Background: Refugees and refugee claimants experience health needs upon arrival in Canada. Retrenchments to the Interim Federal Health program (IFHP) in 2012 greatly reduced healthcare access for refugee claimants, generating concerns among healthcare providers and other stakeholders affected by the reforms. In 2014 a new IFH program temporarily reinstated access to some health services however, little is known about the reforms and more information is needed to map its impact on key stakeholders. This study aims to examine the perception of key stakeholders regarding the impact of the 2014 reforms on the policy’s intermediary goals: access and provision of healthcare. Methodology: Data was collected using semi-structured key informant interviews with refugee health policy stakeholders (n=23), refugees and refugee claimants (n=6), policy makers and government officials (n=5), civil society organizations (n=6) and professionals and practitioners (n=6). Data was analysed using a constant comparative approach with NVivo 10 (QSR International). A stakeholder analysis was used to map out key stakeholder perceptions, interests and influences in refugee health policy and a content analysis was further employed to abstract themes associated with barriers and facilitators to access and provision of healthcare in the current situation. Results: The findings provide information for management of stakeholder engagement revealing the perceptions of key stakeholders on the 2014 reforms: eight were opposed to the reforms, eight held mixed positions, four supported the reforms and one did not comment. Five facilitators to accessing healthcare were identified. Eighteen themes emerged under four health care access and provision barrier categories: cognitive, socio-political, structural and financial. There were four common themes perceived among all stakeholder groups: lack of communication and awareness of refugee and provider, lack of care provider training leading to unfamiliarity with IFHP, lack of continuity and comprehensive care and the political discourse leading to refugee and claimant social exclusion. Other common barrier themes included healthcare affordability for refugees and the healthcare system, fear of the healthcare system, and interaction with the Ontario Temporary Health Program. Conclusion: The study highlights that reforms to the IFHP in 2014 have transferred refugee health responsibility to provincial authorities and healthcare institutions resulting in bureaucratic strains, inefficiencies, overburdened administration and increased health outcome disparities as refugees and claimants choose to delay seeking healthcare due to existing barriers. There are some benefits to the reforms, but the lack of support and mixed opinions among the majority of stakeholders emphasize the need for reformulation of policy with stakeholder engagement. This study recommends future refugee health reform strategies incorporate stakeholder leadership, cooperation and perspectives, as revealed in this research, to successfully move healthcare policy from theory to practice. / Thesis / Master of Science (MSc)

Background: Public deliberation can be used in a number of decision-making processes to make the health system more responsive to public values, and to help inform and refine health system policy decisions. This study evaluates how the McMaster Health Forum implements the key elements of public deliberation and identifies both areas of strength and potential areas for improvement. Methods: An evaluative case study approach was used. Data were collected from three sources: quantitative and open-ended responses to questionnaires from 19 panels (200 respondents); panel summaries from 13 panels; and transcripts of 2 panel deliberations. Thematic analysis was used to assess four key elements of deliberation: the representativeness of participants, the information supports provided to them, the procedural criteria used, and the focus on explicit reasoning in coming to conclusions. Results: Participants felt that the McMaster Health Forum recruited a representative sample of participants based on gender and diversity of opinion. However, participants noted that the panels could be improved by striving for more age and ethnocultural diversity while also including health professionals or policymakers. Participants mostly occupied the role of a ‘consumer’ of health services. They viewed the information presented in citizen briefs as credible but had questions about the brief-development process. Procedurally, the panels fostered openness without impeding consensus and facilitators fostered mutual respect among participants. Finally, the groups incorporated values, showed an ability to come to a deeper understanding of policy options and harnessed the diverse experiences of their fellow participants as they reasoned. Discussion: This case study is part of a larger evaluation process that assesses all of the McMaster Health Forum citizen panels which aim to elicit citizens’ values and preferences about health system issues in Canada. The framework used to assess the public deliberation process can be used to evaluate other processes in the future. / Thesis / Master of Science (MSc)

Background and aim: Lung cancer is the leading cause of cancer incidence and mortality in Canada. Population-based screening programs using low dose computed tomography are being more widely used. Screening reduces lung cancer mortality. It also introduces potential ethical issues that need to be elucidated to inform the ethical, equitable, and effective implementation of screening programs. This aim of this research was to begin developing an understanding of what the ethical issues are and how they are being, and should be, approached in health policy. Methods: Using empirical ethics inquiry, this research produced descriptive evidence via three independent studies: a systematic literature review and mixed methods integrative synthesis of public perspectives on screening benefits and harms, and two qualitative description studies about public and key informants’ ethical and social values on ethical issues in screening. Results: The major finding of this research was the preponderance of ethical issues located within health and social systems and structures, including equity of screening access, stigma against people who currently smoke commercial tobacco, commercialization of tobacco, and the need for increased investment in primary prevention of lung cancer. These ethical issues reflect the social, economic, and political determinants of lung cancer and the means available to reduce the burden of lung cancer in Canada, including but not limited to screening. In health policy, there was a lack of ethical frameworks or principles currently being used to address these ethical issues and the sometimes-conflicting perspectives found between the public and key informants. Discussion: Future empirical and normative research is needed to understand ethical and social values related to screening by populations with high lung cancer incidence and mortality, and to integrate empirical evidence with appropriate ethical theories to make recommendations for ethical, equitable, and effective population-based LDCT lung cancer screening policy in Canada. / Thesis / Candidate in Philosophy / Lung cancer is the top cause of cancer in Canada. An estimated 30,000 people were diagnosed with lung cancer and 20,700 people died from lung cancer in 2022. Screening is being more widely used to find and treat lung cancer in earlier stages. There are some ethical questions to consider, like how to ensure that screening programs are fair and effective. This research focused on understanding what the ethical issues are and how they could be solved in health policy. Perspectives on ethical issues were collected and analyzed from the public and lung cancer screening leaders. The two major ethical issues were fair access to screening and stigma against people who currently smoke commercial tobacco. There was a lack of ethical guidance to address these issues in health policy. Ethical concepts about justice and individual choice, and ethics research with key communities, may help navigate ethical issues in health policy.

There's frequent discourse regarding the rising cost of insulin in the US. Insulin is a drug that over 7 million people rely on for survival, and it has tripled in cost over the last decade. The pricing regulation of the drug is dependent on multiple stakeholders, including wholesalers, pharmacy benefit managers, and manufacturing companies. Due to the lack of governmental intervention in the process of pharmaceutical cost regulation in the US, data on the price negotiations and the rebate system between these entities is unavailable in public records, making it difficult to determine a primary cause as the root of the issue of insulin costs. This paper attempts to understand the policies in place that impact the nature of insulin affordability and assesses the Canadian regulation of the cost of insulin to understand the discrepancy between the affordability in Canada in comparison to the affordability of insulin in US. A literature review was conducted to examine the policies and congressional discourse in order to analyze the current insulin market and the policies currently in discussion. Ultimately the discrepancy between the nature of health care in Canada and in the US is characterized by the underlying social principles that govern each country in terms of health policy. The Canadian health care system is built on the foundation that health care is a human right, whereas in the United States, health care is a commodity. The effect of this ideology is observed in the costs and regulation of pharmaceutical insulin.

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This dissertation examines the formation of health policy as a cultural process in a large federal bureaucracy in the United States, namely the Department of Veterans Affairs (VA). The everyday experience of bureaucrats working in the VA is used to answer the question: why does the VA fail to meet veterans’ needs in the face of a sacred trust, available political will, and robust resources? To answer the question, this project employs ethnographic methods that draw on participant observation at the headquarters office of the VA in Washington DC, archival research, and interviews with current and former VA employees during the Obama administration. I argue that care of veterans during post-war periods are critical moments of intervention that not only improved the population health of veterans but also impacted the ways in which America conceives and responds to health challenges. I also argue that when the VA operates at its best, it is often the leading edge of health reform, setting new standards for care and effectively establishing alternative models of care. Finally, my findings show that institutional factors play an important role in the process of health policy formation in ways that contribute to new understanding about causal conceptions of health. I conclude with a framework that draws on the lessons the VA affords, for health reform and advancing just health for all. / Anthropology

Information and communication technology (ICT) can enhance communication among health care providers which may lead to various health system improvements, such as gains in efficiency. However, there is inadequate evidence regarding the extent to which ICT improves communication among specific groups of health care professionals. This dissertation incorporates a mix of methodological approaches across three interrelated research studies to address this gap. Study 1 consists of a systematic review which suggested that ICT can play an important role in enhancing health care related communication among physicians, but the extent of that benefit is influenced by: 1) the impact of ICT on existing work practices; 2) the availability of adequate resources for ICT implementation and use; and 3) the nature of institutional elements, such as privacy legislation. Study 2 consists of a document analysis that examined guidelines for health information protection when using ICT from the provincial regulatory colleges for physicians. These documents were notable for the considerable variation in the scope and detail of guidance provided, which may result in unequal and inequitable protection of health information across the provinces. Study 3 is a case study that examined the use of a relatively novel form of ICT, smartphones, for communication among postgraduate medical trainees (medical residents). Efficiency and convenience were identified as the main reasons that medical residents use smartphones to communicate health care related information with colleagues. In addition, by applying a neo-institutional perspective, it became clear that medical residents base their smartphone use primarily on normative elements (professional norms; what peers/staff are doing) and cultural-cognitive elements (beliefs/perceptions regarding facilitation of task completion). Regulative elements (guidelines/policies) around smartphone use play a smaller role in shaping behaviour, particularly when they: 1) lack clarity; 2) are not seen as credible/legitimate; or 3) are viewed as cumbersome and do not align with workflow needs. Taken together, these studies provide timely insights regarding the use of ICT by physicians, which can be drawn upon by a variety of decision-makers as efforts to improve health system performance continue. / Thesis / Doctor of Philosophy (PhD) / The goal of this doctoral dissertation was to develop a better understanding of how and why physicians are using information and communication technology (ICT) to exchange health care related information, along with the role of such communication in enhancing health system performance. Findings indicate that physicians use ICT in various circumstances as they perceive it to be more convenient and efficient. However, guidelines for the exchange of health information in digital/electronic format vary by jurisdiction and organization, which may result in different uses of ICT by physicians. Moreover, as these guidelines often lack clarity or are not seen as credible/legitimate, some physicians base their use of ICT primarily on what peers/colleagues are doing or by acting in a manner that they believe facilitates task completion and, hence, patient care. The insights gained from this work can be adopted by decision-makers to improve communication among physicians using ICT and, consequently, health system performance.

OBJECTIVES: The Government of Canada legalized the recreational use of cannabis on October 17th, 2018. Our objectives were to determine the prevalence of Canadians (aged 15 years or older) intending to try or increase their cannabis use following legalization and explore characteristics associated with the intent to try or increase use. METHODS & DATA ANALYSIS: A secondary data analysis was conducted of cross-sectional data from Waves 1–3 of the National Cannabis Survey collected from February to September 2018. All respondents’ data were weighted and bootstrapped multivariable logistic and multinomial regression models were developed. Relative measures of association were reported as adjusted odds ratios (aORs) and relative risk ratios (RRRs), and absolute measures of association as adjusted risk differences (ARDs). RESULTS: Response rates were 51.2% (Wave 1), 51.3% (Wave 2), and 51.6% (Wave 3). An estimated 18.5% (95%CI: 17.6–19.5) of the study population indicated that they intended to try (12.3%) or increase (6.2%) cannabis use following legalization. Our weighted analysis represented 27,808,081 Canadians 15 years of age or older (unweighted n = 17,089). In our adjusted logistic model, being more likely to try or increase cannabis use was associated with younger age (15–24 years versus ≥65; aOR 3.8, 95%CI: 2.6–5.6; ARD 20.1%, 95%CI: 13.9–26.2), cannabis use in the past three months versus not (aOR 3.3, 95%CI: 2.8–3.9; ARD 20.4%, 95%CI: 17.1–23.6),higher income (≥$80,000 versus <$40,000; aOR 1.5, 95%CI: 1.3–1.9; ARD 6.1%, 95%CI: 3.2–9.0), and poor or fair mental health compared to good or excellent mental health (aOR 2.0, 95%CI: 1.6–2.6; ARD 11.5%, 95%CI: 6.7–16.2). CONCLUSIONS: Nearly 1 in 5 respondents reported their intention to try or increase cannabis use post–legalization. Intentions may not lead to actual changes in behaviour and further surveillance of cannabis use can help determine impact of policy change. / Thesis / Master of Public Health (MPH)