O Papel das Agências de Viagens e Turismo no Desenvolvimento do Turismo Emissor e Receptor

Devido a mudanças tecnológicas e da globalização, o turismo vem passando por grandes transformações, permitindo um maior acesso às informações e uma maior aproximação entre o consumidor e o mercado turístico. O papel das agências de viagens e turismo (AVT’s) é de fundamental importância para o desenvolvimento da actividade turística de um país. Face a isto, as AVT’s devem aderir ao novo cenário, procurando acompanhar a evolução, renovando e actualizando sempre os seus serviços. O presente estudo tem por objectivo avaliar o papel das AVT’s da ilha de São Vicente, no âmbito do turismo emissor e receptor. Foi realizado um estudo de caso, incluindo os doze representantes das AVT’s da ilha de S. Vicente, com excepção das empresas exclusivamente marítimas. Foi usado um guião de entrevistas para a obtenção de dados relacionados aos responsáveis dos serviços, a empresa, aos colaboradores internos, clientes, serviços oferecidos, sazonalidade e sua problemática, parceiros, as tecnologias de informação e as perspectivas futuras. As informações foram analisadas sob um enquadramento teórico e prático. Constatou-se que sete agências dedicam-se ao turismo emissor e receptor, três ao turismo emissor, e duas ao receptor. Foi possível observar que as AVT’s apresentam semelhanças na prestação de serviços e a maioria tem a preocupação de acompanhar as exigências actuais do turismo. Pode-se concluir que o turismo emissor e receptor estão bem representados pelas AVT’s de São Vicente. Technological changes and globalization has allowed big transformations in Tourism, greater access to information and a closer relationship between the consumer and tourist market. The role of the Travel and Tourism Agencies (TTA) has fundamental importance for the tourism development in a country, and they must adhere to the new environment, trying to follow the evolution, always renewing and updating their services. The present study aims to evaluate the role of TTA’s in São Vicente Island, in the field of inbound and outbound tourism. It was conducted a case study, including 12 representatives of TTA's in São Vicente, with exception of shipping companies. It was used a scripted interview to obtain data about the service delegate, the company, internal employees, customers, offered services, seasonality and its problems, partners, information technology and future prospects. Data were analyzed from a theoretical and practical view. It was found that seven agencies dedicated to inbound and outbound tourism, three to outbound and two to inbound. The TTA’s have similarities in service delivery and most have the concern to keep up with current demands of tourism. It can be concluded that inbound and outbound tourism are well represented by TTA’s in São Vicente.

State of Iowa Department of Administrative Services Human Resource Enterprise: Review of State Hiring Practices, April 30, 2007

The State of Iowa and the Hiring Practices Working Group commissioned this review of the State’s hiring practices in response to recent concerns about these practices involving racial discrimination claims against the Departments of Human Services, Transportation, and Iowa Workforce Development. The State of Iowa should be commended for undertaking this review. The State has a longstanding Affirmative Action Program and commitment to diversity – they instituted their Affirmative Action Program in 1973, and continue their commitment to its success by making the changes necessary to ensure the program is viable and sustainable. Iowa Department of Administrative Services In July 2003, the State created the Iowa Department of Administrative Services (DAS) as a way to manage and coordinate the major resources of state government. DAS provides human resource services through an entrepreneurial management model. Entrepreneurial management is a customer-focused approach to delivering services. The customer departments have input about what services and products they want from DAS and in turn DAS is funded by the customer departments through purchases of DAS services and products. DAS looks to offer new and additional services (for example recruitment support and coordination) to various customers on a fee-for-service basis. A customer council is charged with approving the DAS business plan, establishing the rate for services, and reviewing service delivery and complaints. Under this entrepreneurial model, human resource services are provided by DAS-HRE (Human Resources Enterprise) central staff, 12 DAS-HRE Personnel Officers located at the customer departments, and customer agency staff. The majority of the recruitment and hiring functions are done by the customer (hiring) departments and their staff. Applications for employment are submitted using the BrassRing system with applicants being qualified by DAS-HRE employees. Since the creation of Human Resources Enterprise, DAS-HRE has strived to provide human resource tools to the departments. The Screening Manual and the Supervisor’s Manual are just two examples of the resources created for the hiring departments. They also provide Supervisor Training for newly appointed supervisors. Larger departments have dedicated staff assigned to human resource activities. The staff at the departmental level may or may not have a human resources background. Iowa Population and Workforce The 2000 U.S. Census indicated that Iowa’s population was 2,926,324. According to this census, 92.6 percent of Iowa’s population identified their race as white (alone). The nonwhite alone or minority population (including Black or African American, Asian, Native Hawaiian or Pacific Islander, Hispanic or Latino, American Indian or Alaska Native, two or more races, or some other race) was 7.4 percent.

Iowa Plan for Brain Injury, 2007-2010

Traumatic Brain Injury (TBI) impacts the lives of thousands of Iowans every year. TBI has been described as the “Silent Epidemic” because so often the scars are not visible to others. The affects of brain injury are cognitive, emotional, social, and can result in physical disability. In addition to the overwhelming challenges individuals with brain injury experience, families also face many difficulties in dealing with their loved one’s injury, and in navigating a service delivery system that can be confusing and frustrating. In 1998, the Iowa Department of Public Health (IDPH) conducted a comprehensive statewide needs assessment of brain injury in Iowa. This assessment led to the development of the first Iowa Plan for Brain Injury, “Coming Into Focus.” An updated state plan, the Iowa Plan for Brain Injuries 2002 – 2005, was developed, which reported on progress of the previous state plan, and outlined gaps in service delivery in Iowa. Four areas of focus were identified by the State Plan for Brain Injuries Task Force that included: 1) Expanding the Iowa Brain Injury Resource Network (IBIRN); 2) Promoting a Legislative and Policy Agenda, While Increasing Legislative Strength; 3) Enhancing Data Collection; and, 4) Increasing Funding. The IDPH utilized “Coming Into Focus” as the framework for an application to the federal TBI State Grant Program, which has resulted in more than $900,000 for plan implementation. Iowa continues to receive grant dollars through the TBI State Grant Program, which focuses on increasing capacity to serve Iowans with brain injury and their families. Highlighting the success of this grant project, in 2007 the IDPH received the federal TBI Program’s “Impacting Systems Change” Award. The Iowa Brain Injury Resource Network (IBIRN) is the product of nine years of TBI State Grant Program funding. The IBIRN was developed to ensure that Iowans got the information and support they needed after a loved one sustained a TBI. It consists of a hospital and service provider pre-discharge information and service linkage process, a resource facilitation program, a peer-to-peer volunteer support network, and a service provider training and technical assistance program. Currently over 90 public and private partners work with the IDPH and the Brain Injury Association of Iowa (BIA-IA) to administer the IBIRN system and ensure that families have a relevant and reliable location to turn for information and support. Further success was accomplished in 2006 when the Iowa legislature created the Brain Injury Services Program within the IDPH. This program consists of four components focusing on increasing access to services and improving the effectiveness of services available to individuals with TBI and their families, including: 1) HCBS Brain Injury Waiver-Eligible Component; 2) Cost Share Component; 3) Neuro-Resource Facilitation; and, 4) Enhanced Training. The Iowa legislature appropriated $2.4 million to the Brain Injury Services Program in state fiscal year (SFY) 2007, and increased that amount to $3.9 million in SFY 2008. The Cost Share Component models the HCBS Brain Injury Waiver menu of services but is available for Iowans who do not qualify functionally or financially for the Waiver. In addition, the Neuro-Resource Facilitation program links individuals with brain injury and their families to needed supports and services. The Iowa Plan for Brain Injury highlights the continued need for serving individuals with brain injury and their families. Additionally, the Plan outlines the paths of prevention and services, which will expand the current system and direct efforts into the future.

Iowa Plan for Brain Injury: Executive Summary, 2007-2010

Traumatic Brain Injury (TBI) impacts the lives of thousands of Iowans every year. TBI has been described as the “Silent Epidemic” because so often the scars are not visible to others. The affects of brain injury are cognitive, emotional, and social and can result in physical disability. In addition to the overwhelming challenges individuals with brain injury experience, families also face many difficulties in dealing with their loved one’s injury and in navigating a service delivery system that can be confusing and frustrating.

Growing The Fields of Opportunity for Children and Adults with Autism in Iowa, 2009-2010

Many would argue that the dramatic rise in autism has reached critical mass, and this council echoes that statement. Iowa, like many states in the nation, is currently ill equipped to handle the large influx of children and adults with autism. When this council was initially formed we were facing diagnosis rates of 1 in 150 and currently the diagnosis rate is 1 in 91. Current resource strains in education, qualified trained professionals, access to care, and financial services are rapidly deteriorating Iowa’s ability to deliver quality services to children, adults, and families affected by autism. If Iowa leadership fails to act quickly the already strained system will face a breaking point in the following areas: financing, coordination of care, educational resources, early identification, adult services, and access to service delivery - just to name a few. This council has taken the past 12 plus months hearing testimony from state officials, providers, and caregivers to ensure that care for those with autism is effective, cost efficient, and accessible. This council will be making recommendations on three major areas; early identification, seamless support/coordination of care, and financing of care. While these areas will be highlighted in this first annual report it in no way minimizes other areas that need to be addressed such as early intervention, special education, training, in-home support services, financing options, and data collection. Implementing the initial recommendations of this council will lay foundational support for the areas mentioned above. Often those in position to help ask what can be done to help families in Iowa. This council has provided a roadmap to help facilitate effective and proven treatments to children and adults with autism.

Local Public-Services Provision under Public-Private Partnerships : Contractual Design and Contracting Parties Incentives

When deciding to resort to a PPP contract for the provision of a local public service, local governments have to consider the demand risk allocation between the contracting parties. In this article, I investigate the effects of demand risk allocation on the accountability of procuring authorities regarding consumers changing demand, as well as on the cost-reducing effort incentives of the private public-service provider. I show that contracts in which the private provider bears demand risk motivate more the public authority from responding to customer needs. This is due to the fact that consumers are empowered when the private provider bears demand risk, that is, they have the possibility to oust the private provider in case of non-satisfaction with the service provision, which provides procuring authorities with more credibility in side-trading and then more incentives to be responsive. As a consequence, I show that there is a lower matching with consumers' preferences over time when demand risk is on the public authority rather than on the private provider, and this is corroborated in the light of two famous case studies. However, contracts in which the private provider does not bear demand risk motivate more the private provider from investing in cost-reducing efforts. I highlight then a tradeoff in the allocation of demand risk between productive and allocative efficiency. The striking policy implication of this article for local governments would be that the current trend towards a greater resort to contracts where private providers bear little or no demand risk may not be optimal. Local governments should impose demand risk on private providers within PPP contracts when they expect that consumers' preferences over the service provision will change over time.

Stage managing bipolar disorder.

OBJECTIVES: Clinical staging is widespread in medicine - it informs prognosis, clinical course, and treatment, and assists individualized care. Staging places an individual on a probabilistic continuum of increasing potential disease severity, ranging from clinically at-risk or latency stage through first threshold episode of illness or recurrence, and, finally, to late or end-stage disease. The aim of the present paper was to examine and update the evidence regarding staging in bipolar disorder, and how this might inform targeted and individualized intervention approaches. METHODS: We provide a narrative review of the relevant information. RESULTS: In bipolar disorder, the validity of staging is informed by a range of findings that accompany illness progression, including neuroimaging data suggesting incremental volume loss, cognitive changes, and a declining likelihood of response to pharmacological and psychosocial treatments. Staging informs the adoption of a number of approaches, including the active promotion of both indicated prevention for at-risk individuals and early intervention strategies for newly diagnosed individuals, and the tailored implementation of treatments according to the stage of illness. CONCLUSIONS: The nature of bipolar disorder implies the presence of an active process of neuroprogression that is considered to be at least partly mediated by inflammation, oxidative stress, apoptosis, and changes in neurogenesis. It further supports the concept of neuroprotection, in that a diversity of agents have putative effects against these molecular targets. Clinically, staging suggests that the at-risk state or first episode is a period that requires particularly active and broad-based treatment, consistent with the hope that the temporal trajectory of the illness can be altered. Prompt treatment may be potentially neuroprotective and attenuate the neurostructural and neurocognitive changes that emerge with chronicity. Staging highlights the need for interventions at a service delivery level and implementing treatments at the earliest stage of illness possible.

On the innovation capacity of technologyrelated knowledge-intensive business services. A case study of the technology and engineering consulting (TEC) sector in Singapore

Even though the research on innovation in services has expanded remarkably especially during the past two decades, there is still a need to increase understanding on the special characteristics of service innovation. In addition to studying innovation in service companies and industries, research has also recently focused more on services in innovation, as especially the significance of so-called knowledge intensive business services (KIBS) for the competitive edge of their clients, othercompanies, regions and even nations has been proved in several previous studies. This study focuses on studying technology-based KIBS firms, and technology andengineering consulting (TEC) sector in particular. These firms have multiple roles in innovation systems, and thus, there is also a need for in-depth studies that increase knowledge about the types and dimensions of service innovations as well as underlying mechanisms and procedures which make the innovations successful. The main aim of this study is to generate new knowledge in the fragmented research field of service innovation management by recognizing the different typesof innovations in TEC services and some of the enablers of and barriers to innovation capacity in the field, especially from the knowledge management perspective. The study also aims to shed light on some of the existing routines and new constructions needed for enhancing service innovation and knowledge processing activities in KIBS companies of the TEC sector. The main samples of data in this research include literature reviews and public data sources, and a qualitative research approach with exploratory case studies conducted with the help of the interviews at technology consulting companies in Singapore in 2006. These complement the qualitative interview data gathered previously in Finland during a larger research project in the years 2004-2005. The data is also supplemented by a survey conducted in Singapore. The respondents for the survey by Tan (2007) were technology consulting companies who operate in the Singapore region. The purpose ofthe quantitative part of the study was to validate and further examine specificaspects such as the influence of knowledge management activities on innovativeness and different types of service innovations, in which the technology consultancies are involved. Singapore is known as a South-east Asian knowledge hub and is thus a significant research area where several multinational knowledge-intensive service firms operate. Typically, the service innovations identified in the studied TEC firms were formed by several dimensions of innovations. In addition to technological aspects, innovations were, for instance, related to new client interfaces and service delivery processes. The main enablers of and barriers to innovation seem to be partly similar in Singaporean firms as compared to the earlier study of Finnish TEC firms. Empirical studies also brought forth the significance of various sources of knowledge and knowledge processing activities as themain driving forces of service innovation in technology-related KIBS firms. A framework was also developed to study the effect of knowledge processing capabilities as well as some moderators on the innovativeness of TEC firms. Especially efficient knowledge acquisition and environmental dynamism seem to influence the innovativeness of TEC firms positively. The results of the study also contributeto the present service innovation literature by focusing more on 'innovation within KIBs' rather than 'innovation through KIBS', which has been the typical viewpoint stressed in the previous literature. Additionally, the study provides several possibilities for further research.

Verkkopalveluiden vaikutukset kuntaorganisaatiossa. Case: Kouvolan kaupunki

Tämän tutkimuksen tavoitteena oli tarkastella tietoverkkojen kautta tarjottavien palveluiden tuomia vaikutuksia kuntaorganisaatiossa organisaation sisäisestä näkökulmasta. Tutkimus jakautuu teoreettiseen sekä empiiriseen osaan. Teoriaosa muodostuu tietoyhteiskunnan asemasta ja tilanteesta toi-mintaympäristön muokkaajana. Lisäksi teoria keskittyy selvittämään verkkopalveluiden asemaa ja kehitystä kunnissa. Tutkimuksen empiirinen aineisto kerättiin teemahaastattelujen avulla case-kohteesta. Tällä hetkellä useat kunnat ovat siirtymässä informaatiopalveluista kohti sähköisiä asiointipalveluja. Tutkimuksessa kävi kuitenkin ilmi, että verkkopalveluiden tuomat muutokset organisaatioon ovat toistaiseksi pysyneet pieninä. Tulevaisuudessa verkkopalvelut koetaan kuitenkin ratkaisevaksi osaksi kuntien palvelutuotantoa. Jatkossa kuntaorganisaatiot tulevatkin kohtaamaan yhä enemmän haasteita palveluiden integroinnissa osaksi toimintaa. Ennen kuin verkkopalveluiden tehokkaampi hyödyntäminen on mahdollista, tulevat haasteet mm. resurssien käytön ja organisaatio muutoskyvyn osalta ratkaista.

The determinants of contractual choice for private involvement in infrastructure projects in the United States

Reliance on private partners to help provide infrastructure investment and service delivery is increasing in the United States. Numerous studies have examined the determinants of the degree of private participation in infrastructure projects as governed by contract type. We depart from this simple public/private dichotomy by examining a rich set of contractual arrangements. We utilize both municipal and state-level data on 472 projects of various types completed between 1985 and 2008. Our estimates indicate that infrastructure characteristics, particularly those that reflect stand alone versus network characteristics, are key factors influencing the extent of private participation. Fiscal variables, such as a jurisdiction’s relative debt level, and basic controls, such as population and locality of government, increase the degree of private participation, while a greater tax burden reduces private participation.

Why do municipalities cooperate to provide local public services? An empirical analysis

Intermunicipal cooperation is being increasingly adopted in various countries as a part of local service delivery reforms. This paper draws on survey data from Spain’s municipalities to examine the reasons underpinning the decisions of local governments to engage in intermunicipal cooperation and privatisation. Our empirical analysis indicates that small municipalities prefer to rely on cooperation for reducing costs, while their larger counterparts prefer to privatise the delivery of services. By cooperating, scale economies can be achieved with lower transaction costs and fewer concerns for competition than is the case via private production.

Patient-centered Care in Maternity Services: A Critical Appraisal and Synthesis of the Literature.

BACKGROUND: Patient-centered care (PCC) has been recognized as a marker of quality in health service delivery. In policy documents, PCC is often used interchangeably with other models of care. There is a wide literature about PCC, but there is a lack of evidence about which model is the most appropriate for maternity services specifically. AIM: We sought to identify and critically appraise the literature to identify which definition of PCC is most relevant for maternity services. METHODS: The four-step approach used to identify definitions of PCC was to 1) search electronic databases using key terms (1995-2011), 2) cross-reference key papers, 3) search of specific journals, and 4) search the grey literature. Four papers and two books met our inclusion criteria. ANALYSIS: A four-criteria critical appraisal tool developed for the review was used to appraise the papers and books. MAIN RESULTS: From the six identified definitions, the Shaller's definition met the majority of the four criteria outlined and seems to be the most relevant to maternity services because it includes physiologic conditions as well as pathology, psychological aspects, a nonmedical approach to care, the greater involvement of family and friends, and strategies to implement PCC. CONCLUSION: This review highlights Shaller's definitions of PCC as the one that would be the most inclusive of all women using maternity services. Future research should concentrate on evaluating programs that support PCC in maternity services, and testing/validating this model of care.

Elinkaarihankkeen rakennusliikeriskit

Tiivistelmä: Elinkaaren palvelumallit ovat suosittuja julkisten palveluiden hankintamuotoja Iso-Britanniassa. PPP–malli on yksi monista julkisten palvelujen kumppanuusmalleista, josta on tullut joissakin kunnissa yhä suositumpi hankintamalli myös Suomessa. Tämä on seurausta kuntien tiukasta taloustilanteesta, jossa PPP–hankkeen katsotaan mahdollistavan julkisen sektorin investoinnit joutumatta leikkaamaan muita pakollisia hankintoja. Kuitenkin koko elinkaaren kattavat palvelutarjonnan hankintamallit ovat vielä melko uusia malleja ja meillä on tarve löytää toimivia sopimusmalleja ja käytäntöjä, jotta hankkeista saadaan rakennusliikettä kiinnostavia liiketoimintamalleja. Ulkomailla elinkaarihankkeista on tehty monia tutkimuksia ja konsultit ovat kääntäneet niitä omiin tarkoituksiinsa sopiviksi. Kuitenkin Suomen lainsäädäntö on erilainen julkisten palveluiden tuottamisessa, erityisesti lakisääteisissä terveydenhuoltopalveluissa, vesi- ja jätevesihuollossa, vankeinhoidossa, ja niin edelleen. Tästä näkökulmasta ulkomailla tehdyt tutkimukset eivät sellaisenaan sovi Suomeen käytettäviksi. Esimerkiksi tutkimuksissa esitetään, että elinkaarihankkeet tuottavat pitkän aikavälin kassavirtaan, mutta tämä etu koskee vain rahoittaja ja kiinteistöpalvelu yrityksiä - ei rakennusyritystä. Tutkimuksissa mainitaan myös muista elinkaarihankkeiden mahdollisuuksista, jotka jäävät kuitenkin rakennusliikkeen näkökulmasta epäselviksi. Perinteisiin rakennuttamisen malleihin verrattuna elinkaarihankkeiden sopimusmenettelyt ovat monimutkaisempia sekä aikaa vievempiä ja sopijaosapuolten yhteistyö elinkaarihankkeissa on välttämätöntä. Käytännössä elinkaarihankkeiden riskienjako nähdään julkisen sektorin ja yksityisen sektorin välillä yksipuoliseksi. Jotta elinkaarimalli yleistyisi Suomessa, niin elinkaarisopimuksen riskienjaosta on tehtävä tasapuolinen ja käyttäjä pitää saada myös riskejä kantamaan. Tässä työssä keskitytään arvioimaan elinkaarimallien keskeisiä menestystekijöitä ja riskitekijöitä ja löytää mahdollisia tapoja tehdä hankintaprosessista helppoa ja sujuvaa. Samalla yritetään selvittää, miten elinkaarihankkeesta saadaan rakennusliikkeen kannalta menestyvää liiketoimintaa. Johtopäätökset perustuvat aikaisempiin tutkimuksiin ja empiiriseen tapaustutkimukseen. Työssä arvioidaan niitä seikkoja, jotka vaikuttavat yksityisen sektorin tarjouspäätökseen. Arvioinnissa erotetaan toisistaan kolme erillistä riskitekijää; tarjouksen tekemisen riskit, rakennushankkeen riskit ja elinkaaren aikaiset riskit. Työssä todetaan, että aikaisemmat tutkimukset ovat riittämättömiä rakennusliikkeen riskien arvioimiseen.

Understanding space, place and leisure of women over 85 living in the community

There is an increase in the number of older adults 85 and over, who are choosing to live alone within the community. Moreover, older adults who live alone are reportedly spending an extensive amount of time alone within the home environment. In an effort to provide additional support and resources to older adults living in the community, a compliment of services are being offered through public and private organizations. These in-home supports focus on the instrumental or functional tasks of daily living, such as personal and rehabilitative care, nourishment, maintenance and upkeep of the home, as well as volunteer social visitation. However leisure resources and programs are not included among these services. Consequently, this creates a gap in leisure provision among this segment of the population. Throughout the life course, an individual's identity, role and purpose are developed and sustained through instrumental work roles in the formal and informal sector, as well as through personally meaningful leisure pastimes and experiences. Although roles shift post retirement, participation in instrumental and expressive activities can provide opportunities through which older adults are able to fulfill their need for agency (individuality and autonomy) and affiliation (social relatedness). Therefore barriers that inhibit instrumental or leisure experiences can negatively impact older adults' quality of life. This study explored the leisure lifestyles of four older adults, all of whom were over 85, lived alone within the community and were oriented to person, time and place. It became apparent that participants ordered their lives around a routine that consisted of instrumental, expressive and socially integrated tasks and activities. Moreover participants purposely chose to remain at home because their home environment facilitated freedom, choice and independence. As a result all four participants viewed their independence within the home as a critical determinant to their overall quality of life. Challenges associated with the home environment, participants' personal capacities and relationships were negotiated on a daily basis. Failure to positively adapt to these challenges inhibited meaningful engagement and personal fulfillment. Traditionally, leisure service delivery has been offered within institutions and through various community based venues. As a result leisure provision has been focused on the needs of the frail elderly who reside in institutions or the well elderly who are able to access leisure amenities within the community. However the growing number of older adults electing to live alone is on the rise. As individuals age the home becomes the preferred context for leisure experiences. If older adults are choosing to live alone, then both their instrumental and leisure needs must be addressed. As a result, it is imperative that leisure professionals extend the scope of service delivery to include home centered older adults.

Predictors of primary health care utilization by former residents of institutions in Ontario

For years institutionalization has been the primary method of service delivery for persons with developmental disabilities (DD). However, in Ontario the last institution was closed on March 31, 2009 with former residents now residing in small, communitybased homes. This study investigated potential predictors of primary health care utilization by former residents. Several indirect measures were employed to gather information from 60 participants on their age, health status, adaptive functioning level, problem behaviour, mental health status and, total psychotropic medication use. A direct measure was used to gather primary health care utilization information, which served as the dependent variable. A stepwise linear regression failed to reveal significant predictors of health care utilization. The data were subsequently dichotomized and the outcomes of a logistic regression analysis indicated that mental health status, psychotropic medication use and, an interaction between mental health status and health status significantly predicted higher primary health care usage.