This research aimed to explore how newly forming Clinical Commissioning Groups (CCGs) were tackling health inequalities (HIs) (if at all) in the UK. In 2010 the current coalition government was formed between the Conservatives and Liberal Democrats. Shortly after this, the White Paper Equity and Excellence: Liberating the NHS (Department of Health, 2010a) was published. This was the starting point for a large variety of policy documents being published outlining the healthcare changes that were to happen within the UK. Following the ‘pause’ a number of amendments to the initial policy proposals were outlined (Department of Health 2011). These included the newly named GPCCs being restructured and renamed as CCGs. Additionally, the Government took on board the recommendations of the Future Forum (June 2011) to make tackling HIs a duty for CCGs. The concept of HIs itself is very complex with a wide variety of definitions that have been discussed within the literature. It was acknowledged early on within this project that because of the complexities and variations in people’s understandings and interpretations of HIs that a fundamental element of understanding how CCGs are tackling health inequalities would be underpinned by individual’s own and organisational conceptualisations of HIs. Three CCGs in the North of England were recruited and qualitative methods, including interviews, observations and document analysis were used to collect data, over a period of 12 months from January 2012-December 2012. The timing of the project meant that data collection was conducted when the NHS was in a state of flux; CCGs were in shadow form, preparing themselves for the authorisation process. Interviews and observations ascertained that HIs were being conceptualised and tackled differently across the three CCGs. There were several common themes that were evidentially important to CCG members when describing the wider influences on their HI understandings and strategies to tackle HIs. These included history, relationships and the role of Public Health. The history of both organisations and relationships were acknowledged by all CCGs in shaping how they had developed under the current policy agenda and how they planned to tackle HIs (if at all). The role of Public Health was a key finding from this research, three different roles were identified, defined and explored in practice, examining how the roles influenced the HIs agenda differently. The Public Health roles of ‘service provider’, ‘co-owner’ and ‘critical friend’ have the potential to shape working relationships between Public Health and the CCG and shape the HIs agenda. Weick’s (1995) concept of sensemaking was used to examine how these main findings helped define the HIs agenda. Overall, HIs conceptualisation, strategies to tackle HIs and wider organisational relationships with PH and the LA are not consciously developed by these organisations. History and local contexts help generate schemata that underpin action.

Magister Public Health - MPH / BACKGROUND: Namibia has generalised Human Immunodeficiency Virus (HIV) and tuberculosis (TB) epidemics. In response to the TB/HIV co-epidemics in Namibia, the Ministry of Health and Social Services approved a policy of TB/HIV collaborative activities at national level and the integration of TB/HIV services at the point of service delivery. The present study explored barriers and facilitators of integration of TB and HIV service delivery in Tsandi District Hospital, which lies in rural northern Namibia. It focused on understanding the perspectives of healthcare workers and service users on integration of TB and HIV services at the health facility. AIMS & OBJECTIVES: The study aimed to describe the barriers, facilitators, and opportunities of integrated TB/HIV service delivery in Tsandi District Hospital. The specific objectives were: to describe the staffing and support systems in place for the integration of TB/HIV care; to describe the perceptions and experiences of integrated TB/HIV care by the health care workers, management and co-infected clients; and to describe the factors that facilitate or hinder the integration of TB/HIV services in the district from the point of view of district hospital managers, health care workers and co-infected clients. METHODS: The study used a descriptive qualitative study design with semi-structured key-informant interviews conducted with five healthcare managers and senior clinicians and focus group discussions with 14 healthcare workers and five TB/HIV co-infected patients, supplemented by non-participant observation in Tsandi district hospital over two weeks between May – June 2011. Sessions were audio-recorded, transcribed, and thematically analysed. RESULTS: Several factors influenced whether and to what degree Tsandi district hospital was able to achieve integration of TB and HIV services. These are: (1) model of care and nature of referral links; (2) the availability and use of human resources and workspace; (3) the system of rotating staff among departments in the hospital; (4) the supply and mode of providing medicines to patients; (5) information systems, recording and reporting arrangements; (6) and the amount of follow-up and supervision of the integrated services. The main suggested barrier factors are: (1) poor communication and weak referrals links between services; (2) inadequate infrastructure to encourage and deliver TB and HIV care; (3) staff shortages and high workload; (4) lack of training and skills among healthcare workers; (5) financial constraints and other socioeconomic challenges; and (6) fragmented recording and reporting systems with limited data use to improve service delivery. The four main facilitating factors are: (1) positive staff attitudes towards TB/HIV integration; (2) common pool of staff managing different programmes; (3) joint planning and review of TB and HIV activities at the ARV Committee; and (4) informal task sharing to alleviate healthcare worker shortages. CONCLUSIONS: This study recommends that the district build on the current facilitators of integration, while the inhibitors should be worked on in order to improve the delivery of TB/HIV services in the district. Simple and practical recommendations have been made to address the some of the barriers at district level. It is hoped that these will inform future planning and review of the current model of care by the District Management Team.

Master of Public Health - MPH / Background: Malaria was a major cause of mortality and morbidity in Namibia from 1999 to 2001. Malaria epidemics were recorded in 1990, 1996, 2000 and in 2001. In 2001 alone 733, 509 malaria morbidity cases and 1,728 mortality cases were documented. In recent years, however, malaria morbidity and mortality in the country have drastically declined by over 90%. This has influenced the Ministry of Health and Social Services (MoHSS) in Namibia to adopt a malaria elimination approach as opposed to the malaria case management approach. A malaria programme, known as the National Vector Disease Control Program (NVDCP) was instituted and mandated to coordinate malaria case management (diagnosis and treatment) as well as the current malaria elimination focus (elimination of transmission foci). This is all aimed at effectively addressing the current malaria epidemiology and sustain the decline observed over the last decade. Aim and Methodology: The study’s purpose was to analyse how the Namibia Malaria Strategic Plan (MSP) for 2010-2016 was developed and its relationship to health promotion. It employed an exploratory design which included stakeholders involved in malaria programmes and activities in the country. Data collection methods were of a qualitative nature through in-depth interviews and documentary review. Seven people were interviewed representing stakeholders from the public and private sectors. Those interviewed from the public sector were the Ministry of Environment and Tourism (MET), MoHSS’s division for Malaria, Policy Planning and Information Education and Communication (IEC). Others interviewed included national and international non-governmental organizations’ representatives from the World Health Organisation (WHO) and Society for Family Health (SFH). Documents reviewed include MSP 2010-2016, MSP 2003-2007, Malaria Policy of 2005, National Health Promotion policy 2012 and the Namibian Constitution. Data was analysed using content and thematic processes. Respondents were assured of confidentiality and anonymity. Key findings: The study found that information with regard to the formulation process of the MSP 2010-2016 was limited to a few superficially described events. These events involved, amongst others, a review of the previous (2003-2007) MSP, a pre-assessment questionnaire and two to three workshops. The events were not explicitly described or documented. The researcher concluded that the evidence to better understand the development processes of the MSP 2010-2016 was deficient. Consequently, the study concluded that the policy formulation aspects of the MSP were inadequate. The literature indicates that policy formulation and analysis is a complex undertaking and the MSP process did not meet these criteria. Amongst the limitations were limited stakeholder engagement and incomplete descriptions of the processes undertaken. In relation to the MSP’s focus on health promotion, the study found varied understanding of health promotion among the stakeholders. Some respondents were not aware of their organisation’s health promotion interventions while others believed that health promotion was limited to the health sector only. However, while national documents, such as the Namibian Constitution, advocate for ‘health investment as a just cause’ the MSPs limited inclusion of relevant stakeholders, such as the Ministry of Environment (MET) and the Information, Education and Communication (IEC) unit, restricted the ability of the MSP to offer malaria expansive programmes – that is, those beyond the health realm. Moreover, the implementation of malaria activities through the involvement of a limited range of actors in the malaria programmes will continue to perpetuate the existing narrow focus of health promotion by these stakeholders, as opposed to a more broad-base understanding. As a result malaria prevention will continue to be delivered as silo events or programmes. This poses serious implications in working towards the MSP goal of malaria elimination. Recommendations: The Ottawa Charter advocates for ‘Building healthy public policies’. This specifically refers to multi-disciplinary programmes. This study therefore recommends that the NVDCP follow existing international and national guidelines which systematically guide the development of MSPs and official health documents. Doing so would enable a more streamlined policy development process which would describe and contextualize the dimension of policy formulation, namely context, content, process and actors. It also recommends that the MSP is developed through a broad-based collaborative stakeholder engagement process which would facilitate an appropriately integrated inter-sectoral approach to malaria in the country.

The current study explored the work-related experiences of psychologists in public health facilities in Botswana. This topic has received minimal research attention, yet the World Health Organization has recognised the importance of treating mental health conditions. There is also recognition that there is a shortage of mental health practitioners, especially psychologists, in low to middle income countries such as Botswana. For this reason, the World Health Organisation has developed an initiative amongst its member states to increase access to mental health services by integrating them into the general health system. This is where psychologists in public health facilities are employed. In order to investigate how psychologists in public health facilities experience this integration, an explorative design was followed which adopted a qualitative methodology for data collection and analysis. Three semi-structured interviews were conducted with clinical psychologists who were recruited through purposive sampling. The data were analysed through thematic analysis. Generally, the participants experienced their work in the public health facilities as a professionally enhancing experience in spite of the various challenges encountered. They described a wide range of supportive and therapeutic functions that served the institutions and society in general. It is hoped that the results of this study can inform policies on mental health and add some valuable insight for further investigation of this topic. / Mini Dissertation (MA)--University of Pretoria, 2019. / Psychology / MA / Unrestricted

UNIVERZITA KARLOVA V PRAZE FAKULTA SOCIÁLNÍCH VĚD Institut sociologických studií Katedra veřejné a sociální politiky Zdeňka Zatloukalová Paliativní péče v České republice Diplomová práce Praha 2012 Diplomová práce Název práce 4 SUMMARY The master thesis "The palliative care in the Czech Republic" is focused on the reflection of the current situation of the problem which is defined as an insufficient capacity of the specialized palliative care. A mere fraction of dying (2,7 %) receives a specialized palliative care in the Czech Republic. Only 7,5 % of cancer patients are provided with the specialized palliative care. (Sláma, 2008) Specialized palliative care has different forms. It is hospice palliative care, special palliative care in the hospital facilities or consulting teams in the hospitals. The hospice palliative care is provided in the form of the inpatient hospice, home palliative care and day care canters. In the practical part of the thesis I focused on the analysis of the state of care through the statistical data obtained mainly from the Czech Statistical Office and the Institute of Health Information and Statistics of the Czech Republic. For the comparison with other countries I used the researches Palliative care in the European Union, 2008 and Economist Inteligence Unit, 2010. The annual...

When the COVID-19 pandemic first reached Ottawa, Canada in March 2020, the lives of nearly all residents were dramatically impacted. From the loss of jobs to the loss of loved ones, many experienced an intense period of loneliness, fear, and uncertainty. This thesis explores residents’ experiences of the pandemic in Ottawa and how these were shaped by the state’s response to COVID-19, namely its public health and economic response. It is based on fieldwork conducted during the first waves of COVID-19, which combined participant observation, interviews, and online observation. It begins by exploring how the state called on residents to take responsibility for public health, thereby enacting a certain type of citizenship, and the ethical striving of my interlocutors to become responsible. It then focuses on how state officials urged people to use their common sense at the limits of state advice and how my informants attempted to cultivate their ability to make safe decisions. Lastly, it analyzes how the introduction of CERB, a social program that targeted un- and underemployed Canadians, renewed public discourse about the purpose of welfare and how the program served as a technology of government that encouraged applicants to reflect on their receipt of the benefit.

The dissertation examines how pregnant women seeking antenatal care at a state facility in the Southern Peninsula of Cape Town conceptualise and experience their pregnancies in relation to the biomedical model that informs state practices of care. I specifically explore the experiences that contribute to the state's definition of 'late' presentation at antenatal clinics (i.e. after the first trimester). The antenatal care model advises that pregnant women report "early", at 12 weeks, and have regular follow up visits up until 40 week period, yet recent public health research showed that women present "late" to the antenatal clinics, with only 40.2% of first antenatal visits occurring in the first trimester in South Africa. The women who were a part of the research were chosen in the clinic space, in waiting rooms, booking rooms and while waiting for ultrasounds. The women were selected based on age (17 upwards), and gestational age at first antenatal booking. I examine the ways biomedicine frames temporality, and the way that health policy enacts this through antenatal care. I contest the brackets of 'lateness' and biomedicalisation of pregnancy, and the state's version of the female reproductive body as I describe the unfolding experiences of a reproductive life, showing how pregnancy and health care seeking are enmeshed in social worlds. The discursive framings of antenatal attendance exhorts women to seek antennal care at 12 weeks gestation, to "be responsible" "good women" managing their sexual and reproductive lives with a mode surveillance that presumes a certain way of knowing and counting the body. I explore the other ways of experiencing, knowing, and counting, showing how pregnancy experiences and healthcare seeking behaviours are influenced by social, economic, political, and historical factors, and by the moral and religious values that shape daily life for women. My thesis is grounded in the growing literature on anthropology of reproduction and the biosocial. In doing so, I examine what it means to have and experience a reproductive body within the unfolding events of everyday life, where moments and 'quasievents' (such as structural inequalities, and the daily bouts of gang violence and domestic violence) become enmeshed, such that they influence temporality, differing perceptions of trust, distrust, risk and testing, and differing social values of testing. I further show how maternal kinship networks of support are valued, yet precarious as are intimate partnerships, which both influence experiences of care, neglect, abuse, punishment and shape antenatal attendance. In contesting temporal boundaries of biomedicine I show how women's bodily and relational experiences, their everyday lives and quasi-events within them are inseparable in shaping antenatal health seeking practices and how pregnancies are imagined.

BACKGROUND: Current efforts to control the obesity epidemic has focused on sugar sweetened beverages (SSB), particularly soda, and less on alcohol intake even though alcohol is also a source of “empty calories”. Few data are available about the association between soda and excessive alcohol consumption and whether people may substitute one form of beverage for the other, essentially “choosing their poison”. METHODS: We used the Behavioral Risk Factor Surveillance System (BRFSS) data from 2017 to examine the relationship between alcohol and soda consumption in adults 18 and older. We first compared the rates of different types of sweetened beverage consumption soda in our population. We then examined the association between the sugar-sweetened beverage and alcohol drinking status using regression models adjusted for potential confounders. Analyses were weighted and adjusted using SAS 9.4 to account for the complex sampling methods. RESULTS: Based on 2017 BRFSS data, we found an inverse relationship between heavy drinking and soda consumption after adjusting for age, sex, race, income, education, marital and insurance status, smoking, diabetes, and hypertension. Compared to those who don’t drink soda, the odds ratio of heavy drinking was 0.75 (95% CI 0.63, 0.90) for those who drink up to one soda/week; 0.66 (0.53, 0.81) for those drinking >1 to <7 sodas/week; 0.73 (0.65, 0.97) for ≥7 to <14 sodas/week; and 0.70 (0.49, 1.02) for ≥14 sodas/week. CONCLUSION: There seems to be an inverse association between soda and alcohol consumption. Public health efforts may want to consider targeting both behaviors concurrently to avoid beverage substitution.

An attempt has been made to examine the relationship between social structure and medical factors in a framework which links cosmopolitanism to health orientation and behavior. Specifically, this study has attempted to investigate the variations in health knowledge, beliefs, attitudes and behavior among individuals whose social structure varies in terms of cosmopolitanism.

Indiana University-Purdue University Indianapolis (IUPUI) / With an estimated 30.2 million diagnosed and undiagnosed cases among adults (and another 84 million at risk), diabetes mellitus is one of the most prevalent chronic conditions and a leading cause of mortality in the US. Diabetes self-management education and training (DSME/T) is a recognized standard of care and provides patients with the requisite knowledge and skills to properly manage the condition, improve long-term health outcomes, and reduce health care expenditures. Yet, DSME/T is greatly underutilized. Health insurance coverage that does not include benefits for DSME/T effectively imposes barriers to access for patients in need of the service. Many states have adopted laws and regulations requiring public and/or private insurers in their market to provide benefits for DSME/T; however, these requirements vary by state. It is unclear if these policies effectively improve access to DSME/T services. This dissertation seeks to rigorously assess the impact of state-mandated benefits and reimbursement provisions on access to DSME/T among adult patients with diabetes. The first analysis utilizes a unique combination of legal and programmatic data to quantify changes in the supply of DSME/T resources after the adoption of state-mandated benefits (potential access). The second analysis merges legal data with the Medical Expenditure Panel Survey (MEPS) from 2008 to 2016 to examine the impact of state mandates and reimbursement provisions on patient utilization of DSME/T (realized access). Lastly, the final analysis utilizes electronic health record data (2010-2016) from a safety net population to determine if patients’ evaluated need for DSME/T predicts the likelihood of receiving a DSME/T referral during a provider encounter (equitable access). Using novel data sources and a sophisticated policy analysis technique, this study provides a rigorous assessment of the impact of decades of state policies designed to improve access to care. / 2020-04-02