Decades of steel production and coking in the community of Sydney, Nova Scotia, have led to severe environmental insult. Increased amounts of air pollution from Sydney Steel Corporation and toxic emissions from the Muggah Creek Watershed have been well documented in several studies of the area since the 1960s. This research examines the potential impacts of exposure to hazardous waste on the reproductive health of women living in Cape Breton Regional Municipality through the following objectives: i) to assess the spatial pattern of various types of adverse reproductive events, plausibly linked to the environmental exposure of interest; ii) to determine if this pattern is related to proximity to the Tar Ponds/Coke Ovens site. To address the first objective, point pattern analysis was applied to observations from the Atlee Perinatal Database to determine if the observed pattern exhibited any clustering. To address the second objective, a multinomial logistic regression model was employed to determine if proximity to the Tar Ponds/Coke Ovens site was an important covariate of the adverse outcomes under study (preterm births, low birthweights, congenital anomalies and stillbirths). The results of the bivariate K-function indicated that there was weak global clustering for preterm births for two different time periods, while the ratio kernel estimates demonstrated that the patterns of the outcomes were non-random even after correcting for the underlying population distribution. The results of the multinomial logistic model demonstrated that variables pertaining to maternal characteristics, pregnancy history, current pregnancy maternal diagnoses, neonatal measures were important explanatory variables in the analysis. Place of residence was an important explanatory variable for preterm births and congenital anomalies. However, due to various limitations these results must be interpreted with caution. / Thesis / Master of Arts (MA)

Children and adults with cerebral palsy (CP) perform reduced physical activity (PA) levels and increased sedentary behaviour (SB), which predisposes them to negative health outcomes. SB is characterized in the typically developing population by an energy expenditure component of ≤1.5 metabolic equivalents of task (METs) while sitting, reclining or lying. There is no consensus on an operationalized definition of SB for the CP population. Furthermore, there are no established outcomes to inform guidelines promoting PA in this population. I will address these two research gaps by investigating the operationalization of SB and by identifying important health outcomes of PA, through expert opinions, in individuals with CP. The first chapter is a scoping review of the operationalization of SB in individuals with CP. I found that, in individuals with CP, i) the definition for SB in the typically developing population of ≤1.5 METs generally applies to sitting and lying, and ii) sitting and lying are reported as operationalizations of SB. The second chapter was a conference-based survey to identify critical and important health outcomes for PA in individuals with CP. Clinicians and researchers (n=55) who attended a workshop on PA in CP rated nine pre-determined health outcomes on a 9-point Likert-type scale from the Grading of Recommendations Assessment, Development and Evaluation Approach. The experts identified both the psychological aspects of health (i.e. anxiety and depression) as being critical. The physical health outcomes rated as critical were sleep, nutrition, and cardiorespiratory endurance, and those rated as important were body size, body composition, blood lipids and glucose, and blood pressure. Together, this research suggests that the operationalization of SB in individuals with CP is similar to that of the typically developing population, and that both the physical and mental aspects of health must be considered in future PA management. / Thesis / Master of Science Rehabilitation Science (MSc)

The need for Registered Nurses (RNs) in the long-term care of older people is being questioned, particularly in the context of nursing shortages, while suggestions for 'professionalising' Care Assistant (CA) roles are emerging. Despite ongoing debates about the importance of their work, research has so far been unable to provide an evidence-base for the outcomes of the work of either RNs or CAs in UK care homes. Using a multi-method interpretive approach, adopting a structure-process-outcome framework and grounded in the philosophical hermeneutics of Hans-Georg Gadamer, this qualitative research sought to illuminate the distinct contributions made by RNs and CAs to outcomes for older people in care homes. RNs and CAs from around the UK contributed 'significant' examples of their work for Phase 1 of the study and Phase 2 comprised researcher fieldwork (observation, interviews and documentary analysis) in three care homes around England. Participants included RNs, CAs, older residents, relatives, home managers and professionals working in the homes. The findings offer a rich and detailed analysis of the realities of the work, much of which takes place 'behind closed doors' and has been described to a limited extent in the literature. They suggest that the CAs' daily support helps residents to function and to feel valued, and that close, reciprocal, family-type relationships develop. The health knowledge and clinical expertise of good RNs is critical in determining residents' health outcomes, particularly in the long-term, and RNs' 24-hour 'perceptual presence' can make life or death differences in acute or emergency situations. RNs also influence the environment, atmosphere and quality of care in the home. In the context of the literature, the findings offer new insights into the role and contribution of RNs and CAs, the outcomes of their work and the priorities of residents. The study produced new models of RN and CA roles in care homes, encompassing dimensions not previously acknowledged in the literature or their job descriptions, and a new framework within which the outcomes of care for older people could be evaluated. The research offers a positive image of work with older people in independent sector care homes.

As medical care becomes an increasingly large share of Gross Domestic Product, understanding the mechanisms for how and why medical care spending is rising becomes increasingly important. Such an evaluation should consider the productivity relationship between medical care and health. An evaluation of medical productivity involves the measurement of medical care input prices, disease treatment output prices, and the productive relationship between medical care inputs and disease treatment health outcomes. Medical care price measurement is complicated by the heterogeneity of services, the role of insurance in negotiating prices, rapid technological advancements in medical care and limited availability of transaction price data. Health outcome prices are difficult to construct because of the difficulty in measuring health outcomes, the heterogeneity of health outcomes, and the messy relationship between consumption goods and health. Finally, in addition to accurate input and output price measurement, a productivity assessment requires a measurable causal relationship between medical care services and health outcomes. To date, all of these requirements have been insurmountable hurdles to assessing the productivity of medical care for the entire United States economy. This dissertation uses the Medical care Expenditure Panel Survey to address the necessary requirements for evaluating the productivity of medical care. The second chapter constructs regional medical care price indices using transaction prices that control for service type heterogeneity. The data employed in the analysis associates the observed medical care spending with the diseases the spending is used to treat. This association is exploited in the third chapter, which constructs medical care treatment prices for twelve of the major health conditions in the United States. The fourth chapter compares the productivity of medical care services used to produce disease treatment health outcomes across insurance types. / text

This thesis consists of an overview and five essays. The purpose of the thesis is to show how economics can contribute to a better understanding of medical practice variations – why they exist, their consequences, and the extent to which they can – and should – be influenced. The first essay, Econometric analysis of variation in cesarean section rates – a cross-sectional study of 59 obstetrical departments in Sweden, is an attempt to identify the causes of variation in cesarean section rates, and to discuss their economic consequences. The econometric model applied explains 27 percent of the variation. We conclude that the unexplained variation in cesarean section rates indicates inefficiency, mainly due to over-utilisation. Estimates of the economic consequences indicate an additional cost for "unnecessary" cesarean sections of 13-16 million SEK per year. The welfare loss to society due to undesired variation is tentatively estimated to be about twice as high. In the second essay, Estimating the effect of cesarean section rate on health outcome – evidence from Swedish hospital data, we test the null hypothesis of a zero effect of cesarean section rate on health outcome, against the alternative of a positive effect. We could not reject the null hypothesis of a zero effect, i.e., we did not find any significant positive relationship between cesarean section rate and health outcome, in terms of perinatal mortality or rate of asphyxia. In the third essay, Benchmarking in obstetric care – a comparative study based on data envelopment analysis (DEA), we apply the DEA method to compare technical efficiency (productivity) of inpatient obstetric care in Swedish hospitals in 1994 and 1995. The results indicate an average potential for enhanced productivity of at least 6-7 percent each year. Most hospitals show decreasing productivity 1994-1995, partly due to inability to adjust production capacity and costs to a decreasing demand. The last two essays apply a new method – Quality Satisfaction Performance (QSP) – for incorporating patient perspectives into the management of health care, i.e., as a basis for quality improvement. Change-oriented patient questionnaires – testing a new method at three departments of ophthalmology, is a pilot study. The results show consistently high patient satisfaction indices. Satisfaction varies somewhat among the different patient segments and departments. We conclude that decisions on improvements must be preceded by thorough assessment of costs as well as effects associated with the various changes. The last essay, Patient satisfaction and priority setting – an economic approach, aims at analysing if and how priorities according to the QSP approach are influenced when an economic perspective is explicitly included. This is accomplished by a cost-effectiveness analysis of certain proposed changes/improvements, and a cost-benefit analysis based upon the patients` willingness-to-pay for these changes. Our results show that the ranking between various improvements is strongly influenced when an economic dimension is included. We conclude that even a methodologically appropriate measurement of patient satisfaction may lead to cost-ineffective priority setting, unless economic consequences are explicitly considered. / Diss. (sammanfattning) Stockholm : Handelshögsk., 2001

Diss. (sammanfattning) Umeå : Univ., 2007. / Härtill 4 uppsatser.

This thesis aims at examining the relationship between single motherhood and the health and academic performance of children in different countries. It was geared toward understanding whether single motherhood has an impact or consequences on the health and academic performance of children. In order to attain this goal, this thesis was sub divided into three main parts (sections) namely; examining whether single motherhood has consequences on the health outcome of children, examining whether single motherhood has consequences on the academic performance of children and finally ascertaining the impact of single motherhood on children's health and academic performance in different economies (Sweden and Germany).  Furthermore, this study adopted the quantitative and cross-cultural approach where quantitative data was obtained across different countries. The Health Behaviour of School aged Children (HBSC) constituted the main source from which responses, respondents and data collection instrument was obtained.  After thorough statistical analysis, the regression mode was used to establish that single motherhood reduced the quality of health and academic outcome of children and thus reflecting a negative impact of single motherhood on the child's health and academic performance.  A cross comparison approach was used to ascertain the economies of Sweden and Germany and compared against the impact of single motherhood on the children's health and academic performance in these two countries. It was then revealed that the impact of single motherhood on children's health and academic performance was dire and common in Germany than Sweden. The study finally concluded that single motherhood negatively impacted the health and academic performance of children with varying impact in different economic context. / Denna uppsats syftar till att undersöka förhållandet mellan ensamstående moderskap och barns hälsa och akademiska prestationer i olika länder. Det var inriktat på att förstå om ensamstående moderskap har en inverkan eller konsekvenser för barns hälsa och akademiska prestationer. För att uppnå detta mål delades denna uppsats upp i tre huvuddelar (avsnitt), nämligen; undersöka om ensamstående moderskap har konsekvenser för barns hälsoutfall, undersöka om ensamstående moderskap har konsekvenser för barns akademiska prestationer och slutligen fastställa effekterna av ensamstående moderskap på barns hälsa och akademiska resultat i olika ekonomier (Sverige och Tyskland). Vidare antog denna studie det kvantitativa och tvärkulturella tillvägagångssättet där kvantitativa data erhölls i olika länder. HBSC (Health Behavior of School Age Children) utgjorde den huvudsakliga källan från vilken svar, respondenter och datainsamlingsinstrument erhölls. Efter noggrann statistisk analys användes regressionsläget för att fastställa att ensamstående moderskap minskade barns hälsa och akademiska resultat och därmed återspeglade en negativ inverkan av ensamstående moderskap på barnets hälsa och akademiska prestationer. En tvärjämförelsestrategi användes för att fastställa ekonomierna i Sverige och Tyskland och jämfördes mot inverkan av ensamstående moderskap på barnens hälsa och akademiska prestationer i dessa två länder. Det avslöjades sedan att ensamstående moderskaps inverkan på barns hälsa och akademiska prestationer var hemskt och vanligt i Tyskland än Sverige. Undersökningen drog slutligen slutsatsen att ensamstående moderskap påverkade barns hälsa och akademiska prestationer negativt i olika ekonomiska sammanhang.

Bakgrund: Epilepsi är klassat som en folksjukdom, ca 50 miljoner människor i världen har diagnosen. Epilepsi innebär att personen har ett kroniskt anlag för att få oprovocerade epileptiska anfall.  Syfte: Syftet var att undersöka vuxna personers upplevelser av vardagslivet med epilepsi. Metod: En litteraturöversikt med kvalitativ metod och induktiv ansats. Artikelsökningen gjordes i CINAHL och Medline samt kompletterandes med en frisökning. Artiklarna är skrivna mellan 2012 och 2022. Analys av elva artiklar skedde med hjälp av Fribergs granskningsmall.  Resultat: Personerna upplevde rädsla för anfall, stigmatisering och utanförskap. Epilepsianfall orsakade frustration då de hindrade personernas vardagsliv.  Vårdmöten var en del i vardagslivet, upplevelserna av dessa var individuella. Personerna behövde omvärdera drömmar och mål som en följd av epilepsin. Detta upplevdes ansträngande och när omvärderingen skett fortlöpte livet i en ny riktning. Personerna använde sig av olika strategier för att hantera sitt vardagsliv. De använde direkta problemlösande metoder, fysisk aktivitet, psykisk bearbetning, informatik och stöd från omgivningen.  Slutsatser: Alla upplevde vardagen med diagnosen olika. Det finns behov av vidare, mer specifika studier. Utveckling av information för vårdpersonal, samhället och individer är vitalt för att skapa möjligheter för en god och fungerande vardag. / Background: Epilepsy is classified as an endemic disease. Around 50 million humans have the diagnosis around the world. Epilepsy is a chronic predisposition for unprovoked epileptic seizures.  Aim: Describe adult people's everyday life with epilepsy. Method: A qualitative study with an inductive approach. The article search was made in CINAHL and Medline, with a complementing free search. The articles are written between 2012-2022. Twelve articles were analysed with the Friberg’s review template.   Result: The individuals experienced fears of seizures, stigmatization, and exclusion. Epileptic seizures caused frustration as they hindered people's everyday lives, this was managed with the help of information and relatives. Healthcare meetings were part of everyday life, the experiences varied. The persons needed to reassess dreams and goals because of their epilepsy. This was a taxing process and afterwards life continued in a new direction. The people used different strategies to manage their everyday life. They adopted direct problem-solving methods, physical activity, mental processing, informatics, and support from society. Conclusion: All subjects experienced everyday life with the diagnosis differently. There is a need for more specific studies. Development of information for healthcare professionals, society and individuals is vital to create opportunities for a good and functioning everyday life.

The aims of this thesis were to evaluate caries-preventive measures from a societal perspective, to demonstrate the use of resources in preventive dentistry, to develop and discuss techniques suitable for evaluating dental care costs and outcomes, and to test costs and consequences within a health economic decision model adapted to preventive dental care. The thesis is based on three separate studies with three separate cohorts. In the first study, performed at a single dental clinic, analysis was made of data on dental caries progression over four years in 92 adolescents, along with the use of resources for preventive treatment. In the second study, data from the intervention study “Evaluation of caries-preventive measures” (performed between 1995 and 1999 at 26 dental health clinics throughout Sweden) were used for economic evaluation. Three different approaches to calculating unit cost were discussed, each of which reflect the differences in treatment costs as influenced by the practitioner’s level of skill and competence (salary) and by methods of handling overhead cost allocation. These methods seem useful for evaluating costs in cost-effectiveness analysis (CEA) and cost-benefit analysis (CBA). The CEA showed an incremental cost-effectiveness over four years of SEK 2 043* per averted decayed (D) enamel (e) and dentine caries, missing (M) and filled (F) surface (S) (DeMFS). In the third study, 82 19-year-old individuals agreed to participate in a pilot exploratory case-control study. Individuals with high caries experience formed the test group while the control group consisted of individuals with no caries experience. To explore whether any differences existed between these two groups in perceived oral health-related quality of life (OHRQOL), two OHRQOL measures were used. Additionally, the willingness of these individuals to pay (WTP) for a preventive strategy was elicited using the contingent valuation method (CVM) within a cost-benefit approach. Using these WTP values, the cost-benefit analyses showed positive net social benefit (NSB) values for both study groups, meaning that the benefits of prevention exceeded the costs. A new outcome measure, Value of Statistical Oral Health (VOSOH), was also presented. Consideration was also made, within the economic framework fundamental to this thesis, of the trend away from a strictly bio-medical paradigm towards a biopsychosocial perspective. The health economic decision model encompasses a number of different techniques for comparing costs with consequences, each with its own advantages and disadvantages and each with its own field of application. These techniques should be seen as complementary rather than competing. Preventive dentistry plays a central role in Swedish dental health care, and it is important that resources are used properly. Accurate evaluation methods are necessary in order to improve the basis for public decision-making; the methods proposed in this thesis seem to be of potential use in this endeavour. *SEK8.54 = US$1 (December 1999).

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