<p><strong>Research objectives</strong>: 1) Develop an online repository of policy-relevant documents addressing healthcare renewal in Canada; and 2) describe the general contents of policy-relevant documents addressing healthcare renewal in Canada. <strong>Methods</strong>: The methods for this study were iteratively developed using an approach similar to a scoping review. Documents were identified through website hand-searches and sixteen Canadian health organizations that contributed to the development of the online repository. The majority of organizations are government health ministries/departments or government-supported health organizations. The focus of the analysis was to calculate general descriptive frequencies of the distribution of documents included in the online repository, specifically: 1) the general characteristics of the documents, such as document type, publication year and jurisdictional focus; 2) document themes by national priority areas; 3) document themes by health system topics; and 4) contributing organizations. <strong>Results</strong>: A total of 304 documents were coded for inclusion in the online repository<br />(<a href="http://eihrportal.org/">http://eihrportal.org</a>). The Health Council of Canada contributed the largest amount of documents (n=60, 19%). The top three types of documents are health and health system data (n=75, 25%), situation analysis (n=72, 24%) and jurisdictional review (n=49, 16%). The top three national priority areas addressed in the documents are health human resources (n=270, 89%), quality as a performance indicator (n=210, 69%) and information technology (n=183, 60%). The least commonly addressed national priority areas are technology assessment (n=19, 6%), prescription drug coverage (n=68, 22%) and Aboriginal health (n=87, 29%). <strong>Conclusion</strong>: The process of developing a systematic method for identifying policy-relevant documents and retrieving useful information from these documents can be reproduced by anyone interested in using this type of evidence to inform their health policymaking. A number of implications exist for policy and research, both in Canada and in low- and middle-income countries, which have to be considered in relation to the unique nature of this type of evidence.</p> / Master of Science (MSc)

<p>The purpose of this dissertation is to discuss and evaluate processes and institutional structures that influence relationships between Aboriginal communities and government in the development, implementation, and evaluation of health policy. It explores the changing nature of Aboriginal health policy and politics in Canada and examines the shift to self-determination that has transpired in Canada’s Aboriginal health policies focusing on their application to Aboriginal peoples. This dissertation examines two Aboriginal health policies in Canada: the federal health transfer policy and Ontario’s Aboriginal Healing and Wellness Strategy. Both policies are intended to improve health at the community level by supporting the development of community-based and culturally appropriate health programs. Thus, using community-based research methods, this dissertation maps some of the key political stakeholders in Aboriginal health policy, from local level community members and health representatives to peak provincial and federal Aboriginal organizations, to the offices of ministers in Canadian parliament. I reflect upon the processes and institutional structures that shape relationships between the Aboriginal community-controlled health sector and government.</p> <p>I examine several First Nations communities in northern Ontario involving both federal and provincially supported initiatives to illustrate the strengths, weaknesses and paradoxes that surface from the implementation of locally controlled health programs. I contrast these efforts with a second First Nations community in Manitoba that operates solely under the federal health transfer policy. I juxtapose these two communities to assess whether additional layers of community-controlled initiatives make tangible differences to community wellness; particularly for Aboriginal peoples living off reserve. This dissertation is being written under the theoretical assumption that governance and community wellness are intrinsically linked. Arguably, there is a definitive correlation between self-determination and community well-being; self-determination may be a determining factor in improving conditions for Aboriginal peoples and understanding resiliency.</p> <p>This dissertation is about a long lasting colonial legacy of social inequalities in Aboriginal health but also about the incredible successes in Aboriginal health. It is also about the many challenges of Aboriginal representation and self-determination in the context of contemporary Canadian society.</p> / Doctor of Philosophy (PhD)

<p>Obesity is a major public health issue across all age groups. The obesity-related health outcomes of children and adolescents are unique and varied, and therefore need to be studied separately. In response, obesogenic environments have been the focus of attention in recent research. Important contributions have been made to focus on social (e.g., economic) and physical (e.g., geographical) environments based on their role in either hindering or facilitating opportunities for healthy eating. However, research on the policy environment is noticeably absent. Schools have been the setting for focused interventions, particularly in the area of obesity and nutrition. However, there is a paucity of research in this area in Ontario, and virtually no Canadian research has examined the secondary school setting. Therefore, this research focuses on local level factors shaping school nutrition policy implementation in Ontario, Canada.</p> <p>The Analysis Grid for Environments Linked to Obesity (ANGELO) Framework was adopted to organize and conceptualize the local level policy environment. In the first phase of the study, a documentary analysis was undertaken to investigate the relationship between regional and upper level policies and technical reports. Results reveal distinct differences across federal, provincial and regional levels, including: 1) the availability of nutritious food in schools and having nutrition education as part of the curriculum were key components of the physical environment across federal and provincial levels; 2) federal and provincial priorities are guided by a health promotion framework, and a partnership approach to policy implementation; and, 3) gaps in regional level policy include incorporating nutrition education in the curriculum, and making the link between nutrition and obesity.</p> <p>The second phase of study includes qualitative key informant interviews with community-and school-level school nutrition policy and program stakeholders (n=22) in nine schools three Ontario school boards, in order to understand local level factors shaping school nutrition policy implementation. The cost of healthy food for sale, revenue loss (economic), proximity of schools to off site food outlets (physical), the restrictive nature of policy, and the role of key stakeholders (political), the role of stigma and school culture (sociocultural), act as local level barriers to policy implementation. Findings suggest the need for consultation and communication between stakeholders, and strategies to reduce stigma and improve the school nutrition culture.</p> <p>In the third and final phase of study three focus group interviews were conducted with secondary students (n=20) in two Ontario school boards in fall 2012. School boards were selected to represent both high-and low-income neighbourhoods. Results reveal high priced policy-compliant food for sale, lower revenue generation capacity, and more students purchasing food off-campus at nearby outlets. Limited designated eating spaces, and time constraints act as local level barriers to healthy eating. Student input on cafeteria menus and school community gardens, can facilitate healthy school nutrition environments. Community partnerships with key external stakeholders are needed to leverage financial and human resources to support school nutrition. Future policies need to consider the social context and conditions surrounding school nutrition. This research makes a number of theoretical, methodological and substantive contributions to the public health, adolescent health, and school health policy literature. Policy implications and future research directions are provided.</p> / Doctor of Philosophy (PhD)

Resource withdrawal from unnecessary medical services is an important issue as the cost of health care continues to rise. In many countries, resource withdrawal is primarily determined by government policies that remove, restrict, reduce, or limit the availability of publically insured medical services. Ideally, resource withdrawal is the result of a careful assessment of clinical and economic evidence regarding a service’s safety and effectiveness in order to ensure that it is the most efficient use of resources. Despite advocacy for a routinized and systematic approach to the withdrawal of resources from medical services, research has indicated that political and social factors often influence government, resulting in decisions that are neither consistent nor transparent. In this dissertation I seek to understand factors that may influence resource withdrawal decisions in an attempt to promote a more routinized and systematic approach. In order to understand the resource withdrawal landscape and provide greater conceptual clarity, the first study in this dissertation identifies and explores its characteristics (antecedents, attributes, and outcomes). Definitions of two prominent terms, disinvestment, and rationing are proposed. In the second study, a qualitative analysis of two examples of resource withdrawal reveals how the characteristics of problem frames affect the shape and timing of government resource withdrawal policies. Findings support the proposition that the complexity of the story told within the problem frame affects the shape of the policy; while visibility affects the timing. In the third study, I analyzed the perspectives of key informants about the Choosing Wisely Canada (CWC) campaign, which has the aim of reducing unnecessary services by encouraging a discussion between physician and patient. Findings reveal that CWC was designed to address pressures from government, patients, and the public. However, CWC was not designed in a way that is expected to address the underlying reasons unnecessary services are provided, including limited time in the clinical encounter, patient demands, uncertainty in the care pathway, and physician fear of litigation. Results from all three studies help establish a common language, identify influences on government led resource withdrawal and reasons why CWC is unlikely to reduce unnecessary services. Together this thesis provides insights into some of the factors affecting resource withdrawal from medical services, and findings may be used to help assess ways to improve the formulation of resource withdrawal policies. / Dissertation / Doctor of Philosophy (PhD) / Currently several governments pay for unnecessary medical services, leading to suboptimal patient health outcomes and a waste of public resources. Several researchers and organizations have proposed methods to identify and assess medical services to determine if they are unnecessary; however, governments have been slow to adopt such methods on a routine basis. It is clear that evidence is rarely sufficient to motivate governments to withdraw resources from unnecessary medical services. Instead, governments are often influenced by social and political factors when they make such decisions. Through a better understanding of these factors, we may be able to find ways to incorporate evidence into governments’ decisions to withdraw resources from medical services. Qualitative methods were used to investigate how resource withdrawal is defined, factors influencing government resource withdrawal decisions in Ontario, and the effectiveness of Choosing Wisely Canada, an initiative led by the medical community to reduce unnecessary services.

Health technology assessment (HTA) frameworks appraise the value of technologies – be they drugs, devices, procedures or services – to inform policy decision-making and resource allocation amongst alternatives within publicly funded health systems. The prevailing principles and metrics by which HTA is conducted were designed with adult health conditions and treatments in mind. The evidentiary and normative dimensions of HTA frameworks may have unique repercussions for drug policy and coverage decisions in children, but their relevance to child health has received almost no critical scrutiny in either academic or policy circles. Approaches to paediatric drug coverage approval and access currently lack child-specific data on social values and priorities, a core component of HTA in most countries with public drug funding programs, including Canada. This thesis presents a mixed methods study of social values relevant to child HTA and drug policymaking in publicly funded health systems, comprised of three original scientific contributions. The first of these is a critical interpretive synthesis (CIS) of the academic literature on the moral dimensions of child health and social policymaking across a range of disciplines and policy domains. The second is a grounded theory analysis of qualitative interviews with diverse health system stakeholders on the social values and health system factors relevant to child HTA and drug funding policy in Canada. The third is a stated preference survey of the general public that assesses societal preferences for health resource allocation to children as compared to adults, to generate evidence for priority setting on health technologies within Canada’s publicly funded health system. Together, these studies yield specific knowledge about the policy landscape for child health technologies in Canada, broad conceptual insights into the normative and methodological dimensions of child HTA, and a foundational understanding of the social values relevant to drug policy decisions for children. / Thesis / Doctor of Philosophy (PhD) / Drug research, development and policy have historically excluded children. One area of persistent neglect is public policy on funding for paediatric medicines. In most publicly funded health systems, including Canada’s, decisions about which drugs to cover are made through a formal process called health technology assessment (HTA). This dissertation examines the role and challenges of HTA as applied to child health technologies, with a focus on the social values that inform drug policy for children. It addresses existing gaps in knowledge through the integration of insights from: 1) a comprehensive review of the academic literature on the moral dimensions of child health and social policymaking; 2) in-depth qualitative analysis of the HTA and drug policy environments for children in Canada, employing Ontario as a case study; and 3) a survey of the Canadian public on health system resource allocation for children. Together, these studies generate a detailed picture of the Canadian policy landscape for child health technologies, insights into the fit of current HTA approaches to the realities of child health and illness, and a foundational understanding of the social values relevant to drug policy decisions for children.

The term telemedicine is broadly defined as the use of information and communication technology to deliver health care at a distance. However, the concept of ‘telemedicine’ still lacks consensus both in the literature and in practice. Generation of telemedicine knowledge and evidence for clinical practice is still controversial within the telemedicine scholarship and among decision-makers as telemedicine objectives remain ill-defined and outcomes vary in time. In Ontario, despite the fast pace of information and communication technology change and the increased interest in its health applications, telemedicine is not a mainstream model of care delivery within the medical system. This study empirically investigates the social construction of telemedicine technologies to understand how telemedicine expectations shaped telemedicine in Ontario (Canada) from 1993 to 2017. Drawing from the Social Construction of Technologies framework (SCOT) and historical narrative analytical techniques, it identifies the shared understandings of what telemedicine is (and is not) and what role telemedicine plays in the health care system. I used grounded theory methodology to develop a narrative theory of how the future of telemedicine in Ontario has been constructed over the last 24 years from national newspaper articles, stakeholder documents, service provider websites, and semi-structured interviews with relevant telemedicine stakeholders. Findings show that the development of telemedicine narratives in Ontario is a multi-storied process of conflicting and overlapping visions and expectations among stakeholders and interests. Telemedicine expectations focus mostly on the process of innovation, the provideroriented approach to telemedicine, and the advantages and risks of adopting consumercontrolled telemedicine in a publicly insured health care system. The telemedicine visions result fragmented among different stakeholders and practices, overall inhibiting telemedicine’s future agenda. These findings intend to help researchers, policy makers, private vendors, and health care providers to create a vision of telemedicine that accommodates competing expectations among the clinical, technical, political, and commercial worlds. / Thesis / Doctor of Science (PhD) / Telemedicine delivers health care at a distance by letting doctors talk to patients or other doctors via video, email, or text messages. However, as simple as this idea is, researchers, physicians, policy-makers, and entrepreneurs have speculative, overlapping, and conflicting views about what it should be. These differing views create ambiguity and often confuse the aims of health policy decision-makers and end-users limiting telemedicine’s development. I intend to clarify telemedicine’s shared and diverging understandings of what telemedicine should be by analyzing how stakeholders in Ontario have told and tell stories about telemedicine’s future over the last three decades. I view stories of the technology’s future as persuasive policy arguments that stakeholders adopt to shape and use telemedicine according to their visions and goals. These findings will help researchers, policy-makers, doctors, and businesspeople understand what telemedicine is (and is not) to help them define policies and guidelines for its adoption and implementation.

The successful elimination of vaccine-preventable diseases is contingent on high-vaccine coverage rates in targeted populations. The proliferation of vaccine misinformation on social media has led to vaccine hesitancy in the past two decades. A highly contextual phenomenon, areas with an increased prevalence of vaccine hesitancy and vaccine exemption have been shown to correlate with decreased immunization coverage and intermittent vaccine-preventable disease outbreaks worldwide. Although the Canadian government has recommended the use of social media to increase public confidence in vaccines, little documentation exists regarding the perceptions of advisors and decision-makers in policy and communications for immunization towards vaccine hesitancy on social media, and the use of social media to increase public confidence in vaccines in the context of Ontario, Canada’s largest province. This thesis employed 3 unique mixed-methods studies to explore the role of social media in addressing the problem of vaccine hesitancy facilitated through misinformation about childhood vaccines in Ontario. The first study is a social network analysis that incorporates sentiment analysis to demonstrate that pro-vaccine and anti-vaccine communities operate in siloes with little interaction with one another. Those interactions that do occur are most commonly facilitated by sentiment and geographic location, rather than profession or affiliation of the social media user. The second study is a mixed methods content analysis illustrating significant differences in user attributes (emotion, medium shared in tweets, direction of information-sharing, and use of Twitter functions) among pro-, neutral, and anti-vaccine Twitter users, suggesting different motivations underlying Twitter use. Qualitative inquiry of links and reasons for negative vaccine sentiment illustrate the proliferation of pseudo-experts occupying social media, as well as concerns about vaccine safety and mistrust towards the government. The third study complements the first two studies, and uses documents and in-depth interviews with 23 advisers and decisionmakers in policy and communications to illustrate that although vaccine hesitancy is of concern, the use of social media to increase public confidence in vaccines is met with resistance due to a myriad of barriers at all levels of immunization policy and program delivery in the Province of Ontario. Implications for policy and practice of this study include the recognition that a multi-pronged approach is needed to increase the public’s confidence in vaccines. Elements of this multi-pronged approach could include: i) commitments to investing in understanding social media’s use in informing immunization at all levels of governance and decision-making; ii) the active surveillance of public sentiment and the public’s concerns about vaccines on social media using network analysis and content analysis; and iii) the fostering of interdisciplinary collaboration to design interventions that facilitate connectivity between siloes. The implications for future research include the need for continued commitment to the design, implementation, and evaluation of public health interventions on social media in the Ontario context. This study points to the need to pay attention to the behavioral attributes and affordances of social media in order to develop policies, communicative strategies, and programmatic designs that comprehensively address public concerns towards vaccines and, in turn, promote increased confidence in them. / Thesis / Doctor of Philosophy (PhD) / Immunization efforts are integral to maintaining herd immunity. Over the past two decades, it has been observed that vaccine hesitancy brought forth by vaccine misinformation has led to reduced confidence in vaccines, contributing to declining vaccination rates that have subsequently led to outbreaks of vaccine-preventable diseases. Vaccine misinformation on social media has played a crucial role in exacerbating vaccine hesitancy. Limited research has explored the use of social media in the Canadian context in relation to how vaccine information is communicated, what is being discussed and with whom. The extent to which decision-makers working in the immunization policy arena in Canada consider the role of social media as a tool for addressing vaccine hesitancy in order to increase vaccine uptake is also unclear. Using a mixed methods approach, this study, carried out in Ontario, Canada, illustrates that communities supporting and opposing vaccines operate in silos that do not necessarily communicate with each other through social media. Although decision-makers acknowledge the role of social media in the salience of vaccine hesitancy, they consider social media to be a less feasible method to increase vaccine confidence. By exploring the networks and conversations about vaccination on social media, and by understanding decision-makers’ perceptions towards vaccine hesitancy and social media, this study identified gaps between the recommendations for addressing vaccine hesitancy, provincial decision-makers’ preference for addressing immunization, and concerns of the vaccine hesitant on social media. These findings can inform the design of public health messaging to increase the public’s confidence in vaccines in Ontario.

This dissertation includes four papers— two conceptual and two empirical— on universal health coverage introduced in global health as a policy concept to improve access to health care. The conceptual papers review the selection process for the Sustainable Development Goal indicator on universal health coverage and propose parameters to guide an evaluation framework for universal health coverage. The first two papers show that including participants from as many sections of the health sector and policy community is recommended in policy formulation and evaluation, and recognize that decision-making might be slower as a result. While the first two papers focus on the third Sustainable Development Goal to achieve universal health coverage, the following two empirical papers focus on the sixth Millennium Development Goal which committed to provide universal access to treatment and care for people living with HIV. The first empirical paper shows how physicians in six Eastern Caribbean countries (Antigua and Barbuda, Dominica, Grenada, St. Kitts and Nevis, St. Lucia and St. Vincent and the Grenadines) cope with the lack of resources for treatment and care. Access was implemented broadly emphasizing the availability of HIV treatment and care while ensuring that everyone who needed antiretrovirals did not incur out-of-pocket costs. In most cases, this meant receiving care in the public system which was mostly centralized and where people living with HIV had concerns about their privacy being compromised in societies where HIV stigma was prevalent. The second empirical paper shows that in St. Lucia, third-line antiretrovirals could be unaffordable to as much as 98 % of the population, depending on how affordability is measured. The papers collectively demonstrate how the Millennium Development Goals provided an opportunity for policy learning by comparing the implementation of universal access for HIV treatment and care with universal health coverage in the Sustainable Development Goals. / Thesis / Doctor of Philosophy (PhD) / The dissertation recognizes the challenges with defining and measuring universal health coverage and with providing access to treatment and care for human immunodeficiency virus (HIV) in the Eastern Caribbean. The first conceptual paper documents the process of selecting indicators for universal health coverage in the Sustainable Development Goals. The second conceptual paper advances recommendations for evaluating universal health coverage. The following two studies then empirically assess the challenges with access to health care for people living with HIV in the Eastern Caribbean. The third paper shows how physicians cope with the lack of appropriate resources and highlights the issue of privacy for patients. The fourth paper uses data from St. Lucia to assess the affordability of antiretrovirals and highlights the difficulties of measuring financial affordability.

Vårdprevention är ett viktigt koncept inom vården som visar hur synen på arbetssätt borde förändras för att klara vårdens framtida utmaningar med tanke på det åldrande samhället. Senior alert, som är ett av de största kvalitetsregistren i Sverige, jobbar ständigt med att stödja vårdprevention genom att erbjuda olika typer av tjänster till deras användare i form av digitala utbildningar, webbinarier, rapporter, coaching och support.    Syftet med undersökningen är att ta reda på hur nöjda användarna är med kvalitetsregistret Senior alerts tjänster och hur deras tjänster upplevs ute i verksamheterna. För att ta reda på detta genomförde vi en kvantitativ undersökning i form av en webbenkät som innehöll frågor om nöjdhet samt fritextfrågor där förslag för förbättring och synpunkter kunde fyllas i.    Resultatet av undersökningen visar att Senior alerts användare är nöjda eller mycket nöjda med registrets tjänster. Angående Senior alerts utbildningsutbud tycker användarna att utbildningarna gav dem en fördjupad förståelse om vårdprevention, där e-lärande användes i verksamheter för att utbilda personalen inom området. Dessutom hjälpte rapporterna användarna att upptäcka risker och planera sina förbättringsarbeten. I undersökningen framkom det att en stor del av användarna inte vet om de individuella coachingtillfällen som erbjuds av Senior alert. Önskemål om förändringar var bland annat att koppla Senior alert till journalsystemet, att förenkla systemet och skapa möjligheter för samarbete mellan användarna, att införa specifika tekniska förändringar i registret och att utöka supportens telefonöppettider. / Preventative care is an important concept in healthcare that shows how the way of working should change to meet the future challenges of healthcare in an ageing society. Senior alert, which is one of the largest quality registries in Sweden, is constantly working to support preventative care by offering different types of services to their users in the form of digital training, webinars, reports, coaching and support.    The purpose of the survey is to find out how satisfied users are with the services of the Senior alert’s quality registry and how their services are perceived in units. To find out that, we conducted a quantitative survey in the form of an online survey containing questions about satisfaction and free text questions where suggestions for improvement and comments could be filled in.    The results of the survey show that Senior alert's users are satisfied or very satisfied with the services of the registry. Regarding the Senior alert's online training program, users think that the training gave them a deeper understanding of preventative care, when e-learning was used in units to employee training. In addition, the reports helped users to identify risks and plan improvements. The survey revealed that a large part of users is unaware of the individual coaching opportunities offered by Senior alert. Desired changes included linking Senior Alert to medical record systems, simplifying the system and creating opportunities for collaboration between users, introducing specific technical changes to the registry and expanding support phone hours. / <p>Examen i vårdadministration, YH-utbildning: 20 Yh-poäng</p>

<p>Examen i Vårdadministration, YH-utbildning: 20 yh-poäng</p>