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• 3681. [Article] Assessing equity in health system finance and health care utilization : the case of Chile, and a model to measure health care access

  Chile has experienced great success in terms of economic growth in the last decades. This growing economy brings changes in the Chilean health care system. Its health care system was primarily funded by ...

  Citation × Citation Citation Abstract Copy Title: Assessing equity in health system finance and health care utilization : the case of Chile, and a model to measure health care access Author: Nunez Mondaca, Alicia Lorena Chile has experienced great success in terms of economic growth in the last decades. This growing economy brings changes in the Chilean health care system. Its health care system was primarily funded by state sources until 1981, when a major reform was introduced that established new rules for the health insurance market. Since then, Chile has a public-private mixed health care system, both in financing and delivery of services. Citizens can choose for coverage between the Public National Health Insurance and the Private Health Insurance system. However, these systems have a common funding source coming from the mandatory contribution of employees, equivalent to 7% of their taxable income with an approximate limit of US$2,800 dollars. One of the more important Chilean health reforms towards the establishment of social guarantees was effective on July 2005, when the Regime of Explicit Health Guarantees, also known as Plan AUGE became effective. Plan AUGE is a health program that benefits all Chileans without discrimination of age, gender, economic status, health care, or place of residence. This plan includes the 69 diseases with higher impact on Chilean population in its different stages, but with feasibility of effective treatments. Changes in the health care system and its last reform brought questions about their impact on the distribution of health care services throughout country. Is Chile moving towards a better and more equitable health care system? The main purpose of this thesis is to investigate equity in health system finance and health care utilization as well as to explore alternative measurement of access to health care in Chile. The first two manuscripts examine equity issues in Chile. The purpose of the first one is to assess equity in health system finance in Chile, accounting for all finance sources. While equity in health system finance has been well studied in OECD countries, there are still few published empirical studies on Latin American health care systems, where there tends to be a wider gap in income-wealth distribution among states. This gap may increase the financial burden for people in the lower spectrum of income groups, which is the main concern in the first manuscript. It will focus on identifying policy variables that may contribute to more equitable distribution of the financial burden in health care. The equity principle we adopt for this study is the ability to pay principle. Based on this, we explore factors that contribute to inequities in the health care system finance and issues about who bears the heavier burden of out-of pocket (OOP) payment, progressivity of OOP payment, and the redistributive effect of OOP payment for health care as a source of finance in the Chilean health care system. Our analysis is based on data from the National Socioeconomic Survey (CASEN), and the 2006 National Survey on Satisfaction and OOP payments. Results from this study provide comprehensive understanding of the financial burden of health care in Chile. This study identified evidence of inequity, in spite of the progressivity of the health care system. Furthermore, our assessment of equity in health system finance identified relevant policy variables such as education, insurance system, and method of payment that should be taken into consideration in the ongoing debates and research in improving the Chilean system. Such findings will also benefit other Latin American countries that are concerned about equity in health system finance. The purpose of the second manuscript was to assess equity in health care utilization in Chile. Secondary data analyses from the National Socioeconomic Survey (CASEN) were performed to estimate the impact of different factors including AUGE in the utilization of health care services. We used a two-part model for the analysis of frequency of health care use in the country. Four other separate two-part models were also specified to estimate the frequency of use of preventive services, general practitioner services, specialty care and emergency care. An assessment of horizontal equity was also included. Results suggest the presence of pro-rich inequities in the use of medical care. The estimation of the two-part model found key factors affecting utilization of health care services such as education and the implementation of the AUGE program. These findings provide timely evidence to policy-makers to understand the current distribution and equity of health care utilization, and to strengthen availability of health services accordingly. The third manuscript was motivated by the previous findings. Its purpose was to explore an alternative measurement for health care access. The majority of studies nowadays use a single proxy to estimate access: the use of health care services. However, we saw many limitations on this approach since it only considers people that are already using the system and ignores those that are not. The final manuscript proposed a model to estimate access to health care services based on communitarian claims. The model identified barriers to health care access as well as the preferences of the community for priority settings. Title: Assessing equity in health system finance and health care utilization : the case of Chile, and a model to measure health care access Author: Nunez Mondaca, Alicia Lorena Chile has experienced great success in terms of economic growth in the last decades. This growing economy brings changes in the Chilean health care system. Its health care system was primarily funded by state sources until 1981, when a major reform was introduced that established new rules for the health insurance market. Since then, Chile has a public-private mixed health care system, both in financing and delivery of services. Citizens can choose for coverage between the Public National Health Insurance and the Private Health Insurance system. However, these systems have a common funding source coming from the mandatory contribution of employees, equivalent to 7% of their taxable income with an approximate limit of US$2,800 dollars. One of the more important Chilean health reforms towards the establishment of social guarantees was effective on July 2005, when the Regime of Explicit Health Guarantees, also known as Plan AUGE became effective. Plan AUGE is a health program that benefits all Chileans without discrimination of age, gender, economic status, health care, or place of residence. This plan includes the 69 diseases with higher impact on Chilean population in its different stages, but with feasibility of effective treatments. Changes in the health care system and its last reform brought questions about their impact on the distribution of health care services throughout country. Is Chile moving towards a better and more equitable health care system? The main purpose of this thesis is to investigate equity in health system finance and health care utilization as well as to explore alternative measurement of access to health care in Chile. The first two manuscripts examine equity issues in Chile. The purpose of the first one is to assess equity in health system finance in Chile, accounting for all finance sources. While equity in health system finance has been well studied in OECD countries, there are still few published empirical studies on Latin American health care systems, where there tends to be a wider gap in income-wealth distribution among states. This gap may increase the financial burden for people in the lower spectrum of income groups, which is the main concern in the first manuscript. It will focus on identifying policy variables that may contribute to more equitable distribution of the financial burden in health care. The equity principle we adopt for this study is the ability to pay principle. Based on this, we explore factors that contribute to inequities in the health care system finance and issues about who bears the heavier burden of out-of pocket (OOP) payment, progressivity of OOP payment, and the redistributive effect of OOP payment for health care as a source of finance in the Chilean health care system. Our analysis is based on data from the National Socioeconomic Survey (CASEN), and the 2006 National Survey on Satisfaction and OOP payments. Results from this study provide comprehensive understanding of the financial burden of health care in Chile. This study identified evidence of inequity, in spite of the progressivity of the health care system. Furthermore, our assessment of equity in health system finance identified relevant policy variables such as education, insurance system, and method of payment that should be taken into consideration in the ongoing debates and research in improving the Chilean system. Such findings will also benefit other Latin American countries that are concerned about equity in health system finance. The purpose of the second manuscript was to assess equity in health care utilization in Chile. Secondary data analyses from the National Socioeconomic Survey (CASEN) were performed to estimate the impact of different factors including AUGE in the utilization of health care services. We used a two-part model for the analysis of frequency of health care use in the country. Four other separate two-part models were also specified to estimate the frequency of use of preventive services, general practitioner services, specialty care and emergency care. An assessment of horizontal equity was also included. Results suggest the presence of pro-rich inequities in the use of medical care. The estimation of the two-part model found key factors affecting utilization of health care services such as education and the implementation of the AUGE program. These findings provide timely evidence to policy-makers to understand the current distribution and equity of health care utilization, and to strengthen availability of health services accordingly. The third manuscript was motivated by the previous findings. Its purpose was to explore an alternative measurement for health care access. The majority of studies nowadays use a single proxy to estimate access: the use of health care services. However, we saw many limitations on this approach since it only considers people that are already using the system and ignores those that are not. The final manuscript proposed a model to estimate access to health care services based on communitarian claims. The model identified barriers to health care access as well as the preferences of the community for priority settings. Close

• 3682. [Article] Evaluating Coastal Protection Services Associated with Restoration Management of an Endangered Shorebird in Oregon, U.S.A.

  Coastal sand dunes and beaches offer a variety of ecosystem services such as coastal protection, sand stabilization, species conservation, and recreation. However, the management and balance of ecosystem ...

  Citation × Citation Citation Abstract Copy Title: Evaluating Coastal Protection Services Associated with Restoration Management of an Endangered Shorebird in Oregon, U.S.A. Author: Carroll, Lindsay J. Coastal sand dunes and beaches offer a variety of ecosystem services such as coastal protection, sand stabilization, species conservation, and recreation. However, the management and balance of ecosystem services offered by dunes and beaches is challenging when ecosystem services interact across the landscape. Management focusing only on one ecosystem service may result in unintended consequences and trade-offs between other key services. Understanding the magnitude of the trade-offs and linkages between services provides a more holistic approach for reducing unintended consequences and maximizing function. The degradation of habitats and land use changes associated with expanding human populations has resulted in the need for species conservation. However, species conservation techniques can sometimes have unintended consequences for other services. Given the mandate of the Endangered Species Act to restore habitat structure and function essential to endangered or threatened species, it becomes critical to evaluate the implications of species conservation management initiatives to reduce negative implications to other key services. The coastal dune systems of the Pacific Northwest (PNW) are a prime example of how ecosystem services, such as species conservation and coastal protection, can interact with one another. Over the last 125 years in the Pacific Northwest (PNW), the intentional introduction of two non-native congeneric beach grasses (Ammophila arenaria and A. breviligulata) has increased coastal protection through the creation of foredunes, but also dramatically altered the dune ecosystem. Both invasive grasses build taller dunes that range from 3 - 18 m in height compared to the native grass, Elymus mollis. Increased foredune elevations generate greater coastal protection services that are increasingly important given sea level rise and extreme storm events on the PNW coast. However, the beach grasses have dramatically changed the beach/dune community, resulting in the decline of several native dune plants and animals. One species that is negatively affected by the grass invasion is the Western snowy plover (Charadrius nivosus nivosus), an endemic shorebird living on beaches and dunes in the Pacific Northwest. This shorebird was listed threatened under the Endangered Species Act in 1993 and a recovery plan was established that employed multiple recovery techniques. The most important part of the plan involves establishing habitat restoration areas (HRAs) where dunes are bulldozed, reducing dune elevations, burying the grass, and returning the dunes to an open shifting sand environment, historically preferred by the plover. Recent coastal hazards modeling revealed that the changes in beach and dune shape associated with plover restoration increases coastal exposure to flooding and erosion at certain locations along the Oregon coast, particularly under projected climate change scenarios of sea level rise and extreme storms. As part of future plover management, four critical habitat areas were proposed for Tillamook County, Oregon: Nehalem River Spit, Bayocean Spit, Netarts Spit, and Sand Lake South. Given the interest in plover habitat restoration in Tillamook County, this research project addresses the following questions: (1) What is the present day dune geomorphology and exposure to coastal hazards at four proposed critical habitat (PCH) areas in Tillamook County, Oregon; and (2) how do changes in beach geomorphology associated with different restoration scenarios alter coastal exposure today, under projected sea level rise and storm scenarios? To address the coastal geomorphological impacts of HRA installation on the four proposed areas, multiple restoration scenarios that reduce foredune elevation were evaluated under present day sea level and potential future sea level rise and extreme storminess scenarios, using coastal exposure modeling techniques. The model projections provide site-specific information on the exposure of HRAs to overtopping under different restoration conditions. We determined that exposure to flooding was dependent on proposed HRA site and restoration scenario, and was exacerbated by sea level rise and extreme storms. Empirical models projected the greatest flooding exposure would occur at Nehalem River Spit, followed by Netarts Spit, and then Bayocean Spit and Sand Lake South, which did not differ. Exposure to flooding at present day dunes was low across all sites, but with increasing exposure to flooding as foredune elevations were reduced to 6.0 m or below, as could happen with plover habitat restoration. Under present day water levels, restoring foredune elevations to 6.0 m or below would likely result in roughly 5 days of overtopping per year at Nehalem River Spit, Bayocean Spit, and Netarts Spit, and 4 days of overtopping at Sand Lake South. Flooding under various foredune restoration scenarios increased under higher sea level rise scenarios. Flooding exposure for the 6.0 m restoration scenario exceeded 10 days per year at Nehalem River Spit and 5 days per year at Bayocean Spit, Netarts Spit, and Sand Lake South. Overall exposure to flooding under the extreme storm scenarios was dependent on proposed HRA site, restoration scenario, and increased wave conditions, such as wave height, period, and water level. Similar to the empirical model, flooding exposure under extreme storm scenarios increased when foredune elevations were reduced to 6.0 m or below, across all sites. The site with the greatest overall flooding exposure during extreme storms was Bayocean Spit. Flooding distance was dependent on restoration scenario and site while flooding duration was only dependent on restoration scenario. The 5.5 m restoration scenario under higher storm water levels resulted in one hour or more of flooding exposure at least one day per year at Nehalem River Spit, Netarts Spit, and Bayocean Spit. The overall likelihood of overwash extending to 150 m or more into the dune field during extreme storms was at least 5 days when selecting to reduce foredune to restoration elevations of 7.0 m or below across all sites. The effect of higher wave heights and greater wave periods was more important to overtopping distance than restoration scenario. Learning from current plover management, combined with the coastal exposure analysis we conducted here, could enable managers to develop site-specific restoration plans that maximize plover recovery while minimizing coastal exposure. This research will give resource managers information on the coastal exposure associated with proposed HRAs and the foredune reduction scenarios they might want to employ at the different sites. It will allow them to identify the best restoration scenarios to maximum habitat restoration without compromising coastal protection, and thus balance some important services of dunes and beaches. Regardless of management objective, identifying the unintended consequences of restoration to key ecosystem services is necessary for the holistic management of our dynamic coasts, especially with projected sea level rise and the uncertainty of frequent and extreme storms. Title: Evaluating Coastal Protection Services Associated with Restoration Management of an Endangered Shorebird in Oregon, U.S.A. Author: Carroll, Lindsay J. Coastal sand dunes and beaches offer a variety of ecosystem services such as coastal protection, sand stabilization, species conservation, and recreation. However, the management and balance of ecosystem services offered by dunes and beaches is challenging when ecosystem services interact across the landscape. Management focusing only on one ecosystem service may result in unintended consequences and trade-offs between other key services. Understanding the magnitude of the trade-offs and linkages between services provides a more holistic approach for reducing unintended consequences and maximizing function. The degradation of habitats and land use changes associated with expanding human populations has resulted in the need for species conservation. However, species conservation techniques can sometimes have unintended consequences for other services. Given the mandate of the Endangered Species Act to restore habitat structure and function essential to endangered or threatened species, it becomes critical to evaluate the implications of species conservation management initiatives to reduce negative implications to other key services. The coastal dune systems of the Pacific Northwest (PNW) are a prime example of how ecosystem services, such as species conservation and coastal protection, can interact with one another. Over the last 125 years in the Pacific Northwest (PNW), the intentional introduction of two non-native congeneric beach grasses (Ammophila arenaria and A. breviligulata) has increased coastal protection through the creation of foredunes, but also dramatically altered the dune ecosystem. Both invasive grasses build taller dunes that range from 3 - 18 m in height compared to the native grass, Elymus mollis. Increased foredune elevations generate greater coastal protection services that are increasingly important given sea level rise and extreme storm events on the PNW coast. However, the beach grasses have dramatically changed the beach/dune community, resulting in the decline of several native dune plants and animals. One species that is negatively affected by the grass invasion is the Western snowy plover (Charadrius nivosus nivosus), an endemic shorebird living on beaches and dunes in the Pacific Northwest. This shorebird was listed threatened under the Endangered Species Act in 1993 and a recovery plan was established that employed multiple recovery techniques. The most important part of the plan involves establishing habitat restoration areas (HRAs) where dunes are bulldozed, reducing dune elevations, burying the grass, and returning the dunes to an open shifting sand environment, historically preferred by the plover. Recent coastal hazards modeling revealed that the changes in beach and dune shape associated with plover restoration increases coastal exposure to flooding and erosion at certain locations along the Oregon coast, particularly under projected climate change scenarios of sea level rise and extreme storms. As part of future plover management, four critical habitat areas were proposed for Tillamook County, Oregon: Nehalem River Spit, Bayocean Spit, Netarts Spit, and Sand Lake South. Given the interest in plover habitat restoration in Tillamook County, this research project addresses the following questions: (1) What is the present day dune geomorphology and exposure to coastal hazards at four proposed critical habitat (PCH) areas in Tillamook County, Oregon; and (2) how do changes in beach geomorphology associated with different restoration scenarios alter coastal exposure today, under projected sea level rise and storm scenarios? To address the coastal geomorphological impacts of HRA installation on the four proposed areas, multiple restoration scenarios that reduce foredune elevation were evaluated under present day sea level and potential future sea level rise and extreme storminess scenarios, using coastal exposure modeling techniques. The model projections provide site-specific information on the exposure of HRAs to overtopping under different restoration conditions. We determined that exposure to flooding was dependent on proposed HRA site and restoration scenario, and was exacerbated by sea level rise and extreme storms. Empirical models projected the greatest flooding exposure would occur at Nehalem River Spit, followed by Netarts Spit, and then Bayocean Spit and Sand Lake South, which did not differ. Exposure to flooding at present day dunes was low across all sites, but with increasing exposure to flooding as foredune elevations were reduced to 6.0 m or below, as could happen with plover habitat restoration. Under present day water levels, restoring foredune elevations to 6.0 m or below would likely result in roughly 5 days of overtopping per year at Nehalem River Spit, Bayocean Spit, and Netarts Spit, and 4 days of overtopping at Sand Lake South. Flooding under various foredune restoration scenarios increased under higher sea level rise scenarios. Flooding exposure for the 6.0 m restoration scenario exceeded 10 days per year at Nehalem River Spit and 5 days per year at Bayocean Spit, Netarts Spit, and Sand Lake South. Overall exposure to flooding under the extreme storm scenarios was dependent on proposed HRA site, restoration scenario, and increased wave conditions, such as wave height, period, and water level. Similar to the empirical model, flooding exposure under extreme storm scenarios increased when foredune elevations were reduced to 6.0 m or below, across all sites. The site with the greatest overall flooding exposure during extreme storms was Bayocean Spit. Flooding distance was dependent on restoration scenario and site while flooding duration was only dependent on restoration scenario. The 5.5 m restoration scenario under higher storm water levels resulted in one hour or more of flooding exposure at least one day per year at Nehalem River Spit, Netarts Spit, and Bayocean Spit. The overall likelihood of overwash extending to 150 m or more into the dune field during extreme storms was at least 5 days when selecting to reduce foredune to restoration elevations of 7.0 m or below across all sites. The effect of higher wave heights and greater wave periods was more important to overtopping distance than restoration scenario. Learning from current plover management, combined with the coastal exposure analysis we conducted here, could enable managers to develop site-specific restoration plans that maximize plover recovery while minimizing coastal exposure. This research will give resource managers information on the coastal exposure associated with proposed HRAs and the foredune reduction scenarios they might want to employ at the different sites. It will allow them to identify the best restoration scenarios to maximum habitat restoration without compromising coastal protection, and thus balance some important services of dunes and beaches. Regardless of management objective, identifying the unintended consequences of restoration to key ecosystem services is necessary for the holistic management of our dynamic coasts, especially with projected sea level rise and the uncertainty of frequent and extreme storms. Close

• 3683. [Article] Students as pro-social bystanders : opportunities, past behaviors, and intentions to intervene in sexual assault risk situations

  Sexual assault is a major public health concern in the U.S, and college students are particularly vulnerable to victimization. A health issue that affects nearly one in four women (Fisher, Cullen, & Turner, ...

  Citation × Citation Citation Abstract Copy Title: Students as pro-social bystanders : opportunities, past behaviors, and intentions to intervene in sexual assault risk situations Author: Hoxmeier, Jill C. Sexual assault is a major public health concern in the U.S, and college students are particularly vulnerable to victimization. A health issue that affects nearly one in four women (Fisher, Cullen, & Turner, 2000; Karjane, Cullen, & Turner, 2005) and that is associated with severe negative health outcomes, including depression substance abuse, suicide ideation, and risky sexual behaviors (CDC, 2012), warrants effective prevention programs. Moving away from traditional prevention efforts, which target females as potential victims in risk reduction programs and males as potential perpetrators in attitudinal-shifting programs, bystander engagement programs have become increasingly more widespread. These programs aim to engage all students on the college campus as potential bystanders who can intervene to prevent a sexual assault or reduce the harm of an assault that has already occurred (Banyard, Moynihan & Plante, 2007). Burn (2009) investigated potential barriers to pro-social bystander intervention using the Situational Model of Bystander Intervention, a model based on the original research of bystander behavior of Latanè and Darley (1970). The model outlines five barriers that influence students' intent to intervene as witnesses to sexual assault: failure to notice the situation, failure to identify the situation as high risk, failure to take intervention responsibility, failure to intervene due to skills deficit, and failure to intervene due to audience inhibition (Burn, 2009). She found that students' perception of barriers negatively correlated with intervention behaviors as bystanders to sexual assault (Burn, 2009). Although bystander engagement programs have shown initial promise in increasing students' intent to intervene, more needs to be known about the opportunities students have to intervene, their past intervention actions, and their intent to intervene in the future across the wide range of situations that encompass sexual assault risk. In addition, to develop effective programs that aim to increase pro-social behavior, understanding the salient influences of students' intent is critical. This study uses the Theory of Planned Behavior (TPB; Ajzen & Fishbein, 1991) to examine the influences of students’ intent to perform 12 different pro-social bystander behaviors. The TPB asserts that individuals' behavior is most proximally influenced by their behavioral intentions, and intentions are influences by their perceived behavioral control to perform the behavior, subjective norms that support performing the behavior, and attitudes toward the behavior (Ajzen & Fishbein, 1991). The four primary aims of this study were: 1) to examine the demographic correlates of students' opportunities, past intervention actions, and reported intent to intervene; 2) to examine any differences in students' intent to intervene based on the level of intervention (pre-, mid-, and post-assault) and type of intervention (with the potential or actual victim compared to the potential or actual perpetrator); 3) to examine the influences of perceived behavioral control, subjective norms, and attitudes on students' intent to intervene as bystanders; and 4) to compare the TPB-based model to the Situational Model of Bystander Intervention (Burn, 2009) in its ability to explain students' intent to intervene as bystanders. In the Fall of 2014, a sample of 815 undergraduate students at Oregon State University completed the Sexual Assault Bystander Behavior Questionnaire (SABB-Q), a tool comprised of items to measure students' opportunities, past behaviors, and future intent, in addition to measures assessing the influences of students' intent in line with the Theory of Planned Behavior and Burn's (2009) Situational Model of Bystander Intervention. Students who participate in Greek communities (fraternities and sororities) reported significantly greater odds of having the opportunity to perform four of the 12 intervention behaviors compared to non-Greek students, while student-athletes reported significantly greater odds of having the opportunity to perform two of the 12 intervention behaviors. Females reported significantly more past pro-social intervention behaviors (x̄ = 0.87) compared to males (x̄ = 0.79; p = 0.007). Regarding intent to intervene in the future, females reported significantly greater intent to intervene compared to males (x̄ = 6.07 vs. 5.68; p = 0.007). Students with friends who have been victims of sexual assault reported greater intent to intervene compared those without friends who have been victims (x̄ = 6.04 vs. 5.89; p = 0.02). Students with a personal history of victimization reported significantly greater intent compared to those without a personal history (x̄ =6.13 vs 5.93; p = 0.03). Students reported significantly greater intent to intervene with the potential or actual victim compared to the potential or actual perpetrator (x̄ = 6.19 vs. 5.74, p < 0.001). Females reported significantly greater intent to intervene with both the potential or actual victims and perpetrators (x̄ = 6.31 and 5.84, respectively) compared to males (x̄ = 5.88 and 5.49, respectively). Both males and females reported the greatest intent to perform post-assault intervention behavior (x̄ = 6.23), followed by pre-assault (x̄ = 6.08) and mid-assault behaviors (x̄ = 5.57). Females reported significantly greater intent to perform nine of the 12 pro-social intervention behaviors compared to males. A multiple regression analysis revealed that perceived behavioral control, subjective norms, and attitudes explained a significant proportion of the variance in intent to intervene (R² = 0.55, F(3, 771) = 315.68, p < 0.000). Perceived behavioral control was highly significant (β = 0.48, p < 0.001), as were subjective norms (β = 0.15, p < 0.001) and attitudes (β = 0.30, p < 0.001). Gender differences were also observed. For females, perceived behavioral control was highly significant (β = 0.49, p < 0.001), as were subjective norms (β = 0.15, p < 0.001) and attitudes (β = 0.29, p < 0.001). For males, perceived behavioral control was highly significant (β = 0.49, p < 0.001), as were attitudes (β = 0.29, p < 0.001). However, males' subjective norms were not significantly related (β = 0.07, p = 0.199) to their intent to intervene. Further analysis revealed a significant interaction between gender and subjective norms (β = -0.28; p = 0.039). The TPB-based model including this moderation effect explained a significant proportion of the variance in students' intent to intervene (R² = 0.57, F(6, 766) = 168.46, p < 0.000). Interveners reported significantly greater perceived behavioral control than non-interveners for seven of the 12 intervention behaviors; more supportive subjective norms than non-interveners for six of the 12 intervention behaviors; more positive attitudes than non-interveners for only one of the 12 intervention behaviors; and greater intent to intervene in the future for six of the 12 intervention behaviors. However, differences in the three TPB variables between interveners and non-interveners were not consistent for the 12 intervention behaviors. Regarding Burn's (2009) Situational Model of Bystander Intervention, a multiple regression analysis revealed two of the five barriers were significantly related to students’ intent to intervene: the failure to take intervention responsibility barrier (β = -0.29, p < 0.001) and the failure to intervene due to audience inhibition barrier (β = -0.22, p < 0.001). The model in whole explained a large proportion of the variance (R2 = 0.25, F(5, 768) = 50.14, p < 0.000). Gender differences were also observed. For females, failure to take intervention responsibility (β = -0.23; p < 0.000) and failure to intervene due to audience inhibition (β = -0.23; p < 0.001) both had a significant, negative influence on their intent to intervene. For males, failure to take intervention responsibility (β = -0.21; p < 0.014) had a significant, negative influence on intent to intervene. Additional analysis revealed no significant interactions between gender and any of the five barriers. The TPB-based model explained a greater proportion of the variance (R2 = 0.55) compared to Situational Model of Bystander Intervention (R² = 0.25) in the multiple regression analysis using all 12 intervention behaviors. All three variables in the TPB-based model were significantly related to students’ intent, whereas only two of the five barriers were significantly related. A final multiple regression analysis was conducted using all three significant TPB variables and the two significant barriers to explain students' intent to intervene. The combined model explained a significant proportion of variance in students' intent (R² = 0.58 F(5, 756) = 206.19, p < 0.000) and significantly improved upon the TPB-based model (Δ R² = 0.03; p < 0.000). The results of this study have several implications for future research and public health practice. First, it is important to ask students about their opportunities to intervene in addition to their actual intervention behaviors because this information helps paint a clearer picture of bystander engagement. This assessment could also help identify high-risk groups: students who have greater opportunities to intervene as bystanders and/or report fewer intervention behaviors compared to their reported opportunities. Second, students may conceptualize intervention behaviors differently depending on the phase of the assault and with whom the intervention behavior requires intervening. Accordingly, programs aimed at encouraging students to intervene should take these differences into consideration. Third, the Theory of Planned Behavior, used to explain and change other health-related behaviors, can effectively be applied to help uncover determinants of pro-social bystander behaviors. Perceived behavioral control, subjective norms, and attitudes appear to be salient influences in students' intent to intervene. Therefore, bystander engagement programs should incorporate activities to heighten students' skills to intervene, change social norms that support bystander intervention, and shift attitudes toward the benefits of intervening. This study demonstrates the importance of using an established, evidenced-based theoretical framework to explain behavioral influences and strengthens the argument for continued use of theory to identify, and potentially change, salient influences in behavioral performance. Students as pro-social bystanders have the potential to make a positive impact on the reduction of sexual assault on the college campus. Although the responsibility for sexual assault rests on those who perpetrate such acts, and primary prevention strategies aimed at those demonstrating a risk for perpetration are imperative, sexual assault is a public health issue that warrants a multi-pronged approach to reduce its incidence and migrate its associated harms. Programs that engage students as pro-social bystanders have the potential to make a positive impact on the reduction of sexual assault incidence in the absence of effective primary prevention strategies. The findings of this study make a contribution to the literature examining influences of students' pro-social bystander intervention to sexual assault situations and provide suggestions for strategies to increase bystander engagement. Title: Students as pro-social bystanders : opportunities, past behaviors, and intentions to intervene in sexual assault risk situations Author: Hoxmeier, Jill C. Sexual assault is a major public health concern in the U.S, and college students are particularly vulnerable to victimization. A health issue that affects nearly one in four women (Fisher, Cullen, & Turner, 2000; Karjane, Cullen, & Turner, 2005) and that is associated with severe negative health outcomes, including depression substance abuse, suicide ideation, and risky sexual behaviors (CDC, 2012), warrants effective prevention programs. Moving away from traditional prevention efforts, which target females as potential victims in risk reduction programs and males as potential perpetrators in attitudinal-shifting programs, bystander engagement programs have become increasingly more widespread. These programs aim to engage all students on the college campus as potential bystanders who can intervene to prevent a sexual assault or reduce the harm of an assault that has already occurred (Banyard, Moynihan & Plante, 2007). Burn (2009) investigated potential barriers to pro-social bystander intervention using the Situational Model of Bystander Intervention, a model based on the original research of bystander behavior of Latanè and Darley (1970). The model outlines five barriers that influence students' intent to intervene as witnesses to sexual assault: failure to notice the situation, failure to identify the situation as high risk, failure to take intervention responsibility, failure to intervene due to skills deficit, and failure to intervene due to audience inhibition (Burn, 2009). She found that students' perception of barriers negatively correlated with intervention behaviors as bystanders to sexual assault (Burn, 2009). Although bystander engagement programs have shown initial promise in increasing students' intent to intervene, more needs to be known about the opportunities students have to intervene, their past intervention actions, and their intent to intervene in the future across the wide range of situations that encompass sexual assault risk. In addition, to develop effective programs that aim to increase pro-social behavior, understanding the salient influences of students' intent is critical. This study uses the Theory of Planned Behavior (TPB; Ajzen & Fishbein, 1991) to examine the influences of students’ intent to perform 12 different pro-social bystander behaviors. The TPB asserts that individuals' behavior is most proximally influenced by their behavioral intentions, and intentions are influences by their perceived behavioral control to perform the behavior, subjective norms that support performing the behavior, and attitudes toward the behavior (Ajzen & Fishbein, 1991). The four primary aims of this study were: 1) to examine the demographic correlates of students' opportunities, past intervention actions, and reported intent to intervene; 2) to examine any differences in students' intent to intervene based on the level of intervention (pre-, mid-, and post-assault) and type of intervention (with the potential or actual victim compared to the potential or actual perpetrator); 3) to examine the influences of perceived behavioral control, subjective norms, and attitudes on students' intent to intervene as bystanders; and 4) to compare the TPB-based model to the Situational Model of Bystander Intervention (Burn, 2009) in its ability to explain students' intent to intervene as bystanders. In the Fall of 2014, a sample of 815 undergraduate students at Oregon State University completed the Sexual Assault Bystander Behavior Questionnaire (SABB-Q), a tool comprised of items to measure students' opportunities, past behaviors, and future intent, in addition to measures assessing the influences of students' intent in line with the Theory of Planned Behavior and Burn's (2009) Situational Model of Bystander Intervention. Students who participate in Greek communities (fraternities and sororities) reported significantly greater odds of having the opportunity to perform four of the 12 intervention behaviors compared to non-Greek students, while student-athletes reported significantly greater odds of having the opportunity to perform two of the 12 intervention behaviors. Females reported significantly more past pro-social intervention behaviors (x̄ = 0.87) compared to males (x̄ = 0.79; p = 0.007). Regarding intent to intervene in the future, females reported significantly greater intent to intervene compared to males (x̄ = 6.07 vs. 5.68; p = 0.007). Students with friends who have been victims of sexual assault reported greater intent to intervene compared those without friends who have been victims (x̄ = 6.04 vs. 5.89; p = 0.02). Students with a personal history of victimization reported significantly greater intent compared to those without a personal history (x̄ =6.13 vs 5.93; p = 0.03). Students reported significantly greater intent to intervene with the potential or actual victim compared to the potential or actual perpetrator (x̄ = 6.19 vs. 5.74, p < 0.001). Females reported significantly greater intent to intervene with both the potential or actual victims and perpetrators (x̄ = 6.31 and 5.84, respectively) compared to males (x̄ = 5.88 and 5.49, respectively). Both males and females reported the greatest intent to perform post-assault intervention behavior (x̄ = 6.23), followed by pre-assault (x̄ = 6.08) and mid-assault behaviors (x̄ = 5.57). Females reported significantly greater intent to perform nine of the 12 pro-social intervention behaviors compared to males. A multiple regression analysis revealed that perceived behavioral control, subjective norms, and attitudes explained a significant proportion of the variance in intent to intervene (R² = 0.55, F(3, 771) = 315.68, p < 0.000). Perceived behavioral control was highly significant (β = 0.48, p < 0.001), as were subjective norms (β = 0.15, p < 0.001) and attitudes (β = 0.30, p < 0.001). Gender differences were also observed. For females, perceived behavioral control was highly significant (β = 0.49, p < 0.001), as were subjective norms (β = 0.15, p < 0.001) and attitudes (β = 0.29, p < 0.001). For males, perceived behavioral control was highly significant (β = 0.49, p < 0.001), as were attitudes (β = 0.29, p < 0.001). However, males' subjective norms were not significantly related (β = 0.07, p = 0.199) to their intent to intervene. Further analysis revealed a significant interaction between gender and subjective norms (β = -0.28; p = 0.039). The TPB-based model including this moderation effect explained a significant proportion of the variance in students' intent to intervene (R² = 0.57, F(6, 766) = 168.46, p < 0.000). Interveners reported significantly greater perceived behavioral control than non-interveners for seven of the 12 intervention behaviors; more supportive subjective norms than non-interveners for six of the 12 intervention behaviors; more positive attitudes than non-interveners for only one of the 12 intervention behaviors; and greater intent to intervene in the future for six of the 12 intervention behaviors. However, differences in the three TPB variables between interveners and non-interveners were not consistent for the 12 intervention behaviors. Regarding Burn's (2009) Situational Model of Bystander Intervention, a multiple regression analysis revealed two of the five barriers were significantly related to students’ intent to intervene: the failure to take intervention responsibility barrier (β = -0.29, p < 0.001) and the failure to intervene due to audience inhibition barrier (β = -0.22, p < 0.001). The model in whole explained a large proportion of the variance (R2 = 0.25, F(5, 768) = 50.14, p < 0.000). Gender differences were also observed. For females, failure to take intervention responsibility (β = -0.23; p < 0.000) and failure to intervene due to audience inhibition (β = -0.23; p < 0.001) both had a significant, negative influence on their intent to intervene. For males, failure to take intervention responsibility (β = -0.21; p < 0.014) had a significant, negative influence on intent to intervene. Additional analysis revealed no significant interactions between gender and any of the five barriers. The TPB-based model explained a greater proportion of the variance (R2 = 0.55) compared to Situational Model of Bystander Intervention (R² = 0.25) in the multiple regression analysis using all 12 intervention behaviors. All three variables in the TPB-based model were significantly related to students’ intent, whereas only two of the five barriers were significantly related. A final multiple regression analysis was conducted using all three significant TPB variables and the two significant barriers to explain students' intent to intervene. The combined model explained a significant proportion of variance in students' intent (R² = 0.58 F(5, 756) = 206.19, p < 0.000) and significantly improved upon the TPB-based model (Δ R² = 0.03; p < 0.000). The results of this study have several implications for future research and public health practice. First, it is important to ask students about their opportunities to intervene in addition to their actual intervention behaviors because this information helps paint a clearer picture of bystander engagement. This assessment could also help identify high-risk groups: students who have greater opportunities to intervene as bystanders and/or report fewer intervention behaviors compared to their reported opportunities. Second, students may conceptualize intervention behaviors differently depending on the phase of the assault and with whom the intervention behavior requires intervening. Accordingly, programs aimed at encouraging students to intervene should take these differences into consideration. Third, the Theory of Planned Behavior, used to explain and change other health-related behaviors, can effectively be applied to help uncover determinants of pro-social bystander behaviors. Perceived behavioral control, subjective norms, and attitudes appear to be salient influences in students' intent to intervene. Therefore, bystander engagement programs should incorporate activities to heighten students' skills to intervene, change social norms that support bystander intervention, and shift attitudes toward the benefits of intervening. This study demonstrates the importance of using an established, evidenced-based theoretical framework to explain behavioral influences and strengthens the argument for continued use of theory to identify, and potentially change, salient influences in behavioral performance. Students as pro-social bystanders have the potential to make a positive impact on the reduction of sexual assault on the college campus. Although the responsibility for sexual assault rests on those who perpetrate such acts, and primary prevention strategies aimed at those demonstrating a risk for perpetration are imperative, sexual assault is a public health issue that warrants a multi-pronged approach to reduce its incidence and migrate its associated harms. Programs that engage students as pro-social bystanders have the potential to make a positive impact on the reduction of sexual assault incidence in the absence of effective primary prevention strategies. The findings of this study make a contribution to the literature examining influences of students' pro-social bystander intervention to sexual assault situations and provide suggestions for strategies to increase bystander engagement. Close