Thesis (Ph. D.)--University of Texas at Austin, 2005. / Vita. Includes bibliographical references.

A PolÃtica Nacional de HumanizaÃÃo da AssistÃncia Hospitalar foi instituÃda em 2003, visando à promoÃÃo de uma cultura de atendimento humanizado na Ãrea da saÃde. As diretrizes sÃo norteadoras e se expressam no mÃtodo da inclusÃo de usuÃrios, trabalhadores na gestÃo dos serviÃos e nas prÃticas de saÃde. Opera com dispositivos, atualizando as diretrizes por meio de estratÃgias destinadas à promoÃÃo de mudanÃas nos modelos de atenÃÃo e da gestÃo. A investigaÃÃo teve como objetivo geral identificar as necessidades de acolhimento aos membros familiares durante a hospitalizaÃÃo e, como especÃficos, desenvolver um grupo de suporte de acolhimento aos familiares de pacientes hospitalizados como estratÃgia da polÃtica de humanizaÃÃo, analisando como acontecem o acolhimento aos familiares dos pacientes hospitalizados e a PolÃtica Nacional de HumanizaÃÃo. Foi realizada sob a abordagem qualitativa, do tipo pesquisa-aÃÃo, por meio do processo grupal, em um hospital geral de ensino, de grande porte, de referÃncia no Estado, localizado na cidade de Fortaleza-CearÃ. Os participantes do estudo foram componentes familiares que estavam acompanhando parentes internados nas clinicas A e B do citado hospital no perÃodo do estudo. Os dados foram coletados no perÃodo de maio a julho de 2013, por meio da entrevista individual, da criaÃÃo de um grupo de suporte aos familiares de pacientes internados e da tÃcnica de colagem. A pesquisa foi realizada com base nos cuidados Ãticos necessÃrios aos seres humanos, preconizados pela ResoluÃÃo n 466/2012, do Conselho Nacional de SaÃde Foi iniciada apÃs a provaÃÃo pelo Comità de Ãtica em Pesquisa da instituiÃÃo. Para manter o compromisso de sigilo contido no Termo de Consentimento Livre e esclarecido, os sujeitos foram codificados com a letra F de familiar e o nÃmero por ordem de registro. Os dados foram analisados pela tÃcnica de AnÃlise de ConteÃdo, de Bardin. Os resultados estÃo expressos na seguinte ordem: apresentaÃÃo dos familiares, anÃlise das entrevistas; realizaÃÃo do Grupo de Suporte aos Familiares; avaliaÃÃo do grupo como estratÃgia para o acolhimento, por meio da colagem e anÃlise do acolhimento no hospital e a PolÃtica de HumanizaÃÃo. Em face dos resultados do estudo, que permitiram alcanÃar os objetivos propostos, espera-se que possam subsidiar a equipe de profissionais da saÃde, bem como a administraÃÃo do referido hospital, a potencializar as aÃÃes e medidas na infraestrutura, como tambÃm as de acolhimento e efetiva humanizaÃÃo na assistÃncia ao familiar durante a internaÃÃo, com interesse nos sentimentos do componente da famÃlia ao acompanhar o seu parente; nas dificuldades em lidar com seus sentimentos; nas necessidades e obstÃculos no hospital, assim como nas formas de ajuda relacionadas Ãs informaÃÃes e ao apoio psicolÃgico solicitado. / The National Policy for Humanization of Hospital Care was established in 2003, aiming to promote a culture of humane health care. The guidelines are expressed in the method of inclusion of users, workers in service management and in health practices. It employs devices, updating the guidelines through strategies designed to promote changes in patterns of care and management. The mail goal of the present study was to identify the needs of welcoming family members during the hospital stay, and as specific objectives, to develop a group to support the family of inpatients as a humanization strategy, analyzing the welcoming of family of patients and the National Humanization Policy. A qualitative action research approach, using a group process, was applied to a large general teaching hospital, reference in the state, located in Fortaleza, Cearà State. The study subjects were family members accompanying inpatients in clinics A and B of that hospital during the study period. Data were collected from May to July 2013 through individual interviews, creating a support group for family members of hospitalized patients, and collage technique. The study was conducted on the basis of ethical considerations to humans, recommended by the Resolution 466/2012, from the National Board of Health, and initiated after the approval by the Research Ethics Committee of the institution. To maintain the commitment to confidentiality of the Informed Consent, the subjects were coded with the letter F (family member) and the number by order of registration. Data were analyzed using content analysis of Bardin. The results are presented as follows: presentation of family members; analysis of the interviews; completion of the Family Support Group; assessment of the group as a strategy of welcoming, through collage and analysis of the welcome at the hospital and the Humanization Policy. Our results allowed the achievement of the proposed objectives, and it is expected that they can support health professionals, as well as the administration of the hospital, to increase the actions and measures in infrastructure, including the welcome and effective humanization in assisting the family during hospitalization, with interest in the feelings of the family when accompanying the relative; the difficulties in dealing with feelings; the needs and obstacles in the hospital as well as in the forms of assistance related to information and psychological support requested.

This research builds upon a body of work on the development and introduction of information systems in the UK National Health Service following the implementation of the White Paper 'Working for Patients'. None of the earlier studies examined the use of the information from those systems for costing health care services, the methodologies used by hospitals for costing their products or the comparability of the output from the costing methodologies used, thereby making this study different from prior work. Costing methodologies cited in the literature are described from the perspective of single organisations. This research analyses the development of an aggregated costing approach, focusing on the issues laced when trying to develop a costing methodology that will be applied to a group of autonomous organisations. The research provides a comparison of health care costing methodologies in both the United Kiiigdom and Ontario, Canada. Collected through interviews and a postal survey tool, data from NHS hospital care providers are analysed to identify both the conformity of the approach and the results of the costing methodologies eniployed. Information from an extended field study is used to review the development of a micro-costing framework in Ontario for radiation therapy services. These findings are then synthesised into a generic framework applicable within other health care organisations seeking to implement a comparative costing methodology. This lramcwork is used to identify possible causes of variance in health care costing approaches. Elements of the framework requiring modification to account for local conditions, such as salary rates or provider availability, are identified and suggestions are made for further work resulting from this research to increase understanding about variability in health care costing methodologies and test the implementation of the generic costing methodology.

Introduction: Beta-Blocker Evaluation Survival Trial (BEST) sub-analyses indicated a likely interaction between bucindolol and race disadvantaging black heart failure (HF) patients (Domanski J Cardiac Fail 2003); Arg389 homozygotes having adjusted reductions of 38% in mortality and 34% in mortality/hospitalization over other genotypes (Liggett PNAS 2006). Bucindolol is being evaluated in Arg389 genotype patients in the GENETIC-AF trial (NCT01970501). Objective: To conduct parallel (using Domanski et al and Liggett et al) ex ante economic evaluations of Arg389 genetic testing in stage III/IV HF to support bucindolol treatment decisions (if Arg389-positive) and carvedilol (if Arg389-negative) treatment versus no such testing and empirical bucindolol; using Domanski et al and Liggett et al BEST sub-analyses. Methods: In both Domanski et al and Liggett et al analyses, we used a decision tree model with time horizon of 18 months divided into 3 six-month cycles to estimate the cost-effectiveness and cost-utility of Arg389 genetic testing, considering overall survival (OS) from Domanski et al and Liggett et al BEST sub-analyses. Costs and utilities were retrieved from literature except for assumed cost for bucindolol treatment (1.5x cost of carvedilol) and genetic testing ($250). Discount rate was set at 3%/yr. Weibull distributions were fitted to OS data. Life-years (LY) and quality-adjusted life-years (QALY) were used to estimate incremental cost-effectiveness (ICER) and cost-utility ratios (ICUR), and results were validated using probabilistic sensitivity analyses (PSA). Results: In the Domanski et-based analysis, Arg389 genetic testing versus no testing was associated with incremental gains of 0.29LYs and 0.27QALYs at incremental cost of $726; yielding ICER of US$2,503/LY and ICUR of US$2,688/QALY gained. In the Liggett et al-based analysis, Arg-389 genetic testing versus no testing was associated with incremental gains of 0.35LYs and 0.32QALYs at savings of -$1.081; for ICER of -US$3,089/LY and ICUR of -US$3,378/QALY gained. Both analyses were confirmed in PSAs. Conclusion: Arg389 genetic testing to support bucindolol treatment in stage III/IV HF patients prevails economically over bucindolol treatment without genetic testing due to superior OS. If bucindolol is priced at 1.5x the cost of carvedilol. this economic benefit is likely to disappear if bucindolol and/ or genetic testing are priced higher. The clinical and economic benefits of bucindolol treatment with versus without Arg389 genetic testing versus empiric carvedilol remains to be assessed.

This research builds upon a body of previous research on health informatics in developing countries. Early research on this area was motivated by a desire to understand the role of different health informatics applications for an effective and efficient health care delivery in developing countries. These applications range from the use of medical expert systems for clinical diagnosis to epidemiological systems at the central level. None of these looked at health information systems at the district level, especially in relation to the information needs of district health staff. Therefore, this research differs from earlier studies in three aspects. First, it looks at the planning and decision-making processes at the district level and how information support could play a crucial role in these processes. Second, it provides a critical evaluation of the existing vertical reporting systems, and through action-research demonstrates the use of an integrated health information system at the district level. Third, it applies multiple perspectives to analyse the research findings in relation to information support for district health care planning and decision making. These three perspectives are the functional perspective, organisational perspective, and the political perspective. To achieve this, the research: • uses a systemic approach to examine the health care system in The Gambia; • uses action-research to design, develop and implement an integrated district health information system in The Gambia; • uses an interpretive evaluation framework to evaluate the impact of the system development efforts in this research; • uses the theory of contextualism to reflect on the research findings over the three year period. Various themes emerged during the research. These themes would be introduced here as the contributions to knowledge arising from the completion of this research project. These include: • a demonstration of the suitability of using a systemic approach for the design, development and implementation of an integrated information system for district health care planning and decision making; • the development of a conceptual implementation framework suitable for the unique characteristics of developing countries; • a manifestation of the implications of an integrated information system for management development, decentralisation, intersectoral coordination and community participation at the district level; • suggestions for further work especially on the need to evaluate the socio-political impact of this research on the existing political and cultural structures in The Gambia.

The purpose of this study is to explore the concept of ‘Healthy Ageing’ in Hong Kong. The research attempts to explore the historical base from which ‘Healthy Ageing’ has been conceptualized in both Western and Chinese societies. This study also tries to provide an overview of literature that relevant to the ‘Healthy Ageing’ concept, and to provide an initial theoretical framework of ‘Healthy Ageing’ in a Hong Kong Chinese context. This study mainly adopts a qualitative approach in exploring the meaning of the concept. Since that ‘Healthy Ageing’ is likely to be conceptualized from the concept of health and ageing, which have been here since the early days, a method of documentary analysis on the origin of the concept and the paths leading to what it is at present has been employed. To re-construct the concept in Hong Kong, this thesis works towards an explanation of the historical base of the concept of ‘Healthy Ageing’ in both Chinese and Western societies since Hong Kong has evolved from a mixture of both cultures. Comparative cultural analysis and research’s own interpretation act as important roles in the present study to consolidate those raw documents in particular of the Chinese literature and construct a new model for the concept. Having constructed a model of ‘Healthy Ageing’, an expert in cultural studies was then interviewed at the end of May 2002 for verifying the model. Adopting a comparative cultural analysis, this study found that the fundamental elements, say physical and psychosocial well-being, in conceptualization of health in both East and West are almost the same, but manifestations and interpretations show some variations. Chinese people are apt to manifest and interpret their concept of health by an holistic approach, while the concept of health in Western societies is more likely to be manifested in a “compartmental” approach. These variations are basically derived from the differences of geo-cultural adaptations and the differences in individual lifestyles. As to the concept of ageing, this study revealed that ageing subject as a process instead of an end-stage of life-span. According to one view of human beings, life-spans can be divided into eight periods: Prenatal (pregnancy), Infancy (0-3), Early Childhood (3-6), Middle Childhood (6-12), Adolescence (12-20), Young Adulthood (20-40), Midlife (40-65) and Old Age (65+). It is a natural and integral process of growing old starting from birth and ending at death, in which a continuous process of biological, psychological and social changes will be experienced in a person’s life-course. After reconstructing health and ageing concepts, a tentative model of healthy ageing was developed in this study. In this study, healthy ageing is an holistic and dynamic concept. It is a state of interactions and adaptations between people and the environment in attaining optimal health in one’s life-span. It is a three-dimensional concept that encompasses health, health-ageing and health-ageing-environment dimensions. For the health dimension, there are six interrelated cross-life domains in achieving healthy ageing, which involve physical, psychological, social, economic, spiritual and environmental well-being. For the health-ageing dimension, people can achieve healthy ageing by attaining health in each stage of life. In this process, the health at younger stage influences the health at older stage. Thus, keeping healthy in early stage benefits the health conditions in later stages, although it cannot be said that what happens in early stage might not be unchangeable for later stages. Adopting health-promoting strategies in later stage can also provide opportunities for individuals to achieve healthy ageing. The health-ageing-environment dimension refers to the people-environment adaptation for attaining optimal health in their life-spans. Basically, people can ideally achieve healthy ageing by adopting health-promoting strategy at every stage of life. However, those favourable and unfavourable external environments will limit and change the opportunities for a person to achieve healthy ageing. To achieve optimal health in their life-spans, people are required to adjust themselves, adapting to their environment and also helping to shape the environment. Therefore, an individual-community approach is crucial for attaining healthy ageing.

There has been a well-documented and causal relationship between cigarette smoking and disease for over forty years, and at least an implicit concern over tobacco and health for decades, if not centuries prior; however, government policy on how to address tobacco as a public health issue has been erratic. At the turn of the twentieth century, when cigarettes first became a national phenomenon, the federal government imposed few if any regulations, and even encouraged the use of cigarettes. By the 1960s, government, public health entities and the tobacco industry were cooperating to try to fix the problem. Although there was great success in this early, if uneasy alliance, by the 1980s this coalition was fragmented and the search for a pragmatic solution to the tobacco problem came to an abrupt end. This dissertation is an investigation into how policy-makers, tobacco industry executives and public health officials each ignored opportunities to come to a practical solution to the problem which confronted them. The 1960s saw these groups work together to formulate a harm reduction policy approach which would lessen, if not eliminate, the concerns from each constituent group. Despite some significant early successes, this effort was derailed due to partisan positioning, misguided self-interest, and certain individual personalities. This analysis of the safer-cigarette campaign sheds light on a little explored avenue in the tobacco debate, as well as highlights the challenges of policy making in Washington.

In the United States, prescription opioids have been a major problem that contributed to the opioid crisis in the country. As dentists prescribe analgesics routinely for dental pain management, further investigation into opioid and non-opioid prescription patterns by dentists on a national level is needed. This research project aimed to examine 1) the trends in opioid and non-opioid analgesic prescriptions by dentists in the US,2) to examine the racial-ethnic disparities in receiving an opioid and non-opioid prescription from a dental professional, 3) the effect of federal Rescheduling of hydrocodone combination on opioid prescription patterns by dentists in a school setting. Data on analgesic prescriptions by dentists were obtained using medical panel survey MEPS (1996- 2015), and Boston University Henry M. Goldman School of Dental Medicine clinical repository (2010 -2019). On average about 31,206 individuals of all ages were interviewed for MEPS each year. The trend in analgesics prescription was reported weighted numbers and proportions of total and dental analgesics prescriptions were reported. Kendall tau correlation test was used to examine trends in the rate of opioid prescriptions per 100 persons over survey years. Racial differences were examined using MEPS data (2002-2015) on dental analgesic prescriptions, dental care utilization, patients’ race, and other demographic information. The outcome was analgesic prescription received. The main independent variable was the patients’ race/ethnicity. Covariates included in the analysis were gender, age, marital status, income, geographical region, and survey year. Using BUSDM data (2010-2019) we examined 12,807 patients who received an opioid prescription from a dentist. The primary outcome variables were opioid prescriptions and opioid morphine milligram equivalent (MME). The primary predictor used is the date of opioid prescription (Time before and after the intervention). To assess the effect of hydrocodone medication reclassification on the outcome variables we used an interrupted time series (ITS) analysis with a segmented regression model. Our results showed a decrease in the proportion of dental opioids out of total opioids from 9.76% in 1996 to 4.5% in 2015. Kendall tau correlation indicated an increase in prescribing rate over the years in total opioids but not in dental opioids. Racial differences were found in opioid prescriptions by dentists with whites having a lower risk of receiving an opioid analgesic compared to other racial minorities. The effect of federal rescheduling of hydrocodone combination on opioid prescription patterns by dentists showed specifically a reduction in non-hydrocodone opioids prescribing rate by morphine milligram equivalent (MME). In conclusion dentists’ contribution to the increase in prescription opioids in the United States seem to be limited compared to other health care professionals. Nevertheless, racial differences were found in whites when compared to other racial minorities. Efforts to curb the use of opioids should be encouraged even more so with evidence supporting the effectiveness of non-opioids analgesics in control of dental pain. / 2022-12-09T00:00:00Z

Objectives: Rates of maternal syphilis have increased five-fold in Brazil in the past decade. While penicillin remains the only appropriate treatment for maternal syphilis, we hypothesized that low non-treponemal titers (<1:16) may lead to reduced penicillin treatment in Brazil. Methods: Using Brazilian Ministry of Health data on women diagnosed with maternal syphilis between January 1, 2010, and December 31, 2018, we conducted a random-effects logistic regression model with a cluster correction at the state level to evaluate predictive factors of penicillin treatment. Results: We observed yearly increases in cases of pregnant women with syphilis from 2010 to 2018. There was significant variation by state: 52,451 cases were reported in São Paulo, followed by 26,838 in Rio de Janeiro. Among 215,937 cases of maternal syphilis, 91·3% received penicillin. In the random-effects model, a non-treponemal titer ≥1:16 was associated with 1·44 higher odds of receiving penicillin (95% confidence interval [CI]: 1·391·48), and prenatal care was associated with a 2·12 increased odds of receiving penicillin (95% CI: 2·022·21). Although there is an association between the absence of prenatal care and inadequate treatment for syphilis, 83·2% of women in this cohort who did not receive penicillin were engaged in prenatal care. Conclusions: Providers may inappropriately exclude low non-treponemal titers and thereby fail to use penicillin treatment in maternal syphilis. While the cause of the maternal syphilis epidemic in Brazil is multifactorial, we believe our findings can be used to develop targeted interventions throughout Brazil as well as shape public health initiatives globally. / National Institute of Mental Health / Revisión por pares

Chronic diseases such as cancer, diabetes, cardiovascular and respiratory diseases are a global concern. In recent decades, Canada has also experienced a major increase in immigration. Yet, a detailed profile of chronic disease and multimorbidity risk patterns across different immigrant populations has been lacking in Canada. The purpose of this dissertation is to identify knowledge gaps in the scientific literature on the development of chronic conditions and multimorbidity across immigrant populations in Ontario, using population-based immigrant and health data housed at ICES. The principal findings of this dissertation indicate that: 1. The risk of developing a chronic condition and multimorbidity was complex and varied by immigrants’ visa category and world region origin since: a. Refugees had the highest risk of developing a chronic condition and multimorbidity (two or more co-occurring chronic conditions) compared to long-term Ontario residents. b. There were differences in the risk of developing a chronic condition and multimorbidity by world regions of origin, when examined across different immigrant categories. 2. Hypertension and diabetes, and in combination with Chronic Obstructive Pulmonary Disease were the leading multimorbidity dyad and triad groups for all immigrant categories and long-term residents of Ontario. 3. The risk of developing a chronic condition increased among immigrants in more recent landing cohorts. The risk was highest among more recent refugees, and lower for family and economic class immigrants, when compared to long-term Ontario residents. These findings provide evidence to inform public health policy and planning by highlighting the complexity and heterogeneity of health outcomes across immigrant populations. Knowledge generated from this work will inform policies and evidence-based decision-making aimed to address the threat of chronic diseases and reduce health disparities.