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Background: The Affordable Care Act (ACA) aimed to enhance access to health care in the United States, particularly for those without comprehensive insurance. This thesis examines the impacts of the ACA on equity of access by investigating its effect on Federally Qualified Health Centers (FQHCs). FQHCs provide essential primary care to low-income people. Their experiences of providing primary care during the period of the ACA's implementation can provide valuable information about the challenges of addressing inequities of access in the context of a dual insurance market. Aim: To examine the ACA's impact on the ability of FQHCs in Arizona, California, and Texas to provide essential primary care to people with limited health care access. Methods: Using a case study approach, the thesis draws on two data sources to contextualize and explore how the ACA was perceived to impact on FQHCs in Arizona, California, and Texas, and how senior FQHC staff responded to these impacts. Data from Uniform Data System (UDS) were analyzed to ascertain trends in overall population insurance coverage and in FQHCs' patient coverage, provided services, and funding sources in Arizona, California, and Texas from 2008 to 2015. The main body of the research focused on administrators' experiences of the ACA's impact on FQHCs and their ability to meet the needs of their patients. This was explored via 23 interviews with executive directors and mid-level managers from 10 FQHCs in the three states, which took place between July and September 2015. Results: Impact on FQHCs: FQHCs in Arizona and California experienced an increase in the proportion of their patients covered by Medicaid following implementation of the ACA. Interviews confirmed that Medicaid expansion in Arizona and California enabled many uninsured patients to obtain coverage and access to care, with FQHCs experiencing increases in demand and revenue. In contrast, FQHC administrators in Texas believed the ACA had minimal impact on both patient coverage and revenues, as the state had not expanded Medicaid. FQHCs in Texas experienced a minimal increase in the proportion of patients with insurance coverage, with most newly insured patients gaining coverage via the private market. UDS data from 2008-2015 showed that FQHCs in all three states experienced an increase in real income from federal grants under the ACA. Response of FQHCs: The majority of key informants in Arizona and California stated the ACA had enhanced their ability to serve their patients, primarily due to increased revenue from Medicaid which enabled FQHCs to increase their capacity and better respond to the needs of their patients. In contrast, there was no consensus among administrators in Texas regarding the impact of the ACA on their ability to serve their patients. The absence of Medicaid expansion and weaknesses of private insurance meant patients in Texas faced particular difficulty in accessing care due to high deductibles, the limited depth of coverage and a small pool of willing providers. Discussion and conclusions: The experience of FQHC administrators provides a valuable lens through which to evaluate the effectiveness of the ACA in terms of one of its core objectives: addressing inequities of health care coverage and access in the U.S. After the legislation took effect, FQHCs in Arizona and California experienced considerable improvements in their ability to meet patient needs, especially due to the expansion of Medicaid in these states. In contrast, FQHCs in Texas did not experience a notable improvement in their ability to serve their patients. The FQHCs in all three states continued to face challenges in securing their patients' access to specialist health services. The findings of this thesis highlight the scale of challenge faced by policymakers that seek to expand health care access within a context of mixed public/private insurance. While the ACA aimed to improve health care access by expanding coverage, its ability to do so was compromised by: i) regulatory barriers to the expansion of public health insurance (a legal challenge and Supreme Court ruling meant half of all US states opted out of Medicaid expansion); ii) limitations in coverage and access associated with private health insurance; and iii) reluctance on the part of some healthcare providers to accept patients with public or more limited private insurance.

Counselors are called to address barriers to human growth and development through advocacy (ACA, 2014), such as those posed by inequitable health care access for socially disadvantaged groups (CDC, 2013; IOM, 2011). Health care contributes to positive health outcomes (Healthy People 2020) and is therefore an important component of advancing health equity among marginalized populations, such as older sexual minority women (SMW) with disabilities. Despite evidence of disparate health care access and health outcomes, no research to date has explored the health needs or health care experiences of disabled older SMW. This study therefore sought to address this gap in the literature by: identifying current levels of health care access and barriers among older SMW with disabilities; exploring predictors of health care access among older SMW with disabilities; and identifying protective factors, such as social support and resilience, that moderate the relationship between health care access barriers and health outcomes. Results obtained from a sample of 208 respondents provided baseline data about health care access and barriers among older SMW with disabilities. Generally, respondents had a place to receive health care, but few had access LGBTQIA+-specific health services despite indicating that this type of health care was important to them. Only about half had accessed mental health services in the last six months, and people who had accessed mental health care perceived it to be easier to access than people who had not. Respondents most highly endorsed external barriers related to cost of health care, and they reported higher health care stereotype threat related to age and disability compared to gender and sexuality. External barriers to health care were predictive of most health care access indicators (e.g., utilization of general and specific health services, as well as health outcomes). Among internal barriers, sexuality- and disability-related health care stereotype threat emerged as predictors of health care access and health outcomes respectively. Similarly, acceptability of health services, accessibility of health services, and affordability of health services were specific external barrier categories that appeared to influence health care access and outcomes among older SMW with disabilities. Neither resilience nor social support moderated the relationship of external access barriers to physical or mental health outcomes. However, resilience had a significant independent relationship with physical health outcomes, and both resilience and social support had significant independent relationships with mental health outcomes. These findings illustrate the structural factors related to health care access and outcomes for older SMW with disabilities, as posited by health equity frameworks (Braveman, 2014). The most influential internal barriers related to health care stereotype threat, which may develop in response to minority stressors specific to health care settings. The findings of this study support lifespan perspectives on LGBTQIA+ health (Fredriksen-Goldsen, Simoni et al., 2014), as well as minority stress processes (Meyer, 2003), as frameworks for understanding LGBTQIA+ health in later life. Implications for counselors, counselor educators, community organizations, and policies are discussed.

This study aimed to understand subjective cognitive decline (SCD) and functional difficulties in older age cohorts with depressive symptoms, using one scoping review and two empirical studies. We implemented the six steps of Arksey and O'Malley's procedure for the scoping review. We used the population, concept, and context (PCC) inclusion and exclusion criteria in the literature search across MEDLINE via Ebscohost, PubMed, and PsycINFO for articles published on ADL/IADL indicators of SCD in older adults with depressive symptoms and that published in English language journals from January 2011 to November 2021. The two empirical studies used the 2019 wave of the Behavioral Risk Factor Surveillance Survey dataset of older adults aged 65 and ≥ 80 from the Centers for Disease Control and Prevention. We used multiple regression and the bias-corrected percentile bootstrap with 5000 samples using standard path-analytic approaches for the moderated mediation for the two empirical studies. Findings supported that instrumental activities of daily living (IADLs) presented more difficulties for older adults with SCD than the basic activities of daily living (B-ADLs), given that IADLs require more cognitive capabilities than B-ADLs. Environmental factors like healthcare access and subjective functional difficulties predicted SCD by mentally unhealthy day (MUD) mediation and age cohort moderation. The middle age cohort (70–74) had the most pronounced effects of the MUDs mediation in the relationship between healthcare access and IADLs in older adults with SCD. The younger-old (65–69) showed more substantial MUD mediation effects in the relationship between subjective functional difficulties and SCD. Worse SCD was associated with being Asians, female older adults, and at lower education years and income levels. Findings profiled SCD indicators in daily living activities across age cohorts and the mentally unhealthy days presentation. We extend the chronic stress theory predictions on accentuated emotional vulnerability from increased functional difficulties, compounding SCD.

Chronic liver disease is increasingly prevalent with high rates of morbidity and mortality, yet it receives less attention than other similar chronic diseases such as cardiovascular disease and chronic obstructive pulmonary disease. Barriers to timely medical care may preclude diagnosis and management and thus, exacerbate potentially avoidable morbidity and mortality for persons with chronic liver disease. This dissertation explored the extent of health care barriers among adults with chronic liver disease compared to other chronic conditions and identified latent classes derived from different health care barriers to phenotype those at highest risk for recurrent acute care use within the adult population with chronic liver disease in the United States.The first paper, “Evaluation of the Extent of Health Care Barriers among Adults with Chronic Liver Disease vs. Other Chronic Diseases in the United States,” compared estimates of any and the number of health care barriers and the association of recurrent acute care use by prevalence of barriers to care among adults with chronic liver disease versus those with cardiovascular disease and/or chronic obstructive pulmonary disease. Using a multivariable hurdle model, the study found that adults with chronic liver disease were significantly more likely to have any barriers to care (incident rate ratio, 1.12), but such a significant difference did not exist for the frequency of health care barriers. There was a dose-dependent relationship between likelihood of recurrent acute care use and prevalence of barriers to care. Inclusion of chronic liver disease as a high-risk group in future health policies that aim to improve access to care may help reduce challenges that persons with chronic liver disease encounter when seeking timely medical care and potentially reduce preventable acute care use.The second paper, “Identification of Hidden Phenotypes Using Self-Reported Barriers to Care to Predict Risk of Recurrent Hospitalization or Emergency Department Visits among Adults with Chronic Liver Disease in the United States,” identified latent classes within the adult population with chronic liver disease using self-reported barriers to care and assessed each phenotype’s likelihood of recurrent acute care use. The best fitting model to the data included four latent classes or phenotypes: minimal barriers, unaffordability, care delays, and inability to establish care. The study used a multivariable multinomial logistic regression model to identify likelihood of class membership. The unaffordability phenotype was significantly associated with younger age, fair or poor health, functional limitation due to health, and uninsurance. Membership in the care delays class was significantly associated with Hispanics, fair or poor health, and functional limitation due to health. The inability to establish care phenotype was significantly associated with younger age, female sex, functional limitation due to health, and non-private insurance. The inability to establish care group had the highest odds of recurrent acute care use, followed by the care delays and unaffordability groups. An emphasis on risk stratification using health care barriers can potentially help improve interventions that aim to reduce recurrent acute care use among adults with chronic liver disease, particularly for those who struggle to establish care.In summary, both chapters highlighted the prevalence of health care barriers and its association with recurrent acute care use for adults with chronic liver disease. Findings from the second chapter showed the consistent disparity in health care barriers for adults with chronic liver disease versus other chronic diseases and aimed to capture the attention of health policy makers to include chronic liver disease in future iterations of existing health policies or new programs that strive to improve outpatient care access to reduce preventable hospitalizations. The third chapter identified novel phenotypes of persons with chronic liver disease with different associated sociodemographic, health, and insurance characteristics and risks of recurrent acute care use. The third chapter also introduced the concept of using self-reported barriers to care as a way to risk stratify and allocate resources to the most vulnerable individuals with chronic liver disease. Both chapters intend to help improve health care access, reduce preventable acute care use, and potentially improve the morbidity and mortality trends among adults with chronic liver disease in the United States.

Background. Cigarette smoking continues to be a major cause of illness, disability, and death and a significant burden in the health care system of the United States. Yet, gaps remain in our understanding of health care access and use related to smoking. Guided by comprehensive health services frameworks and recent data, this research explored smoking-related disparities in health care access and utilization among adults. We used large statewide surveys conducted in Ohio to (1) assess trends in health care access measures among low-income adults by smoking status following Ohio’s Medicaid expansion and (2) describe factors associated with overuse of emergency departments (EDs) and underuse of preventive care among adult smokers. Using a related follow-up panel survey, we (3) examined the relationship between smoking and COVID19-related health care use and testing during the early months of the COVID-19 pandemic in Ohio.Methods. We assessed trends in five health care access measures by smoking status covering the pre- (i.e., 2012) and post-Medicaid expansion (i.e., 2015 to 2019) periods in Ohio using survey-weighted multivariable logistic regression. We carried out the analysis in ten multiply imputed datasets to handle missing data. We built multivariable descriptive models for factors associated with ED overuse and preventive care underuse in ten multiply imputed datasets accounting for potential contextual determinants of care. We examined the association between smoking and COVID-19-related health care use and COVID-19 testing using survey-weighted multivariable logistic regression models.Results. Compared to the pre-expansion period, we found improvements in unmet dental care needs, unmet medical exam or supply needs, and the ability to pay medical bills among smokers. However, we did not find an improvement in having a usual source of care (USC) or unmet mental care needs. We also found that progress in access measures among smokers is not as notable as that of non-smokers. ED overuse was related to poorer self-rated health, low income, Medicaid insurance or uninsurance, mental distress, and chronic health conditions. Underuse of preventive care was associated with lack of a USC, uninsurance, low income, and being unmarried or male. We found that current smokers, compared to never smokers, were more likely to seek both virtual and in-person care for COVID-19-related concerns during the early months of the pandemic, although differences in COVID-19 testing were short-lived.Conclusion. This research improved the existing knowledge of health care disparities by characterizing access measures and determinants of use among smokers. The study's findings could be leveraged to support policies and interventions to further reduce unmet care needs, improve preventive care use, and lower avoidable health care spending attributed to smoking. The research will also serve as an input for future research examining the long-term impact of the COVID-19 pandemic on health care access and use among smokers.

Background: Lung cancer remains the leading cause of death from cancer within Ohio. Early detection is one of the most effective approaches to reducing mortality among those at greatest risk of lung cancer. Screening through low-dose computed tomography (LDCT) has relatively recently been demonstrated as an effective means of reducing mortality due to lung cancer. Lung cancer does not impact Ohioans at the same rate across the state. Barriers to access of both LDCT screening for lung cancer, as well as equal access to care, may not be available for those in need of these services in Ohio. Thus, regional variations in access to both screening and care may lead to differences in lung cancer outcomes, including stage at diagnosis, survival time, and mortality.Methods: Data from the Ohio Cancer Incidence Surveillance System (OCISS), the state’s cancer registry, were analyzed using identified lung cancer cases from 2000-2016. Age-adjusted incidence rates were calculated for all lung cancer cases by histologic subtype across the four Ohio Medicaid Assessment Survey (OMAS) county types. Rates were stratified by sex and race/ethnicity. Models for the odds of diagnosis of lung cancer at an early (local) stage were then fit using multilevel generalized linear models with random effects for both the ZIP code tabulation area (ZCTA) and county of residence at the time of screening in order to account for clustering. Our exposures of interest were travel distance (in miles) and travel time (in minutes) to the nearest site of care for lung cancer, travel distance, and travel time to the nearest potential site of lung cancer screening using LDCT, and OMAS county type of residence at diagnosis. The average travel distance and average travel time by county type was also compared. Finally, survival analyses were conducted to identify differences in survival outcomes by county type through the use of both Cox proportional hazards with robust standard errors accounting for clustering at the county level and Fine and Gray competing risk regression models.Results: Rates of lung cancer, continue to be highest among counties in Ohio where smoking rates have historically been highest (rural Appalachia). The incidence of pulmonary adenocarcinomas increased for all subgroups between 2000-2016, particularly among females; whereas rates of large cell carcinomas declined. Rates of small cell and squamous cell lung cancers remained relatively stable. Rates were higher among males for most histologies, and particularly among Black/African American males in metropolitan counties. Residents of rural Appalachian counties on average had the furthest to travel and the longest commute to access sites of screening and sites of care for lung cancer. The odds of being diagnosed earlier with lung cancer was higher in rural Appalachian counties relative to metropolitan counties. Travel distance and travel time to a site of care were generally not found to have a significant association with the odds of being diagnosed with lung cancer at an earlier stage after adjusting for other factors. Finally, no appreciable differences were found in survival time across the four county types. A slight association was found between increased travel distance and increased travel time to sites of care and the hazard of death from lung cancer using Cox proportional hazards models. However, this association was not present when using Fine and Gray models to account for competing risks of death from another cause.Conclusions: Overall rates of lung cancer within the state have leveled off or are in decline across most histologic types with the exception of adenocarcinoma, which aligns with trends observed in other, more broad studies. No associations were present between either travel distance or travel time and the stage age diagnosis of lung cancer. Residence in a rural Appalachain county type at the time of diagnosis did increase the odds of being diagnosed with lung cancer at an early stage. When modeling the association between survival and our exposures of interest using Cox proportional hazards models, there was an increase in the hazard of death from lung and bronchus cancer for those further from sites of care. This association was not present when modelling using Fine and Gray competing risk regressions. Future research should evaluate the impact of travel to a primary care provider on screening behavior, as well as provider knowledge, attitudes, and beliefs surrounding lung cancer screening across different regions of the state.

This dissertation presents three empirical papers investigating how disruptions in Medicaid coverage affect enrollees. Medicaid is unique among public insurance programs in the United States because eligibility is means tested and, in most states, enrollment in private managed care plans is mandatory. Medicaid enrollees are low-income adults, children, and seniors, as well as people with disabilities, and these populations often face barriers to navigating the complexities of Medicaid enrollment, eligibility, and managed care. Changes in personal circumstance or state and federal policies can lead Medicaid enrollees to experience unanticipated changes to their health insurance coverage. Most Medicaid enrollees receive coverage through publicly financed, privately administered Medicaid managed care plans. States contract with Medicaid managed care organizations and offer most enrollees a choice of several plans. The high dollar amount of managed care contracts has led most states to select Medicaid plans using competitive bidding. When states conduct competitive bidding to select which plans to offer, enrollees may be forced to change managed care organizations if their plan's contract is not renewed. There is a sizable literature about plan switching in private insurance, but this type of disruption has not been extensively studied in Medicaid. Chapter 1 investigates how being forced to switch Medicaid managed care plans affects health care use and continuity of care for Medicaid enrollees. In 2016, Minnesota's state government used competitive bidding to contract with a new set of Medicaid managed care organizations. More than half of enrollees in the state were forced to change plans as a result of the bidding. I use data from the Minnesota All Payer Claims Database to show that enrollees who were forced to switch plans used fewer health care services after enrolling in their new plan. Plan switching also led to increased new provider visits, which is a sign of disrupted continuity of care. The effects on health care use were large, representing 30 percent reductions across a wide range of health care services, but were concentrated among enrollees who joined a specific managed care organization. These findings suggest that while states may be able to leverage competition between managed care plans to generate financial savings, being forced to switch insurers can be disruptive for Medicaid enrollees. Disenrollment from Medicaid is a second type of disruption. Some people lose Medicaid benefits because changes in their income or circumstances make them ineligible for the program, but others are disenrolled despite remaining eligible. This can occur when enrollees do not complete the necessary steps to renew or re-certify their Medicaid eligibility. Many people who are disenrolled later return to Medicaid. Losing Medicaid may result in uninsurance, even if benefits are restored in subsequent months. Transitioning in and out of Medicaid coverage may make it difficult for some people to receive regular medical care. Chapter 2 uses ten years of Medicaid enrollment data to measure the frequency of disenrollment and coverage disruption in Minnesota. I estimate the rate at which individuals disenroll from Medicaid, the share of disenrollments that result in uninsurance, and the share of enrollees who disenroll but return to the program within twelve months, which is called churn. I use medical and pharmacy claims data to show that the adults and children who experience disruptions in coverage are a lower spending population and leverage a unique feature of the Minnesota All Payer Claims Database to show that most enrollees do not have private insurance coverage during periods outside of Medicaid. This chapter demonstrates the role that All Payer Claims Databases can play in understanding coverage transitions in the fractured American health insurance system. I discuss state and federal policies that can help streamline Medicaid renewal and enrollment, with the goal of improving retention in the program and reducing the frequency of churn. Chapter 3 expands on Chapter 2 by examining how health care spending and use patterns differ between Medicaid enrollees who churn. I show that re-enrollment is highly correlated with short-term increases in medical spending and health care use and that enrollees who churn back into Medicaid coverage have higher spending throughout the re-enrollment period. This is the first paper to use administrative data to estimate the association between Medicaid churn and spending among non-elderly adults and shows how Medicaid enrollment policies like retroactive eligibility interact with disenrollment and churn.

Study OnePurpose: Latina women face various health disparities and social determinants of health based off their ethnicity, age, sex, and socioeconomic profile. A sample of Latina women between the ages 40 and 65 years old from the 2020 Behavioral Risk Factor Surveillance System (BRFSS) by the Centers for Disease Control and Prevention (CDC) was assessed to measure health status, health care access, and preventive health seeking behaviors (PHSBs). Methods: Secondary data analysis of BRFSS, a system of health-related telephone surveys was conducted with 19 variables. Results: The final sample size was N = 8,621. For questionnaire language 4,714 completed the questionnaire in English and 3,907 in Spanish. Results showed that 74.2% (n = 6,383) rated their health as being good or better. Regarding PHSBs majority of the participants received a mammography exam, a colonoscopy, had a routine check-up and dental visit. As for health care access most reported having health care coverage through an employer or union however, 18.3% (n = 1,569) of participants could not see a doctor because of cost within the past 12 months. Pearson Chi-square revealed statistical associations in reported PHSBs, health status, and health care access factors by demographics and questionnaire language. ANOVA testing revealed statistical significance in total number of PHSBs by demographic characteristics. Those who had reported poor health care access factors had lower mean scores for total PHSBs. Conclusion: Low educational attainment, low income, and lack of insurance are contributing factors for Latinas in receiving the recommended care to enhance their health status and quality of life.Study TwoPurpose: Health disparities around sexually transmitted diseases, cervical cancer, and diabetes are prevalent for Latina women. These health disparities can also exist in association with engaging in health risk behaviors. A sample of Latina women between the ages 18 and 40 years old from the 2020 BRFSS was assessed to measure PHSBs, health risk behaviors (HRBs) and health status. Methods: BRFSS telephone survey data was used to conduct a secondary data analysis with 22 variables. Results: The final sample size was N = 8,635. Among respondents a total of 5,654 completed the questionnaire in English and 2,981 in Spanish. Results showed that 89.1% (n = 7,689) rated their health as being good or better. Most participants reported receiving a Pap test, HPV test, routine check-up, and dental visit. However, a small portion reported ever having an HPV vaccine (36.8%, n = 262). Regarding HRBs, respondents did engage in e-cigarette use, smoking, marijuana use, drinking, and no physical activity and those who did engage in HRBs were less likely to engage in some PHSBs. Pearson Chi-square revealed statistical association in reported PHSBs and health status by demographic characteristics and questionnaire language. ANOVA testing revealed statistical significance in total number of PHSBs by demographics, however there were no differences in the total number of HRBs by demographics. Conclusion: Results showed that those who made less than $25,000, who did not graduate from high school or were current students were not engaging in preventive care.

Using data from the 2018 National Health Interview Survey (NHIS), this study examined racial group differences in health care access, including measures for usual place of sick or preventative care and delayed or forgone care and the mechanisms that explain those differences. This study integrated the Fundamental Cause Theory and Anderson’s Behavioral model to understand the causal mechanism responsible for racial disparities in health care access. Results showed that Hispanics were more likely to have no usual place for sick or preventative care and more likely to delay care than other racial groups. Blacks were more likely to use other sick or preventative care places than a doctor’s office and more likely to forgo care due to cost than other racial groups. Whites were more likely to have a doctor’s office as a place for sick or preventative care, followed by Asians, Hispanics, and Blacks. In addition, health insurance coverage highly contributed to explaining racial differences in health care access for Blacks and Hispanics, followed by family income, marital status, education attainment, and employment status. Results show that Blacks and Hispanics are at a higher disadvantage in accessing health care. Therefore, further research needs to focus on reducing disparities in health care access, especially for Blacks and Hispanics. Advisor: Christina D. Falci

Epilepsy is a neurological condition, marked by seizures that are caused by abnormal electricity activity in the brain. The Centers for Disease Control and Prevention have identified epilepsy as an emerging health issue. Diseases and illnesses are changing, and the way they are presented and treated is also changing. People with epilepsy frequently cannot drive. Because PWE need to see their doctors regularly, a break in their continuity of care can be detrimental. However, if they live in a car-centric suburban area without a means to get to their appointments, PWE may miss appointments. People with epilepsy may use their social networks to overcome their transportation burdens. This dissertation presents three distinct manuscripts. The first manuscript suggests a need for the reconceptualization of the sick role (Parsons 1951). This study examines the illness experience via an autoethnography, through the lens of someone living with epilepsy. The second manuscript identifies the barriers to transportation access for an individual living with epilepsy in suburban areas, specifically five suburbs of Cleveland, Ohio. These limitations may directly affect health care outcomes due to lack of health care access. The third manuscript explores how social networks may help reduce the transportation barrier to obtaining health care. Reducing the need for people with chronic illness to depend on their social networks for access to health care will help them maintain their health. Epilepsy is a public health issue. This dissertation contributes to sociology in several ways. The autoethnography is filling a gap in the research while also demonstrating how identity research applies to disability, specifically epilepsy. The second manuscript shows how transportation access can affect health care access. The third manuscript demonstrates how loss of autonomy, such as the independence that comes with driving privileges, can lead to missing health care appointments, which shapes health and its maintenance. This dissertation as a whole, and within each manuscript, contributes to Sociology by showing how epilepsy is a public health problem and how lack of access to health care in suburban areas contributes to that problem.

PURPOSE: Sickle cell disease (SCD) is an inherited blood disorder that affects the hemoglobin protein of red blood cells and has a significant impact on morbidity, mortality, and quality of life. Hydroxyurea has been FDA approved since 1998 as a disease-modifying therapy for SCD. However, hydroxyurea has not been optimally utilized for those with SCD. The purpose of this study was to evaluate reasons for hydroxyurea use, from the perspectives of providers, adults with SCD, and parents/caregivers of children with SCD, as well as perceived barriers to its use. We examined indications and reasons for being “on hydroxyurea,” defined by patients as currently taking hydroxyurea, and reported on pain frequency, perceptions of barriers, hydroxyurea adherence, and health care access for patients with SCD who were either on and not on hydroxyurea. METHODS: We conducted a cross sectional analysis of data collected within the Pacific Sickle Cell Regional Collaborative (PSCRC), a consortium of nine western U.S. states. Individuals were eligible for this study if they 1) had a confirmed diagnosis of SCD, 2) were followed at one of the PSCRC sites, and 3) were eligible for hydroxyurea therapy. Parents/caregivers of children with SCD less than 18 years and adults with SCD 18 years and older completed a brief survey about hydroxyurea use, indications, side effects, pain frequency, number of hospital and emergency department (ED) admissions per year, and individual and family perceptions of barriers to hydroxyurea use. Participants completed a follow-up survey annually, but we reported only on baseline data. Data collection occurred between February 2016 and May 2018. RESULTS: Individuals with SCD (n = 413) included 1) children (n=178; 6.7 ± 3.4 years), 2) adolescents (n=66; 15.0 ± 1.4 years), 3) young adults (n=57; 21.4 ± 2.6 years), and 4) adults (n=112; 39.2 ± 10.6 years). The majority were predominantly female (51.6%), African American (93.2%), and had HgbSS (74.1%) genotype. The majority of children (65.2%), adolescents (62.1%), and young adults (54.4%) were on hydroxyurea; fewer adults (39.3%) were on hydroxyurea. The majority with HgbSS (65.5%) were adherent to hydroxyurea. There was no significant difference in hospitalizations for pain, ED visits, and pain severity in the previous 12 months between individuals who were and were not on hydroxyurea, and between individuals who were and were not adherent to hydroxyurea. For those with a current prescription for hydroxyurea, the majority (66.5%) were receiving hydroxyurea for recurrent pain episodes or acute chest syndrome (19.9%). Hydroxyurea was discontinued because of patient/family preference (34.5%), chronic transfusions (31.1%), and side effects (24.1%). Patients prescribed hydroxyurea for empiric use (n=21) had fewer hospitalizations for pain, ED visits, and severe pain interfering with daily activities. The major barriers to hydroxyurea use, from the perspective of individuals with SCD or their caregivers, were 1) forgetting to take the medicine (19.4%), 2) worried about side effects (16.4%), and 3) lack of knowledge about hydroxyurea (13.6%). Fewer young adults (49.1%) and adults (50.0%) had primary care providers than children (78.1%) and adolescents (65.2%). CONCLUSIONS: Barriers to hydroxyurea use persist with emerging solutions to alleviate these barriers. For this sample, while hydroxyurea prescription rates by sickle cell specialists were similar to what has been seen in some other studies, neither hydroxyurea use nor adherence were associated with decreased frequency of hospitalizations for pain, ED visits, and severe acute pain episodes in the previous 12 months. Future studies need to evaluate hydroxyurea prescription patterns, duration on hydroxyurea, and adherence to hydroxyurea. Healthcare providers are recommended to prescribe hydroxyurea for eligible individuals who may benefit from it, such as those HgbSS or HgbS-β0 thalassemia genotype, and prescribe for empiric use to minimize complications. Provider and patient education about hydroxyurea could reduce common barriers experienced by individuals with SCD. It is important to customize educational resources to specific concerns for different age groups. Individuals 18 years and older with SCD have been documented with more ED visits and hospitalizations due to pain, most likely because they did not have a primary care provider and an adult hematologist with expertise in SCD. Future studies need to evaluate whether primary care providers who receive SCD education may promote hydroxyurea use and adherence. Dedicating time and resources for shared decision making between providers and patients/families can address concerns about hydroxyurea and increase patient/family confidence when deciding about hydroxyurea. As more disease-modifying therapies become available for individuals with SCD, strategies for shared decision making facilitate standardization and optimize the use of hydroxyurea and emerging therapies.

Abortion, the termination of pregnancy, is safe when provided as a surgical procedure by a trained provider or when the correct dosage of the drugs mifepristone and/or misoprostol are used. Despite this, many barriers to abortion care exist. In the United States (US), targeted state-level abortion restrictions create barriers to care, which make it so that people who wish to utilize abortion care face difficulty or are unable to do so. Such barriers to care have important public health implications, as studies have shown that individuals who cannot access wanted abortion care have poorer psychological, physical, social, and economic outcomes than those who obtained care. This dissertation aims to examine one component of abortion access, accessibility, operationalized as the drive time from a woman’s home to the nearest abortion-providing facility. We employ a novel measure of abortion accessibility constructed from three data sources: (1) the Advancing New Standards in Reproductive Health facility database; (2) US Census estimates and shapefiles; and (3) OpenStreetMap data. In the first study, we used geographic information systems (GIS) to explore the effect of programmatic and policy changes related to telemedicine for medication abortion services (TMAB) on population-level measures of abortion accessibility, or drive time to the nearest abortion-providing facility. We found that either expansions in TMAB services or removal of TMAB bans could improve abortion accessibility in the US. For these two exposure scenarios, compared to the current abortion provision scenario, increases in the proportion of women within a 30-, 60-, and 90-minute drive time of an abortion-providing facility ranged from 1.25 percentage points, or an additional 781,556 US women aged 15-44 years with accessibility, to 5.66 percentage points, or an additional 3,530,423 US women aged 15-44 years with accessibility. In the second study, we used GIS to assess the potential effect of the geographic unit of analysis (i.e., block group, ZIP code tabulation area [ZCTA], or county) on misclassification of the proportion of US women of reproductive age within a 30-minute drive time of an abortion-providing facility relative to a measure calculated using Census blocks. We found that block group- or ZCTA-based estimates of abortion accessibility were an underestimate, but resulted in little misclassification relative to measures constructed using Census blocks at the national level; however, county-based measures substantially underestimated abortion accessibility compared with Census block-based measures. Nationwide, the Census block-based abortion accessibility estimate was 0.35 percentage points greater than the block group-based estimate, 2.72 percentage points greater than the ZCTA-based estimate, and 24.21 percentage points greater than the county-based estimate. By state, the Census block-based abortion accessibility estimate ranged from 0 to 8.51 percentage points greater than the block group-based estimate, from 0 to 27.86 percentage points greater than the ZCTA-based estimate, and from 0 to 79.49 percentage points greater than the county-based estimate. Given that state-level ZCTA-based estimates could be substantially different from the Census block-based estimate, ZCTA-based estimates are likely not appropriate for state-level analyses or US analyses stratified by state. Finally, in the third study, we assessed the relationship between level of accessibility in an abortion client’s home ZCTA and the gestational age at which the client obtained abortion care, using fine stratification by propensity score to control confounding. We found that compared with living in a ZCTA with >0% accessibility, living in a ZCTA with 0% accessibility was associated with a decreased risk of being at or beyond 14 weeks’ gestation at abortion visit. These unexpected findings could be due to a selection bias induced by limiting the sample to those who obtained abortion care, uncontrolled or poorly controlled confounding, misclassification of exposure and/or outcome, and/or unidentified effect measure modification by state abortion provision landscape. Through these three dissertation studies, we highlighted the potential impact on abortion accessibility in the US with different changes in programming and policy, quantified misclassification of abortion accessibility, and examined how misclassification varied by geographic measure and location. The third study in this dissertation suggests a need for more research to identify how selection bias may affect studies of abortion access in the US that rely on data only from those who are able to access care.

Background: Agriculture industry has the highest fatality rate among all United States industries. Farmworkers experience high rates of occupational injury, illness, and mortality, yet have limited access to health care. Implementation of the Patient Protection and Affordable Care Act (ACA) of 2010 increased health care accessibility and broadened farmworker eligibility for health insurance, yet no study has measured the impact of the ACA upon U.S. farmworkers. Purpose: The purpose of this research was to examine health care access and health care services utilization among U.S. farmworkers following the implementation of the ACA in 2010. Specific Aims: 1. Apply the Behavioral Model for Vulnerable Populations (BMVP) with a national sample of U.S. farmworkers to describe the predisposing, enabling, and need factors, with U.S. health care utilization. 2. Describe the predisposing, enabling, and need factors independently associated with U.S. health care utilization. 3. Determine the odds of U.S. health care utilization as accounted for by the BMVP predisposing, enabling, and need factors. Method: A retrospective cross-sectional design was employed using secondary data from the 2011 – 2014 National Agricultural Workers Survey (NAWS). Respondents of the NAWS include U.S. hired farmworkers who labor for a U.S. agricultural employer for crop-related production (n=7260). Data analysis examined the relationships between BMVP factors and U.S. health care utilization among U.S. farmworkers. Results: More than half (60%) of farmworkers utilized U.S. health care. All predisposing (age, education, ethnicity, country of origin, gender, legal status, marital status, English speaking and reading proficiency), enabling (access to transportation, income, insurance status, Medicaid), and need (barriers to care, health status) factors were independently associated with U.S. health care utilization when analyzed for the full sample (p Implications: Nurses play an important role in mitigating barriers to health care for farmworker families. Understanding the many barriers and influencing factors of health care utilization can inform nurse-led outreach efforts, community programs, and health policies to improve health care service delivery for this underserved group.

Study One:Purpose. Identify differences in child mental health factors, perceived neighborhood safety, and child health care access by demographic characteristics. Methods. Secondary data analysis of the 2017 Interact for Health Child Well Being Survey. Primary caregivers (n = 2,757) responded to questions about children. A random-digit dial structured questionnaire was utilized. Results. Caregivers reported that less than two-in-ten children (14.5%, n = 398) had good emotional health, 4.1% (n = 112) had depression, and 9.1% (n = 250) anxiety. Depression was higher among White, female, and 11-17 years, and African American children below 100% FPL. White children, age 11-17 years were diagnosed with anxiety more than African American or Other. Most caregivers felt their child was always safe (62.5%, n = 1,719) with 1.0% (n = 27) feeling their child was never-safe in their neighborhood. Caregiver’s reported 98.5% (n = 2,705) had health insurance, 98.8% (n = 2,723) had a medical home, 88.3% (n = 2,426) received preventive care services while 11.7% (n = 322) did not. Statistical analyses revealed several differences. Conclusions. White, suburban, higher income, or children from married families received diagnosis and treatment for depression and anxiety more than low income, urban, or minority children found to have lower mental health scores. Increased screening for mental health disorders among vulnerable populations needs to be addressed as a priority. Study Two:Purpose. Identify differences in child caregiver physical health status, mental health status, level of parent emotional support, and perceived levels of neighborhood safety. Methods. Data (n = 2,757) from the 2017 Child Well Being Survey were utilized. Results. Nearly 7 in 10 caregivers reported their physical health as very good or good (68.1%, n = 1,878). A majority of caregivers reported their mental health as very good or good (62.2%, n = 1,707) and 93.3% (n = 2,571) had someone to provide day-to-day parenting emotional support. A majority of caregivers reported neighborhood safety as always or usually safe (93.9%, n = 2,587). Caregivers who were 65 or older, female, African American, unmarried, unemployed, high school graduates (or lower), a guardian or other relation to the child, lived in a 1-adult household, below 200% FPL, or in urban or rural areas; had lower physical health and mental health status scores. Neighborhood safety was reported less among caregivers who were unmarried, female, African American, Hispanic, high school graduates (or less), in single-adult households, below 200% FPL, or in urban settings. Parenting emotional support was lower among those ages 45-65, African American, Hispanic, not married, not employed, less than high school education, in 1 or 3+ adult households, or living below 200% FLP. Conclusions. Increased levels of perceived parenting socio-emotional support appeared to positively influence caregiver physical and mental health outcomes and perceived neighborhood safety. Additionally, results support efforts to address support as a mediator of caregiver mental and physical health, especially among low-income, urban, and minority caregivers at risk for adverse outcomes.

This dissertation consists of two studies. Study one examined Physical and Mental health related quality of life (HRQOL) based on health behaviors and access to health care among African American adults. Study two examined physical and mental HRQOL based on health behaviors and access to health care among Hispanic/Latino adults.Study One AbstractIntroduction: The primary aim of this study was to examine whether physical and mental health-related quality of life (HRQOL) of African American adults differed based on age, sex, income, health behaviors (current exercise, current smoking, recent alcohol use, and recent binge drinking), and access to health care (health care coverage, have a doctor/primary care provider, and physical checkup in last 12 months). Methods: Secondary analysis of the 2014 Behavioral Risk Factor Surveillance System survey was performed. Participants were African American adults (n = 35,493). Results: Results indicated that those reporting the highest physical and mental HRQOL were female, age 65 years or older, with an income of $20,000 or greater and those who had at least one doctor and access to health care. Discussion: The findings of this study can be used by health educators interested in increasing HRQOL among African American adults.Study Two AbstractIntroduction: The primary aim of this study was to examine whether physical and mental health-related quality of life (HRQOL) of Hispanic adults differed based on age, sex, income, health behaviors (current exercise, current smoking, recent alcohol use, and recent binge drinking), and access to health care (health care coverage, have a doctor/primary care provider, and physical behaviors (current exercise, current smoking, recent alcohol use, and recent binge drinking), and access to health care (health care coverage, have a doctor/primary care provider, and physical checkup in last 12 months). Methods: Secondary analysis of the 2014 Behavioral Risk Factor Surveillance System survey was performed. Participants were Hispanic adults (n = 35,906). Results: Results indicated that those reporting the highest physical and mental HRQOL were females, age 65 years or older, and with an income of $20,000 or greater, and access to health care. Discussion: Having health care access was positively associated with physical HRQOL but not with mental HRQOL. Discussion: The findings of this study can be used by health educators interested in increasing HRQOL among Hispanic adults.

Study One Purpose. Study one assessed perceived cultural competence, satisfaction with health care, and mental health care access among post-secondary foreign-born students. Method. A secondary analysis of a cross-sectional study using a subsample (n=655) from the 2017 National Health Interview Survey was used. Chi-square and ANOVA tests assessed levels of satisfaction with health care services received in the prior year and evaluated differences with satisfaction by place of birth, English skill, and length of residence. Differences in proportions between foreign-born and U.S. born were evaluated to see which group was more likely to have health insurance, a medical home, or have seen a mental health or general doctor in the prior 12 months. Results. Foreign-born participants were almost two times as likely to report not having a medical home and three times less likely to have seen a mental health provider. Foreign-born post-secondary students had higher levels of dissatisfaction than their U.S born counterparts. Effect size analyses showed that the magnitude of difference was small. The majority of post-secondary students had access to health care and were satisfied with the health care they received. Conclusion. More research needs to be done to better understand the health gaps and differences for foreign-born students. Future research should include immigration status and foreign-born students who might have recently arrived in the U.S.Study TwoPurpose. To assess the presence of mental health distress symptoms, levels of severe mental health distress, and health care access patterns among post-secondary students and to determine if differences by place of birth, English skill, and length of residence existed. Method. The study utilized a subsample (n = 655) of data from the 2017 National Health Interview Survey. Selected items measured the presence of mental health distress, levels of severe mental health distress, health care access, and selected demographics. ANOVA analyses were used to assess levels of mental health distress by place of birth, English skill, and length of residence among the participants. Chi-square tests were used to determine if mental health care access differed among the participants by place of birth, English skill, and length of residence. Results. Only 2.7% of participants reported severe mental health distress. Additionally, levels of severe mental health distress did not differ by place of birth, English skill, or by length of residence. Mental health care access significantly differed by place of birth. U.S. born post-secondary students were 3 times more likely to report seeing a mental health care provider in the last 12 months when compared to foreign-born post-secondary students. Foreign-born students who had lived in the U.S. for more than 15 years were more likely to report having seen a mental health care provider in the prior year as well. Conclusion. Some post-secondary students who screened positively for mental health distress still do not seek the care they need, and this could lead to negative health outcomes. Future research should address factors influencing attitudes towards accessing mental health services and suggest interventions or approaches that might help foreign-born students.

Since 2005, US states have passed hundreds of immigration policies. Among state policies that restrict rights for immigrants, omnibus immigration policies are the harshest. Omnibus immigration policies expand local enforcement of federal immigration law; create penalties for employers who hire undocumented immigrants; and restrict undocumented immigrants’ access to public benefits. Omnibus immigration policies have attracted considerable attention and concern from researchers, policymakers, health care providers, and civil rights advocates. However, no single resource has compiled a comprehensive list of omnibus immigration policies. In Paper 1, I used a clear definition of omnibus immigration policies—policies that incorporate three or more immigration-related measures in a single law—to identify all omnibus immigration policies passed between 2005 and 2014. I identified 19 omnibus laws in 11 states. Paper 1 discusses the provisions in each of these laws; the outcomes of lawsuits challenging the laws; and the current status of each law. This review provides a critical resource for researchers who seek to understand the factors that predict passage of an omnibus policy, or to examine the effects of omnibus policies. There is evidence that omnibus immigration policies increased barriers to health care for all Latinos, regardless of immigration status, but no studies have used rigorous, quasi-experimental methods to examine these potential effects. To fill this gap, Paper 2 used comparative interrupted time series and data from the National Health Interview Survey to estimate the long-term effects of omnibus policy passage on health insurance coverage, public insurance coverage, and unmet health care needs for citizen Latino children, and to examine how these effects varied by parent citizenship. After policy passage, health care access increased for children of citizens, increased or stayed the same for children of mixed-status parents, and decreased for children of noncitizens. Effects emerged immediately upon policy passage and declined over time. Our findings that restrictive immigration policies reduce health care access for children of immigrants are consistent with earlier qualitative and small, quantitative studies. This is the first study to demonstrate that restrictive immigration policies are followed by a temporary increase in health care access for Latino children of citizens.

Abstract: Throughout the twentieth century, tuberculosis (TB) was and continues to be a pressing health problem facing Canadians. Aboriginal peoples living in Canada carry a large burden of the disease with those living in the Prairie Provinces facing TB rates consistently higher than the national average. Tuberculosis affects Aboriginal peoples and their communities differently, while some reserves have been left relatively untouched, others face TB rates which are exceptionally higher than the national average. Currently, researchers have been trying to understand why TB continues to impact Aboriginal peoples in Canada. The research has largely been conducted on the historical trauma that Aboriginal peoples faced when being treated for TB, as well as on the socioeconomic disparities that increase the spread of the disease. The central purpose of this study was to understand the TB experience for Aboriginal peoples living in different community settings across the Prairie Provinces, from experiencing symptoms, to seeking a diagnosis, to being treated. This study used secondary qualitative data from a larger research project. Interviews from 48 Aboriginal participants who lived in urban centres and on non-remote, remote, and isolated reserves in Alberta, Saskatchewan, and Manitoba were used to answer the research question. The interviews were analyzed using qualitative content analysis. Four prominent themes emerged which impacted the TB experience including the role of the individual, the impact of social connections, the impact of community, and the impact of isolation policies. Within each theme there were many sub-themes that highlighted important similarities and differences that Aboriginal peoples from various community settings experience when living and being diagnosed with TB. The findings highlight the value of connections in the lives of Aboriginal peoples experiencing TB. Not all individuals are equally connected to a source of support that could improve their overall TB experience therefore, there is a need to improve current TB policy and practice for Aboriginal peoples living both in urban centres and on-reserve.

For this dissertation two studies were conducted. The first part of the abstract addresses the manuscript from the first study and the second part addresses the second manuscript from the second study. Manuscript one aimed to explore the relationship between demographic variables, literacy, numeracy, general health status, health care access factors and marketplace utilization among citizens and immigrants in the United States. Manuscript two examined and compared the relationships between immigrants’ and citizens’ awareness, perceptions, concerns in relation to the Affordable Health Care Act and Marketplace utilization.Manuscript One AbstractIntroduction: This study aimed to explore the relationship between demographic variables, literacy, numeracy, general health status, health care access factors and marketplace utilization among citizens and immigrants in the United States. Method: This study was carried out as a secondary data analysis of an internet based survey of U.S. residents who responded to the 2014 fourth quarter Urban Institute’s Health Reform Monitoring Survey (HRMS). A subsample of immigrants who participated in the HRMS was selected for secondary data analysis (n= 369). Twenty-one outcomes of interest were selected including demographic characteristics, literacy, numeracy, health status, health care access, and Marketplace utilization. Results: Regression analyses indicated that numeracy and age were predictors of general health status among immigrants. Chi square analyses indicated that age is associated with health care access among this sample of immigrants. A minority of immigrants report utilizing the Marketplace to purchase their health insurance coverage. Discussion: Further research is needed to explore these relationships with a more representative sample of immigrants.Manuscript Two AbstractIntroduction: This study examined and compared the relationships between immigrants’ and citizens’ awareness, perceptions, concerns in relation to the Affordable Health Care Act and Marketplace utilization. Method: A secondary data analysis of participants who self-identified as citizens and non-U.S. citizens was carried out. The entire fourth quarter 2014 survey sample made up of citizens and immigrants was used. Specific questions that were utilized in this study included demographic items such as gender, age, ethnicity/race, employment status, marital status, education, perceptions regarding the Affordable Healthcare Act (ACA), awareness of the Marketplace and concern. Results: Analyses indicated that citizens have less favorable opinions about the ACA than do immigrants. Awareness was higher among immigrants and immigrants were more likely to report having used the marketplace than citizens. Results further indicated that citizens were less likely than immigrants to report knowing someone with concerns that Immigrants, Health Status, Access, and the ACA affect utilization of the Marketplace. Discussion: Findings can be utilized to further research these variables with a more comprehensive survey and more representative sample.

To achieve the goal of universal coverage of health insurance for the Americans, in March 2010, the Patient Protection and Affordable Care Act (ACA) was signed into law. The ACA targets at providing help to improve access to affordable health coverage for everyone and protect consumers from abusive insurance company practices. One of the precedent mandates, implemented in September 2010, is to expand coverage on young adults of age 19 to 26, who may lose insurance coverage due to the remove from their parents’ plan after age 18 and lacking of productivity to bargain with employers in the labor market. This dissertation looks into the impact of the ACA health insurance coverage expansion for young adults on the subsequent health outcomes, health care utilization, and further social impact on traffic fatalities. Difference-in-differences models are used with different treatment groups and corresponding control groups. Chapter I uses survey data (BRFSS) to evaluate health care access, health behavior and self-assessed health status. The results suggest an improvement in health care access and self-assessed health but more risky behavior. Chapter II uses hospital discharge data (NIS) to estimate avoidable hospitalization in order to assess primary care utilization. The result shows that less primary care was consumed, which leads to more avoidable hospitalization but health may have been improved by using more hospital care. The results from both chapters imply potential ex ante moral hazard among young adults in the policy targeting age group. Thus, chapter III uses accident records data (FARS) to examine the impact of the health insurance expansion on traffic fatality for young adults, to see whether young drivers perform ex ante moral hazard through risky behavior like drunk and/or reckless driving after they get covered by the health insurance expansion policy. Primary result shows that there is an increase in traffic accidents and fatalities for those younger adults as a result of the ACA dependent coverage expansion.

Background: To curb the transmission of HIV/AIDS and other infectious diseases several studies indicate the need for improved access to medical care for injection drug users (IDUs) including those already linked to syringe exchange programs (SEPs). However, availability and access to services remains a problem for many IDUs. This study seeks to examine perceptions of medical care access among a pharmacy-based sample of IDUs, utilization of medical services among IDUs and, identify barriers to accessing health care services to help ensure that IDUs receive appropriate care when needed and reduce the transmission of diseases. Methods: Data was obtained from the Pharmacists As Resources Making Links to Community Services (PHARM-Link) study. Dependent variables: health care access to the same provider and receiving care a usual source, health care utilization of services including the emergency room, clinic, medical office, medical mobile unit and hospital; and health care barriers categorized as personal or structural. Independent variables were insurance status, homelessness in the prior six months, case management, drug treatment and socio-demographic characteristics such as age, sex, income, education and employment status. Descriptive statistics analysis and logistic regression were performed using SAS version 9.4 (2013) with significance set at p Results: Our sample included 615 IDUs participating in the PHARM-Link study. Overall, IDUs accessed health services and having the same provider remained statistically higher among those with legal income above $5,000 OR: 1.60 (95% CI: 1.03- 2.48), the insured OR: 4.11 (95% CI: 2.48-6.79), and those with positive HIV status OR: 7.64 (95% CI: 3.18 – 18.36), while those who were homeless reported lower access to the same provider OR: 0.63 (95% CI: 0.43 – 0.92). Only the older age group OR: 2.85 (95% CI: 1.42-5.73) and the insured OR: 3.42 (95% CI: 1.81-6.46) remained significantly associated with more access to receiving health needs at the same location. Those with some college education had less frequent visits to the clinic OR: 0.59 (95% CI: 0.38-0.92) and medical office OR: 0.64 (95% CI: 0.41-0.99), while the homeless were more likely to visit the emergency room OR: 1.49 (95% CI: 1.06-2.11). Females were less likely to go to a mobile unit OR; 0.52 (95% CI: 0.33-0.83) and married people were more likely OR: 1.95 (95% CI: 0.28-0.91). Visit to the hospital were less likely among females OR: 0.54 (95% CI: 0.36-0.81) and among those with some college education OR: 0.63 (95% CI: 0.41-0.96). Those with legal income above $5,000 were less likely to have any personal barriers OR: 0.64 (95% CI: 0.45 – 0.92). Structural barriers remained more likely among those who were homeless OR: 1.62 (95% CI: 1.13-2.39), but less likely among those 44 years and older OR: 0.58 (95% CI: 0.40-0.85), the insured OR: 0.60 (95% CI: 0.38-0.94), those with positive HIV status OR: 0.53 (95% CI: 0.28-0.99), as well as Non-Hispanic Blacks OR: 0.47 (95% CI: 0.14-0.83) and Latinos OR: 0.47 (95% CI: 0.25-0.86). Conclusion: Our results suggest that most IDUs linked to care through pharmacy-based SEP programs established to expand health services and improve health, did access available health services. However, some continue to experience difficulties such as structural barriers among the homeless as well as few reported visits to the clinic, medical office and the hospital among the employed believed to have resources to pay for such services. These services may have been underutilized because the participants were unsatisfied with the services provided. Therefore, interventions should target structural barriers such as homelessness among IDUs as well as health insurance coverage to help increase access to and utilization of health services.

Background: Disparities in unintended pregnancy are partially due to ineffective contraceptive method choice among vulnerable populations. Improved understanding of the ecological, individual, and health system related determinants of contraceptive choice can provide guidance for how to reduce ineffective contraceptive method choice among women at high risk for unintended pregnancy.Objectives: Secondary data analysis is performed on visit data from women utilizing Title X Family Planning services at the Cincinnati Health Department's Reproductive Health & Wellness Program (RHWP) to determine the significance of predisposing factors (age, African-American race, education), enabling factors (income, health insurance status, socio-behavioral risks), need factors (having had a recent birth, number of living children) on choosing an ineffective contraceptive method. Mediation analysis is performed to determine if health system factors mediated the effect of these explanatory variables.Methods: Using data from 1,119 RHWP clients who were not seeking pregnancy, multinomial logistic regression is used to compare pill, patch, and ring users, depot medroxyprogesterone acetate (DMPA) users, and long-acting reversible contraception (LARC) users with a reference group of ineffective method users. Multinomial logistic regression is first performed with all independent variables except health system mediation. Then, it is performed with inclusion of health system mediation. Multiple linear regression analysis is performed to determine significant relationships between independent factors and health system mediation. Mediation analysis is performed for any independent variable that is significantly correlated with both contraceptive method choice and health system mediation for the purpose of determining if any witnessed mediation effect is statistically significant. Results: The model including health system mediation is found to account for more variance in the data than the model excluding health system mediation (Nagelkerke R-squared = 0.195 and 0.158, respectively). Through both models, and in all three comparisons, higher age is found to reduce the odds of choosing a more effective method with only minor mediation effects. Having more children results in higher odds of both DMPA and LARC uptake in both models and is unmediated by the health system. Being of African-American race results in lower odds of LARC use in both models – a finding that is also not mediated by the health system. Health system mediation effects are found in the LARC and DMPA comparisons and not in the pills, patch, or ring comparison. In the DMPA comparison, inclusion of health system mediation eliminates income and insurance status as significant explanatory variables. In the LARC comparison, inclusion of health system mediation eliminates the explanatory significance of having a recent birth.Conclusions: Analysis of the role of health system mediation suggests that health system level factors play a large role in explaining contraceptive choice among contraceptive methods that require increased health care utilization. The impact of health system mediation on the significance of other predisposing, enabling, and need variables implies that health care access, utilization, and quality are important factors that should be included in future models for understanding contraceptive choice.

Every year in Ohio and throughout the United States women of childbearing age are increasingly making the decision to forgo the hospital setting and give birth at home. The evidence has shown that women’s decisions to birth at home are highly influenced by their desire for greater control over their birth process in order to avoid unnecessary, technology-intensive interventions in the normal birth process. The body of research has demonstrated similar safety ratings for both the mother and child in planned low-risk home and hospital births attended by skilled providers. Compared with low-risk hospital births, outcomes of intended home births have consistently shown considerably lower rates of medical intervention in episiotomy, electronic fetal monitoring, caesarean section, and vacuum extraction with home birth care providers receiving higher client satisfaction ratings than their in-hospital counterparts. Currently over half of U.S. states regulate home birth midwife practice (most commonly the Certified Professional Midwife, CPM) through some form of licensure or statute. Ohio currently does not regulate the practice, leaving women seeking a midwife for a home birth without a legally recognized care provider. Recognizing home birth as an option, tracking down a home birth midwife, and going through an entire pregnancy planning a home birth are not highly visible options for the majority of women in part because of the uncertainty around home midwifery practice and the potential for it to be construed as “practicing medicine without a license” and prosecuted as such. Though prosecution is infrequent in Ohio, most midwives practice with caution, receiving clients by word of mouth and association rather than advertising online or from a public business model. Beyond the fact that we know home birth is happening in Ohio and that it is increasing at a high rate, very little has been demonstrated in the research about how women find their midwives and their experiences with that care. This research was carried out using an online, anonymous survey distributed through social media and email community lists. Surveys sought participation from Ohio mothers who had planned a home birth for their child in the previous 5 year time period. The results yielded participation by 365 women, an estimated 10% of the potential sample size. While demographically the sample was similar to prior studies of U.S. home birth populations, new information and characteristics of the population and their choices were revealed. The results of the study painted a picture of women planning and seeking home birth, somewhat contrary to the risk-taking, anti-doctor, technology-averse, picture of which home birthing women are typically painted in American popular culture. A majority of the women who planned home births were highly educated, concerned with safety, sought a backup or collaborative healthcare physician, and participated in ultrasound testing. Other findings revealed the difficulties the women faced in obtaining an appropriate care provider: traveling longer distances to receive care, few care provider options, paying fees out of pocket, and hiring midwives later in their pregnancy. The results of the study indicate the need for policy in Ohio to improve access to qualified home birth health care providers

Author's Abstract: Ambulatory care sensitive conditions (ACSCs) resulting in hospitalizations make up a substantial proportion of health care costs, but should not because these conditions are manageable in quality primary care settings that promote prevention in an effort to avoid exacerbations that can lead to hospitalization. The use of emergency departments (EDs) as a safety net for ACSCs has increased the burden on hospitals because patients who do not regularly utilize primary care often resort to the use of EDs for treatment of ACSCs. Federally qualified health centers (FQHCs) are designed to provide consistent, high-quality primary care to all people, but provisions are in place to ensure that economically vulnerable populations also have access to quality primary care. FQHCs are primary care access points that guarantee variable rates as determined by patient income, and the patient knows ahead of time what the costs will be. In this study, hospital and ED discharges for ambulatory care sensitive chronic conditions (ACSCCs) were used as indicators of quality primary care. Hospital discharges represented indicators of low utilization of primary care leading to hospital level needs due to exacerbations of ACSCCs, and ED discharges were used as indicators of the ED as a safety net. A general linear model was used to determine per capita rate variations in hospital and ED discharges for ACSCCs in counties before and after FQHC additions. In the final model, race, payer-type, and age, overall, showed significant variations in hospital and ED discharges. Findings from this study indicated that most counties with FQHC presence had had lower hospital and ED discharge rates. Counties with multiple FQHCs showed greater improvement in discharge rates and rural counties showed the least improvement in rates, overall. There is a need for further exploration to understand reasons for increases in hospital and ED discharges for some years during the study period. Additionally, health care utilization behavior and social interactions may further inform researchers about the effects of wait times, hours of operation, co-pays, and other factors not measured in this study.

Cervical cancer disproportionately affects minority, immigrant, and low-income women. Human Papillomavirus (HPV) vaccines have the potential to substantially prevent high risk HPV infections and future cases of cervical cancer. Recent studies show that HPV vaccine uptake in high risk groups remains low. Even with available programs that provide the vaccine for free to low-income populations, multiple barriers, including lack of geographic accessibility to safety-net immunization clinics, may prevent disadvantaged adolescent girls from obtaining the vaccine. Current disparities in cervical cancer will likely persist as a result of HPV vaccine under-utilization among disadvantaged populations.This dissertation is comprised of three studies that explore the roles of geographic and neighborhood factors on HPV vaccine access and uptake among low-income, racial/ethnic minority populations in Los Angeles County (LAC). Data collected from mothers of HPV vaccine age-eligible girls as well as secondary data from the U.S. Census Bureau, LAC Sexually Transmitted Diseases Program and LAC Cancer Surveillance Program were used in the analyses. Geographic information system mapping (GIS) techniques and multivariate logistic regression models for clustered data were employed.This research found that HPV vaccination services via safety-net clinics are, in general, geographically accessible for low-income, high-risk populations in Los Angeles County. Some exceptions to the primary findings should be noted: (1) some racial/ethnic differences in proximity to clinics emerged and warrant further exploration, (2) a few specific neighborhoods with high cervical cancer risk may benefit from targeted improvements in geographic access to HPV vaccination services, and (3) particular attention should be paid to low-income girls living in moderately poor neighborhoods where geographic access to nearby safety-net services is limited. Increased proximity to safety-net clinics was not significantly associated with increased vaccine uptake. While vaccination rates were highest among low-income girls in neighborhoods with the greatest poverty and proportion of minority residents, these factors were not independently related to vaccination after controlling for individual factors. Mother's awareness of HPV, age of girl, and having public insurance were also significant predictors of uptake.Findings suggest that low-income communities continue to need increased access to information about HPV. Results also suggest health care coverage, specifically underinsurance among low-income adolescents, and clinic-based operational factors are worth exploring in future research as barriers to HPV vaccination. Future research should continue to focus on individual, physician, and organizational strategies to increase vaccine uptake, especially in relation to high-risk populations that could benefit most from the HPV vaccine.

Maternal mortality is an important public health problem in Mexico. Although the Mexican government has invested many physical and economic resources to strategies specifically created to reduce this problem and reach the Millennium Development Goals, Mexico is not going to achieve this goal on time. Maternal Mortality is a problem of inequality and social injustice. Access to health services is unequally distributed among regions and among population within those regions. Despite a general decline in childbirth deaths worldwide, differences still exist depending on the level of urbanization and size of residence. Because of extreme inequality in Mexico, pregnant women living in rural and highly marginalized areas face the highest risk of dying for maternal causes. The main strategies Mexican government has adopted to reduce maternal mortality target the unsecure, rural and poor population, with the aim of closing the significant gap between geographic regions and social groups.

There is a growing population worldwide who are not able to receive dental care. The numbers and trend are increasing and the availability of providers and resources are dwindling in comparison. The dissertation starts off with an example of how the current dental healthcare system has allowed some tragic outcomes. This paper will discuss the barriers of obtaining dental care for this growing population, challenges in dental education and offer some future solutions. Using the example of a dental tragedy, we hope to be inspired as a call to action to avert further fatalities and improve the dental healthcare system. The paper reviews the issue from: 1. A Long term perspective with the current and projected statistics for special needs population nationwide and California. 2. An Expanding population perspective that focuses on patients with autism spectrum disorder. 3. A Complex needs perspective of an example of the increasing necessity of hospital dentistry care.

Older gay men and lesbians, out of fear of discrimination, are five times less likely to access health care and social services. There are a few studies that have explored usage rates and factors that influenced non use of these services. This investigator examined the physical and mental health care service use for gay men 45 years of age and older. A cross-sectional study design employed the use of a web based survey. A sample of 260 participants from across the United States was collected within a 3-month collection timeframe. Participants for this study were obtained using gay choruses and an older gay men’s social group called the Prime Timers. A conceptual framework developed for this study drew upon the combined contribution from the Andersen-Newman’s Behavioral Model of Health Service Use (1973), and the Minority Stress Conceptual Framework proposed by Meyer (Meyer, 1995). The goals of this study was to understand whether enablers defined by Anderson and Newman (1974) and psychosocial stress and individual health coping factors identified by Meyer (1995) were influential on the use of physical and mental health service use. Regression analysis was used to analyze the relationships based on correlational interactions between enabling, psychosocial stressors, and individual health coping variables on service use. Additionally, researchers have found that 51% to 82% of lesbians and gay men do not disclose their sexual orientation to health and social service providers. Independent sample t-test was used to identify the significance of sexual identity disclosure on use of both physical and mental health service use. The results of this study found that for mental health service use, community support and resiliency were significant predictors of service use. Physical health visits were found to be significantly influenced by support from friends, internalized homophobia and mental health distress. Discrimination was a significant factor in use of physical health visits, and it was found to decrease physical health service use. Physical health status and mental health distress were significant in seeking both physical and mental health services. The importance of understanding the connection between physical health status and mental health distress was found increasing the need for interventions that incorporate both in the scope of service. More importantly, the effects of discrimination for midlife and older gay men is further understood and discussed with implications on physical health visits. The outcomes of this study provide a starting point to understand factors that affect how midlife and older gay men on the use of health services. The promotion of more effective policies and programs as well as, interventions within a community based support model would increase the health and well-being of this population. The study highlights the importance of social workers affirming a gay identity to increase one’s self confidence in seeking health services through direct intervention and policy changes.

The need for health in general and oral health in particular is a basic and fundamental element for a quality life. Not everyone in America has access to basic oral health services. California, in particular, has greater challenges than other areas of the country in providing basic oral health services to everyone. This paper will discuss the problems of accessing oral health care, the importance of achieving oral health care, the necessity of maintaining oral health, the factors influencing oral health care access, and the response of the dental profession to the problems of access to oral health care. These problems will be examined from the following three perspectives: (1) Statewide Perspective, (2) Locality Perspective, (3) Individual Perspective. Potential solutions for vulnerable populations in accessing oral health care will be developed using data from quantitative and qualitative methodologies.

This dissertation evaluated the association between measures of geographic accessibility and attendance at primary care visits in a sample of poor, urban, diabetic patients that received care from a large health care network in Cuyahoga County (MetroHealth System, or MHS). Study Design: The study had three aims. In the first two aims, we assessed associations between Euclidean distance from home to clinic and attendance to primary care clinic in our study sample, then used a subsample of Medicaid patients selected by a stratified random process to evaluate a novel measure of geographic accessibility (“Activity Density of Clinic Location”, or ADCL) based on “activity space”, or the subset of locations where individuals conduct their daily lives. The outcome of interest was attendance at primary health care visits (1=attended/0=missed) scheduled between July and December of 2006. Data was drawn from the electronic medical records (EMR) of the study sample and responses to a cross-sectional phone survey of the subsample. Multivariate logistic regression was used to evaluate associations between geographic accessibility and attendance after adjusting for transportation, demographics, and clinical characteristics. In Aim 3, we conducted contextual analysis of archival information and text from interviews with MHS decision-makers to describe how siting decisions were made by MHS in expanding its primary health care system from 1992 to 2005. Principal Findings: Distance was not associated with attendance at primary care visits in this sample, even after adjusting for demographic, clinical, and transportation-related factors. After rigorous adjustment for confounders, a 1 unit increase in ADCL was associated with a 7% decrease in probability of attending a visit (OR=0.93; 95% CI 0.87-1.00) in our sample of Medicaid patients, although the association was marginally significant (p=0.05). In our case study, MHS leaders, motivated by an altruistic mission and a strategy of solidifying its patient referral networks, based the siting of community health centers on patient location and the location of neighborhood centers of activity. Conclusions: Our activity-space based measure appeared to measure aspects of geographic accessibility in urban areas distinct from distance, and may have better distinguished individual differences in geography. Future studies should evaluate similar measures, address effect modification, and explore how health systems can use such information to address geographic issues in their patient populations.

Recent data show that immigrant women in the U.S. are generally in poorer health than U.S.-born women and immigrant men , and many immigrant women encounter some difficulties in obtaining health care assistance, such as health insurance. Yet American researchers are only beginning to make a contribution to this area of scholarship. This thesis examines in detail the health status of immigrant women, the means by which immigrant women obtain health insurance, and several factors that are likely to influence their health care access. I mainly examine the associations between three factors (public policy, employment status, and marital status) and access to health care assistance. I do so because employers and government-sponsored health care programs are both major insurance providers, and being married is an important factor in accounting for immigrant women's health insurance coverage. The project consists of case studies in three states — California, Florida and New York — using both qualitative and quantitative research methods. The data come from two rounds of the National Survey of America's Families (NSAF 1997 and NSAF 1999) and documentation of welfare reform rules. The results of this study demonstrate that all three factors contribute to immigrant women's health insurance coverage and that anti-immigrant sentiments are inadequate for explaining immigrants' health care circumstances.

This research investigated physician and emergency room use among representative samples of children in the Dallas metropolitan area (N = 1606) and among patients who used Children's Medical Center of Dallas' First Care services (N = 612). Through telephone interviewing, caregivers to children under fifteen years of age were asked about an array of health service use behaviors, social-psychological issues related to acquiring health care for their children, and demographic characteristics as outlined by the Andersen & Newman model of health care service use. Children's use of physician services is best predicted by whether or not they have medical insurance, their level of income, and whether or not they have medical homes. Although having commercial managed care and fee-for-service Medicaid insurance consistently predicted increased physician use, neither independently reduced reliance on emergency rooms for non-emergent care. Managed care insurance and Medicaid did, however, significantly improve the odds that children would have medical homes, which significantly decreased emergency room use for non-emergent care. Further, increasing physician use and reducing reliance on hospital emergency rooms for non-emergent care will require ensuring that children have medical homeseither private physicians or community health centersat which they can readily and consistently receive sick and well care. Although some ethnic differences were observed, few of the broad array of factors in the Behavioral Model significantly predicted either physician or emergency room use. Moreover, educational levels and health beliefs rarely, and if significant negligibly, influenced physician and emergency room use. Health policy for children would best be served by focusing on programs that facilitate parent's ability to secure health insurance for their children and allocating children to medical homes where they can readily and consistently access sick and well care.

Managed Care has become a major player in the health care industry. Employers, looking to save health care costs, were the initial driving force. The financial benefits have been documented, but quality of care and access have been debated. The private sector of health care initially became involved, however the public sector, particularly Medicaid has followed. The push in the public sector has also been to save money, and many Medicaid recipients are being mandated to join a managed care plan. However, consumers, employers and public policymakers all want to assure that quality of care and access to care are not sacrificed. Thus, quality and access are being monitored under managed care. One method utilized to assess quality and access is the patient satisfaction survey. Medicaid patient satisfaction surveys reviewed in Michigan from 1988-1998, were utilized to gather data on changes in quality and access. Improvement I quality and access could not be documented when utilizing this method.

This study focuses on the problems of health care access experienced by undocumented Latinas: women from Mexico, Central and South America, and the Caribbean. Those who are undocumented may encounter significantly reduced access to health care, for the risk of discovery causes them to be more furtive in their activities. Undocumented immigrants to the U.S., especially Latin women, confront myriad obstacles in obtaining health care that are sociocultural, political, economic, and personal. The problem of competing policies in the health care arena represents one of the most formidable obstacles for undocumented persons. These conflicting conditions are such that some services are easier to access, while other services are more difficult to obtain. For example, undocumented Latinas are likely to find family planning services easier to obtain than prenatal care under terms of the new federal welfare law that eliminates prenatal care for undocumented immigrants. Even health care providers appear to have limited awareness about competing policies. As such, this qualitative interview study illustrates that it is possible to promote greater knowledge and understanding about the problems of competing policies among a selected group of health care administrators and providers. The data analysis portrays their new awareness for which policy revisions are needed to rectify and expand undocumented Latinas' access to health care services. The data support the review of literature which together suggest that ignorance on the part of providers, the public, politicians, and the media is the most critical barrier preventing health care access for undocumented Latinas. Consequently, the participants promote education for themselves and for the community as the essential remedy to alleviate this population's pain, despair, and increased morbidity related to health care exclusion. Moreover, the participants believe education represents the crucial tool for subjugating this wrath of ignorance among the political elite. The participants' recommendations point out that social justice perspectives are integral to redefining, reconstructing, and remedizing health care policy. Recommended remedies include: upholding Latinas' right to health care by expanding health care services, establishing universal access and universal health insurance, and promoting federalized reimbursement for health care. The recommendations center upon renewed emphasis in education, research, and leadership through empowerment from participation in coalitions and fora, volunteerism, partnerships between hospitals and the community, and knowledge distribution.