Purpose: Contact lens (CL) materials, modalities of wear and replacement, and care systems have changed considerably since the early studies of CL compliance were first conducted. Silicone hydrogel (SiHy) and daily disposable (DD) lenses are now the most popular lenses worn worldwide and the care systems that are currently available for them have been designed to be straightforward to use. The purpose of this research was to investigate patient knowledge of and compliance with the use of these contemporary CLs and care products, to determine whether non-compliant CL wearers experience ocular complications relating to lens wear more frequently and are more likely to discontinue lens wear, and to try to determine the factors that may constrain or enable patients to follow recommendations for appropriate lens wear and care. Methods: There are many ways in which compliance can be assessed in health care. Several different methodologies were employed during this research: A questionnaire was administered to just over 100 current lens wearers to determine whether photographic aids would help them to recognize which products they were using. More than 500 contact lens (CL) wearers were recruited by their eye care practitioners (ECPs) and mailed a questionnaire designed to evaluate their compliance with contact lens wear and care and to determine whether they had experienced any contact lens related complications which may have occurred as a result of non-compliance. Close to 5000 Current and lapsed CL wearers in Canada were recruited using Facebook to take part in an on line survey investigating CL wearing experiences during 2008 – 2010 and to establish the percentage of participants who temporarily and permanently discontinued CL wear during the period surveyed, the reasons for discontinuation and whether compliance with lens wear and care may have played a role. ECPs and patients independently completed more than 2000 linked questionnaires evaluating their contact lens wear and care. In addition the frequency with which patients attended their ECP’s office for eye examinations was assessed to determine whether there was a relationship between this and their patients’ compliance. More than 800 daily disposable contact lens (DDCL) wearers in four countries completed an online questionnaire designed to investigate how frequently they reused their lenses, the reasons for reuse and how the lenses were stored between uses. Quantitative (online questionnaire) and qualitative (focus groups) research methods were used to explore in detail the lens wear and care habits of adapted contact lens wearers in an attempt to seek a better understanding of what enables and constrains patient compliance with appropriate lens wear and lens care. Results: The rates of non-compliance with the wear of contemporary CLs were found to be similar to those previously reported. Non-compliance with recommendations for CL replacement was shown to be associated with a higher rate of CL related problems. CL wearers continue to “drop-out” for reasons of discomfort and dryness with their lenses but the drop out rates were not found to be different between compliant and non-compliant CL wearers. Patients who were non-compliant with lens replacement were found to attend their ECP’s offices less frequently. Wearers of DDCLs were the most compliant with lens replacement; however, some did report reusing these lenses and sleeping overnight in them. Focus group participants were able to provide a greater insight into why non-compliant behaviour occurs in CL wearers with the most frequently occurring themes identified as the “consequences” that may occur if patients are non-compliant with one or more aspects of their contact lens wear and the importance of receiving “instructions” regarding the most appropriate way to wear and care for their lenses. Most of the themes that emerged from this qualitative research study were both constraints to, and enablers of, compliance. Conclusions: Compliance with contemporary CLs and care products remains poor. Non-compliant behaviour can result in serious complications and patients may not always be aware of this. Careful counseling and education on the risks associated with CL wear is required to provide patients with a better lens wearing experience and continued successful contact lens wear. ECPs and the contact lens industry can hopefully apply this greater understanding of why patients fail to wear and care for their lenses as they should and to help them develop strategies and tools to aid compliance and success in contact lens wear.

DM is a serious and complex public health problem in the U.S. The CDC (2013) estimated that 25.8 million people, or 8.3% of the U.S. population, were suffering from DM in 2011. DM can significantly affect patient’s quality of life. Additionally, DM places a significant economic burden on the U.S. healthcare system. Over the past two decades, DMPs have emerged as a promising intervention to improve health outcomes for patients suffering from chronic conditions, such as DM, and to bend the cost curve. DMP’s aim is to improve communication and follow-up so that patients can better manage their chronic condition(s) to avoid costly hospital stays and emergency room visits (Fireman, Bartlett, & Selby, 2004). The Georgia region of Kaiser Permanente (KPGA) is a fully integrated health system that serves 260,000 members at 28 medical offices along with two specialty offices in the metropolitan Atlanta area. The Center for Care Partnership, the population care division of KPGA, administers a chronic disease management program (DMP), Healthy Solutions (HS). HS exists to improve and maintain the health of chronically ill KPGA members, including patients diagnosed with diabetes mellitus (DM), by providing health coaches via telephone who counsel members on their specific chronic disease and aid members in starting or maintaining a physician approved self-care management plan. In order to determine the impact HS has on KPGA members with DM, an evaluation plan was created to evaluate the impact HS has on members’ glycated hemoglobin (A1C), blood pressure, and emergency department (ED) utilization. This capstone thoroughly details the proposed evaluation plan created for HS by using Robert Milstein and Scott Wetterhall’s six-step framework for program evaluation. Additionally, further evaluation questions are suggested and discussed in order to provide a more complete picture of program performance to stakeholders.

Kurpė V. Korupcijos kontrolė Lietuvos sveikatos apsaugos sistemoje / magistro baigiamasis darbas. Vadovė Dr. N. Černiauskienė – Vilnius: Mykolo Romerio universitetas, politikos ir vadybos fakultetas, 2014. – 76 p. Magistro baigiamajame darbe išanalizuota ir įvertinta korupcijos kontrolė Lietuvos sveikatos apsaugos sistemoje, iškeltos korupcijos sveikatos apsaugos sistemoje problemos. Pirmoje dalyje remiantis mokslinės bei teisinės literatūros šaltiniais nagrinėjama teorinė dalis: korupcijos sąvoka, formos, korupciją įtakojantys veiksniai. Antroje dalyje analizuojamas korupcijos lygis bei korupcijos kontrolė sveikatos apsaugos sistemoje. Trečioje dalyje pagrindžiama tyrimo problema, pateikiamas instrumentarijus, aptariama atliekamo tyrimo eiga. Ketvirtoje dalyje analizuojamas visuomenės bei gydytojų požiūris į korupciją sveikatos apsaugos sistemoje. Pagrindiniai žodžiai: korupcija, korupcijos kontrolė, sveikatos apsauga, sveikatos apsaugos sistema. / Kurpe V.. Corruption control in Lithuania health care system / Master’s Work in. Supervisor assoc. N. Cerniauskiene – Vilnius: Fakulcity of Fakulcity Policy and Management, Mykolas Romeris University, 2014. – 76 p. Master's thesis analyzed and evaluated corruption control Lithuanian health system, bringing health care system corruption problems. In the first part of the scientific and legal literature examines the theoretical part: Corruption concept, shape, corruption influencing factors. The second part analyzes the level of corruption and corruption control health care system. The third section justifies the problem, the instrumentation, discusses the progress of the investigation. The fourth part analyzes public perceptionsand doctors position of corruption in the health care system.

Purpose: Contact lens (CL) materials, modalities of wear and replacement, and care systems have changed considerably since the early studies of CL compliance were first conducted. Silicone hydrogel (SiHy) and daily disposable (DD) lenses are now the most popular lenses worn worldwide and the care systems that are currently available for them have been designed to be straightforward to use. The purpose of this research was to investigate patient knowledge of and compliance with the use of these contemporary CLs and care products, to determine whether non-compliant CL wearers experience ocular complications relating to lens wear more frequently and are more likely to discontinue lens wear, and to try to determine the factors that may constrain or enable patients to follow recommendations for appropriate lens wear and care. Methods: There are many ways in which compliance can be assessed in health care. Several different methodologies were employed during this research: A questionnaire was administered to just over 100 current lens wearers to determine whether photographic aids would help them to recognize which products they were using. More than 500 contact lens (CL) wearers were recruited by their eye care practitioners (ECPs) and mailed a questionnaire designed to evaluate their compliance with contact lens wear and care and to determine whether they had experienced any contact lens related complications which may have occurred as a result of non-compliance. Close to 5000 Current and lapsed CL wearers in Canada were recruited using Facebook to take part in an on line survey investigating CL wearing experiences during 2008 – 2010 and to establish the percentage of participants who temporarily and permanently discontinued CL wear during the period surveyed, the reasons for discontinuation and whether compliance with lens wear and care may have played a role. ECPs and patients independently completed more than 2000 linked questionnaires evaluating their contact lens wear and care. In addition the frequency with which patients attended their ECP’s office for eye examinations was assessed to determine whether there was a relationship between this and their patients’ compliance. More than 800 daily disposable contact lens (DDCL) wearers in four countries completed an online questionnaire designed to investigate how frequently they reused their lenses, the reasons for reuse and how the lenses were stored between uses. Quantitative (online questionnaire) and qualitative (focus groups) research methods were used to explore in detail the lens wear and care habits of adapted contact lens wearers in an attempt to seek a better understanding of what enables and constrains patient compliance with appropriate lens wear and lens care. Results: The rates of non-compliance with the wear of contemporary CLs were found to be similar to those previously reported. Non-compliance with recommendations for CL replacement was shown to be associated with a higher rate of CL related problems. CL wearers continue to “drop-out” for reasons of discomfort and dryness with their lenses but the drop out rates were not found to be different between compliant and non-compliant CL wearers. Patients who were non-compliant with lens replacement were found to attend their ECP’s offices less frequently. Wearers of DDCLs were the most compliant with lens replacement; however, some did report reusing these lenses and sleeping overnight in them. Focus group participants were able to provide a greater insight into why non-compliant behaviour occurs in CL wearers with the most frequently occurring themes identified as the “consequences” that may occur if patients are non-compliant with one or more aspects of their contact lens wear and the importance of receiving “instructions” regarding the most appropriate way to wear and care for their lenses. Most of the themes that emerged from this qualitative research study were both constraints to, and enablers of, compliance. Conclusions: Compliance with contemporary CLs and care products remains poor. Non-compliant behaviour can result in serious complications and patients may not always be aware of this. Careful counseling and education on the risks associated with CL wear is required to provide patients with a better lens wearing experience and continued successful contact lens wear. ECPs and the contact lens industry can hopefully apply this greater understanding of why patients fail to wear and care for their lenses as they should and to help them develop strategies and tools to aid compliance and success in contact lens wear.

A Madagascar, la géographie et la démographie déterminent des besoins de santé particuliers. L’histoire a permis la création d’un système de soins moderne, que l’économie et la politique ont grandement affaibli. L’ethnologie a maintenu au fil du temps des pratiques de santé traditionnelles. La géographie de la santé fait le lien entre toutes ces disciplines. Ce travail est une plongée dans le milieu rural malgache. Madagascar est en effet resté un pays à prédominance rurale ; 75% de la population vit à la campagne où l’agriculture demeure la seule source de revenus des ménages. Le pays compte cent onze districts, entités administratives de référence ; ils marquent également l’échelle du découpage sanitaire. Deux districts ruraux, Mandritsara au Nord et Békily dans le Sud, sont retenus pour proposer une étude comparative des besoins de santé et du système de soins. Les besoins de santé sont largement dominés par les maladies infectieuses, au premier rang desquelles figure le paludisme. Il reste la cause d’une mortalité infantile élevée. Viennent ensuite la bilharziose, endémique, la tuberculose, maladie de la pauvreté puis toutes les infections de l’appareil digestif, diarrhées et autres dysenterie, parasitoses banales pour certaines, d’autres se montrant plus invalidantes. L’eau est un sujet de préoccupation permanent pour la population rurale ; cet élément vital peut rapidement se révéler létal. En cas d’excès, l’eau est un facteur favorisant le développement de certains germes ou autres vecteurs de maladies infectieuses. Si elle est insuffisante, apparaissent des problèmes majeurs d’hygiène publique. La malnutrition affecte les populations du Sud de Madagascar, qui deviennent à cet égard dépendantes de l’aide internationale. Le système de soins affiche des carences importantes, en terme de ressources humaines et d’accessibilité. A Mandritsara, une offre de soins privée pallie une partie des insuffisances du système public et une nouvelle offre de soins est en gestation : la formation de personnels paramédicaux. Le Sud semble vivre hors du temps ; les pratiques de santé traditionnelles y sont encore très largement répandues. / In Madagascar, geography and demography determine specific medical needs. History has permitted the creation of a modern health care system, which has greatly been weakened by economy and politics. Ethnology has maintained traditional medical practices. Health geography links up all these various disciplines. This work is an immersion in Malagasy rural environment. In fact, Madagascar is still mainly a rural country : 75 % of the population live in the country and agriculture remains the household only source of income. Madagascar is divided into one hundred and eleven administrative districts, which are sanitary divisions as well. Two rural districts, Mandritsara in the north and Békily in the south, have been chosen to make a comparative study of the medical needs and the health care system. On the whole, infectious diseases prevail and malaria ranks first. It is still the cause of high infant mortality. Bilharzia, which is endemic in Madagascar, comes next. After we find tuberculosis, the disease of poverty, and then all the infections of the digestive system, like diarrhea and dysentery, ordinary parasitosis or incapacitating ones. Water is a permanent cause for concern to the rural population. This vital element can quickly become lethal. The excess of water is a facilitating factor leading to the development of some germs or other infectious disease vectors. The lack of water causes major problems of public hygiene. People in the south of Madagascar suffer from malnutrition and get dependent on international aid. The health care system shows considerable deficiencies in terms of human resources and accessibility. In Mandritsara, a private health care service partly makes up for the inadequacies of the public system, and a new resource is emerging with the training of paramedics. The south seems to live in a different age : traditional health practices are still widely spread.

The purpose of this study was to show how information from the District Health Information System can be used to empower managers to make evidence-based decisions that will strengthen the health care system to reduce the under-five mortality rate. A quantitative, contextual, exploratory evaluative and descriptive approach was followed and a data extraction framework, based on systems theory, was developed to guide the process of extracting existing routine data. A results-based approach was used to measure under-five mortality related health care in terms of impact, outcomes, outputs, processes and inputs. The study has highlighted that proxy indicators obtained this way places health care managers in the position to monitor progress towards achieving the Millennium Development Goal for child mortality in the interim periods between large population surveys. The findings displayed in the diagnostic performance profile revealed that drastic interventions are required to reduce the under-five mortality rate. / Health Studies / M.A. (Health Studies)

A large part of the work has been devoted to regulation fees as one of the health care systems regulating mechanisms. An essential place in the work is taken by elaboration of the topic of increase of costs for the health care systems functioning in the current world and the possibilities of their solution. The work also deals with an extensive and frequently discussed topic of justice in the physician-patient relationship. This topic has been processed in connection with historical circumstances and a philosophical dimension of perception of justice in health care. Further to this, ideas and ideological foundations of justice, which project into political ideologies, have been dealt with. Health care systems, the system of health insurance in the Czech Republic and its legal regulation have been briefly characterized. The aim of the work was to map an opinion of some ordinary citizens regarding perception of justice in the Czech health care and introduction of the regulation fees. Partial goals were to find out in what way political orientation reflects in the opinion on justice of the collected regulation fees and furthermore to map, in what way an amount of income of respondents influences an opinion that regulation fees represent an income for a health care facility. Two hypotheses were determined. Hypothesis no. 1: University graduates understand better the system of regulation fees. Hypothesis no. 2: More than 80% or respondents consider it unjust that regulation fees represent an income of a physician, health care facility, or pharmacy. A method of questioning was used for the processing, data collection was carried out by using a questionnaire technique. Statistical methods suitable for an analysis of categorical data were used for evaluation of information. 300 questionnaires were handed out, the return rate being 74%, the final research population consisted in 182 respondents from the city of Votice. Another employed processing method was the secondary data analysis. Results of the questionnaire research brought a number of intriguing facts relating to attitudes of the respondents as to the issue of justice and state of the Czech health care. Further to this, it has been confirmed that university educated respondents understand better the system of regulation fees. In more than 65%, respondents consider it unjust that the proceeds from the regulation fees collection represent income of a health care facility. One of the hypothesis was confirmed and the other was disproved. The acquired information can be used as a guideline for public discussion.

Que signifie « Faire de l'humanitaire en France » ? Cette thèse se concentre sur un dispositif proposé et réalisé, en France, par une association médicale humanitaire, Médecins du Monde, et qui insiste sur la prise en charge de la santé des populations en situation de précarité. Soigner les populations précaires, et témoigner de leur situation, tel est le rôle que s'est assigné cette association. A partir d'une enquête comparative de quatre structures de l'association dans des villes françaises, cette étude de cas analyse et explique la spécificité de l'action humanitaire médicale et son articulation avec le système officiel de santé au niveau local, au niveau national français et son extension au niveau européen. L'analyse concrète du travail associatif, au sein de réseaux d'action publique et auprès de publics cibles (les migrants, les Roms et les SDF), permet de dresser un modèle des organisations privées non marchandes qui participent aux politiques publiques en France aujourd'hui. Les modes d'intervention employés par l'acteur associatif permettent de réinterroger la place des initiatives associatives et de les envisager comme constitutives du système français de protection sociale. / This Ph-D thesis focuses on a system provided, in France, by an humanitarian and medical NGO, Doctor of the World, which takes responsibility for the health of the precariousness populations. Heal the poorest and provide evidence : this is the action this NGO proposes. It is based on extensive fieldwork in four associative structures in France. This case analyses and explain the particularity of the humanitarian action and its articulation with the French health-care system in a local level, in a national level and its extension in the European level. The practical associative work, in political networks and centred to specified population (migrants, Roma and homeless people), highlights a model of non-profit organizations which participate to public policies in France. From the methods of intervention proposed by this NGO, this thesis examines the place of associative initiatives and wonders if whether or not they are constituent of the French health-care system.

A dissertação trata do acesso aos serviços de alta complexidade, particularmente os exames diagnósticos e complementares, estudado entre usuários de planos de saúde privados que buscam atendimento e diagnóstico especializado. Desde a década de 80 o usuário do sistema público de saúde vem procurando a saúde suplementar. Contudo, afirmar que o acesso é garantido no domínio privado, através da contratação dos planos de saúde, é uma incerteza que rodeia a inspiração para esta pesquisa, que se justifica pela relevância de ações que possibilitem a melhora da qualidade regulatória dos planos de saúde, a partir do controle social de seus usuários. O objetivo geral é analisar as percepções do acesso aos exames de alta complexidade nos serviços de saúde privados entre usuários de planos de saúde. Os objetivos específicos são descrever as percepções dos usuários de planos de saúde acerca do acesso aos exames de alta complexidade; analisar as motivações dos usuários de planos de saúde privados para a realização de exames de alta complexidade através da rede privada de assistência; e analisar o nível de satisfação dos usuários de planos de saúde quanto ao acesso aos exames de alta complexidade. A metodologia é qualitativa-descritiva, onde a amostra foi de trinta usuários de planos de saúde, acima de 18 anos, selecionados no campo de estudo no ano de 2010. O cenário de estudo foi um laboratório privado de medicina diagnóstica no Rio de Janeiro. As técnicas de coleta de dados utilizadas foram formulário e entrevista individual estruturada. A análise do formulário foi realizada através de estatística descritiva, e as entrevistas através da análise de conteúdo temática-categorial. Os usuários de plano de saúde declararam que o acesso é garantido com facilidade para os exames de alta complexidade. Suas principais motivações para a realização desses exames na rede privada de assistência foram caracterizadas pela rapidez de atendimento, flexibilidade e facilidade de marcação pela internet, telefone ou pessoalmente no laboratório estudado, pronta entrega dos resultados, dificuldade e morosidade do atendimento do SUS, localização do prestador credenciado próxima de bairros residenciais ou do trabalho, resolutividade diagnóstica de imagem de excelência, possibilidade de escolha pelo usuário entre as modalidades aberta e fechada de ressonância magnética e tomografia computadorizada, além da densitometria óssea que foram facilmente acessíveis a todos os sujeitos da pesquisa. O nível de satisfação foi correspondido com a rapidez na realização dos exames em caráter eletivo e de urgência quase equiparados na escala de tempo de acordo com os usuários. Contudo, embora as notas de avaliação dos usuários quanto aos seus planos de saúde tenham sido altas, foram abordadas algumas dificuldades, tais como: prazos de validade dos pedidos médicos com datação prévia; solicitações de senhas de autorização pela operadora; burocracia nos procedimentos de agendamento; dificuldades de acesso para tratamentos como implantes, fisioterapia, RPG, pilates, home care, consultas de check up; negação de reembolsos; restrição de materiais cirúrgicos, em especial as próteses e órteses; e restrições específicas de grau para cirurgias de miopia. Conclui-se que o atendimento rápido dos exames de imagem de alto custo na amostra foi descrito como satisfatório, embora a percepção de rapidez possa variar em função do tipo de produto do plano de saúde privado contratado, com necessidade de melhoria regulatória em alguns aspectos pontuais da saúde suplementar. / This dissertation deals with access to services of high complexity, particularly diagnostic and complementary exams between users of private health system that seek specialized treatment and diagnosis care. Since the 80's people has being looking for additional health system. However, say that access is guaranteed in the private system, is an uncertainty that leads the inspiration for this research, which is justified by the importance of actions that enable the improvement of regulatory quality of health plans from social control of its users. The overall objective is to analyze the perceptions to access high complexity exams in the health system between users of private health plans. The specific objectives are to describe the perceptions of users of health plans to access high complexity exams; analyze motivations from users of private health plans for the exams of high complexity through the private network; and analyze the level of users satisfaction with health plans regarding access to tests of high complexity. The methodology is qualitative-descriptive, and the sample was thirty users of private health care system greater than 18 years, selected in 2010. The research scenario was a private laboratory of medical diagnostic in Rio de Janeiro. Data collection techniques used were individual interviews and structured form. The analysis was performed by the form of descriptive statistics, and interviews through the analysis of thematic content-category. Users of health plan stated that the access is guaranteed with facility for tests of high complexity. Their main motivations for doing exams in private health care services were characterized by quick responsiveness, flexibility and ease of marking their exams by internet, telephone or personally in the laboratory, prompt delivery of results, difficulty and length of service in SUS, location of laboratory near home or work, excellence resolution in diagnostic image, user choice between open and closed methods of magnetic resonance and computed tomography, and bone densitometry were easily accessible to all research subjects. Satisfaction level was reached by quickly resolution of the exams, and performing elective and emergency procedures in almost similar time scale, according to users. However, although evaluation from users with their health plans have been high, some difficulties were pointed such as validity periods for realization of exams; according to the date on the medical application; password requests for authorization by the operator; bureaucracy in procedures for scheduling exams; and poor access to treatments such as implants; physiotherapy; RPG; pilates; homecare; check ups; denied refunds; restricted surgical materials; in particular prosthetics and orthotics; and specifics degree limitation for myopia surgery. We conclude that the quickly response of high complexity exams were described as satisfactory, although the perception of speed may vary depending on the type of private health plans contracted, with the need for regulatory improvement in specific points in privete health system.

In 2010 the new Swedish national system for health care 1177.se was launched in order for users to have one place where to find health care related information. The primary stakeholders of this system, which is online based, are the counties and regions of Sweden. The purpose of the thesis is to identify what improvements can be made on the health care system in order to benefit new technologies and in the end the users. The main question that the thesis will address is: * How can a PACT analysis improve the design of health the health care system 1177.se to benefit new technologies in order to be as available as possible. The method that has been used in order to gain knowledge in the subject has been literature studies, observations, scenario building and also an interview. The analysis of the empirical and theoretical studies has shown that more attention should be placed on people that have different disabilities and people with other origins then Sweden. People that are not so comfortable with Internet technology also is a group of people that needs to be placed in focus. / 1177.se är det nya svenska informationssystemet för vård som lanserades 2010. Initiativtagarna är regioner och landsting i Sverige. Målet med 1177.se är att den ska bli den ledande resursen för de svenska invånarna när det kommer till information och råd om hälsa, sjukvård och tandvård. Det senaste decenniet har Internet utvecklats så pass mycket att vården kan använda dess kapacitet för invånarna i Sverige. Regionerna och landstingen såg en möjlighet att använda en gemensam plats för alla invånare att hitta information om hälsa, sjukvård och tandvård. Sverige har ungefär 9,5 miljoner invånare (SCB, 2011) som alla vid någon tidpunkt kommer i kontakt med det svenska sjukvårdssystemet. De kan lida av alla från sorters sjukdomar till att enbart söka information eller hitta information om vård i närområdet och leta efter fakta själva. Det finns flera olika användningsområden för informationssystemet 1177.se vilket betyder att hur man designar systemet är av yttersta vikt. En PACT (People, Activities, Contexts, Technologies) analys strävar mot att identifiera vilka olika aktiviteter som människor gör och i vilka kontexter samt vilken teknik man använder för att ge en indikation på vad man bör tänka på då ett informationssystem designas. Denna uppsats är ett försök att analysera informationssystemet 1177.se och ge min syn på vilka förbättringar som kan göras efter att ha gjort en PACT analys.