Assent, currently defined as “a child’s affirmative agreement”, is a way in which some children are included in the decision-making process regarding their participation in clinical research. Current guidelines for paediatric research do not provide clear directions for how assent should be handled, resulting in confusion among researchers. The goal of this research project was two-fold: to examine the ethical arguments for assent with a view to developing concrete moral justification for its being required, and to develop a framework of significant issues for an investigator to consider when deciding whether to gain assent from an individual child. After an in-depth analysis, it was determined that the ethical justification for assent arises from the researcher’s dual obligations to the child and his parents. A child’s parents are responsible for determining when and how he will develop his decision-making ability. The researcher has an obligation to engage with the child in a manner that complements their pedagogical style, while also treating the child as a being of moral worth. As a child’s family context has an influence on his participation in medical decision-making, further research on children’s daily decision-making within their families is needed. To this end, a three-phase research agenda was designed: a qualitative focus group study, a quantitative questionnaire study, and a discussion panel with paediatric experts. The children in these studies clearly desired to make decisions but did not express an interest in having complete control. They expected their parents to provide them with decision-making guidance in most aspects of their lives. Data collected from parents illustrated that they often tried to involve their children in decisions by providing them with limited options from which to choose and encouraging family discussion. Participants in the discussion panel stated that they did not expect children to make an independent decision regarding medical care, but they might attempt to give children smaller decisions, such as the arm used to provide a blood sample. These results indicate that the definition of assent should be revised, emphasising the child’s involvement in the overall decision making process, without an expectation of an “affirmative agreement”, likely mimicking a familiar decision-making setting from his family context. This could then be documented in the child’s clinical notes through a brief description of all relevant interactions and/or discussions with the child, resulting in an accurate portrayal of the entire assent process.

Aims: The aims of this thesis were to investigate the risk of severe maternal morbidity amongst women from different socioeconomic groups in the UK, explore why these differences exist and compare these findings to the setting in Australia. Methods: Three separate analyses were conducted. The first used UK Obstetric Surveillance System (UKOSS) data to assess the incidence and independent odds of severe maternal morbidity by socioeconomic group in the UK. The second analysis used quantitative and qualitative data from the 2010 UK National Maternity Survey (NMS) to explore the possible reasons for the difference in odds of morbidity between socioeconomic groups in the UK. The third analysis used data from the Victorian Perinatal Data Collection (VPDC) unit in Austra lia to assess the incidence and odds of severe maternal morbidity by socioeconomic group in Victoria. Results: The UKOSS analysis showed that compared with women from the highest socioeconomic group, women in the lowest 'unemployed' group had 1.22 (95%CI: 0.92 - 1.61) times greater odds associated with severe maternal morbidity. The NMS analysis demonstrated that independent of ethnicity, age and parity, women from the lowest socioeconomic quintiJe were 60% less likely to have had any antenatal care (aOR 0.40; 95%CI 0.18 - 0.87), 40% less likely to have been seen by a health professional prior to 12 weeks gestation (aOR 0.62; 95%CI 0.45 - 0.85) and 45% less likely to have had a postnatal check with their doctor (aOR 0.55; 95%CI 0.42 - 0.70) compared to women from the highest quintile. The Victorian analysis showed that women from the lowest socioeconomic group were 21% (aOR 1.21 ; 95% CI 1.00 - 1.47) more likely and that Aboriginal and Torres Strait Islander women were twice (aOR 2.02; 95%CI 1.32 - 3.09) as likely to experience severe morbidity. Discussion: The resu lts suggest that women from the lowest socioeconomic group in the UK and in Victoria have increased odds of severe maternal morbidity. Further research is needed into why these differences exist and efforts must be made to ensure that these women are appropriately prioritised in the future planning of maternity services provisio n in the UK and Australia.

Thesis (DPhil (Philosophy))--University of Stellenbosch, 2010. / ENGLISH ABSTRACT: This dissertation has two quite separate and rather different starting points. The first centres on the significant renaissance of virtue ethics as a moral theory that has occurred in the last 50 years. The second starting point is embedded in the recent discourse about the need for an ethical framework for public-health policymaking. (Up until now the ethical theories of deontology, manifested as either a ‘principlebased’ or ‘human-rights’ approach, and utilitarianism, have provided the theoretical background to this discourse.) When these two starting points fuse, the question arising – can character or virtue ethics contribute positively to the moral debates surrounding many vexing public-health issues? – seeks an answer. Broadly speaking, the ethics of public-health policymaking deals with ethical issues that occur within the macro-environment and that arise out of relationships between entities other than individuals, for example, states, regions, institutions, etcetera, and the policies in terms of which these interactions are regulated. Public health ethics ‘seeks to find a balance between the notions of ‘common good’ or ‘public interest’ and individual autonomy. I plan to investigate whether a virtue-based ethics, -which is concerned with a notion of human flourishing that is not primarily atomistic but intricately linked to the mutual well being of others and to notions of what the ‘good life for man’ means within the context of a shared history and connectedness with fellow human beings,- could contribute positively to current ‘public health ethics’ discourse. I believe that an exploration of the ethical basis of public health decision-making, focusing particularly on virtue ethics, but also examining other approaches like utilitarianism, principlebased approaches and the human-rights approach, will make a positive and original contribution to this area of philosophical discourse. Chapter one is an introduction which provides the rationale and motivation for the dissertation and briefly introduces the layout of each subsequent chapter. Chapter two is a concept analysis of ‘public health’ and justifies why I argue that the concept of public health is contingent, and ought to be contingent on an inextricably linked, and context appropriate concept of social justice. In this chapter I clarify the scope of the concept of public health used for this dissertation. Chapter three is an in-depth literature review of virtue ethics and similarly the next chapter is a literature review of the current status of public health ethics. Chapter five is entitled “Virtue Ethics, Social Justice and Public health”. My overall aim in this dissertation is to consider if virtue ethics as a moral theory can contribute positively to the practice of public health and thus by inference to an underlying concept of social justice. This receives in-depth consideration in this chapter. In chapter six I explore virtue theory in relation to public health from various other perspectives. In particular I return to MacIntyre to consider his concept of a ‘practice’1 which I apply specifically to the domain of public health, exploring the concepts of “extrinsic goods” and “intrinsic goods”, and how they translate to the practice of public health. Chapter VII is entitled “Theory and Practice: Critical Perspectives”. In this chapter I explore the challenges of adapting philosophical theory to actual context. I focus particularly on the problems of public health policy within a Southern African context. I conclude this dissertation by conceding that while virtue ethics can indeed make a positive contribution in some respects, its applicability is largely limited to public health problems that pertain to specific localised contexts. It has very limited applicability as an ethical theory or framework for trans-global public health issues, and public health issues influenced by global politics and economics. / AFRIKAANSE OPSOMMING: Hierdie verhandeling het twee heeltemal afsonderlike en taamlik uiteenlopende uitgangspunte. Die eerste handel oor die beduidende oplewing in deugde-etiek as 'n morele teorie oor die afgelope 50 jaar. Die tweede uitgangspunt is veranker in die onlangse diskoers oor die behoefte aan 'n etiese raamwerk vir die bepaling van openbaregesondheidsbeleid. (Tot dusver het die etiese teoriee van deontologie, hetsy in die vorm van . 'beginselgegronde' of 'menseregte'-benadering, en utilitarisme as teoretiese grondslag vir hierdie diskoers gedien.) Wanneer hierdie twee uitgangspunte egter byeenkom, ontstaan die vraag: Kan karakter- of deugdeetiek 'n positiewe bydrae tot die morele debatte oor talle netelige openbaregesondheidskwessies lewer? Oor die algemeen handel etiek in die bepaling van openbaregesondheidsbeleid oor etiese kwessies in die makro-omgewing wat ontstaan vanuit die wisselwerking tussen entiteite anders as individue, soos state, streke en instellings, en die beleid wat hierdie wisselwerking reguleer. Openbaregesondheidsetiek is daarop uit om 'n balans te vind tussen die konsepte 'algemene welsyn' of 'openbare belang', en individuele outonomie. Hierdie ondersoek beoog om vas te stel of 'n deugdegegronde etiek 'n wat gemoeid is met 'n konsep van menslike welstand wat nie grootliks atomisties is nie, maar ten nouste verband hou met die onderlinge welstand van ander, en 'n begrip van 'die goeie lewe' in die konteks van 'n gedeelde geskiedenis en verbondenheid met ander mense 'n positief tot die huidige diskoers oor 'openbaregesondheidsetiek' kan bydra. Die navorser argumenteer dat 'n ondersoek van die etiese grondslag van besluitneming oor openbare gesondheid, met 'n bepaalde klem op deugde-etiek, dog ook 'n nuwe bydrae tot ander benaderings soos 'n utilitaristiese benadering, beginselgegronde benaderings en die menseregtebenadering, 'n positiewe en oorspronklike bydrae tot hierdie filosofiese diskoers (kan) lewer. Hoofstuk 1 bied 'n inleiding wat die beweegrede en motivering vir die verhandeling uiteensit, en verduidelik kortliks die uitleg van elke daaropvolgende hoofstuk. Hoofstuk 2 is 'n konseptuele ontleding van 'openbare gesondheid', en ondersteun die navorser se betoog dat die konsep van openbare gesondheid afhanklik is en afhanklik behoort te wees van . kontekstoepaslike begrip van sosiale geregtigheid wat onlosmaaklik daarmee verbind is. In hierdie hoofstuk word die betekenis en omvang van die begrip 'openbare gesondheid' soos dit in hierdie verhandeling gebruik word, ook verduidelik. Hoofstuk 3 bevat 'n omvattende literatuuroorsig van deugde-etiek, terwyl die daaropvolgende hoofstuk eweneens 'n literatuuroorsig van die huidige stand van openbaregesondheidsetiek behels. Hoofstuk 5 is getiteld 'Deugde-etiek, sosiale geregtigheid en openbare gesondheid'. Die oorkoepelende doelwit van hierdie verhandeling is om daaroor te besin of deugde-etiek as 'n morele teorie positief tot die praktyk van openbare gesondheid, en dus ook tot 'n onderliggende konsep van maatskaplike geregtigheid, kan bydra. Dit word omvattend in hierdie hoofstuk bespreek. In hoofstuk 6 ondersoek die navorser deugde-teorie met betrekking tot openbare gesondheid uit verskeie ander oogpunte. Die studie konsentreer in besonder op MacIntyre se konsep van . 'praktyk',2 wat bepaald op die gebied van openbare gesondheid toegepas word om so die begrippe 'ekstrinsieke goedere' en 'intrinsieke goedere', en hoe dit in die praktyk van openbare gesondheid omgesit word, te bestudeer. Hoofstuk 7, getiteld 'Teorie en praktyk: Kritiese perspektiewe', bevat . ondersoek van die uitdagings om filosofiese teorie by die werklike konteks aan te pas. Die navorser konsentreer veral op die probleme van openbaregesondheidsbeleid in Suider-Afrikaanse verband. Die verhandeling sluit af deur toe te gee dat, hoewel deugde-etiek inderdaad in sommige opsigte 'n positiewe bydrae kan lewer, die toepaslikheid daarvan grootliks tot openbaregesondheidsprobleme in bepaalde gelokaliseerde kontekste beperk is. Dit het 'n uiters beperkte nut as 'n etiek-teorie of raamwerk vir globale openbaregesondheidskwessies, en openbaregesondheidskwessies wat deur die wereldpolitiek en -ekonomie geraak word.

Within the field of public health, there has been increasing interest in the factors that influence national priorities in health in low- and middle-income countries (LMICs), where resources are often particularly scarce and decision-making processes are often ad- hoc. Understanding how priorities are set in these countries necessitates a look at the process concealed in the black box that transforms policy inputs into outputs. However, rigorous health policy analysis of macro-level priority setting in LMICs is rare. Using a case study approach, this thesis explores the drivers of priority for primary health care, sanitation and HIV/AIDS over the past five decades in Barbados. To do this I use process tracing techniques, drawing on analysis of public expenditure on health from 1960 to 2010, in-depth interviews with key policy actors, non-participant observation, archives, media reports, parliamentary records and other documents. I argue that powerful individual policy actors or 'policy entrepreneurs' act as necessary drivers of macro-level priority setting in Barbados, although they do not single- handedly determine the outcomes. In particular, I find that these actors are successful in generating priority when they are able to propagate powerful framing ideas and can effectively navigate the policy context by seizing windows of opportunity and managing negative constraints. Moreover, because resources are scarce, their ability to mobilize external financial support is also important. In particular, this thesis stresses the fact that allocating public resources for health is a political process and suggests that it is best explained by considering a set of interrelated factors. In doing so, it illustrates the utility of health policy analysis in helping to open the black box of macro-level priority setting in LMICs more broadly.

Bakgrund: Risken att insjukna i depression vid något tillfälle i Sverige, ligger på cirka 23 procent för män och cirka 31 procent för kvinnor. Efter första episoden av depression, ligger risken för att återinsjukna på cirka 50 procent. När en förälder har drabbats av depression, kan det påverka övriga familjemedlemmar, då det oftast är någon av föräldrarna som har det största ansvaret inom familjen och för ekonomin.Syfte: Syftet var att beskriva barns upplevelser av att leva med en förälder som har depression.Metod: En systematisk litteraturstudie med induktiv ansats har använts. Både kvalitativa och kvantitativa artiklar inkluderades och kvalitativ innehållsanalys beskriven av Lundman & Hällgren Graneheim användes vid analysen.Resultat: Analysen resulterade i fyra kategorier: Behov av copingstrategier, Olika insikter, En förändrad tillvaro och Behov av hjälp. Barn som distanserade sig från sin förälder, upplevde det som ett sätt att skydda sig själva. En del barn hade dålig insikt om förälderns depression, de berättade att de inte märkte att något annorlunda eller fel. Barn anpassade sig efter situationen och utvärderade effekten av sin anpassning, de justerade sina handlingar efter det. Familjen samtalade sällan om förälderns depression och barnen fick inte någon information.Slutsats: Barn distanserade sig i både positiv och negativ bemärkelse. Vissa barn hade insikt i förälderns depression och anpassade sig utefter den, medan andra förnekade dess existens eller inte förstod sjukdomen. Barnen fick ett ökat ansvar i hemmet vilket resulterade i ett försämrat mående. En positiv aspekt var att vissa barn hävdade att de hade blivit starkare som person och fått mer empati för andra människor. Den allmänna sjukvården hade otillräcklig kunskap och resurser vid bemötande av barn som anhörig, vilket kan åtgärdas med mer utbildning och vidare forskning av problemområdet.

Young women are particularly vulnerable to HIV. Despite the successful HIV prevention efforts in Thailand in the past, young Thai women are at increased HIV risk and in urgent need of effective HIV interventions. Numerous studies have emphasised the importance of family in determining young people’s sexual behaviour. This thesis explores the roles of family in shaping young people’s sexual decisions and examines the potential of family-involved HIV interventions (FIHIs) for young Thai women. The thesis systematically examines studies across settings to determine whether involving family in HIV interventions could influence young people’s sexual behaviour. The findings suggest that FIHIs have a potential in shaping young people’s condom use practices. It identifies several key characteristics of effective FIHIs that can potentially be valuable for future HIV development in other contexts. Qualitative data collected from focus groups of young Thai women in Bangkok are analysed using the framework developed from the systematic review of qualitative studies. The findings highlight several challenges for future FIHIs for young Thai women. These are barriers to parent-child communication, a tension of coexistence of two divergent sexual norms - traditional/Thai versus modern/globalised, alternative sources of sexual health and HIV knowledge, the importance of family relationships, and the different circumstances and needs of young Thai women from different backgrounds. Future FIHIs for young Thai women should consider a comprehensive, structural and eco-developmental approach, simultaneously targeting both individuals and the wider environment. This thesis offers a new contribution to the HIV prevention and sexual health education literature and identifies the potential effectiveness of FIHIs tailored to young Thai women,constituting an important step in addressing the public health problems of HIV/AIDS infections in Thailand.

This thesis explores the use of observational microdata in cost-effectiveness analysis. The application of econometric methods adjusting for selection bias is first reviewed and critically appraised in the economic evaluation literature using a structured template. Limitations of identified studies include lack of good quality evidence regarding the performance of different analytical approaches; inadequate assessment of the sensitivity of their results to violations of fundamental assumptions or variations to crucial estimator parameters; failure to combine the cost and effectiveness outcomes in a summary measure; and no consideration of stochastic uncertainty for the purpose of evaluating cost-effectiveness. Data from the Birthplace national cohort study are used in an attempt to address these limitations in the context of an empirical comparison of estimators relying on regression, matching, as well as the propensity score. It is argued that although these methods cannot address the potential impact of unobservable confounding, a novel approach to bias-corrected matching, combining entropy balancing with seemingly unrelated regression, still has the potential to offer important advantages in terms of analytical robustness. The net economic benefit is proposed as a straightforward way to exploit the strengths of rigorous econometric methodology in the development of reliable and informative cost-effectiveness analyses.

This thesis explores the implications of democratisation on the regulation of health care providers. It examines the reforms in relation to two regulatory policies in the pharmaceutical market of the National Health Insurance (NHI) in South Korea – the separation of prescribing and dispensing (SPD) and the pharmaceutical pricing policy – conducted in two periods – the 1980s under the authoritarian regime and the 1990s under the democratised regime. The misuse and overuse of drugs had long been recognised as a problem for the NHI, and the tight regulation of the SPD and pharmaceutical pricing as potential solutions. Democratisation seems unlikely to tighten the government’s regulation of the SPD and pharmaceutical prices. On the one hand, the Korean authoritarian regime was known as being capable of conducting top-down regulation of societal groups, and democratisation as having liberalised the government-society relationship. On the other, pharmaceutical regulation is a sophisticated and detached issue, which restricts the ability of laypeople to mobilise and exert bottom-up pressure for regulation. Nevertheless, the authoritarian government failed to tighten, and even loosened these regulations, whereas the democratised government tightened them. This thesis explains this puzzle by focusing on the features of the agenda-setting process and the articulation of policy issues therein. In the 1980s, the SPD and the pharmaceutical reimbursement pricing policy were administrative issues, discussed exclusively between bureaucrats and the central associations of health care providers, which resulted in loose regulation. In contrast, in the 1990s, reform-oriented professionals and NGOs raised these issues and put them on the political agenda, which motivated the government to conduct tighter regulation. This thesis suggests some general implications of democratisation on the politics of regulation. The hierarchical and exclusive authoritarian policy network aims to realise policy goals set by ruling elites; however, for other policy issues, societal partners can utilise this network to promote their preferred policies. Democratisation, which promotes competitive elections and political rights, allows previously excluded policy actors to participate in policy-making networks. These new actors include professionals and activists who are able to understand regulatory issues and articulate them in ways that are salient to politicians and the general public, which will motivate the government to tighten the regulation governing its traditional policy partners.

This thesis presents an empirical investigation into substance use, situational characteristics and sexual outcomes in men who have sex with men (MSM) motivated by the high rates of substance use in MSM; the association between substance use and sexual risk behaviours in MSM; the lack of specific theory addressing relationships between substance use, sexual interactions and social interactions between MSM; and the need for clearer understandings of encounter-level associations with sexual risk. Qualitative metasynthesis. This thesis begins with laying the methodological groundwork for a qualitative metasynthesis that theorises the relationship between substance use and social spaces in MSM, with a particular focus on sexual outcomes. The qualitative metasynthesis derives the key organising perspective of ‘littoral spaces’ in which substance use is associated with a pre-planned, though temporary, escape from the boundaries of everyday life to engage in maximal sensory exploration, including through sexual contact. <b>Systematic review of multiple-event analyses. The thesis then turns to a systematic review of previous quantitative multiple-event analyses examining associations between situational characteristics and sexual outcomes, which establishes the need for additional multiple-event analyses addressing specific substance use, location of sex, partner serodiscordance and partner type. Multiple-event analyses. Finally, informed by the qualitative metasynthesis and the systematic review of event-level analyses, this thesis presents multiple-event analyses addressing unprotected anal intercourse (UAI), pleasure and control as sexual outcomes in MSM in England. These analyses found that substance use was associated with greater odds of UAI and pleasure, but not with control, and that non-private locations of sex were associated with decreased odds of UAI and pleasure, but not control. Furthermore, there was sparse evidence of interactions between respondent and partner substance use and between respondent substance use and location of sex in associations with sexual outcomes. These analyses contribute to understandings of associations between substance use, situational characteristics and sexual risk behaviour by presenting the first known analyses on MSM in England and by examining sexual outcomes besides UAI.

Reduction in the price of oil in the mid-eighties forced the Saudi government to adopt new health policies in order to finance health services. On August 11, 1999, the Saudi government approved a new Mandatory Cooperative Health Insurance Program (MCHIP). This new health policy was enacted to replace the current policy of providing free health care. MCHIP is intended to reduce the financial burden on government by sharing the costs of health care with the public. This study had a dual purpose: to analyze the components of MCHIP program by comparing it with the American health system, and to investigate the perceptions of Saudi students attending American universities towards MCHIP program, based on the students' experiences with the American health care system.A multiple methods approach was used to conduct the study. A descriptive approach was employed to compare components of the MCHIP program with similar components of the American health care system. A survey method was used to investigate the perceptions of Saudi students attending American universities toward the new MCHIP program. Scales were constructed to measure the students' expectations of the MCHIP program with respect to cost, quality, and access of health care. Additional scales were used to measure the students' knowledge of the MCHIP program, knowledge of the American health system, and total health insurance knowledge. An electronic survey was posted on the VCU SERL Web page, and a link was e-mailed to 2210 Saudi students using a list provided by the Saudi Arabian Cultural Mission (SACM). The survey response rate was 40.6 percent.During the first phase of the research, the comparison to American health care identified areas in which the United States of America experience could be useful in promoting effective implementation of the MCHIP program in Saudi Arabia. In sum, the comparison indicated that the American health insurance model may not be an ideal approach for the Saudi health system. During the second phase of the study, survey results indicated that students expected MCHIP implementation to increase total health costs, improve quality of health care, and increase access to health care in Saudi Arabia. The students' total knowledge of health insurance had a significant effect on students' perceptions of cost and a non-significant effect on their perceptions of quality and access to health care. In order for the MCHIP program to be effectively implemented, study results point to the need for regulation of the Saudi insurance market and for health insurance-related systems (such as for coding, billing, and maintaining effective medical records) to be established. American health insurance system models are not ideal for the Saudi health system, although certain aspects may be useful. To promote success, the MCHIP program should be structured to meet the goal of providing affordable and accessible quality health care to the population, based on Islamic principles.