The experience of emotional expression in the context of social relations for people diagnosed with schizophrenia : a phenomenological explication

The experience of emotional expression in the context of social relations is not well understood for people diagnosed with schizophrenia. Early phenomenological research on the experience of people diagnosed with schizophrenia traditionally focussed on self experience in isolation from others, with later research explicating isolated aspects of self experience in relation to others. The current research aimed to focus on the progressive experience of emotional expression of people diagnosed with schizophrenia in relation to others over 12 months, in order to gain a broad spectrum of experience. This study involved unstructured interviews with 7 participants, an average of 4 times each, over a period of 12 months. Due to the unstructured nature of the interviews, a great breadth of experience was explicated. From the interviews there emerged 6 themes grouped together as a transition into, and 5 themes grouped together as a recovery from, symptoms associated with a diagnosis of schizophrenia. Special significance was given to the theme of relational confusion as an experience that provides an understanding of the relationship between social stressors and personal characteristics with responses that are associated with a diagnosis of schizophrenia. It was suggested that participants experienced themselves, including their distancing and isolating responses, as a part of a social system. The breadth of experiences that emerged afforded a framework of experiences within which prior phenomenological research findings on static moments of experience have been located. A more meaningful understanding of the transitioning into and recovery from the experiences associated with a diagnosis of schizophrenia will afford advances in mental health practice.

The experience of China-educated nurses working in Australia : a symbolic interactionist perspective

Transnational nurse migration is a growing phenomenon. However, relatively little is known about the experiences of immigrant nurses and particularly about non-English speaking background nurses who work in more economically developed countries. Informed by a symbolic interactionist framework, this research explored the experience of China-educated nurses working in the Australian health care system. Using a modified constructivist grounded theory method, the main source of data were 46 face to face in-depth interviews with 28 China-educated nurses in two major cities in Australia. The key findings of this research are fourfold. First, the core category developed in this study is reconciling different realities, which inserts a theoretical understanding beyond the concepts of acculturation, assimilation, and integration. Second, in contrast to the dominant discourse which reduces the experience of immigrant nurses to language and culture, this research concludes that it was not just about language and nor was it simply about culture. Third, rather than focus on the negative aspects of difference as in the immigration literature and in the practice of nursing, this research points to the importance of recognising the social value of difference. Finally, the prevailing view that the experience of immigrant nurses is largely negative belies its complexities. This research concludes that it is naïve to define the experience as either good or bad. Rather, ambivalence was the essential feature of the experience and a more appropriate theoretical concept. This research produced a theoretical understanding of the experience of China-educated nurses working in Australia. The findings may not only inform Chinese nurses who wish to immigrate but also contribute to the implementation of more effective support services for immigrant nurses in Australian health care organisations.

The impact of presbyopic spectacles and contact lenses on driving performance

Presbyopia affects individuals from the age of 45 years onwards, resulting in difficulty in accurately focusing on near objects. There are many optical corrections available including spectacles or contact lenses that are designed to enable presbyopes to see clearly at both far and near distances. However, presbyopic vision corrections also disturb aspects of visual function under certain circumstances. The impact of these changes on activities of daily living such as driving are, however, poorly understood. Therefore, the aim of this study was to determine which aspects of driving performance might be affected by wearing different types of presbyopic vision corrections. In order to achieve this aim, three experiments were undertaken. The first experiment involved administration of a questionnaire to compare the subjective driving difficulties experienced when wearing a range of common presbyopic contact lens and spectacle corrections. The questionnaire was developed and piloted, and included a series of items regarding difficulties experienced while driving under day and night-time conditions. Two hundred and fifty five presbyopic patients responded to the questionnaire and were categorised into five groups, including those wearing no vision correction for driving (n = 50), bifocal spectacles (BIF, n = 54), progressive addition lenses spectacles (PAL, n = 50), monovision (MV, n = 53) and multifocal contact lenses (MTF CL, n = 48). Overall, ratings of satisfaction during daytime driving were relatively high for all correction types. However, MV and MTF CL wearers were significantly less satisfied with aspects of their vision during night-time than daytime driving, particularly with regard to disturbances from glare and haloes. Progressive addition lens wearers noticed more distortion of peripheral vision, while BIF wearers reported more difficulties with tasks requiring changes in focus and those who wore no vision correction for driving reported problems with intermediate and near tasks. Overall, the mean level of satisfaction for daytime driving was quite high for all of the groups (over 80%), with the BIF wearers being the least satisfied with their vision for driving. Conversely, at night, MTF CL wearers expressed the least satisfaction. Research into eye and head movements has become increasingly of interest in driving research as it provides a means of understanding how the driver responds to visual stimuli in traffic. Previous studies have found that wearing PAL can affect eye and head movement performance resulting in slower eye movement velocities and longer times to stabilize the gaze for fixation. These changes in eye and head movement patterns may have implications for driving safety, given that the visual tasks for driving include a range of dynamic search tasks. Therefore, the second study was designed to investigate the influence of different presbyopic corrections on driving-related eye and head movements under standardized laboratory-based conditions. Twenty presbyopes (mean age: 56.1 ± 5.7 years) who had no experience of wearing presbyopic vision corrections, apart from single vision reading spectacles, were recruited. Each participant wore five different types of vision correction: single vision distance lenses (SV), PAL, BIF, MV and MTF CL. For each visual condition, participants were required to view videotape recordings of traffic scenes, track a reference vehicle and identify a series of peripherally presented targets while their eye and head movements were recorded using the faceLAB® eye and head tracking system. Digital numerical display panels were also included as near visual stimuli (simulating the visual displays of a vehicle speedometer and radio). The results demonstrated that the path length of eye movements while viewing and responding to driving-related traffic scenes was significantly longer when wearing BIF and PAL than MV and MTF CL. The path length of head movements was greater with SV, BIF and PAL than MV and MTF CL. Target recognition was less accurate when the near stimulus was located at eccentricities inferiorly and to the left, rather than directly below the primary position of gaze, regardless of vision correction type. The third experiment aimed to investigate the real world driving performance of presbyopes while wearing different vision corrections measured on a closed-road circuit at night-time. Eye movements were recorded using the ASL Mobile Eye, eye tracking system (as the faceLAB® system proved to be impractical for use outside of the laboratory). Eleven participants (mean age: 57.25 ± 5.78 years) were fitted with four types of prescribed vision corrections (SV, PAL, MV and MTF CL). The measures of driving performance on the closed-road circuit included distance to sign recognition, near target recognition, peripheral light-emitting-diode (LED) recognition, low contrast road hazards recognition and avoidance, recognition of all the road signs, time to complete the course, and driving behaviours such as braking, accelerating, and cornering. The results demonstrated that driving performance at night was most affected by MTF CL compared to PAL, resulting in shorter distances to read signs, slower driving speeds, and longer times spent fixating road signs. Monovision resulted in worse performance in the task of distance to read a signs compared to SV and PAL. The SV condition resulted in significantly more errors made in interpreting information from in-vehicle devices, despite spending longer time fixating on these devices. Progressive addition lenses were ranked as the most preferred vision correction, while MTF CL were the least preferred vision correction for night-time driving. This thesis addressed the research question of how presbyopic vision corrections affect driving performance and the results of the three experiments demonstrated that the different types of presbyopic vision corrections (e.g. BIF, PAL, MV and MTF CL) can affect driving performance in different ways. Distance-related driving tasks showed reduced performance with MV and MTF CL, while tasks which involved viewing in-vehicle devices were significantly hampered by wearing SV corrections. Wearing spectacles such as SV, BIF and PAL induced greater eye and head movements in the simulated driving condition, however this did not directly translate to impaired performance on the closed- road circuit tasks. These findings are important for understanding the influence of presbyopic vision corrections on vision under real world driving conditions. They will also assist the eye care practitioner to understand and convey to patients the potential driving difficulties associated with wearing certain types of presbyopic vision corrections and accordingly to support them in the process of matching patients to optical corrections which meet their visual needs.

One-time-password-authenticated key exchange

To reduce the damage of phishing and spyware attacks, banks, governments, and other security-sensitive industries are deploying one-time password systems, where users have many passwords and use each password only once. If a single password is compromised, it can be only be used to impersonate the user once, limiting the damage caused. However, existing practical approaches to one-time passwords have been susceptible to sophisticated phishing attacks. ---------- We give a formal security treatment of this important practical problem. We consider the use of one-time passwords in the context of password-authenticated key exchange (PAKE), which allows for mutual authentication, session key agreement, and resistance to phishing attacks. We describe a security model for the use of one-time passwords, explicitly considering the compromise of past (and future) one-time passwords, and show a general technique for building a secure one-time-PAKE protocol from any secure PAKE protocol. Our techniques also allow for the secure use of pseudorandomly generated and time-dependent passwords.

Food insecurity in Brisbane : the single mother’s struggle

Using a feminist reflexive approach this paper reports on interviews with single mother’s in the Brisbane area about their experiences with food shopping and household food security. Preliminary findings suggest that most experience significant stress around the amount of money they have available for food. As the price of food and other costs of living increase, the only budget item that is flexible – groceries - is squeezed tighter. All women expressed a reluctance to ask for help from strangers at agencies instead relying on the support of family and friends to keep them food secure. Sometimes family and friends had no spare resources to help or were not aware of the extent their friend or relative might be struggling. The increased risks of poverty and food insecurity mean many go without as feeding the children takes precedence. The quality of their diets is variable with many reporting on aiming for quantity rather than being concerned with nutritional balance. Exhaustion and stress from being over-committed doing three roles, mother, father and housekeeper was self-identified as a key factor leading to mental health conditions such as depression, burnout and break down. Female single parent households are vulnerable to reducing welfare benefits as children grow or child support changes. Current policy forces single parents out to work but many can only manage part-time work for lower wages and are barely able to cope with this extra burden often resenting the reduction in benefits it brings. Public perceptions, derision and the notions of choice surrounding single parenting leave the cohort divided and silent for fear of reprisals. In my investigation issues arise about welfare policy that keep benefits low and workplace patriarchal power that can contribute to systemic poverty and the widening of the gender gap in poverty. So far analysis suggests a better support system around community food security including some hands on home help services, nutritional information, cooking classes, community gardening and other social capital building activities are needed for these women in order to avoid long-term health problems and help them better care for the next generation.

Contributions of vision-proprioception interactions to the estimation of time-varying hand and target locations

We investigated the relative importance of vision and proprioception in estimating target and hand locations in a dynamic environment. Subjects performed a position estimation task in which a target moved horizontally on a screen at a constant velocity and then disappeared. They were asked to estimate the position of the invisible target under two conditions: passively observing and manually tracking. The tracking trials included three visual conditions with a cursor representing the hand position: always visible, disappearing simultaneously with target disappearance, and always invisible. The target’s invisible displacement was systematically underestimated during passive observation. In active conditions, tracking with the visible cursor significantly decreased the extent of underestimation. Tracking of the invisible target became much more accurate under this condition and was not affected by cursor disappearance. In a second experiment, subjects were asked to judge the position of their unseen hand instead of the target during tracking movements. Invisible hand displacements were also underestimated when compared with the actual displacement. Continuous or brief presentation of the cursor reduced the extent of underestimation. These results suggest that vision–proprioception interactions are critical for representing exact target–hand spatial relationships, and that such sensorimotor representation of hand kinematics serves a cognitive function in predicting target position. We propose a hypothesis that the central nervous system can utilize information derived from proprioception and/or efference copy for sensorimotor prediction of dynamic target and hand positions, but that effective use of this information for conscious estimation requires that it be presented in a form that corresponds to that used for the estimations.

Incidental walking activity is sufficient to induce time-dependent conditioning of the Achilles tendon

The Achilles tendon has been seen to exhibit time-dependent conditioning when isometric muscle actions were of a prolonged duration, compared to those involved in dynamic activities, such as walking. Since, the effect of short duration muscle activation associated with dynamic activities is yet to be established, the present study aimed to investigate the effect of incidental walking activity on Achilles tendon diametral strain. Eleven healthy male participants refrained from physical activity in excess of the walking required to carry out necessary daily tasks and wore an activity monitor during the 24 h study period. Achilles tendon diametral strain, 2 cm proximal to the calcaneal insertion, was determined from sagittal sonograms. Baseline sonographic examinations were conducted at ∼08:00 h followed by replicate examinations at 12 and 24 h. Walking activity was measured as either present (1) or absent (0) and a linear weighting function was applied to account for the proximity of walking activity to tendon examination time. Over the course of the day the median (min, max) Achilles tendon diametral strain was −11.4 (4.5, −25.4)%. A statistically significant relationship was evident between walking activity and diametral strain (P < 0.01) and this relationship improved when walking activity was temporally weighted (AIC 131 to 126). The results demonstrate that the short yet repetitive loads generated during activities of daily living, such as walking, are sufficient to induce appreciable time-dependant conditioning of the Achilles tendon. Implications arise for the in vivo measurement of Achilles tendon properties and the rehabilitation of tendinopathy.

Emergency department nurses' understanding and experiences of implementing discharge planning

Aim: This paper is a report of a study conducted to describe emergency department nurses' understanding and experiences of implementing discharge planning. ---------- Background: Discharge planning in the emergency department is an important issue because of increased healthcare costs and greater emphasis on continuity of care. When executed as a collaborative process involving a multi-disciplinary team with the patient and family, discharge planning provides continuity of care for patients, less demand on hospitals, improvement in community services and in the services of other healthcare organizations. ---------- Method: The qualitative approach of phenomenography was used in this study. Thirty-two emergency department nurses were recruited between July and September 2005. Semi-structured interviews were conducted. ---------- Findings: From interviewees' descriptions of implementing discharge planning, six categories were established: implementing discharge planning as 'getting rid of my patients', completing routines, being involved in patient education, professionally accountable practice, autonomous practice and demonstrating professional emergency department nursing care. The referential meaning of implementing discharge planning 'in the outcome space' was the professional commitment to emergency department provision of effective discharge services. ---------- Conclusion: The results of this research contribute to knowledge of emergency department nurses' experience in the implementation of the discharge planning process. Key requirements for the provision of manageable discharge services both in Taiwan and worldwide highlighted by this study include adequate workloads, sufficient time, clear policies and standards of discharge planning and enhancement of professional commitment.

Educating the world's railway engineers

An increasing loss of engineering expertise from the railway industry globally coincides with a rapid expansion of the industry. Continuing professional development is critical to this sector, but needs to be distance based to cater for the international demand for such development. A unique Master degree in railway infrastructure was created out of extensive materials prepared by expert engineers, which captured their detailed knowledge. A team at Queensland University of Technology in Australia prepared the detailed and high quality online resources needed for this degree; the team comprised an academic, a project manager, learning designers and a publisher, all with experience in distance education. The degree has been running for 12 months with students from many countries. A key aim of the degree is to create a collaborative community comprising learners, teachers and practicing engineers from around the world. The team has also worked hard to ensure the content of the study materials, the form of the assessment tasks and the interactive learning sessions relate closely to real-world problems and challenges faced by the students in their workplace, wherever that is. Widely differing time zones are a challenge but are usually obviated by the asynchronous nature of the online resources.

How environmental and organizational complexity affects opportunity recognition and exploitation in development projects

Principal Topic: Project structures are often created by entrepreneurs and large corporate organizations to develop new products. Since new product development projects (NPDP) are more often situated within a larger organization, intrapreneurship or corporate entrepreneurship plays an important role in bringing these projects to fruition. Since NPDP often involves the development of a new product using immature technology, we describe development of an immature technology. The Joint Strike Fighter (JSF) F-35 aircraft is being developed by the U.S. Department of Defense and eight allied nations. In 2001 Lockheed Martin won a $19 billion contract to develop an affordable, stealthy and supersonic all-weather strike fighter designed to replace a wide range of aging fighter aircraft. In this research we define a complex project as one that demonstrates a number of sources of uncertainty to a degree, or level of severity, that makes it extremely difficult to predict project outcomes, to control or manage project (Remington & Zolin, Forthcoming). Project complexity has been conceptualized by Remington and Pollock (2007) in terms of four major sources of complexity; temporal, directional, structural and technological complexity (See Figure 1). Temporal complexity exists when projects experience significant environmental change outside the direct influence or control of the project. The Global Economic Crisis of 2008 - 2009 is a good example of the type of environmental change that can make a project complex as, for example in the JSF project, where project managers attempt to respond to changes in interest rates, international currency exchange rates and commodity prices etc. Directional complexity exists in a project where stakeholders' goals are unclear or undefined, where progress is hindered by unknown political agendas, or where stakeholders disagree or misunderstand project goals. In the JSF project all the services and all non countries have to agree to the specifications of the three variants of the aircraft; Conventional Take Off and Landing (CTOL), Short Take Off/Vertical Landing (STOVL) and the Carrier Variant (CV). Because the Navy requires a plane that can take off and land on an aircraft carrier, that required a special variant of the aircraft design, adding complexity to the project. Technical complexity occurs in a project using technology that is immature or where design characteristics are unknown or untried. Developing a plane that can take off on a very short runway and land vertically created may highly interdependent technological challenges to correctly locate, direct and balance the lift fans, modulate the airflow and provide equivalent amount of thrust from the downward vectored rear exhaust to lift the aircraft and at the same time control engine temperatures. These technological challenges make costing and scheduling equally challenging. Structural complexity in a project comes from the sheer numbers of elements such as the number of people, teams or organizations involved, ambiguity regarding the elements, and the massive degree of interconnectedness between them. While Lockheed Martin is the prime contractor, they are assisted in major aspects of the JSF development by Northrop Grumman, BAE Systems, Pratt & Whitney and GE/Rolls-Royce Fighter Engineer Team and innumerable subcontractors. In addition to identifying opportunities to achieve project goals, complex projects also need to identify and exploit opportunities to increase agility in response to changing stakeholder demands or to reduce project risks. Complexity Leadership Theory contends that in complex environments adaptive and enabling leadership are needed (Uhl-Bien, Marion and McKelvey, 2007). Adaptive leadership facilitates creativity, learning and adaptability, while enabling leadership handles the conflicts that inevitably arise between adaptive leadership and traditional administrative leadership (Uhl-Bien and Marion, 2007). Hence, adaptive leadership involves the recognition and opportunities to adapt, while and enabling leadership involves the exploitation of these opportunities. Our research questions revolve around the type or source of complexity and its relationship to opportunity recognition and exploitation. For example, is it only external environmental complexity that creates the need for the entrepreneurial behaviours, such as opportunity recognition and opportunity exploitation? Do the internal dimensions of project complexity, such as technological and structural complexity, also create the need for opportunity recognition and opportunity exploitation? The Kropp, Zolin and Lindsay model (2009) describes a relationship between entrepreneurial orientation (EO), opportunity recognition (OR), and opportunity exploitation (OX) in complex projects, with environmental and organizational contextual variables as moderators. We extend their model by defining the affects of external complexity and internal complexity on OR and OX. ---------- Methodology/Key Propositions: When the environment complex EO is more likely to result in OR because project members will be actively looking for solutions to problems created by environmental change. But in projects that are technologically or structurally complex project leaders and members may try to make the minimum changes possible to reduce the risk of creating new problems due to delays or schedule changes. In projects with environmental or technological complexity project leaders who encourage the innovativeness dimension of EO will increase OR in complex projects. But projects with technical or structural complexity innovativeness will not necessarily result in the recognition and exploitation of opportunities due to the over-riding importance of maintaining stability in the highly intricate and interconnected project structure. We propose that in projects with environmental complexity creating the need for change and innovation project leaders, who are willing to accept and manage risk, are more likely to identify opportunities to increase project effectiveness and efficiency. In contrast in projects with internal complexity a much higher willingness to accept risk will be necessary to trigger opportunity recognition. In structurally complex projects we predict it will be less likely to find a relationship between risk taking and OP. When the environment is complex, and a project has autonomy, they will be motivated to execute opportunities to improve the project's performance. In contrast, when the project has high internal complexity, they will be more cautious in execution. When a project experiences high competitive aggressiveness and their environment is complex, project leaders will be motivated to execute opportunities to improve the project's performance. In contrast, when the project has high internal complexity, they will be more cautious in execution. This paper reports the first stage of a three year study into the behaviours of managers, leaders and team members of complex projects. We conduct a qualitative study involving a Group Discussion with experienced project leaders. The objective is to determine how leaders of large and potentially complex projects perceive that external and internal complexity will influence the affects of EO on OR. ---------- Results and Implications: These results will help identify and distinguish the impact of external and internal complexity on entrepreneurial behaviours in NPDP. Project managers will be better able to quickly decide how and when to respond to changes in the environment and internal project events.

Time alone

Time Alone is the introductory image to the exhibition Lightsite, which toured Western Australian galleries from February 2006 to November 2007. It is a five-minute-long exposure photographic image captured inside an abandoned building which the author converted into a camera obscura. It depicts an inverted image of the outside environment and the text 'time' - which is constructed by torch-light within the building interior and during the photographic exposure. The image evokes isolation and the temporality of inhabitation within the remote farmlands of the Great Southern Region of Western Australia: the region of focus for all of the twelve works in Lightsite. Indeed the owner of this now-abandoned house passed away and was not found for a week - bringing poignancy to the central theme of this creative work.

Forecasting time-varying value-at-risk

In this thesis we are interested in financial risk and the instrument we want to use is Value-at-Risk (VaR). VaR is the maximum loss over a given period of time at a given confidence level. Many definitions of VaR exist and some will be introduced throughout this thesis. There two main ways to measure risk and VaR: through volatility and through percentiles. Large volatility in financial returns implies greater probability of large losses, but also larger probability of large profits. Percentiles describe tail behaviour. The estimation of VaR is a complex task. It is important to know the main characteristics of financial data to choose the best model. The existing literature is very wide, maybe controversial, but helpful in drawing a picture of the problem. It is commonly recognised that financial data are characterised by heavy tails, time-varying volatility, asymmetric response to bad and good news, and skewness. Ignoring any of these features can lead to underestimating VaR with a possible ultimate consequence being the default of the protagonist (firm, bank or investor). In recent years, skewness has attracted special attention. An open problem is the detection and modelling of time-varying skewness. Is skewness constant or there is some significant variability which in turn can affect the estimation of VaR? This thesis aims to answer this question and to open the way to a new approach to model simultaneously time-varying volatility (conditional variance) and skewness. The new tools are modifications of the Generalised Lambda Distributions (GLDs). They are four-parameter distributions, which allow the first four moments to be modelled nearly independently: in particular we are interested in what we will call para-moments, i.e., mean, variance, skewness and kurtosis. The GLDs will be used in two different ways. Firstly, semi-parametrically, we consider a moving window to estimate the parameters and calculate the percentiles of the GLDs. Secondly, parametrically, we attempt to extend the GLDs to include time-varying dependence in the parameters. We used the local linear regression to estimate semi-parametrically conditional mean and conditional variance. The method is not efficient enough to capture all the dependence structure in the three indices —ASX 200, S&P 500 and FT 30—, however it provides an idea of the DGP underlying the process and helps choosing a good technique to model the data. We find that GLDs suggest that moments up to the fourth order do not always exist, there existence appears to vary over time. This is a very important finding, considering that past papers (see for example Bali et al., 2008; Hashmi and Tay, 2007; Lanne and Pentti, 2007) modelled time-varying skewness, implicitly assuming the existence of the third moment. However, the GLDs suggest that mean, variance, skewness and in general the conditional distribution vary over time, as already suggested by the existing literature. The GLDs give good results in estimating VaR on three real indices, ASX 200, S&P 500 and FT 30, with results very similar to the results provided by historical simulation.

Understanding parental physical activity : meanings, habits, and social role influence

Objectives: The research aimed to explore parents’ understandings of physical activity (PA), patterns of PA-related behaviour, and how constructions of social role expectations might influence their PA behaviour. Design and Method: Using a qualitative descriptive design and adopting a social constructionism approach to broaden interpretations of parents’ understandings, 40 adults (21 mothers, 19 fathers; aged 23 to 49 years) living in South East Queensland, Australia participated in semi-structured individual and group interviews. The interviews were analysed using thematic analysis. Results: Parents had clear understandings of what constitutes PA and engaged in various activities which were integrated with or independent of the children. Being active with children, however, was not always constructed favourably in which many parents described the difficulties of being active with their children. All individuals experienced changes in their PA behaviours after having children. For most, a decline in PA level, intensity, and structure was experienced; however, some did experience parenthood as a time to be active. A level of acceptance for the lack of activity performed was also expressed as were feelings of resentment and envy for those who maintained previous activity habits. Parenting and partner roles were considered most influential on PA-related behaviour and were constructed in ways that had both positive and negative influences on activity performance. Parents, however, were empowered to construct strategies to resolve conflicts between social role performance and being active. Conclusion: Results show that parents experience unique difficulties that intervention work should consider when designing programs aimed at increasing parental PA.

Health, endogenous time preference, and inequality : a political economy perspective

We study an overlapping-generations model in which agents' mortality risks, and consequently impatience, are endogenously determined by private and public investment in health care. Revenues allocated for public health care arc determined by a voting process. We find that the degree of substitutability between public and private health expenditures matters for macroeconomic outcomes of the model. Higher substitutability implies a “crowding-out" effect, which in turn impacts adversely on morality risks and impatience leading to lower public expenditures on health care in the political equilibrium. Consequently, higher substitutability is associated with greater polarization in wealth, and long-run distributions that are bimodal.