate level of attainment of the health goals or equitable distribution, due to dysfunction of the four health system functions. In addition, the findings draw attention to the important role of the stewardship function in health system performance. This function can play a key role in health system reform, as it influences management of the health system and should work across all elements of the system to ensure a well-functioning health system and efficient use of resources. The findings also underline the important role of health system related factors rather than simply population factors (such as individual, household, and community factors) in the low service utilisation among women in poor settings. While it shows that certain population characteristics such as household income and education do have a significant impact on the utilisation, the health system functions, and in particular the stewardship function, are also demonstrated to be of considerable importance. Implication: These findings have implications for policy and practice, indicating that simply blaming women for not using maternal health services is unhelpful and inappropriate and indicate that decision makers should focus more fully on improving the performance of the health system. According to the comprehensive assessment of the health system performance, the study proposes several recommendations for each health system function to enhance the performance in the context of limited resources, ultimately to improve women’s and community health in Sudan.

This thesis is about the Utilisation of Maternal and Child Health Care Services (MCH) in Rural Bangladesh. Investigations have been made to identify the underlying causes of low use of the MCH services provided through the public sector health care facilities, which is a major concern for the government of Bangladesh. This thesis focuses on the factors that are affecting the use of MCH services both from population and provider perspectives. Socio-economic condition of people, their knowledge and attitudes towards the public sector health care services are considered as population factors, while different aspects of quality of public health services, access to the service facilities and provider's behaviour are explored as the providers' factors. Aims: The aim of this research was to provide policy recommendations for improving utilisation of the public health services at the primary health care level by redesigning more accessible, acceptable and quality health care services, especially for rural women and children. Scope: Maternal health services: antenatal care; tetanus vaccination; place of child delivery; and postnatal care are considered in this study. While two major killer diseases: diarrhoea and acute respiratory infections, and immunisation of children under five years of age are included as child health care services. Methods: A combination of qualitative and quantitative methods are used to collect data /information from 360 mothers, 28 formal and informal community leaders, 44 various types of health care providers and 22 public sector facilities in a rural area of Bangladesh. The World Health Organisation (WHO) recommended 30 cluster sampling method was used in sample design. Household survey, in-depth interview, informal and formal discussion, participant observation and document analysis have been carried out to obtain necessary information/data. Data analyses: The quantitative data have been analysed by using STATA and SPSS statistical computer programme, performing descriptive, bivariate and logistic regression analysis. The qualitative information has been analysed in a descriptive way. Results: The results show that the use of government health facilities: THC, FWC and VHCP is generally very low with an exception of the use of VHCP for TT vaccination to women and child immunisation. The use of VHCP is encouraging for the government policy makers and planners. THC is partially meeting the health care need of rural people and mainly serving the interest of people of relatively high socio-economic condition. FWC is the most unused health care facility at the rural areas of Bangladesh. The majority of people (86%) received health care from non - qualified health care providers. Among the socio-economic factors - family education and income were found to be significant both individually and jointly with the variations of use of MCH services. The majority of the sample population does not have knowledge about the MCH service availability and possessed negative attitudes towards the public sector MCH services. These are attributable to the under utilisation problem. Nine gaps have been identified between peoples' `reasonable expectation' and the `existing' MCH service delivery system. Peoples' involvement in the health service organisation at the thana and union level was found almost nil. However their involvement in the operation of VHCP was encouraging. Low (2-3 minutes) consultation time, lack of privacy in treatment, unregulated involvement of public sector provider in private practice, lack of accountability, supervision and improper behaviour of providers deteriorating the quality of services hence decreases the use of public sector facilities. Unavailability of drug was found to be the single most important reason that deters people from using public facilities. Difficulties in access to quality services were found to be a major problem than access to the service facilities. Conclusions: This thesis suggests that giving priority to improving the service qualities of the existing facilities rather than construction/development of additional facilities at PHC level. It also suggests the initiation of behaviour change programmes for public sector health care providers. Secondly an effective mechanism needs to be developed to ensure peoples' involvement in the management and operation of public health care facilities to enhance accountability of public sector provider to the population and reduce the gap between them. Initiatives could be taken to improve the quality of non-qualified health care providers, as they are the main source of health care for the majority of population. Finally, increasing the education level of rural population particularly for women could increase the use of health services.

Despite the growth in research on masculinities and health help seeking behaviour we have little idea of how gender and ethnicity intersect to inform health help seeking behaviour among men in multi-ethnic cultures. This paper presents findings from a PhD research project investigating how being a man in Brunei Darussalam, a country with a strong religious and diverse cultural society; influences men’s perceptions of and attitudes towards their health and health help seeking behaviour. Using Grounded Theory, this thesis reports a study that utilised semi structured interviews and focus group discussions with a total of 47 men and women from diverse ethnic backgrounds in Brunei Darussalam. Three key themes emerged from the analysis of interviews with men: 1) The physicality of health and its importance to masculinity; 2) “Ikhtiar” as a way of ‘doing masculinity’ in the context of experiences of ill-health; and 3) masculinity and legitimation of health help seeking. A core concept found in this study relates to the process by which men operate and re-negotiate their masculinity in relation to their engagement with health care services, particularly when their ability to perform masculine responsibilities are potentially jeopardised by ill-health. Themes emerging from interviews with women focused on the relationship between wives and husbands, and daughters and fathers, and the way caring responsibilities reinforced bonds within the family. Women saw men’s reluctance to use healthcare as ‘normal for men’, while men acknowledged that pressure from wives was a factor in their decision to seek help. This study contributes to the development of knowledge about masculinities and health in a geographical region where to date there has been no empirical research, despite the existence of epidemiological evidence indicating that men’s health needs are serious and appear to be unmet.

This investigation aimed to determine factors that influence women's utilisation of maternal health services, with specific focus on the quality of care and services available to disadvantaged communities in South Africa. It used the women's perspectives to assess the quality of maternal healthcare services in peri-urban commercial farming and rural areas with the purpose of understanding why women utilise maternal services the way they do.

The thesis aims to investigate whether need is the major determinant of ambulatory health care utilisation for Saudi nationals in Saudi Arabia. This is done by applying multivariate analysis on the utilisation of both curative and preventive services on the data provided by the 1996 Saudi Arabia Family Health Survey. The analysis is applied within the framework of Andersen's sociobehavioural model, categorizing the factors that affect health services utilisation into predisposing, enabling and need factors. It can be concluded from the results that although need seems to be an important determinant of ambulatory health care utilisation, some of the predisposing and enabling factors were also found to affect health services utilisation, although the degree of their effect differs according to the health condition and type of services tested for. Need is dominant with regards to the utilisation of health services in response to children's diarrhoea, infants' full immunisation and attending at least one prenatal care session. But since some of the predisposing and enabling factors were found to affect health services utilisation, this highlights the importance of addressing the factors that were found to impede the utilisation at the health care system level as well as at the society level in order to achieve a more equitable health care system.

Includes bibliographical references.
Background: The Lesbian, Gay, Bisexual and Transgender (LGBT) community has historically been marginalised. Increased international awareness of the LGBT profile has led to the recognition that the medical profession has overlooked the health needs of lesbian women, with a resultant paucity of data regarding lesbian women’s health risks. International literature has shown that lesbians remain at risk of sexually transmitted infections and HIV; are at significant risk of mental health disorders; exhibit a high-risk profile for cardiovascular disease, diabetes, as well as cancer, and underutilise health care services due to experiences of homophobia. South African data is almost non-existent. Objective: To explore Cape Town wsw’s (women who have sex with women) experiences with, and trends of utilisation of Reproductive Healthcare Services. Study Design: Cross Sectional Survey. Methods: A sample of self-identified wsw was recruited using a snowball sampling method to complete an anonymous, self-administered online questionnaire during February 2013. Outcome Measures: Predominantly descriptive, with an aim to validate the study questionnaire for the South African context. Results: A total of 116 responses were analysed. The mean age of the population was 37 years of age, with the majority identifying as lesbian. The population comprised predominantly of Caucasian, middle class suburban residents, with most having medical aid, and accessing private health care. A significant proportion of respondents reported previous intercourse with a male sexual partner. Barrier contraception was not always used during intercourse with men and almost never during sex with women. There were a significant number of sexually transmitted infections in women with no previous male sexual partners. Most respondents considered themselves to be at low risk of contracting HIV, and at intermediate risk of cervical and breast cancer, and showed higher than average utilization of cervical screening practices for 4 this population, despite a general perception that screening is unnecessary in lesbian women. A general trend towards disclosure of sexual orientation was noted; however users of private healthcare were significantly more likely to have disclosed their orientation to their physician than users of public and NGO services. Respondents held a preference for practitioners that were themselves gay/lesbian.The study tool was validated for use in the South African context; however redundancy could not be formally excluded from the questionnaire. Conclusions: Wsw from Cape Town experience internationally comparable exposures and risks of gynaecological problems. Further research is required to fully understand the healthcare needs of lesbian women living in lower socio-economic conditions.

Background: University of Fort Hare (UFH) provides health care services to its students and staff; however, whether the health care services are being utilised by the staff is only speculative. Hence, the aim of the study was to determine the level of employees’ awareness regarding availability of University Health Care Services (UHS) and factors responsible for their utilization. wildlife and thereby may constitute a serious risk to public health. Therefore, it is recommended that proper regulation of the use of the compounds and their safe disposal be ensured to protect aquatic resources and the well-being of humans. Methodology: This quantitative descriptive study involved conveniently selected 255 UFH employees who were either permanently employed or on contract employment for two years and above. A structured self-administered questionnaire was used for data collection. The questionnaire solicited information on demographics variables, awareness of employees regarding the existence of university health services, and factors affecting utilization of university health services (UHS) by employees. Data was analysed using descriptive statistics (frequency and percentages) and inferential statistics (logistic regression analysis). Results: -Two hundred and thirty three (91 percent) of sampled UFH employees in both campuses are aware of the UHS. The longer the duration of employment and the older the employee (above 50 years old) the more likely the employees are aware of UHS. However, the elderly employees displayed poor utilization of health care services. Accessibility of UHS (96 percent), satisfaction with UHS (95 percent), listening to others (word of mouth) (61.2 percent) and having a health concern (51 percent) encourage UHS utilization whereas being unaware (8.6 percent) of the UHS remains the barrier for utilisation. Having medical aid (81 percent) prevent those who are aware of UHS from utilising the university health care services. Operating hours (30 percent), staff attitudes (50 percent) and long waiting time (70 percent) with lack of essential medicines (38 percent) prohibit employees from revisiting. Conclusion: The University of Fort Hare’s health care services are well known by almost every employee through “word of the mouth” though they are not completely aware as to which health service programmes are being offered. The utilization of University of Fort Hare’s health care services is positively and adversely influenced by different factors.

Background: International research has shown that socioeconomically disadvantaged groups experience significantly higher mortality and morbidity rates than other groups. Both cardiovascular disease (CVD) and diabetes are major contributors to Australia's burden of disease, and individuals from lower socioeconomic groups are more likely to be affected by both, and to have worse prognoses and outcomes. There is substantial research evidence that a range of preventive activities can reduce the morbidity and mortality associated with these conditions. Research in countries with good access to primary health care services has demonstrated that socioeconomically disadvantaged groups tend to have higher levels of medical consultations, but make less use of preventive care and screening services. This fact contributes to their poorer health outcomes, as diagnosis will typically occur later than for more advantaged individuals, thus leading to a poorer prognosis. However, to date, there has been little research on the differential utilisation of preventive health services for CVD and diabetes by different socioeconomic groups in Australia. To understand socioeconomic influences on the use of preventive health services, a comprehensive review of the literature of determinants of health service utilisation was conducted and a number of explanations for this relationship considered. It was proposed that the following factors are likely to be important in this relationship: differences in the perception of the availability of, and accessibility to health care, attitudes and beliefs toward preventive health care, having a regular source of care, perception of interpersonal care from general practitioners, and social support. A number of theoretical models were also reviewed; in particular, the Andersen Behavioural Model of Health Service Research Utilisation. Aims: This doctoral research program has described the relationship between socioeconomic position (SEP) and utilisation of preventive health services in relation to CVD and diabetes. It aims to improve the understanding of the determinants of uptake and utilisation of preventive health services in general practice by different socioeconomic groups in Australia. Methods: The study was conducted in Brisbane Australia, in 2004, using a cross-sectional design and a self-administered mailed survey for data collection. A sample of adults aged 25-64 years was selected randomly from the Brisbane Electoral Roll. A conceptual model incorporating a range of relevant socio-demographic, risk-factor and behavioural variables in the relationship between SEP and GP-based use of preventive health services was used to develop a self-administered questionnaire. The questionnaire was pilot-tested and then reviewed by a panel of international experts. A new self-administered questionnaire, the Health Service Utilisation Questionnaire (HSUQ), was developed. It included 79 items: 12 socio-demographic items; 10 items assessing health status, disease conditions and smoking status; 20 items assessing use of health services; and 37 items assessing the factors that might affect use of health services utilisation. The HSUQ was then mailed to 800 randomly selected survey participants. The survey response rate was 65.6 per cent. After exclusion of those patients with cardiovascular diseases and diabetes, the final sample size was 381, consisting of 155 males and 226 females. Socioeconomic indicators were individual education level and family income. Blood pressure, blood cholesterol and blood glucose check-ups by general practitioners (GPs) were used as the major outcome variables. Nine scales and two dichotomous variables that measure those potential factors were derived following Principal Component Analysis and reliability testing. The data were analysed separately by gender, and adjusted for age and each of the socioeconomic indicators. Statistical description, bivariate analysis and multivariable modelling in SPSS were applied for the data analysis. Results: The survey results were suggestive of socioeconomically disadvantaged people being less likely than more advantaged people to utilise preventive health services for CVD and diabetes. For males, the low socioeconomic groups recorded the least use of preventive health services among the three education and income groups, including blood cholesterol and blood glucose check-ups, while the high socioeconomic group recorded the greatest use of preventive health services. There was no apparent relationship between education level and blood pressure check-up, while individuals from low-income families were less likely to go for a blood pressure check-up. For females, most of the results suggested that the low socioeconomic groups were less likely than the high socioeconomic groups to have blood cholesterol and blood glucose check-ups. However, this was not the case for blood pressure check-ups. The results showed that the low and middle socioeconomic groups were more likely than the high socioeconomic groups to have BP check-ups. However, the low socioeconomic groups were still less likely than the middle socioeconomic groups to have a blood pressure check-up. Overall, there was a similar pattern between education and income and the use of GP-based preventive health services among both males and females. The findings from the examination of the mediating factors between SEP and the GP-based use of preventive health services suggested that socioeconomically disadvantaged adults (both low level of education and low income) are more concerned about transport and travel time to health care, and accessibility to health care in terms of finding a GP who bulk bills, the cost of seeing a GP and having a choice of GP. They are also less likely to have a regular place of care and social support. These potential factors are likely to result in a lesser use of preventive health services than their high-SEP counterparts. In addition, the findings also suggested that respondents with a low level of education have less-positive attitudes towards health care, and that those from low-income families do not have a regular care provider and are less likely to visit their GP for a preventive check-up in relation to CVD and diabetes in Australia. Conclusions: Strategies for reducing socioeconomic health inequalities are partly associated with changing social and economic policies, empowering individuals, strengthening social and family networks, and improving the equity of the health care system. Strategies have been recommended for implementation in general practice that are directed at targeting the needs of disadvantaged groups; for example, providing longer consultation time and actively offering information on preventive care. Implementation of health promotion programs is needed in disadvantaged areas to keep the community informed about the availability of health services and to make health services more accessible. The health care system needs to be geographically accessible through improvements to the transport system. In addition, improving access to a regular source of primary health care is likely to be an important step in encouraging low-SEP individuals to use preventive health services.

Background: International research has shown that socioeconomically disadvantaged groups experience significantly higher mortality and morbidity rates than other groups. Both cardiovascular disease (CVD) and diabetes are major contributors to Australia's burden of disease, and individuals from lower socioeconomic groups are more likely to be affected by both, and to have worse prognoses and outcomes. There is substantial research evidence that a range of preventive activities can reduce the morbidity and mortality associated with these conditions. Research in countries with good access to primary health care services has demonstrated that socioeconomically disadvantaged groups tend to have higher levels of medical consultations, but make less use of preventive care and screening services. This fact contributes to their poorer health outcomes, as diagnosis will typically occur later than for more advantaged individuals, thus leading to a poorer prognosis. However, to date, there has been little research on the differential utilisation of preventive health services for CVD and diabetes by different socioeconomic groups in Australia. To understand socioeconomic influences on the use of preventive health services, a comprehensive review of the literature of determinants of health service utilisation was conducted and a number of explanations for this relationship considered. It was proposed that the following factors are likely to be important in this relationship: differences in the perception of the availability of, and accessibility to health care, attitudes and beliefs toward preventive health care, having a regular source of care, perception of interpersonal care from general practitioners, and social support. A number of theoretical models were also reviewed; in particular, the Andersen Behavioural Model of Health Service Research Utilisation. Aims: This doctoral research program has described the relationship between socioeconomic position (SEP) and utilisation of preventive health services in relation to CVD and diabetes. It aims to improve the understanding of the determinants of uptake and utilisation of preventive health services in general practice by different socioeconomic groups in Australia. Methods: The study was conducted in Brisbane Australia, in 2004, using a cross-sectional design and a self-administered mailed survey for data collection. A sample of adults aged 25-64 years was selected randomly from the Brisbane Electoral Roll. A conceptual model incorporating a range of relevant socio-demographic, risk-factor and behavioural variables in the relationship between SEP and GP-based use of preventive health services was used to develop a self-administered questionnaire. The questionnaire was pilot-tested and then reviewed by a panel of international experts. A new self-administered questionnaire, the Health Service Utilisation Questionnaire (HSUQ), was developed. It included 79 items: 12 socio-demographic items; 10 items assessing health status, disease conditions and smoking status; 20 items assessing use of health services; and 37 items assessing the factors that might affect use of health services utilisation. The HSUQ was then mailed to 800 randomly selected survey participants. The survey response rate was 65.6 per cent. After exclusion of those patients with cardiovascular diseases and diabetes, the final sample size was 381, consisting of 155 males and 226 females. Socioeconomic indicators were individual education level and family income. Blood pressure, blood cholesterol and blood glucose check-ups by general practitioners (GPs) were used as the major outcome variables. Nine scales and two dichotomous variables that measure those potential factors were derived following Principal Component Analysis and reliability testing. The data were analysed separately by gender, and adjusted for age and each of the socioeconomic indicators. Statistical description, bivariate analysis and multivariable modelling in SPSS were applied for the data analysis. Results: The survey results were suggestive of socioeconomically disadvantaged people being less likely than more advantaged people to utilise preventive health services for CVD and diabetes. For males, the low socioeconomic groups recorded the least use of preventive health services among the three education and income groups, including blood cholesterol and blood glucose check-ups, while the high socioeconomic group recorded the greatest use of preventive health services. There was no apparent relationship between education level and blood pressure check-up, while individuals from low-income families were less likely to go for a blood pressure check-up. For females, most of the results suggested that the low socioeconomic groups were less likely than the high socioeconomic groups to have blood cholesterol and blood glucose check-ups. However, this was not the case for blood pressure check-ups. The results showed that the low and middle socioeconomic groups were more likely than the high socioeconomic groups to have BP check-ups. However, the low socioeconomic groups were still less likely than the middle socioeconomic groups to have a blood pressure check-up. Overall, there was a similar pattern between education and income and the use of GP-based preventive health services among both males and females. The findings from the examination of the mediating factors between SEP and the GP-based use of preventive health services suggested that socioeconomically disadvantaged adults (both low level of education and low income) are more concerned about transport and travel time to health care, and accessibility to health care in terms of finding a GP who bulk bills, the cost of seeing a GP and having a choice of GP. They are also less likely to have a regular place of care and social support. These potential factors are likely to result in a lesser use of preventive health services than their high-SEP counterparts. In addition, the findings also suggested that respondents with a low level of education have less-positive attitudes towards health care, and that those from low-income families do not have a regular care provider and are less likely to visit their GP for a preventive check-up in relation to CVD and diabetes in Australia. Conclusions: Strategies for reducing socioeconomic health inequalities are partly associated with changing social and economic policies, empowering individuals, strengthening social and family networks, and improving the equity of the health care system. Strategies have been recommended for implementation in general practice that are directed at targeting the needs of disadvantaged groups; for example, providing longer consultation time and actively offering information on preventive care. Implementation of health promotion programs is needed in disadvantaged areas to keep the community informed about the availability of health services and to make health services more accessible. The health care system needs to be geographically accessible through improvements to the transport system. In addition, improving access to a regular source of primary health care is likely to be an important step in encouraging low-SEP individuals to use preventive health services.

Includes bibliographical references (leaves 149-176).
Diabetes is a growing problem worldwide. It is estimated that at least 171 million people have diabetes worldwide and this figure is projected to more than double by 2030. Mauritius has not been spared from diabetes. Indeed, it has one of the highest diabetes prevalence in the world. It is creating tremendous pressure not only on households but on the health care system.

Malawi has one of the highest maternal mortality ratio (MMR) in sub-Saharan Africa (SSA). Despite investments in family planning and emergency obstetric care (EmOC), Malawi’s Millennium Development Goal (MDG) target of reducing maternal deaths to 155 deaths per 100,000 live births was not met by the end of 2015. Between 2010 and 2015, Malawi was only able to reduce the MMR from 675 to 439 per 100,000 live births. Inadequate utilisation of perinatal services is the contributing factor to the MMR target not being achieved. One approach for improving the utilisation of perinatal services is to invest in community health workers (CHWs). CHWs can be trained to: identify women of child bearing age (WCBA) who need perinatal services; provide community education; encourage timely referral of clients to the nearest health facility; and undertake community follow up for WCBA who are pregnant and/or have recently given birth. We evaluated changes in utilisation of antenatal care (ANC), facility based births, and postnatal care (PNC) after CHW deployment to conduct monthly home visits to WCBA for pregnancy identification and escorting women to ANC, labour and facility birth and PNC clinics in Neno district, Malawi. The CHW programme was implemented in two catchment areas from March 2015 to June 2016. Methodology: We employed a retrospective quasi-experimental study design to evaluate the impact of CHWs on changes in the utilisation of ANC, facility based births, and PNC in Neno district, Malawi between March 2014 and June 2016 (pre-intervention period: March 2014 to February 2015, and post-intervention period: March 2015 to June 2016). Monthly outcomes were compared between a combined CHW intervention area and its synthetic control area using the synthetic control method. The synthetic control area (or synthetic counterfactual of the CHW) 14 was the control area that was created from multiple available control sites where the CHW programme was not implemented to allow the comparison of outcomes between the sites where CHWs were implemented and the sites where CHWs was not implemented. Two hundred and eleven CHWs (128 existing CHWs plus 83 new CHWs from the community) were trained in maternal health and deployed to cover an estimated 5,132 WCBA living in a catchment area of about 20,530 people. The primary focus of the CHWs was to conduct monthly household visits to identify pregnant women, and then escort pregnant women to their initial and subsequent ANC appointments, facility births, and to PNC check-ups. As part of package of care, community mobilisation and improvements in services to achieve a minimum package of services at the local health centres were also added. Using the synthetic control method, as developed by Abadie and Gardeazabal (2003) and Abadie, Diamond and Hainmueller (2010) and a Bayesian approach of synthetic control developed by Brodersen (2015), a synthetic counterfactual of the CHW intervention was created based on six available public control facilities. The synthetic counterfactual trend was created to have similar pre-intervention characteristics as the CHW intervention trend. The impact of the CHW intervention was the difference between the CHW intervention site and its synthetic counterfactual Results: CHWs in the intervention areas visited an average of 3,147 (range 3,036 – 3,218) of WCBA monthly, covering 61.0% of WCBA. During these visit 3.6% (97 women per month) of WCBA were suspected to be pregnant every month. Of those women suspected to be pregnant, 67.8% (66 women per month) were escorted to health facilities immediately every month. CHWs 15 visited an average of 254 pregnant women enrolled in ANC and 64 women in postpartum period monthly. ANC and facility births utilisation in the CHW intervention site increased in comparison to the control site. Firstly, the number of new pregnant women enrolled in ANC per month increased by 18.0 % (95% Credible Interval (CrI) 8.0%, 28.0%), from 83 to 98 per pregnant women. Secondly, the proportion of women starting ANC in first trimester increased by 200.0% (95% CrI 162.0%, 234.0%), from 9.5% to 29.0% per month. Thirdly, the number of women attending four or more ANC visits increased by 37.0% (95% CrI 31.0%, 43.0%), from to 28.0% to 39.0%. Lastly, the number of facility births increases by 20% (CrI 13.0%, 28.0%), from 85 women to 102 per month. However, there was no net difference on PNC visits between the CHW intervention site and its counterfactual unit (-37.0%, 95% CrI -224.0%, 170.0%). Conclusions: CHW intervention significantly increased the utilisation of ANC and facility based births in Neno, Malawi. However, CHWs had no net difference on PNC utilisation.

Master of Public Health - MPH
Background- Sexual and Reproductive Health (SRH) problems continue to affect adolescents’ health and well-being even into their adulthood. Globally and especially within sub-Saharan Africa with a heavy burden of adolescent SRH problems, increased attention is being paid to these issues. This study looks at adolescents’ awareness, utilisation of and experiences of the available SRH services in Omaruru District, Namibia. Methodology- This analytical cross-sectional study used a two-stage cluster sampling method. Data from students aged 15-19 years in secondary schools were collected and analysed using a structured self-administered questionnaire and STATA statistical software respectively. Ethical approval was obtained from the Biomedical Research and Ethics Committee (University of the Western Cape) and the Namibian Health Ministry. Written parental/caregiver informed consent and written participant assent, as per the Namibian law were obtained. Results- While 87% of respondents had heard of SRH, 46% had ever used SRH services. Of these 44% were contraceptive services. Fifty-one percent had ever had sex (of which 17% had given birth to or fathered their first child), 56% of their first sexual experiences were between ages 15-17 years. Twelve percent had used illegal drugs three months prior to the survey. In multivariate analyses female sex, urban residence and reported sexual debut had significant independent relationships with contraception use. Use of SRH services was independently significantly associated with having had sexual debut. Among SRH services users: 71% would recommend these services to their friends, 51% and 56% found health providers welcoming, with good attitudes, and guaranteeing their privacy and confidentiality. Conclusion Greater effort is needed to curb teenage pregnancy in school-going adolescents by promoting the use of all SRH services especially contraception among sexually active adolescents. It is encouraging that respondents who had used SRH service reported that their privacy and, confidentiality were respected and that healthcare providers’ attitudes generally satisfactory. Lower SRH knowledge, service use and use of contraception and condoms needs further investigation in rural youth and then programmatic and service changes tailored to their needs. Gender norms that underpin adolescent females disadvantage in a number of SRH areas needs to be addressed

A total of 425 questionnaire-based interviews and 15 in-depth interviews with FSWs in Nepal including non-participant observation in the field were conducted in 2006. The age range of the FSWs participated was 15-46 years.  FSWs (30.8%) reported having had STI symptoms in presences 12 month.  The quantitative findings suggested that many reported having used condoms during their last sexual intercourse, but in-depth interviews suggested the opposite.  One fifth (21%) had never visited health facilities.  Of those who visited, 149 (50.3%) turned to a private clinic and pharmacy; 181 (61.1%) used Non-Governmental Organisation (NGO) clinics, 79 (26.6%) resorted to care in hospital and 30 (10.1%) treated themselves.  The remainder 85 (28.7%) were found to seek help from primary health care centre, health posts, family planning clinic or other health institutions for treatment.  The behaviour theories and models used in this study (i.e. health belief model, theory of reasoned action and planned behaviour) partly explain the decisions of FSW on use and non-use of available health services.  The study identified that lack of confidentiality and privacy created distrust among FSWs and stopped them from accessing health services.  Embarrassment, disregard by health care providers and poor communication with them, long waiting time and fear of exposure as a sex worker were major barriers to seeking health services. It is therefore necessary to provide specific training to service providers in all types of health care institutions in order to promote confidential and quality health services.

Objectives: To contribute to the U.K. research literature on psychological morbidity and helpseeking in farmers, and to explore factors involved in their use of mental health care, using the constructs of alexithymia and somatisation.;Design: A within-subjects survey design employing retrospective self-report was utilised to examine relationships between alexithymia, somatisation, health care utilisation and helpseeking attitudes. Method: A total of 54 male owner/tenant farmers between 18 and 65 years were recruited via the National Farmers' Union and Young Farmers Clubs. Participants completed the Hospital Anxiety and Depression Scale, Toronto Alexithymia Scale, Use of Healthcare questionnaire, Farming Life questionnaire, Medical Problems and Complaints questionnaire and the Helpseeking questionnaire. Data was analysed using chi-square, correlations, and multiple regression.;Results: The sample demonstrated elevated levels of psychological morbidity compared to normative samples. Participants were not found to be significantly alexithymic, and no associations were found between alexithymia and health care utilisation. Farmers were no more likely to seek help from family members than external sources, and their reported reasons for helpseeking delay/avoidance were not associated without he use of G.P or outpatient psychotherapy. No significant predictors were found for G.P. utilisation, but isolation was found to be a significant predictor of psychological morbidity.;Conclusions: Participants' high levels of psychological morbidity corroborate previous findings in the U.S. and U.K. Other findings are discordant with existing research, posing more questions regarding farmers' use of rural primary healthcare and helpseeking behaviour. More research is required to examine systemic factors in healthcare use and to explain the relationship between alexithymia and somatisation, using more robust measures of somatisation. Recommendations are put forward to broaden future study to incorporate systemic factors within rural primary care.

The Kingdom of Saudi Arabia (KSA) faces an increasing chronic disease burden. Despite the increase in numbers of primary health care centres (PHCCs) current evidence from the KSA, which is limited overall, suggests that access and utilisation of PHCCs, which are key to providing early intervention services, remain unequal with its rural populations having the poorest access and utilisation of PHCCs and health outcomes. There is a dearth (lack) of information from the KSA on the barriers and facilitators affecting access and utilisation of primary health care services (PHCS) and therefore this study aimed to examine the factors influencing the access and utilisation of primary health care centre (PHCC) in urban and rural areas of Riyadh province of the KSA. The behavioural model of health services use (Andersen’s model) provided the contextual and individual characteristics and predisposing, enabling and need factors which assist with an understanding of the barriers and facilitators to access and utilisation of PHCCs in Riyadh province. A mixed methods approach was used to answer the research questions and meet the objectives of the study. The converged qualitative and quantitative findings show that there are a number of predisposing (socio-demographic characteristics; language and communication and cultural competency) enabling barriers such as; distance from PHCCs to the rural residence, lack of services, new services, staff shortages, lack of training, PHC infrastructure, and poor equipment. Facilitators: service provider behaviour/communication, free PHCS, service provision and improvements, primary health care (PHC) infrastructure, manpower, opening hours, waiting time, and segregated spaces and need (increasing prevalence of chronic diseases, PHC developments in the KSA) factors influencing access and utilisation of PHCS. This study highlights important new knowledge on the barriers and facilitators to access and utilisation of PHCS in Riyadh province in the KSA. The findings have some important policy and planning implications for the MOH in the KSA. Specifically, the findings suggest: the need for clear documentation/guidance on minimum standards against which the PHCS can be measured; an audit of service availability at the PHCCs, regular patient satisfaction evaluations of PHCS, that the MOH take a parallel approach and continue to resource and improve buildings and equipment in existing PHCCs, the recruiting of more GPs, nurses, pharmacists, nutritionists and physiotherapists to meet patient demand and more Saudi health care staff, more targeted health education and interventions for the prevention of chronic diseases in the KSA and the need for an appointment system for attending the PHCCs. There is a need for further research into the barriers and enablers to accessing and utilising health care in Riyadh and the KSA overall. This research would be made easier with a clearer definition of rural and urban in the KSA context which would allow a greater comparability between urban and rural PHCS for future research, audit and evaluation as well as comparison with PHCS in other parts of the world. The Andersen model provided a useful conceptual model to frame this research and provided a structure for contrasting and comparing the findings with other studies that have used the Andersen model to understand the barriers and enablers to accessing and utilising health care services.

Cette thèse de doctorat est composée de trois chapitres distincts et indépendants qui ont pour objectif d’analyser certaines politiques de santé au Québec notamment les incitatifs financiers, les délais d’attente et les soins à domicile sur la santé des patients et l’utilisation de services hospitaliers. Le premier chapitre porte sur l’impact des incitatifs financiers sur la santé des patients, spécialement le cas des soins spécialisés. Il faut noter de prime abord que la demande de soins de santé a beaucoup augmenté au Québec ces dernières années pour certains types de chirurgies. Cette augmentation, dont les causes sont multiples notamment les changements démographiques, a entraîné des temps d’attente plus élevés que les temps médicalement requis pour ces chirurgies. Pour résorber ce problème, le gouvernement québécois a mis en place en 2004 le Programme d’Accès à la Chirurgie (PAC), afin d’inciter financièrement les hôpitaux à pratiquer plus de chirurgies pour lesquelles les délais d’attente étaient plus importants. Ce programme a permis de diminuer la durée moyenne d’attente pour ces chirurgies, mais a aussi entraîné une augmentation des dépenses liées à ces chirurgies. Ces dépenses accrues étaient également dûes à certaines lacunes du programme. Une réforme majeure, qui consistait essentiellement à la modification des incitatifs financiers, a eu lieu en avril 2011, afin que le financement vienne appuyer la bonne pratique et le choix du plateau technique le plus adéquat. Notre étude, constituant une première évaluation de cette réforme, a pour but d’analyser l’impact de cette réforme sur la santé des patients, notamment les durées de séjour à l’hôpital après l’opération chirurgicale et les réadmissions après la sortie de l’hôpital. Notre application porte sur les chirurgies thoraciques et cardiovasculaires. Les résultats montrent une diminution significative des durées de séjour après l’introduction de la réforme et un impact non significatif sur les réadmissions urgentes. Dans le premier chapitre, les différentes politiques mises en places ont été initialement motivées par des délais d’attente excessifs. Pourtant, peu d’études ont analysé les impacts des délais d’attente sur la santé des patients au Québec. Tel est l’objectif du deuxième chapitre de la thèse, analyser si un délai d’attente élevé est associé à un risque de détérioration de la santé des patients. Nous utilisons des modèles empiriques pour analyser cette problématique. Nous introduisons le différentiel de distance du domicile du patient à l’hôpital le plus proche relativement à l’hôpital le plus proche parmi les hôpitaux avec de faibles délais d’attente comme variable instrumentale pour tenir compte de l’endogénéité potentielle des temps d’attente. Dans ce chapitre, nous analysons les variables de santé en termes de probabilité de réadmission urgente et de durée de séjour excédentaire (durée de séjour supplémentaire après la durée de séjour maximal recommandée). Les résultats montrent que les longs temps d’attente augmentent la probabilité d’être réadmis en urgence pour les patients qui ont eu une chirurgie de l’arthrose du genou, une chirurgie thoracique ou cardiovasculaire, une neurochirurgie, ou une chirurgie pour une tumeur de l’utérus. Il n’y a pas d’effet significatif des temps d’attente sur la probabilité de réadmission pour les chirurgies de l’arthrose de la hanche et des tumeurs de la prostate. Les longs temps d’attente augmentent également la durée de séjour à l’hôpital et les coûts d’hospitalisation après une chirurgie de l’arthrose du genou ou de la hanche. Le vieillissement de la population québécoise entraîne plusieurs enjeux cruciaux pour les services de soins de santé notamment les soins à domicile pour les personnes âgées (OIIQ, 2017). Les soins à domicile sont composés de tous les soins de santé que les établissements publics ou privés offrent aux individus à leur domicile. Ces services sont souhaitables pour toute personne qui a besoin de soins pour maladies chroniques, de soins palliatifs, de soins de réadaptation, de soins de fin de vie, ou des soins pour perte d’autonomie liée au vieillissement. Les soins à domicile pourraient constituer une alternative sécuritaire, à moindres coûts, aux soins de santé dans les hôpitaux. Les soins à domicile contribuent donc au maintien à domicile des personnes en offrant des services paramédicaux des infirmières, des aide-soignantes, coordonnés avec ceux des autres intervenants à domicile comme les kinésithérapeutes, les aides-ménagères, les auxiliaires de vie. Nous analysons dans le troisième iv chapitre, dans quelles mesures les services hospitaliers et les soins à domicile pour les personnes âgées sont substituables. Nous analysons également l’impact des soins à domicile sur l’admission dans les centres d’hébergement de soins de longue durée (CHSLD). Notre analyse montre que l’augmentation des soins à domicile pour les personnes âgées réduit la probabilité d’admission et la durée de séjour en urgence. L’effet des soins à domicile est plus prononcé chez les personnes âgées avec des pertes d’autonomie plus légères. Les résultats montrent également qu’une augmentation des soins à domicile réduit la probabilité d’être admis en CHSLD.
This doctoral thesis is composed of three separate and independent chapters that aim to analyze certain health policies in Quebec, including financial incentives, waiting times and home care on patients’ health and the use of hospital services. The first chapter focuses on the impact of financial incentives on the health of patients in Quebec, especially the case of specialized care. It should be noted, first of all, that the demand for health care has increased significantly in Quebec in recent years for certain types of surgery. This increase, which has many causes, including demographic changes, resulted in higher waiting times than the medically required times for these surgeries. To solve this problem, the Quebec government implemented in 2004 the Access to Surgery Program (ASP) to financially encourage hospitals to perform more surgeries for which waiting times were longer. This program allowed to reduce the average waiting time for these surgeries, but has also led to an increase in expenses related to these surgeries. These increased expenditures were also due to some weaknesses in the program. A major reform, which consisted mainly of modifying the financial incentives, took place in April 2011, so that the funding would support good practice and the choice of the most appropriate technical platform. Our study, which is a first evaluation of this reform, aims to analyze the impact of this reform on the health of patients, including the length of stay in hospital after surgery and readmissions post-discharge. The results show a significant decrease in length of stay after the introduction of the reform and a non-significant impact on urgent readmissions post-discharge within 30 days. In the first chapter, the various policies were initially motivated by excessive waiting times. Yet, few studies have analyzed the impact of wait times on patient health in Quebec. This vi is the purpose of the second chapter, to analyze whether a high waiting time is associated with a risk of deterioration of the patients’ health. We use empirical models to analyze this problem. We introduce the differential distance from the patients’ home to the nearest hospital relative to the nearest hospital among hospitals with low wait times as an instrumental variable to account for the potential endogeneity of the waiting time. In this chapter, we analyze health variables in terms of the probability of urgent readmission post-discharge within 30 days and excess length of stay (additional length of stay after the maximum recommended length of stay). The results show that long waiting times increase the likelihood of emergency readmissions for patients who had a knee surgery, a thoracic or cardiovascular surgery, a neurosurgery or a surgery for a tumor of the uterus. There is no significant effect of waiting times on the probability of readmission for hip and prostate surgeries. Long waiting times also increase the hospital length of stay and costs of hospitalization for knee and hip surgeries. The aging of the Quebec population is leading to many crucial issues for health care services, particularly home care for the elderly (OIIQ, 2017). Home care is composed of all health care that public or private institutions provide to individuals in their homes. These services are desirable for anyone who needs care for chronic illnesses, palliative care, rehabilitation care, end-of-life care, or care for loss of autonomy linked to aging. Home care could be a safe, low-cost alternative to health care in hospital. Home care, thus contributes to people to stay at home and receive paramedical services from nurses and care assistants, coordinated with those received from other home care providers such as physiotherapists, housekeepers and carers. In the third chapter, we analyze the extent to which hospital services and home care for the elderly are substitutes. We also analyze the impact of home care on admission to long-term care facilities (LTCFs). Our analysis shows that increased home care for the elderly reduces the probability of admission and the length of stay in emergency. The effect of home care is greater for seniors with less disabilities. The results also show that an increase in home care reduces the probability of being admitted to LTCFs.

Doctor of philosophy (PhD)
Abstract As one of the most culturally diverse countries in the world, Australia has a high proportion of minority communities. However, its ageing population, particularly within these ethnic minorities, faces a range of barriers or difficulties in gaining access to and using health and aged care services. This study aims to identify the acculturation factors that affect the health status of Iranian-born elderly immigrants to Australia and their utilisation of health and community aged care services. The results of this study will be of value to Iranian elders, their families, and Australian aged health care service providers. The findings could also contribute towards enriched multicultural policy and improved social fairness, access to services, and equity for the aged from different ethnic backgrounds. 302 Iranian migrants aged 65 years who had lived in the Sydney Metropolitan area for at least six months were surveyed via a written questionnaire, face-to-face interviews, and telephone interviews. The results were analysed using SPSS and then compared to the findings from a 1999 survey of NSW elderly. The results indicate that Iranian migrants suffer higher levels of psychological distress and are more limited in their physical functioning than the general population of older Australians. They are in greater need of assistance with activities of daily living, have a lower sense of wellbeing, and are far less likely to utilise aged care services. Iranian migrant who do not speak English at home experience these disadvantages to an even greater extent English language proficiency was the only acculturation factor found to affect whether Iranian elderly utilised health and community aged care services, while ability to engage in activities of daily living (ADL) was the only health variable associated with their utilisation of community supportive aged care services. This variable did not predict the use of community aged care services in the broader sample of NSW respondents. Since limited proficiency in English placed elderly Iranian migrants at greater health risk and impeded their access to necessary assistance, the findings suggest that they would clearly benefit from English classes and from access to health and community care services and information regarding these services in the Farsi language.