This policy paper reviews the history, use and significance of telehealth in primary care. The emergence of telehealth as a primary strategy to continue to deliver value based, timely primary care during COVID-19 is discussed with recommendations for future applications, payment and preparation of providers to continue to provide quality care of clients in the future using telehealth.

The COVID-19 pandemic and the AIDS epidemic in the United States have taken a burden on the population. Both are diseases that are fatal if the disease is not taken care of. In the 1980s, the fear of the uncertainty surrounding AIDS, and the unknown pathogen at the time HIV, caused panic. The one aspect that people knew about AIDS was that the epidemic was predominantly affecting homosexual men. Hence, people who were diagnosed as HIV positive were also stigmatized as homosexuals by members of society. With the advancement of antiretroviral therapies in the 1990s, having HIV became a chronic disease since it was manageable and did not lead to death. Nowadays, people who are HIV positive can lead long lives with the use of the antiretroviral therapies. However, the stigma of having HIV is still present. Extensive research has been conducted in order to study the causes of HIV-related stigma and minimize the stigma. The effects of HIV-related stigma affect those who are HIV positive and cause some patients to discontinue care—predisposing to having AIDS. The people who face HIV-related stigma are men who have sex with men (MSM) and other high-risk populations such as intravenous drug users or sex workers. The prevalence of HIV has affected minority populations such as African Americans, and in the early 2000s the number of new cases of HIV has increasingly been coming from the Southeastern United States, also known as the Bible Belt. There has been more HIV-related stigma in this region of the United States as evident by some of the prejudiced views of health care workers in this region who may blame the actions of people for their positive HIV serostatus. The laws in 37 of the states in the United States criminalize the nondisclosure of HIV. Experts theorize that these laws increase the stigma of having HIV rather than actually decrease rates of transmission, as the laws were intended to do. The United States has been one of the worst affected nations with the COVID-19 pandemic. The efforts to stop the spread of SARS-CoV-2 have been monumental with government guidelines suggesting social distancing, as SARSCoV-2 is airborne and very contagious. The stigma related to COVID-19 has been targeted at groups of people that are believed to be sources of spread. Asian Americans have been subject to the targeting of people blaming them for the spread of SARS-CoV-2 due to language such as the “Chinese Virus” that propagates stigma and leads towards harassment of Asian Americans. This review of the literature attempts to address whether there were similarities in the HIV-related stigma in the United States to the current day stigma experienced during COVID-19.

京都大学 / 新制・課程博士 / 博士(医学) / 甲第24285号 / 医博第4901号 / 新制||医||1061(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 髙折 晃史, 教授 小杉 眞司, 教授 佐藤 俊哉 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

Purpose - The thesis determined how policy implementation and change management can be improved in Nigeria, with the health insurance scheme as the basis for narrative exploration. It sets out the similarities and differences in assumptions between supra-national organisations such as the World Bank and World Health Organisation on policy implementation and change management and those contained in the Nigerian national health policy; and those of people responsible for implementation in Nigerian organisations at a) the federal or national level and b) at sub-federal service delivery levels of the health insurance scheme. The study provides a framework of the dimensions that should be considered in policy implementation and change management in Nigeria, the nature of structural and infrastructural problems and wider societal context, and the ways in which conceptions of organisations and the variables that impact on organisations¿ capability to engage in policy implementation and change management differ from those in the West. Design/methodology/approach - A qualitative approach in the form of a case study was used to track the transformation of a policy into practice through examining the assumptions and expectations about policy implementation of the organisations financing the policy's implementation through an examination of relevant documents concerning policy, strategy and guidelines on change management and policy implementation from these global organisations, and the Nigerian national health policy document. The next stages of field visits explored the assumptions, expectations and experiences of a) policy makers, government officials, senior managers and civil servants responsible for implementing policy in federal-level agencies through an interview programme and observations; and b) those of sub-federal or local-level managers responsible for service-level policy implementation of the health insurance scheme through an interview programme. Findings - There are conflicts between the rational linear approaches to change management and policy implementation advocated by supra-nationals, which argue that these processes can be controlled and managed by the rational autonomous individual, and the narratives of those who have personal experience of the quest for 'health for all'. The national health policy document mirrors the ideology of the global organisations that emphasise reform, efficiencies and private enterprise. However, the assumptions of these global organisations have little relevance to a Nigerian societal and organisational context, as experienced by the senior officials and managers interviewed. The very nature of organisations is called into question in a Nigerian context, and the problems of structure and infrastructure and ethnic and religious divisions in society seep into organisations, influencing how organisation is enacted. Understandings of the purpose and function of leadership and the workforce are also brought into question. Additionally, there are religion-based barriers to policy implementation, change management and organisational life which are rarely experienced in the West. Furthermore, in the absence of future re-orientation, the concept of strategy and vision seems redundant, as is the rationale for a health insurance scheme for the majority of the population. The absence of vision and credible information further hinder attempts to make decisions or to define the basis for determining results. Practical implications - The study calls for a revised approach to engaging with Nigerian organisations and an understanding of what specific terms mean in that context. For instance, the definitions and understanding of organisations and capacity are different from those used in the West and, as such, bring into question the relevance and applicability of Western-derived models or approaches to policy implementation and change management. A framework with four dimensions - societal context, external influences, seven organisational variables and infrastructural/structural problems - was devised to capture the particular ambiguities and complexities of Nigerian organisations involved in policy implementation and change management. Originality/value - This study combines concepts in management studies with those in policy studies, with the use of narrative approaches to the understanding of policy implementation and change management in a Nigerian setting. Elements of culture, religion and ethical values are introduced to further the understanding of policy making and implementation in non-Western contexts.

Introduction: Pharmaceutical sales visit claims of drug efficacy can influence physician prescribing. Efficacy claims may be susceptible to exaggeration in promotions for drugs approved on the basis of surrogate outcomes. They may also be different in countries with different sales visit regulations. Objectives: To compare the frequency of physician-reported claims of serious morbidity or mortality benefit in promotions for drugs approved on the basis of surrogate outcomes (where claims are unwarranted) with those approved on the basis of serious morbidity or mortality. Additionally, to compare the frequency of unwarranted claims of serious morbidity or mortality benefit by country of promotion. Methods: From 2009 to 2010, primary care physicians in Canada, France, and the United States reported via pre-set questionnaires on claims of serious morbidity or mortality benefit in consecutive cardiovascular drug promotions. Promoted drugs were either 1) approved on the basis of surrogate outcomes, or 2) approved on the basis of serious morbidity or mortality. Using generalized estimating equations, the frequency of reported efficacy claims was compared between the two promotion types. The frequency of unwarranted claims drug benefit was also compared by country. Results: 448 promotions were analyzed. Claims of serious morbidity or mortality benefit were reported in 156/347 (45%) promotions for drugs approved on the basis of surrogate outcomes and 72/101 (71%) promotions for drugs approved on the basis of serious morbidity or mortality, p<0.001. Despite stricter sales visit regulations, unwarranted claims of serious morbidity or mortality benefit for drugs approved on the basis of surrogate outcomes were reported most frequently in France (59%) compared to Canada (46%), p=0.2 or the United States (26%), p=0.02. Conclusions: Across countries, unwarranted claims of drug benefit were frequently reported in promotions for drugs approved on the basis of surrogate outcomes. These claims amount to off-label promotion and contravene national sales visit regulations. / Thesis / Master of Science (MSc)

No description available.

Background While an estimated 70%–75% of the health workforce are women, this is not reflected in the leadership roles of most health organisations— including global decision-making bodies such as the World Health Assembly (WHA). Methods We analysed gender representation in WHA delegations of Member States, Associate Members and Observers (country/territory), using data from 10 944 WHA delegations and 75 815 delegation members over 1948–2021. Delegates’ information was extracted from WHO documentation. Likely gender was inferred based on prefixes, pronouns and other gendered language. A gender-to- name algorithm was used as a last resort (4.6%). Time series of 5-year rolling averages of the percentage of women across WHO region, income group and delegate roles are presented. We estimated (%) change ±SE of inferred women delegation members at the WHA per year, and estimated years±SE until gender parity from 2010 to 2019 across regions, income groups, delegate roles and countries. Correlations with these measures were assessed with countries’ gender inequality index and two Worldwide Governance indicators. Results While upwards trends could be observed in the percentage of women delegates over the past 74 years, men remained over-represented in most WHA delegations. Over 1948–2021, 82.9% of delegations were composed of a majority of men, and no WHA had more than 30% of women Chief Delegates (ranging from 0% to 30%). Wide variation in trends over time could be observed across different geographical regions, income groups and countries. Some countries may take over 100 years to reach gender parity in their WHA delegations, if current estimated trends continue. Conclusion Despite commitments to gender equality in leadership, women remain gravely under-represented in global health governance. An intersectional approach to representation in global health governance, which prioritises equity in participation beyond gender, can enable transformative policymaking that fosters transparent, accountable and just health systems.

The opioid epidemic impacts all levels of society, yet discernible disparities exist concerning opioid use disorder (OUD) prevalence and access to treatment, including medications for opioid use disorder (MOUDs). Specifically, adults involved in the justice system face a disproportionate burden of OUD and are more likely to go untreated. Insurance coverage plays a critical role in facilitating healthcare access, including OUD treatment. Under the Affordable Care Act, select states elected to expand their Medicaid coverage to more low-income individuals. Additionally, some incarcerated individuals are affected by the "inmate exclusion" law which bars Medicaid from covering healthcare for those in correctional facilities. Some states automatically terminate Medicaid eligibility upon incarceration, while others choose to suspend. Although research indicates that Medicaid expansion correlates with increased insurance coverage and MOUD access and utilization within the general population, the effects on justice-involved individuals remain inadequately understood. To address these gaps, this dissertation examines the effects of state policies expanding access to Medicaid coverage on outcomes for individuals with OUD referred to treatment by the justice system using a quasi-experimental, difference-in-difference framework and data from the Treatment Episode Dataset-Admissions (TEDS-A) from 2006-2019. More specifically, we estimated the effects of Medicaid expansion on insurance coverage at admission (i.e., Medicaid, private, uninsured, or other) and planned utilization of MOUD for all justice referrals and the effects of suspension and Medicaid expansion on outcomes for individuals referred from prison or probation/parole since suspension policies should only affect recently incarcerated individuals. We found that Medicaid coverage increased while uninsurance decreased, and planned utilization of MOUD improved by 133%. Moreover, in expansion states, Medicaid coverage and planned utilization of MOUD increased. For the prison and parole/probation subpopulation, we found that Medicaid expansion improved Medicaid coverage and planned utilization of MOUD, but that Medicaid suspension was not associated with either outcome.

Chronic kidney disease (CKD) is a condition that requires access to renal replacement therapies (RRTs) to enable patients to live. The use of such therapies has been continuously researched due to the high cost to payers and their patients. This dissertation aimed to analyze the incidence, prevalence, and mortality of renal replacement therapies in patients with end-stage renal disease (ESRD), and document cost trends and analyze possible inequalities in access to these therapies. Based on an integrated health risk management (IHRM) model, this study examined patient characteristics associated with renal replacement therapies in ESRD patients through a pooled cross-sectional study based on USRDS (United States Renal Data System), and examined information related to costs and utilization of health services one year after the initiation of dialysis through a retrospective cohort study. Findings suggest that morbidity and mortality measures of renal replacement therapies continue to increase from 2001 to 2018, and costs continue to decrease from 2014 to 2017 in the United States. In-center hemodialysis (ICHD) (196.2 cases per 100,000 inhabitants) continues to be the most prevalent RRT utilized over home hemodialysis (HHD) (4.4 cases per 100,000 inhabitants) and peritoneal dialysis (PD) (24.7 cases per 100,000 inhabitants). The cost for ICHD (306,705,989 million dollars) is significantly higher than HHD (234,559,170 million dollars) and PD (5,360,136 million dollars). White patients have a 25% lower probability of accessing in-center hemodialysis compared to patients of other races. Hispanic patients were also found to be 31% more likely to access in-center hemodialysis compared to non-Hispanic patients, which would indicate potential inequities in access to these alternative RRTs. Study findings provide critical data to inform decision-makers on the use of HHD, PD, and ICHD among ESRD patients in the US and increase awareness of PD and HHD to reduce long-term costs to the healthcare system.

Trots den utbredda personalbristen inom vården så finns det ett sjukvårdsområde, nämligen Rättspsykiatri Vård Stockholm, som mot alla odds inte har samma svårigheter som andra inom regionen att behålla sin personal. I ett samhälle där fler lever längre behöver fler arbeta upp i högre ålder. För att möjliggöra detta behöver arbetsgivare och arbetstagare tillsammans skapa en hälsofrämjande och hållbar arbetsplats genom att stärka och behålla faktorer som bidrar tillarbetsengagemang. Ett tillvägagångssätt är att undersöka vilka faktorer som arbetstagarna upplever är motiverande och som har betydelse för deras upplevda arbetsengagemang. Syftet med studien är att beskriva vilka yttre och inre faktorer som arbetstagare inom rättspsykiatrisk vård upplever som motiverande i sin arbetsmiljö och värdesätter för att stanna kvar på arbetsplatsen en längre tid. Som metod användes semistrukturerad djupintervju med fenomenografisk ansats där sex intervjuer genomfördes. Resultatet mynnade ut i fyra beskrivningskategorier som värderades från högst till lägst enligt följande av deltagarna; känslan av att kunna göra skillnad, upplevelsen av samhörighet på arbetsplatsen, arbetsplatsens möjligheter till självförverkligande och flexibilitet i relation till arbetet och privatlivet. En samstämmighet med självbestämmandeteorins begrepp självstyrande motivation samt med tvåfaktorsteorins motivationsfaktorer i form av inremotivationsfaktorer framkom i studien. Bristande hygienfaktorer i form av yttremotivationsfaktorer var däremot inte motivationssänkande för deltagarna. Vårdorganisationer bör fokusera på att möjliggöra och öka arbetstagarnas upplevelser av inre motiverande faktorer som ett steg för att motverka ohälsa och främja en hållbar och hälsofrämjande arbetsplats. Det finns goda möjligheter för andra vårdorganisationer att skapa hälsofrämjande förbättringsåtgärder på arbetsplatsen med studiens utfallsrum som grund. / Despite the widespread staff shortage in healthcare, there is one healthcare area, namely Forensic Psychiatry Stockholm, which, against all odds, does not have the same difficulties as others in the region in retaining its staff. In a society where more people are living longer, more people need to work to an older age. To make this possible, employers and employees together need to create a health-promoting and sustainable workplace by strengthening and maintaining factors that contribute to commitment to work. One approach is to examine which factors the employees perceive to be motivating and which are significant for their perceived commitment to work. The purpose of the study is to describe extrinsic and intrinsic factors that employees in forensic psychiatric care experience as motivating in their work environment and value in order to remain at the workplace for a longer period of time. The method used was a semi-structured in-depth interview with a phenomenographic approach where six interviews were conducted. The results led to four description categories that were rated from highest to lowest according to the following by the participants; the feeling of being able to make a difference, the experience of togetherness in the workplace, the workplace's opportunities for self-realization and flexibility in relation to work and private life. Our study accords with self-determination theory’s concept of self-directed motivation and with two-factor theory's motivational factors in the form of intrinsic factors. In contrast, lack of hygiene factors in the form of extrinsic motivation factors did not lower motivation for the participants. Healthcare organizations should focus on enabling and increasing workers' experiences of intrinsic motivation as a step towards countering ill-health and promoting a sustainable and health promoting workplace. There are good opportunities for other healthcare organizations to create health-promoting improvement measures in the workplace using the study’s outcome space as a basis.