Thesis (D.P.H.)--University of Michigan, 1994.

Thesis (D.P.H.)--University of Michigan, 1994.

Intro: Rural America experiences disparities in healthcare access, socioeconomic status, health-related behaviors, and chronic conditions, compared to non-rural America. The Appalachian region, specifically the counties within Central Appalachia (CA), are among the poorest and most rural in the country with very poor health, economic, and educational outcomes. Moreover, Appalachia is faces a unique set of challenges even when compared with other rural or disadvantaged regions in the U.S. This study compares such outcomes between the counties of Central Appalachia to the counties of the rest of the United States. Methods: Data from County Health Rankings, American Community Survey, and the Institute of Health Metrics and Evaluation were combined using FIPS codes to create the analytic dataset. Demographic, health outcome/behaviors, socioeconomic, and clinical care characteristics were compared between Central Appalachia (238) and the rest of the U.S. (2,902) using independent samples t-tests. Results: In 26 different measures, Central Appalachia performed significantly worse (p =.05) when compared to the rest of the U.S. Among the most striking results is the difference between years of potential life lost (YPLL), where Central Appalachian counties have a mean YPLL of 10,657 years and the rest of the United States have a mean YPLL of 8,399 years. Discussion: This research highlights health disparities faced by rural areas, such as Central Appalachia, compared to the rest of the U.S. Ultimately, these results indicate the need to examine regional differences and variation in population-level characteristics in order to understand and improve the health of these disparate populations.

No description available.

The following thesis presents an analysis of power and control in the English National Health Service. Notably, it focuses upon power and control over knowledge; over defining what is 'valid' knowledge; over the production of that valid knowledge; and over how, what, when and where that knowledge is used in everyday clinical practice. The issue reaches to the heart of professional conception and definition and hence, control over professions themselves. The thesis attempts to demonstrate the relationship between the different professional groups in the NHS, through the analysis of national, regional and local documents, and interviews with managers, doctors, nurses, dietitians and physiotherapists in three case studies, the thesis shows the complex pattern of relations and behaviour at play. Particular attention is paid to Michael Power's notion of audit and the 'Audit Explosion', which provides a framework for the thesis, and to the work of Michel Foucault, especially his ideas about power, control and panopticism. These are used as a useful metaphor to understand and explain NBS research and audit in relation to the NHS professions. The thesis ends with a cross-case analysis which draws together the rich variety of data and concludes with an analysis of the wider sociological implications ofthe thesis.

Evidence available shows that the ethics review process in Malaysia suffers from a range of problems (Kaur, 2011). These problems may be the result of a lack of training given for REC members and relatedly, it may stem from a lack of understanding of the role of RECs. Since Malaysia is striving to promote the country as a research hub for international collaboration, it is important that the ethics review system that is in place is well set up to ensure only ethical research are being approved. The aim of this thesis is to develop three important key elements of a framework that can be used to provide practical guidance for RECs and their governance in Malaysia. These three important elements of the ethics review process are: - the role of RECs, the criteria of REC membership and the acceptability of variation in decisions made between different RECs. These analysis is then applied to the Malaysian context. My initial recommendation is for RECs to adopt the Daniels and Sabin (1997) accountability for reasonableness model to assist with the decision-making process. The adoption of the model helps to clarify the role of RECs and can be used as a basis to develop the criteria for REC membership as well as to provide a better understanding of the acceptability of variation in decisions between different RECs.

This thesis examines how women with a diagnosis of borderline personality disorder (BPD) negotiate their identity in relation to risk, also referred to as their ‘risk identity’. This is defined as, ‘…the view people have of themselves and project to others in their talk and actions in relation to risk and risk taking’. The theoretical perspective which underpins the study is informed by ontological realism, epistemological discursive/linguistic social constructionism, and an ideological critical liberatory position primarily derived from the work of Foucault (1978; 1991a; 1991b; 1998; 2002; 2008a; 2008b; 2009). This perspective informed the decision to adopt email interviews as a method for generating appropriate texts for analysis. Eight women diagnosed with BPD were interviewed over a period of ten months. Adopting a critical emancipatory methodology which incorporated feminist principles of research, Lather’s (1991) adaptation of Van Maanen’s (1988 cited in Lather 1991) ‘four tales’ was employed to view and analyse the texts from four theoretical perspectives; a ‘Realist Tale’, a ‘Critical Tale’, a ‘Deconstructivist Tale’, and a ‘Reflexive Tale’. By ‘layering’ these tales, the findings revealed sets of tensions discernable within the context of interactions with staff, the nature of services, and the wider material and discursive resources at play which inform how risk identities are negotiated. Converging Western discourses of the subject, binary gender discourse, neoliberal discourse, ‘psy’ discourses, and discourses around motherhood were found to be key discursive resources through which risk identity is produced, resisted and projected. In addition these to broad discursive findings, the study also contributes to the existing empirical literature that focuses on the lived experience of those with a BPD diagnosis. A conclusion is drawn that women with a BPD diagnosis not only receive a label which discursively excludes them from being able to be viewed as a ‘good subject of psychiatry’ (and hence leads to them being viewed as dangerous and risky), but that their difficulties and need for relational approaches to manage risk and promote recovery run counter to the way that mental health services are structured in the current neoliberal era.

No description available.

Emerging conversations within oncology have drawn more attention to cancer among young adults (ages 18-45). Recent research has illuminated many of the psychosocial difficulties young adults face as they go through the many trials and tribulations of chronic illness. However, a subject still understudied, much is unclear about the personal as well as the cultural implications of being diagnosed during this period of time. In a book of cancer stories, performer and young adult cancer patient Kairol Rosenthal (2009) expressed her frustration with what she saw as “stereotypes” promulgated by the limited public discourses that exist on the subject (p. 7). She sought to counterbalance these representations with stories capturing the “complexities of our real daily lives” (p. 7). Indeed, in oncological discourses young adults tend to be cast in oversimplified terms, based upon cultural expectations about what young adulthood should be and pressures to conform to those standards. Intersecting with dominant discourses within narrative identity development, two imperatives are placed upon young adults’ stories: integration of different life experiences and selves into a coherent narrative and developing a sense of self-authorship in the direction of one’s life. What seems to be lost in these imperatives within the existing research is what is at stake for individual lives (a phenomenological perspective) and how those stakes are negotiated or contested with hegemonic trajectories of life (a critical perspective). Receptive to Rosenthal’s critique of dominant discourses around cancer and young adulthood, the purpose of this thesis was to explore the complexity and diversity of young adults living with cancer. More specifically, I intended to interrogate some of their existential and biographical challenges as expressed in their narratives of cancer, as well as their engagements with ideological constructions of young adulthood, namely, the expectations of narrative coherence and self-authorship. This research marked a departure from most studies on the subject in its qualitative methodology (i.e., narrative analysis) and in its explicit evaluation of the effects of cultural discourses on young adults’ attempts to make meaning. More generally, this research shows the importance of language—in discourses, narratives, and metaphors—in constructing and communicating illness experiences. For this project, I gathered a mix of written and oral narratives (through semi-structured interviews) from 21 participants from across Canada. The foci of analyses were on what could be called narrative ‘moments of meaning’ and ‘moments of being,’ that is, situated expressions of how they made sense of their worlds and themselves. Many of these were critical moments in the sense of questioning and resisting dominant discourses of cancer and young adulthood. Their moments of meaning often expressed negotiation of personal desires and innovative intentions with familiar cultural narratives or “prototypical plots” (Good, 1994)—including stories of battling cancer, embarking on a life journey, nearing recovery, encountering unpredictability and mystery, and living with chaos. These moments of meaning served an array of purposes well beyond the expected function of constructing a coherent narrative. When telling of identity disruptions and the liminality of cancer, participants produced both more orderly moments of being (e.g., survivor, patient, or warrior identities) and more liminal moments of non-being (e.g., victim, phoenix, or trickster identities). Self-authorship seemed to be present among the former, while the latter expressed less control and certainty of being—which was not always seen as a problem. These moments of being and non-being were collaborated and contested within the intersubjective spaces of their clinical relationships, local worlds, and cancer patient communities. More specific to their age group, their moments of being and non-being often related to what may be understood as developmental identities, including the ‘traditional milestones’ such as individual autonomy, family (i.e., marriage and parenthood), and vocation (i.e., getting an education and building a career). In their struggles they sometimes reaffirmed these cultural ideals toward identity integration and other times resisted them as “normalizing ideologies” (Becker, 1997) of young adulthood. As part of these larger negotiations of meaning and being, the participants expressed struggles to understand the moral significance of their illnesses. Confronted with what may be called “causal ontologies” of suffering (Shweder, 1997), they spoke of different etiological models of cancer’s origins as well as reconciliatory models for living with cancer in the future. Their narratives sometimes led toward “remoralization” (Kleinman, 1988)—couching experiences of suffering in terms of a moral order (narrative coherence) and personal responsibility (self-authorship)—and sometimes led away from it, depending on whether they believed their illnesses originated from events in their personal and social lives. Overall, the participants in this study communicated complex and potentially chronic existential challenges. In many ways their narratives resisted dominant representations of young adults with cancer—and of cancer patients in general—suggesting that such representations need to be rethought. Their critical moments of meaning and being may serve as counternarratives to the stereotypes of concern to Rosenthal and many other cancer patients. Specifically, their narratives revealed the merits and limits of the ideological construction of young adulthood as a time of narrative coherence and self-authorship. This study has important implications for future health research and psychosocial support in the field of oncology; building upon a “narrative medicine” (Charon, 2006), sensitivity to how language is used among young adult cancer patients may lead toward more inclusive clinical practices.

Efficient allocation of scarce resources to health programs involves measuring the economic benefits of life saving and/or improvement in health status. While several attempts have been made to quantify individual preferences for life, only a few, if any, have attempted to measure individual preferences for quality of life. In this thesis, we develop a methodology based on the estimation of individual preference functions to arrive at monetary measures of the value of marginal improvements in health status. / The first chapter reviews conventional methodologies for estimating the value of human life, and points out many theoretical and empirical propositions related to our own concerns. The second chapter analyzes various procedures used to quantify variations in health status. We distinguish non-monetary procedures, which combine recent psychometric techniques and research on health level scaling to obtain estimates of the relative desirability of a state of health, and monetary procedures which, we conclude, still need to be developed. / The third chapter presents a new methodology based on the direct estimation of bivariate welfare function of income and level of health. The theoretical basis of our approach and the data source are described in this chapter. Various functional forms were tried but we have finally retained the log-normal specification to derive estimates of the monetary value of a marginal change in the state of health for different subgroups of individuals. / We conclude with critical discussion of our results. Some improvements over the approach used are suggested in the fifth chapter.