Health policy making is fraught with difficult decisions that result from conflicts between people’s values. Citizens are important stakeholders in this process, and it is through methods of public engagement that they can be involved in developing health policy. Deliberative forms, in particular, have the ability to improve decision quality and promote greater acceptance of decisions. This study used the Toronto Health Policy Citizens Council to examine citizens’ values on 7 specific health policy questions asked over a two-year period. A thematic analysis was performed on the transcript content derived from the audiotaped deliberations from Council meetings. Nineteen values were identified. The results suggest that it may be a combination of factors of the health policy topic discussed that shapes the values elicitation seen in this kind of public engagement. In conclusion, citizens councils appear effective at eliciting citizens’ values, and are a good way to actively educate participants about health care.

The issue of how to test and ultimately regulate tobacco products represents a critical challenge for the public health community. Although the current international testing regime for conventional cigarettes is widely acknowledged to be seriously flawed, there is a lack of data to guide potential alternatives, particularly in the area of human puffing behaviour. The current study sought to: 1) collect naturalistic measures of smoking behaviour, 2) examine the extent to which levels of tar, nicotine, and carbon monoxide from each of five testing protocols were associated with measures of nicotine uptake among smokers, and 3) examine the validity of self-report measures of smoking behaviour. These questions were examined through two different studies. First, a field study of smoking behaviour was conducted with 59 adult smokers, who used a portable device to measure smoking topography over the course of 3 one-week trials. Participants were asked to smoke their usual ?regular-yield? brand through the device for Trial 1 and again, 6 weeks later, at Trial 2. Half the subjects were then randomly assigned to smoke a ?low-yield? brand for Trial 3. The smoke intake and constituent yield of each brand was then tested under five testing protocols: ISO, Massachusetts, Canadian, a Compensatory protocol, and a Human Mimic regime. Participants also completed self-report measures of puffing behaviour at recruitment and immediately following each of the three one-week smoking trials. Several of these self-report measures were subsequently included in the Waves 2 and 3 of the International Tobacco Control Policy Evaluation (ITC) Survey?an international cohort survey of adult smokers from Canada, Australia, the US, and the UK. <br /><br /> The results of the field study indicate a high degree of stability in puffing behaviour within the same smoker over time, but considerable variability between smokers, including those smoking the same brand. Puffing behaviour was strongly associated with cotinine levels, particularly when included in an interaction term with cigarettes per day (<em>Part r</em> = . 50, <em>p</em><. 001). Smokers who were switched to a ?low-yield? cigarette increased their total smoke intake per cigarette by 40% (<em>p</em>=. 007), with no significant change in their in salivary cotinine levels. <br /><br /> The results indicate systematic differences between human puffing behaviour and the puffing regimes used by machine testing protocols. The puffing behaviour observed among participants during the one-week smoking trials was significantly more intense than the puffing parameters of the ISO and Compensatory testing regimes. When cigarette brands were machine tested using participants? actual puffing behaviour, the results suggest that participants ingested two to four times the level of tar, nicotine, and carbon monoxide indicated by the ISO regime, and twice the amounts generated by the Compensatory regime for ?regular-yield? brands. The Canadian and Massachusetts regimes produced yields much closer to the ?Human Mimic? yields, although nowhere near a maximum or intense standard, as they were designed to do. Only the nicotine yields from the Human Mimic regime were correlated with measures of nicotine uptake among smokers, and only moderately so (<em>Part r</em> = . 31, <em>p</em>=. 02). <br /><br /> Self-report measures of puffing behaviour collected during the field study were moderately correlated with physiological measures of puffing and exposure. Self-report measures of puff depth and puff number showed some promise as predictors of salivary cotinine, although the results are characterized by inconsistencies across models. The self-report measures included in the ITC survey were only weakly associated with age and cigarettes per day, with modest between-country differences. <br /><br /> Overall, this research highlights the importance of puffing behaviour as a determinant of smoke exposure, and provides strong evidence of compensatory smoking for ?low-yield? brands. The findings also highlight the variability in human smoking behaviour and the limitations associated with machine testing protocols. Perhaps most important, the findings underscore the immediate need to revise the ISO protocol, which systematically underestimates smoking behaviour among humans and exaggerates differences between cigarette brands.

PURPOSE: To evaluate Canada’s most comprehensive outdoor smoke-free ordinance, in Woodstock, Ontario, using both quantitative (longitudinal cohort survey) and qualitative methods (key informant interviews with policy makers). Measures include levels of support for outdoor smoking restrictions, smoking behaviour in outdoor environments, measures of the social denormalization of smoking, measures of concern about litter or fires caused by discarded cigarette butts, and reported changes in use of services, facilities or businesses that were regulated by the by-law. This study also sought to understand aspects of the policy development process and determine to how relevant the findings may be to other communities across Canada, and the world. BACKGROUND: The City of Woodstock, Ontario created a comprehensive outdoor smoke-free ordinance (OSFO) that came into effect on September 1, 2008. This by-law restricted or banned smoking in 5 different outdoor environments owned or regulated by the city including patios on downtown sidewalk cafés, parks and recreational fields, areas around transit stops and shelters, and doorways of city run facilities such as city hall. The by-law also created two schedules to further regulate smoking in other outdoor environments if elected by citizens in the community; one for non-city-owned properties such as private business to regulate smoking in their doorway environments and a second schedule for outdoor events organized by groups in the community. The schedules allowed council to pass a by-law that could easily regulate and enforce additional smoke-free environments, as requested by citizens, without the need for council approval. METHODS: Qualitative and quantitative methods were used to address the research objectives. Quantitative measures were collected using a pre-post survey design, interviewing smokers and non-smokers, in the City of Woodstock, and a neighbouring community (Ingersoll) in the same county (Oxford County). Before the by-law was enacted, two surveys were conducted. The telephone survey (August 13-28, 2008) was a random digit dialled (RDD) general adult population survey of non-smokers (n=373) and smokers (n=234). A face-to-face survey (August 13-19, 2008) was conducted among a targeted sample of smokers who were observed smoking in one of the outdoor areas that was to become smoke-free in accordance with the by-law (n=176). Face-to-face interviewers used handheld Palm III devices to assist in the interviewing of these respondents. Surveying both samples ensured the beliefs, attitudes, and behaviour of those smokers who, given circumstances of their recruitment, would be more likely to be affected by the by-law, would be measured in this evaluation study. Using a longitudinal cohort design, respondents from both Wave 1 surveys were re-contacted by telephone in approximately one year after the ban was implemented (August 18-September 15, 2009), to measure changes in the key outcome variables. The Wave 2 survey was conducted entirely by telephone with no replenishment. The Wave 2 survey included respondents that were successfully re-contacted from the general population sample (non-smokers n=299, smokers n=182), and respondents from the targeted sample (n=61). This qualitative study sought to identify any specific lessons or findings from the process undertaken that would be applicable or helpful to other communities. The qualitative study involved 6 key informant interviews with identified public health and city staff and an elected official who were involved in different aspects of the by-law, from development to enforcement. The data collected from the key informant interviews was analysed using an inductive qualitative method called the ‘framework approach’. RESULTS: After the Woodstock outdoor smoking restrictions had been in place for approximately 1 year, most respondents from the general population survey, smokers, (71%), and non-smokers (93%), supported or strongly supported the by-law. Most smokers (82%) and non-smokers (96%) agreed or strongly agreed that the by-law had been good for the health of the children of Woodstock. The by-law was also associated with increased quit intentions; 15% of the smokers from the general population sample reported that the smoke-free by-law made them more likely to quit, and approximately 26% of the smokers from the targeted sample reported the by-law made them more likely to quit. Smokers from both the general population (30%) and the targeted sample (42%) reported that the smoke-free outdoor by-law had helped them cut down on the number of cigarettes they smoke. There were 30 respondents in the Wave 1 survey that were smokers, who had successfully quit at the time of the Wave 2 survey. Of these ‘quitters’, 33% reported that they outdoor smoke-free by-law had helped them to quit smoking, and approximately half (48%) reported that they by-law had helped them to stay a non-smoker. The overwhelming majority of smokers reported that the by-law did not impact their use of facilities or businesses that had been regulated by the by-law. The key informant interviews revealed that the outdoor smoke-free ordinance was developed by following a standard public health policy development process that involved community (public) participation, exploration of policy options, and a political decision made by the city’s elected officials. It was identified that the implementation of two schedules in the by-law, which allows for expansion of the environments regulated and enforced by the city, was an effective strategy to gradually increase smoke-free spaces without burdening the City Council with regular needs to amend or update a by-law. Appropriate public relations were engaged including disseminating information about the by-law, and publicizing it through established networks in the community. Signage in the regulated environments, and enforcement were considered critical by the implementation team. City staff members recommended that other communities should consider passing similar by-laws and dedicate more effort to implementing and enforcing restrictions, rather than discussing or debating whether or not to enact a by-law. An analysis of the key informant interviews revealed that there were no unique features or circumstances specific to Woodstock that would suggest this by-law could not be developed or passed in another area municipality provided the community already has established smoke-free policies in indoor or enclosed public spaces. If Woodstock is unique in any way, it was in the presence of conditions such as high smoking prevalence and close proximity to tobacco growing regions that make it less likely to have successfully enacted an outdoor smoke-free ordinance. CONCLUSION: Support for the Woodstock comprehensive outdoor smoking by-law is high among smokers and non-smokers. The overwhelming majority of residents interviewed supported the by-law and felt that the by-law was good for the health of the children of Woodstock. The by-law has not had negative impacts on use of facilities including parks and recreational fields. Further, a third of smokers reported that the outdoor by-law has helped them to cut down how much they smoke and almost a fifth of smokers reported that the by-law has made them more likely to quit smoking. Approximately half of the quitters in the sample also reported the by-law helped them to stay quit. These findings suggest that expanding smoke-free ordinances to include a range of outdoor environments will be supported by citizens, and will help smokers to reduce how much they smoke, encourage quitting and help those that quit, remain abstinent. The findings from the key informant interviews suggest that other jurisdictions should explore expanding their smoke-free ordinances to include outdoor environments, particularly environments frequented by children.

Objective: The main objective was to examine characteristics associated with cigarette access behaviours among underage current youth smokers. Methods: This cross-sectional study used self-reported data collected from 29,296 students in Grades 9 to 12 who participated in the 2008-09 Youth Smoking Survey (YSS), and data from the 2008-09 DMTI-EPOI (Enhanced Points of Interest) data file. Multilevel logistic regression analyses were used to jointly examine whether student characteristics and the number of tobacco retailers surrounding schools were associated with the odds of a current youth smoker accessing cigarettes from: (a) a retailer source, (b) a family member, and (c) a friend or someone else. Results: Among underage current smokers, the majority reported usually buying their own cigarettes from a retailer (44.1%), and getting cigarettes from a friend or someone else (42.2%). Significant between-school random variation was identified for youth cigarette access from a retailer source, and from a friend or stranger. Males were more likely to buy their own cigarettes from a retailer (OR 2.08, 95% CI 1.74-2.48), whereas females were more likely to access cigarettes from a family member (OR 0.68, 95% CI 0.53-0.88), or a friend or someone else (OR 0.52, 95% CI 0.44-0.61). Binge smoking was associated with buying cigarettes from a retailer (OR 0.65, 95% CI 0.48-0.86). Youth with a smoking parent or guardian (OR 2.95, 95% CI 2.02-4.31) were more likely to get cigarettes from a family member. Youth who reported that they sometimes (OR 2.80, 95% CI 1.94-4.04), or usually or always (OR 3.15, 95% CI 2.17-4.58) share cigarettes with others was associated with accessing cigarettes from a friend or someone else. Each additional tobacco retailer surrounding a school was associated with an increased likelihood of youth purchasing their own cigarettes from a retailer (OR 1.04, 95% CI 1.01-1.07). Conclusion: Tobacco point-of-sale restrictions are inadequate as youth can still procure cigarettes from both retailers and social sources. Future studies should explore beyond individual-level factors and examine what influences cigarette access behaviours in the broader school context. Such insight will inform the development of new school-level tobacco control initiatives that can more effectively prevent youth from acquiring cigarettes.

Tobacco use is responsible for 5.4 million deaths every year worldwide and a leading cause of preventable death. The burden of these deaths is rapidly shifting to low and middle-income countries, such as Brazil. Brazil is widely regarded as an international leader in tobacco control. The country has prohibited most forms of advertising; however, the cigarette pack remains a primary source of tobacco marketing. The current study sought to examine how tobacco packaging influences brand appeal and perceptions of health risk among female youth in Brazil. A between-subjects experiment was conducted in which 640 Brazilian females between the ages of 16 to 26 years participated in an online survey. Each participant was asked to view and rate a series of cigarette packages that were digitally altered to correspond to one of three experimental conditions: (1) “standard” branded cigarette packages, (2) the same packs with all brand imagery removed (“plain packaging”), or (3) the same packs with all imagery and brand descriptors removed. Participants rated the packages on perceived appeal, taste, smoothness, health risk, ease of quitting, desirability to be seen smoking, preference to try, and smoker attributes through single pack ratings and two-pack comparisons. A pack offer was used as a behavioural measure of general appeal. Linear and logistic regression modeling was used to test for differences between and within experimental conditions. Branded packs were rated as significantly more appealing, better tasting, and smoother on the throat than plain packs. Branded packs were also associated with a greater number of positive smoker attributes including style and sophistication, and were perceived as more likely to be smoked by females than the plain packs. Removing descriptors from the plain packs further decreased the ratings of appeal, taste and smoothness, and also reduced associations with positive attributes. Results of the study also indicated that packages marketed as lighter, through use of lighter coloured pack imagery, and descriptors referring to lighter colours and flavours, were more likely to be rated favourably. Over 52% of participants accepted a pack offer at the end of the study, and of those who selected a pack, more than three-quarters chose a branded pack over a plain pack. Overall, the findings suggest that plain packaging and removing descriptors from cigarette packs, including those that refer to flavours, may help to reduce the appeal of smoking, and consequently reduce smoking susceptibility among young women in Brazil.

Thesis (Ph. D.)--University of Washington, 2001. / Vita. Includes bibliographical references (leaves 69-79).

There has been an increase in empirical evidence indicating an association between governance and health systems, suggesting that better governed countries tend to have healthier populations with better performing health systems. This is an important finding, as it could point to structural public health interventions having a greater impact on health systems performance than individually targeted interventions. This doctoral thesis in public health (DrPH) from Brunel University is a compilation of three independent research projects undertaken under different settings, converging in the examination of the relationship between governance and health systems. The first project was a study conducted in the African region of the World Health Organization with the aim of understanding how and to what extent measures of governance are statistically correlated with performance of health systems as measured by a key health outcome: the under-five child mortality. The second project was a case study from a high income country in Europe during the period in which it went through an economic meltdown, the focus being a qualitative analysis of the extent to which the response to economic crisis influenced public health policy making and short term performance of the health system. The third project was a policy analysis carried out in an upper middle income country in Asia and the focus was to examine how the long history of health financing reform has influenced the performance of the health system. All research projects indicate an association between governance and health systems and the case studies provide empirical evidence of how health systems are affected by governance quality. The African study shows a statistically positive relationship between governance indicators and health outcomes, suggesting better governed countries to have lower child mortality. The European and the Asian cases suggest accountability, responsiveness, transparency and fair partnership to be important governance qualities for successful policy making and reforms. This evidence could be of use to current and future policy makers and others with the authority to configure and implement new public health policies. It indicates the importance of comprehensive analytical work prior to policy making with easy access to documents and fair participation with all stakeholders to increase the probability of reaching consensus oriented policy proposals followed by successful implementations. The main contribution of this thesis is to provide evidence through robust statistical/ qualitative analysis around the association between governance and health systems in countries at all income levels. The originality is located in the breadth (three different settings) as well as depth (three distinct, robust methods) of this kind of research. The congruence of findings regardless of study locations, the outcome measures used or types of methods applied have added to the growing evidence that there is a strong correlation between governance and health systems performance. This increased knowledge provides policy makers with additional evidence which can be applied to develop and improve governance with the aim of allocating public resources more efficiently and equitably. However, further research is required on governance and its link to health systems, inter alia how health equity is affected by selective partnership in the decision making processes and how political ideologies influence governance practices.

The existing literature about the causes of welfare state change, including health care reform, emphasizes stability, yet there is evidence of remarkable changes taking place in welfare systems in much of the developing world. This study analyzes health care reform in Ghana, a country which has experienced significant path-departing changes in just four decades (1957-2003). These changes – the establishment of a National Health Service system with deep (first-dollar) coverage, the introduction of a user-fee system, and the transition to a social health insurance scheme – have been pursued despite key countervailing factors, especially the high political costs associated with them. The study argues that to adequately account for these changes, the policy process should be given special consideration, particularly through the examination of how new policy proposals moved onto the agenda; how they were formulated, adopted, implemented and sustained; and how the reformers managed the entire reform process over time. Based on this analysis, I identified three main interconnected contextual and agential explanatory factors: (a) conjunctural factors, which created windows of opportunity for the changes to occur; (b) policy entrepreneurs, whose leadership, commitment and strategies helped in taking advantage of these opportunities to propel, sponsor, design, adopt, implement and sustain the policy changes; and (c) the concentrated institutional configuration of Ghana, which limited the number and scope of the veto points available to interest groups opposed to the proposed changes. While these three factors contributed to why and how the changes occurred, I identified policy entrepreneurs’ commitment, leadership and strategies, including the feedback effects of those strategies, as the most crucial factors. The study contributes to existing health policy literature by showing how perspectives such as the window of opportunity thesis, the dynamic political process model, the historical institutionalist approach to radical policy change and, finally, the ideational scholarship on framing processes can be combined to enrich our understanding of radical policy change. The study also introduces additional mechanisms of policy change that involve the use of repressive strategies before suggesting some modifications to a number of widely-shared assumptions within the welfare state literature focusing on path dependency, globalization, partisan ideology and vested interests.

Objectives: Evaluate the association of cancer on net worth, consumer debt, mortgage debt, home equity and changes in retirement trends. Methods: Data from the Health and Retirement Study from 1998-2010 was used. Persons had to have a diagnosis of cancer. The index date was the corresponding HRS wave of the year of the first diagnosis of cancer. The pre-index date was 2 years and a 2-year and 4-year post index was observed. Primary outcomes of interest were zero/negative net worth and net worth. Multiple logistic regression was used to test for the association between demographic, economic, human capital, and cancer-related variables on outcomes. Generalized linear models were conducted to assess the association of cancer on net worth, consumer debt, mortgage debt, and home equity. Multinomial logistic regression was performed to assess the association of cancer on retirement. Results: A total of 6,055,110 individuals (weighted) qualified. The majority of patients in this sample were male (53.8%), non-Hispanic (95.5%), and white (90.3%). Marital status (p<0.05), alcohol consumption (p=0.046), hypertension (p = 0.034), private insurance (p=0.001), cancer status (p<0.001), and cancer treatment (p=0.022) were significant predictors of zero/negative net worth 4-years after cancer diagnosis. Patients receiving treatment for their cancer were 71% more likely to have consumer debt 4-years post diagnosis (p=0.006). Patients who reported their cancer improving 4-years post diagnosis were significantly less likely (p=0.008) to have consumer debt (OR=0.59; 95%CI: 0.41-0.87). Cancer treatment and cancer status were significant predictors of mortgage debt (p<0.001 and 0.024, respectively). For individuals whose cancer either improved (OR=1.46; 95%CI: 1.04-2.06) or worsened (OR=4.09; 95%CI: 1.38-12.15), both groups were significantly more likely (p=0.030 and 0.011, respectively) to have home equity 4-years post diagnosis. Cancer status was a significant predictor of individuals transitioning from working to retired (p=0.022).Conclusion: This nationally representative investigation of 6.1 million patients over 50 years of age with cancer found that approximately 65% of cancer patients reported zero/negative net worth of cancer and almost 45% of cancer patients reported consumer debt four-years post diagnosis. Cancer-related characteristics explain a significant amount of the change in net worth four-years post diagnosis of cancer.

In the United States, a growing proportion of the population is aged 65 and older. Associated with this demographic transition is a rise in the number of people who are aging with chronic disease. While there is a cultural ideal for older adults to remain in the community and out of institutional settings ("aging in place"), there is little recognition of the work and experience of trying to accomplish this. In the following papers, I draw on 12 months of ethnographic research in the Southwest US to describe the work of "aging in place." As a starting point, I use Medicare-funded home health care (HHC), which stands at the crossroads of acute-based institutional care and custodial, long-term care. In the first paper, using definitions of place from cultural geography, I explore the work of aging from the perspective of chronically ill older adult HHC users. I illustrate how bodies, practices, and places shift as processes of disease and medicalization inscribe them with risk, and the ways in which people accept, resist, and negotiate these changes. The second paper extends the work on audit culture to describe how Medicare's audit system has structured the organization and practice of HHC, and how this has reinforced the commodification of patients. I note how HHC nurses can draw on personal and professional logics in their documentation practices as a means of resisting rationalizing forces and opening up eligibility for care. The third paper uses case studies to push the literature on family caregiver burden to include the fraught, yet highly meaning-filled experience of caregiving. The cases show the difficulties and ambivalence in providing care to a chronically ill family member. Throughout these articles, underlying the tensions, uncertainties, and gaps I explore questions about what type of care is needed, who is worthy of care, and how responsibilities are distributed. I focus on how people's worlds and work are structured by larger scale social, cultural, and economic forces, and attend to the ways in which they reproduce, contend, and negotiate these forces from their unique positions, in effort to protect what they value.