Previous research has examined patients’ level of satisfaction with the care, in an attempt to develop health care services that match patients’ expectations and needs. Nevertheless, there is still considerable debate among researchers over conceptual and methodological issues. This research programme investigated factors that contribute to patient satisfaction with health care in two fairly different European health care systems (the UK’s NHS and Greece’s ESY). A further aim was to develop a scale to assess patient satisfaction and health care evaluations within these two cultural contexts. In order to achieve those aims, a sequential exploratory strategy incorporating, qualitative and quantitative designs was used to explore patient health care evaluations, patient satisfaction, expectations, health care experiences, interpersonal qualities of the doctor-patient relationship and health care contextual factors at both micro and macro level. Three studies were conducted: Studies 1a and 1b examined levels of patient satisfaction with health care delivery in Greece and the UK respectively. More similarities than differences were found between the two samples, but aspects of health system evaluation differed. The data obtained from this study informed the development of the Patient Expectation and Satisfaction Scale (PESS). The psychometric properties of the preliminary version of the scale were subsequently tested in non clinical populations in Greece and the UK (Studies 2a and 2b). The pilot testing of the PESS was based on a proposed theoretical framework suggesting that patients’ expectations depend on the nature of past experiences and current expectations. The variable that influences some of the differences between the two countries is health culture in terms of contextual health care differences. Although findings revealed similarities between the two cultures, differences were found relating to dissatisfaction, health care evaluations, expectations and the quality of the doctor-patient relationship. A revised version of the PESS, based on these findings, was administered to hospital outpatient populations in both countries (Study 3). The Patient Satisfaction and Expectation Model that emerged from this analysis incorporated three levels of patient satisfaction: at the micro level, the macro level and the interpersonal level. The importance of patients’ understanding of professional competence and its salience as a predictor of the effectiveness of the doctor-patient relationship was highlighted. The quality of the doctor-patient relationship emerged as an important determinant of patient satisfaction and adherence. The overall findings of this research programme suggest that patient satisfaction is multidimensional; despite contextual differences between the two health care systems, a universal concept exists that includes health care expectations, health care experiences, interpersonal qualities and aspects relating to operational and organisational structures at both micro and macro level.

This dissertation consists of two empirical papers and one methods paper. The first two papers use quasi-experimental methods to evaluate the impact of universal health insurance reform in Massachusetts (MA) and Thailand and the third paper evaluates the validity of a quasi-experimental method used in comparative effectiveness research (CER).

This dissertation explores tensions between individual freedom and institutional authority. Chapter one examines public perceptions of the legitimacy of "new frontier" public health measures. I present results from a national survey of 1,817 adults concerning the acceptability of public health interventions for noncommunicable diseases. We found that support for these interventions is high overall; strongly associated with race and political orientation; and tied to perceptions of democratic representation in policy making. There was much support for strategies that enable people to exercise healthful choices, but considerably less for more coercive measures. These findings suggest that the least coercive path will be the smoothest. Additionally, the findings underscore the need for policy makers to involve the public in decision making, understand the public's values, and communicate how policy decisions reflect this understanding.

This thesis examines the experiences of people living with dystonia1 and the ways these are represented by people living with dystonia, the Dystonia Society, neurologists, quality of life (QOL) researchers and pharmaceutical companies. Drawing on ethnographic fieldwork conducted within the Dystonia Society and on projects developing a disease-specific QOL measure, and investigating the impact of dystonia on people’s QOL, the thesis explores a series of questions about the conceptual and practical problems inherent in such measures. It asks: • How dystonia is defined and represented and its impact on people’s lives • Whether people’s experiences of living with dystonia can be adequately mapped by generic or disease-specific QOL measures and how the methodology used in their creation might affect such representations • How QOL measures are used to classify and compare and why it is now deemed necessary to represent people’s experiences in this form The thesis is contextualised within a historical account of the origins of QOL measurement and the social and economic context to its rapid expansion, including the pharmaceutical industry’s use of QOL to bring together diverse groups of actors. I address traditional anthropological questions about measuring and creating universal systems of classification and valuation, but go beyond this to link QOL measurement to the classification and hierarchisation of “audit culture”. I describe how attempts to articulate “the patient’s voice” through measures of QOL can silence the voices of people with limiting conditions and suggest we approach their experiences through narratives that embed their conditions in their lives and give them a meaning that is not wholly negative. I argue that even though the phrase “quality of life” promises an empowering and holistic vision of health, there are two main reasons why QOL measurement cannot fulfil this promise. Firstly, it is primarily a tool for audit, and secondly, new measures reproduce the assumptions of existing measures or clinical models and exclude the elements that people consider most important in maintaining quality of life. Paradoxically, the discourse can reduce people’s QOL when it is used to justify rationing in the UK and redirection of resources internationally. However, despite my criticisms of QOL, I conclude that it has benefited people living with dystonia by creating a discursive space for the discussion of health in non-clinical terms and a language to make claims for resources and the acknowledgement of their experiences. 1A chronic neurological condition involving involuntary muscle spasms in one or more body parts.

Since the economic reform in 1978, China’s health system moved from a commune-based system to a market-driven system. This drastic change resulted in various market failures, including cost inflation, perverse incentives for providers and supplier-induced demand for unnecessary care, increasing inequality in access across regions based on economic status, and other problems. Though China attempted to correct its policy mistakes and reform its inadequate and unjust health care system in order to provide basic universal health coverage for all over the past decade, not everyone has equal access to the same quality of affordable health care, especially the non-resident workers, the poor urban residents, and the rural population. This research uses the framework of the five intellectual tasks to assess the history of China’s health policies, the political economy factors that have driven and shaped the reform of China’s health system, the likely projections of policy options, and potential alternatives for policymakers.

Folkhälsopolitiken skapar förutsättningar för befolkningens hälsa. Folkhälsoinsatserna bör vara politiskt förankrade på nationell, regional och lokal nivå för att förstärka folkhälsan. Hälsopolicytriangeln är ett hjälpmedel för de aktörer som vill skapa eller revidera handlingsplaner som används för att styra och följa upp kommunalt folkhälsoarbete. Syftet med studien var att beskriva arbetet med policyformuleringen för Eskilstuna kommuns handlingsplan för folkhälsa ur ett aktörsperspektiv. Studiedesignen var kvalitativ med deduktiv manifest innehållsanalys med stöd av analysverktyget hälsopolicytriangeln. Totalt genomfördes fem intervjuer med politiker, tjänstemän och kommunchefer. I resultatet framkom det att intervjupersonerna beskrev arbetet i policyformuleringen som demokratiskt, att det inte fanns någon hierarki eftersom de strävade mot ett gemensamt mål för folkhälsan. Det framkom även att de ser policyformuleringen som en central och viktig roll i hela policyprocessen för handlingsplanen, eftersom det är där beslut tas angående vad som ska finnas med och vilka folkhälsoinsatser som kommunen ska göra. Handlingsplanen för folkhälsoarbetet speglas av kommunens politiska folkhälsoinriktning, tidigare folkhälsoarbeten och styrdokument. Slutsatserna var att aktörerna beskriver arbetet i policyformuleringen som prestigelöst och demokratiskt för att nå de gemensamt uppsatta målen för folkhälsan i kommunen. Policyformuleringen upplevdes av aktörerna som en central och viktig del i policyprocessen och att lokal folkhälsopolitik tillsammans med tidigare erfarenheter av lokalt folkhälsoarbete samt styrdokument för folkhälsa utgör underliggande faktorer för utformningen av Eskilstuna kommuns handlingsplan. / Public health politics creates opportunities for population health. Public health efforts must be politically supported to be able to enhance public health at national, regional and local level. Health policy triangle is a tool for operators who want to create or revise action plans that are used to control and monitor the municipal public health work. The purpose of this study was to describe the process of policy formulation for Eskilstuna action plan for public health from an actor's perspective. The study design was qualitative with deductive manifest content analysis supplemented by the analysis tool of health policy triangle. A total of five interviews with politicians, officials and municipal managers were conducted. The result shows that the interviewees described the work in policy formulation as democratic, that there was no hierarchy because they strove toward a common goal of public health. It also emerged that they see policy formulation as a central and vital role in the policy process of the action plan. It is where decisions are made and about what should be included and what public health actions that the municipality should do. The action plan for public health greeted appearance mirrored by municipal policy focus on public health, previous public health works and policy documents. The conclusions were that participants describe the work of policy formulation as unpretentious and democratic order to achieve the common goals of public health in the municipality. Policy formulation was perceived by participants as a central and important part of the policy process and that local public health policy, along with previous experience in local public health and regulatory documents for public health serve as underlying factors in the design of Eskilstuna Municipality's action plan.

The dissertation examines the economic and behavioral factors influencing 'sector-switching' in Kazakhstan's health care industry. Sector-switching involves doctors moving from the national to the private system, which is not well established, thereby raising questions about why the switch occurs. It addresses the question: why health care professionals in Kazakhstan switch from the public sector to similar jobs in the private or nonprofit sectors? This study addresses a key issue in public management (sector switching) and also offers insights into the dynamics of the transition from a centralized economy to a market economy. As such, its findings have `real-world' applications beyond the particular case being studied i.e. Kazakhstan. This study is based on two simple claims. First, fundamental to the reforms that characterize transitional economies is effectively moving public sector employees to a nascent private sector. Second, such switches are unique because the risks related to transitioning to the private sector are different in transitional economies than in established market economies. Thus, the study considers: the degree to which economic and behavioral factors interact with different perceptions of sectoral risk, and subsequently shape the decision to move from the public sector to the private sector; in particular in Kazakhstan's health industry. The data supporting this study come from a survey covering approximately 1,000 health care professionals (practicing physicians working in both the public and private health care sectors) from nine regions of Kazakhstan. The data includes information about individual incentives physicians have for switching sections and their perceptions of perceived risks and uncertainties given the economic transition currently underway in Kazakhstan. The findings of the research suggest the strong support for the proposed hypotheses and have revealed some of the dynamics of sector switching behavior and the characteristics of "sector switchers" in Kazakhstan. The results demonstrate that physicians' overall job dissatisfaction, relative salary compared to physicians in a different sector, their risk-taking behavior, the national health care system's deterioration compared to previous years, as well as problems with providing medical services in the country affect physicians in making their decision to change their employment sector.

“Earth, Air, Water, Oil: Regulating Fracking in the Monterey Shale with Health and Environment in Mind,” explores how hydraulic fracturing regulation in California’s oil-rich Monterey Shale will impact regional public health, including groundwater and air quality. This is achieved through a combination of case study and policy analysis on both the state and national level.

Background: Intensity Modulated Radiation Therapy (IMRT) is a method of delivering high-dose radiation to tumours while sparing surrounding healthy tissues. Despite its wide availability IMRT utilization varies across Ontario. The study’s objective was to examine key steps in the implementation process and identify factors that facilitate or impede IMRT implementation. Research Methods: An embedded multiple case study design, utilizing document analysis and key-informant interviews, was employed. Four cancer centres were selected and key-informant interviews were conducted with radiation oncologists, physicists, radiation therapists, and administrators. Results: Eighteen of 21 invited key-informants participated (86% participation rate) providing a range of insights on the factors influencing IMRT implementation. Overall, three cases made progress in the implementation of IMRT, while one case had limited implementation over the same time period. Conclusion: These findings help explain the observed variation in IMRT implementation across Ontario, which is multifaceted and reflects ongoing processes of change and reinvention.

Background: Intensity Modulated Radiation Therapy (IMRT) is a method of delivering high-dose radiation to tumours while sparing surrounding healthy tissues. Despite its wide availability IMRT utilization varies across Ontario. The study’s objective was to examine key steps in the implementation process and identify factors that facilitate or impede IMRT implementation. Research Methods: An embedded multiple case study design, utilizing document analysis and key-informant interviews, was employed. Four cancer centres were selected and key-informant interviews were conducted with radiation oncologists, physicists, radiation therapists, and administrators. Results: Eighteen of 21 invited key-informants participated (86% participation rate) providing a range of insights on the factors influencing IMRT implementation. Overall, three cases made progress in the implementation of IMRT, while one case had limited implementation over the same time period. Conclusion: These findings help explain the observed variation in IMRT implementation across Ontario, which is multifaceted and reflects ongoing processes of change and reinvention.