In Mississippi, approximately 4,700 deaths are caused by smoking and approximately 3,500 young Mississippians begin smoking each year. Nearly 9 out of 10 smokers start smoking by age 18, and 99% start by age 26. Because of the early age of initiation, policy changes and other initiatives that affect smoking rates among youth are of particular interest, including tax increases. In 2009, Mississippi increased its state excise tax on tobacco from $.18 to $.68 per pack which was in addition to the federal tax increase to $1.0066 (an increase of $.6166 from the previous amount of $.39). This study examined the effect of Mississippi's tobacco tax increase on youth smoking initiation and tobacco consumption behavior using difference-in-difference analysis. Using the SmartTrackTM School Survey this study analyzed changes in youth who reported ever smoking and their recent consumption from the three years prior to the tax increase to the three years following it using data from the Louisiana Caring Communities Youth Survey as the control group since Louisiana did not experienced a state-level cigarette tax increase during this period. The analysis showed mixed results for a statistically significant difference in smoking initiation (ever smoked cigarettes) rates, and moderately supported the hypothesis of past 30 day youth smoking rates being reduced by the tax increase on cigarettes in Mississippi. While youth smoking rates declined significantly during the study period, the difference-in-difference analysis of youth who reported ever smoking showed only a small but statistically significant effect across all grades, but had a notable impact on 6th graders. The analysis of past 30 day use showed no short term effect on Mississippi youth in the year after the 2009 tax increase, but difference-in-difference comparisons showed a moderate and statistically significant impact on those rates the longer term. The results of this study will be of interest to scholars, policymakers, and tobacco control advocates as they make decisions about whether to increase state level taxes on cigarettes to prevent smoking initiation and curb youth tobacco use. / acase@tulane.edu

acase@tulane.edu

acase@tulane.edu

acase@tulane.edu

acase@tulane.edu

Background During the 1990s, Tanzania, like many other developing countries, adopted health sector reforms. The most common policy change under health sector reforms has been decentralisation, which involves the transfer of power and authority from the central levels to the local governments. However, while decentralisation of health care planning and priority-setting in Tanzania gained currency in the last decade, its performance has, so far, been less than satisfactory. In a five-year EU-supported project, which started in 2006, ways of strengthening fairness and accountability in priority-setting in district health management were studied through action research. As part of this overall project, this doctoral thesis aims to analyse the existing health care organisation and management systems, and explore the potential and challenges of implementing Accountability for Reasonableness approach to priority setting in Tanzania. Methods A qualitative case study in Mbarali district formed the basis of exploring the socio-political and institutional contexts within which health care decision-making takes place. The thesis also explores how the Accountability for Reasonableness intervention was shaped, enabled and constrained by the interaction between the contexts and mechanisms. Key informant interviews were conducted with the Council Health Management Team, local government officials, and other stakeholders, using a semi-structured interview guide. Relevant documents were also gathered and group priority-setting processes in the district were observed. Main findings The study revealed that, despite the obvious national rhetoric on decentralisation, actual practice in the district involved little community participation. The findings showed that decentralisation, in whatever form, does not automatically provide space for community engagement. The assumption that devolution to local government promotes transparency, accountability and community participation, is far from reality. In addition, the thesis found that while the Accountability for Reasonableness approach to priority setting was perceived to be helpful in strengthening transparency, accountability, stakeholder engagement and fairness, integrating the innovation into the current district health system was challenging.   Conclusion This thesis underscores the idea that greater involvement and accountability among local actors may increase the legitimacy and fairness of priority-setting decisions. A broader and more detailed analysis of health system elements, and socio-cultural context, can lead to better prediction of the effects of the innovation, pinpoint stakeholders’ concerns, and thereby illuminate areas requiring special attention in fostering sustainability. Additionally, the thesis stresses the need to recognise and deal with power asymmetries among various actors in priority-setting contexts.

Thesis (MEng)--Stellenbosch University, 2012. / ENGLISH ABSTRACT: Telemedicine is a rapidly developing field in the medical sector that utilises modern day technology to provide improved health services to rural and remote areas. Telemedicine can also provide specialist support and remote consultation to facilities where there is a lack of resources. In South Africa, where a large percentage of the population live in rural and remote areas, telemedicine has the potential to alleviate the burden on national health resources, whilst improving the quality of healthcare. Various telemedicine projects have been piloted in South Africa from its inception in 1998, with the primary objective being to address the inequalities of healthcare delivery in South Africa. Most of these projects did not get past their initial pilot phase. It is often difficult to determine the factors that contribute to a telemedicine project’s success or demise, due to the unavailability of documentation for projects. The purpose of this research project is to contribute towards sustained implementation of telemedicine projects, by assisting the Medical Research Council (MRC) in their current efforts. This has been done through the development of an information management system which can record and store relevant information regarding telemedicine projects in South Africa. The system allows users to document telemedicine projects, whilst also giving them access to technical- and descriptive information. A total of 102 projects from the international academic domain were used to perform a meta-study, in order to determine the nature of telemedicine projects. Articles documenting various telemedicine projects were selected from the Journal of Telemedicine and Telecare. The telemedicine process data was then extracted and uploaded from these articles to the first version of the information system developed in this thesis. The meta-study was also used as the first phase of verification for the information system being developed. Changes were made to the information system after the meta-study was completed. These changes included alterations to the database and the interface of the information system. Additional tables were added to the database of the information system, to store the data required by the MRC, in order to document telemedicine projects in South Africa. The verification of the information system consisted of two testing phases. The first testing phase, the alpha test, was performed as part of the meta-study. The second testing phase was conducted after changes were incorporated into the information system, as necessitated by the alpha test and meta-study. In this phase of testing users could access the information system via the Internet. The information system was validated in two phases. Firstly it was shown that the information system met the objectives set out for this project. Secondly it was shown that the information system has the capacity to assist in planning, development, implementation, and research through retrospectively examining two telemedicine projects in which Dr. Sam Surka (senior scientist and clinical manager at the MRC) was involved. Outcomes of the project indicated that the information system is a useful tool for identifying similar telemedicine projects, and for assisting stakeholders in telemedicine projects. Finally the research process was reflected upon to identify future work in terms of collecting telemedicine process data, as well as the assistance of telemedicine research within the South African context / AFRIKAANSE OPSOMMING: Telemedisyne is 'n vinnig ontwikkelende veld in die mediese sektor wat gebruik maak van moderne tegnologie om verbeterde gesondheidsdienste te verskaf aan landelike en afgeleë gebiede. Telemedisyne kan ook spesialis-ondersteuning en afstandsraadgewing bied aan fasiliteite waar daar 'n gebrek aan hulpbronne is. In Suid-Afrika, waar 'n groot persentasie van die bevolking in landelike en afgeleë gebiede woon, het telemedisyne die potensiaal om die las te verlig op nasionale gesondheid hulpbronne, asook die gehalte van gesondheidsorg te verbeter. Verskeie telemedisyne projekte is in Suid-Afrika geloods vanaf 1998, met die primêre doel om die ongelykhede van gesondheidsorg in Suid-Afrika aan te spreek. Meeste van hierdie projekte het egter nie voortbestaan na hul aanvanklike proeffase nie. Dit is dikwels moeilik om die bydraende faktore te bepaal wat 'n telemedisyne projek se sukses of ondergang veroorsaak, as gevolg van die onbeskikbaarheid van dokumentasie vir die projekte. Die doel van hierdie navorsingsprojek is om ‘n bydrae te lewer tot die volhoubare implementering van telemedisyne projekte deur hulp te verleen aan die Mediese Navorsingsraad (MNR) se huidige ondernemings. Dit is gedoen deur 'n inligtingstelsel te ontwikkel wat relevante inligting opneem en stoor ten opsigte van telemedisyne projekte in Suid-Afrika. Die stelsel laat gebruikers toe om telemedisyne projekte te dokumenteer, asook toegang te bekom tot tegniese en beskrywende inligting. 'n Totaal van 102 projekte van die internasionale akademiese omgewing is gebruik om 'n meta-studie uit te voer ten einde die aard van telemedisyne projekte te bepaal. Artikels wat verskeie telemedisyne projekte dokumenteer is gekies uit die “Journal of Telemedicine and Telecare”. Die telemedisyne proses data is vanuit hierdie artikels onttrek en opgelaai na die eerste weergawe van die inligtingstelsel wat in hierdie tesis ontwikkel is. Die meta-studie is ook gebruik as die eerste fase van verifikasie vir die inligting stelsel wat ontwikkel word. Veranderinge was aangebring aan die inligtingstelsel na die meta-studie voltooi was. Hierdie veranderinge sluit in die uitbreiding van die databasis en die koppelvlak van die inligtingstelsel. Addisionele tabelle is bygevoeg tot die databasis van die inligtingstelsel om die addisionele data te stoor soos vereis deur die Mediese Navorsingsraad (MNR), ten einde die telemedisyne projekte in Suid-Afrika te dokumenteer. Die verifikasie van die inligtingstelsel bestaan uit twee toets fases. Die eerste toetsfase, die alfa toets, was uitgevoer as deel van die meta-studie. Die tweede toetsfase was uitgevoer na veranderinge aan die inligtingstelsel gemaak is, soos genoodsaak deur die alfa toets en meta-studie. In hierdie toetsfase kon gebruikers toegang tot die inligtingstelsel kry deur die Internet. Die inligtingstelsel was bekragtig in twee fases. Eerstens, dit is aangetoon dat die inligtingstelsel die doelwitte bereik het, soos uiteengesit vir hierdie projek. Tweedens was aangetoon dat die inligtingstelsel die vermoë het om te help met die beplanning, ontwikkeling, implementering, en navorsing deur twee telemedisyne projekte te ondersoek waarin Dr. Sam Surka (senior wetenskaplike en kliniese bestuurder by die MNR) betrokke was. Uitkomste van die projek het aangedui dat die inligtingstelsel 'n nuttige hulpmiddel is vir die identifisering van soortgelyke telemedisyne projekte, terwyl dit ook belanghebbendes van telemedisyne projekte ondersteun. Ten slotte was daar besin oor die navorsingsproses om toekomstige werk te identifiseer in terme van die versameling van telemedisyne proses data, asook die ondersteuning van telemedisyne navorsing binne die Suid-Afrikaanse konteks.

This thesis sheds light on differences in health insurance enrolment determinants and uptake barriers between urban and rural areas in the Jirapa district of Ghana. The National Health Insurance Scheme in Ghana has made significant progress in terms of enrolment, which has had a commensurate increase in utilization of health care services. However, there are challenges that pose a threat to the scheme’s transition to universal coverage; enrolment in the scheme has not progressed according to plan, and there are many barriers known to impede uptake of health care. Interestingly, these barriers vary in relation to locality, and rural residents appear to carry a disproportionate portion of the burden. A mixed method approach was employed to collect and analyse the data. On the basis of the primary qualitative and quantitative results, the thesis argues that the costs of enrolling and accessing health care is disproportionately higher for rural residents than it is their urban counterparts. It also highlights that the distribution of service benefits both in terms of the NHIS and health care in the Jirapa district favours urban residents. Lastly, the thesis found that whereas rural residents prefer health care provision to be social in nature, urban residents were more interested in the technical quality aspects of care. These findings suggest that rural residents are not benefitting from, or may not be accessing health services to the extent as their urban counterparts. Affordability, long distance to health facilities, availability and acceptability barriers were found to influence the resultant pro-urban distribution of the overall health care benefit.

p. 1-77 / Submitted by Santiago Fabio (fabio.ssantiago@hotmail.com) on 2013-05-07T19:36:53Z No. of bitstreams: 1 6666666666666.pdf: 313932 bytes, checksum: 01602d9f39df99bc370c99662eeaebd4 (MD5) / Approved for entry into archive by Maria Creuza Silva(mariakreuza@yahoo.com.br) on 2013-05-13T13:45:11Z (GMT) No. of bitstreams: 1 6666666666666.pdf: 313932 bytes, checksum: 01602d9f39df99bc370c99662eeaebd4 (MD5) / Made available in DSpace on 2013-05-13T13:45:11Z (GMT). No. of bitstreams: 1 6666666666666.pdf: 313932 bytes, checksum: 01602d9f39df99bc370c99662eeaebd4 (MD5) Previous issue date: 2008 / A avaliação de desempenho dos sistemas de saúde das nações vem ganhando importância crescente entre os gestores do setor saúde e o setor acadêmico, sendo considerada como etapa essencial para o planejamento das ações voltadas para garantia da qualidade da atenção e subsidiar decisões que atendam às necessidades da população, constituindo-se uma tecnologia de gestão. Este artigo objetiva conhecer as características atuais do debate sobre a avaliação de desempenho dos sistemas de saúde, por meio da procedência da produção científica, dos atributos relacionados à estrutura, processo e resultado dos sistemas, bem como das opções metodológicas utilizadas para desenvolver estes estudos. A coleta de dados foi realizada por meio das bases de dados indexadas: Medline, Lilacs e Scielo, no período de 1990 a 2007, sendo excluídos da pesquisa os estudos que trataram da avaliação de ações e programas de saúde. Foram analisados os atributos relativos à eficiência, qualidade e efetividade, estando os mesmos relacionados à estrutura, processo e resultado, respectivamente. Os resultados apontam uma tendência de maior preocupação da academia dos países desenvolvidos com o desempenho dos sistemas de saúde, especialmente com os aspectos de qualidade. Entretanto, os sistemas de saúde do Brasil têm dedicado mais espaço à produção científica deste tema. Foram os estudos de avaliação de intervenção, aqueles desenvolvidos em maior número, cuja relação se dá com a estrutura dos sistemas de saúde. Uma maior freqüência de estudos empíricos certamente contribuirá com a institucionalização da avaliação de desempenho, especialmente nos países em desenvolvimento. / Salvador

abstract: Suicide is one of the fastest-growing and least-understood causes of death, particularly in low and middle income countries (LMIC). In low-income settings, where the technical capacity for death surveillance is limited, suicides may constitute a significant portion of early deaths, but disappear as they are filtered through reporting systems shaped by social, cultural, and political institutions. These deaths become unknown and unaddressed. This dissertation illuminates how suicide is perceived, contested, experienced, and interpreted in institutions ranging from the local (i.e., family, community) to the professional (i.e., medical, law enforcement) in Nepal, a country purported to have one of the highest suicide rates in the world. Drawing on a critical medical anthropology approach, I bridge public health and anthropological perspectives to better situate the problem of suicide within a greater social-political context. I argue that these complex, contestable deaths, become falsely homogenized, or lost. During 18 months of fieldwork in Nepal, qualitative, data tracing, and psychological autopsy methodologies were conducted. Findings are shared through three lenses: (1) health policy and world systems; (2) epidemiology and (3) socio-cultural. The first investigates how actors representing familial, legal, and medical institutions perceive, contest, and negotiate suicide documentation, ultimately failing to accurately capture a leading cause of death. Using epidemiologic perspectives, surveillance data from medical and legal agencies are analyzed and pragmatic approaches to better detect and prevent suicidal death in the Nepali context are recommended. The third lens provides perceived explanatory models for suicide. These narratives offer important insights into the material, social, and cultural factors that shape suicidal acts in Nepal. Findings are triangulated to inform policy, prevention, and intervention approaches to reduce suicidal behavior and improve health system capabilities to monitor violent deaths. These approaches go beyond typical psychological investigations of suicide by situating self-inflicted death within broader familial, social, and political contexts. Findings contribute to cultural anthropological theories related to suicide and knowledge production, while informing public health solutions. Looking from the margins towards centers of power, this dissertation explicates how varying institutional numbers can obfuscate and invalidate suffering experienced at local levels. / Dissertation/Thesis / Doctoral Dissertation Social Science and Health 2017