Efficient allocation of scarce resources to health programs involves measuring the economic benefits of life saving and/or improvement in health status. While several attempts have been made to quantify individual preferences for life, only a few, if any, have attempted to measure individual preferences for quality of life. In this thesis, we develop a methodology based on the estimation of individual preference functions to arrive at monetary measures of the value of marginal improvements in health status. / The first chapter reviews conventional methodologies for estimating the value of human life, and points out many theoretical and empirical propositions related to our own concerns. The second chapter analyzes various procedures used to quantify variations in health status. We distinguish non-monetary procedures, which combine recent psychometric techniques and research on health level scaling to obtain estimates of the relative desirability of a state of health, and monetary procedures which, we conclude, still need to be developed. / The third chapter presents a new methodology based on the direct estimation of bivariate welfare function of income and level of health. The theoretical basis of our approach and the data source are described in this chapter. Various functional forms were tried but we have finally retained the log-normal specification to derive estimates of the monetary value of a marginal change in the state of health for different subgroups of individuals. / We conclude with critical discussion of our results. Some improvements over the approach used are suggested in the fifth chapter.

Introduction The centrality of the patient to health care has been increasingly recognised both politically and professionally. Patient-centred care has become synonymous with high-quality care and a number of studies have reinforced patient's desire for, and the positive impact of the approach. Although the concept emerged over 30 years ago, it is still not clear what it is, upon what theories it is based, or how to measure it. Whilst the concept has been explored within medicine, nursing and other allied health professions, within physiotherapy there has only been minimal discussion. The aim of this research was to explore the meaning of patient-centred care in relation to low back pain, from the perspective of musculoskeletal physiotherapists. Methods Purposive sampling was initially used to select participants. Subsequently theoretical sampling was adopted whereby analysis of the data informed the sample selection. Nine musculoskeletal physiotherapists agreed to participate in the study. They ranged in experience from five to 25 years. Individual semi- structured interviews were adopted as the method of data collection. The interviews were audio taped and then transcribed verbatim. Analysis broadly followed the Grounded Theory approach outlined by Strauss and Corbin (1990). It consisted of a process of open, axial and selective coding. Constant comparative analysis resulted in the identification with a core category and three inter-related sub-categories and the development of a substantive theory of patient-centred care.

This study explored the ways experienced mental health nurses working within a local acute mental health NHS Foundation and Teaching Hospital Trust felt about being unobtrusively observed in their everyday clinical practice. Participants were recruited from eight local units: four Community Mental Health Teams (CMHT), one Crisis Resolution Home Treatment Team (CRHT), one inpatient ward, one in-patient rehabilitation unit and an Assertive Outreach Team (AOT).

Introduction The Northwest Territories as a rural and remote region of Canada has higher colorectal cancer rates and lower uptake of colorectal cancer screening compared to the rest of the country. Understanding the complex health system processes involved in screening is necessary to develop informed solutions to improve screening access amongst marginalized populations. A systems approach to describe and understand the health care processes and system-level factors influencing colorectal cancer screening access was undertaken. Methods Semi-structured interviews with health care providers (N=29) involved in colorectal cancer screening in all health authorities within the Northwest Territories (N=8) were performed from September to December 2015. Interview transcripts were analyzed using qualitative content analysis methods within a Collaborative Information Behaviour (CIB) and Continuity of Care framework. Exploratory models of colorectal cancer screening processes were developed and translated into quantitative parameters for simulation modelling. Results Colorectal cancer screening access was defined by patient health care interactions supported by foundational information processes. Eighteen models of colorectal cancer screening access within the territory were identified, with varying complexity in care access seen across communities. Screening access problems included screening initiation, colonoscopy scheduling, screening recall and information silos, and were influenced by multiple contextual factors including a transient health work force, social health determinants, and patient travel. Qualitative models were translated into a system dynamics (SD) design framework for development of further quantitative modeling. Conclusions Colorectal cancer screening access in the Northwest Territories is a complex process comprising patient interactions and information processes linking primary care and hospital care processes, which are influenced by challenging contextual factors in the rural and remote health care environment. In developing screening access solutions the foundational role of information support and the need for system trade-offs in restructuring health system processes are necessary considerations. Optimizing information processes through the utilization of health informatics tools such as standardized referral forms and EMRs may also support health system transformation to improve screening access across the Northwest Territories. Understanding and evaluating system trade-offs may be best achieved using a combination of qualitative and quantitative modeling through future application of SD modeling research.

Purpose of review Transgender individuals experience unique health disparities but are the subject of little focused health research. This manuscript reviews current literature on transgender medical and mental health outcomes and proposes research priorities to address knowledge gaps. Recent findings Published research in transgender healthcare consists primarily of case reports, retrospective and crosssectional studies, involving largely European settings. Challenges to US-based transgender health research include a diverse population where no single center has sufficient patient base to conduct clinical research with statistical rigor. Treatment regimens are heterogeneous and warrant study for best practices. Current research suggests increased mortality and depression in transgender individuals not receiving optimal care, and possibly a modest increase in cardiovascular risk related to hormone therapy. Current evidence does not support concerns for hormone-related malignancy risk. Summary The priorities for transgender medical outcomes research should be to determine health disparities and comorbid health conditions over the life span, along with the effects of mental health, medical, and surgical interventions on morbidity and mortality. Specific outcomes of interest based on frequency in the literature, potential severity of outcome, and patient-centered interest, include affective disorders, cardiovascular disease, malignancies, fertility, and time dose-related responses of specific interventions.

This talk will: 1. Define existing breastfeeding best practices 2. Review breastfeeding initiatives and metrics 3. Discuss geographical considerations and cultural competency 4. Examine case studies of at-risk breastfeeding families

Health research has demonstrated that regular leisure-time physical activity (LTPA) during pregnancy and the postnatal period may play a crucial role in managing the physical and psychological challenges that women face during these times of transition. The purpose of this dissertation was to investigate LTPA patterns during pregnancy and in the postnatal period and identify social-cognitive correlates associated with regular LTPA. Three inter-related studies were conducted. The purpose of Study 1 was to conduct an in depth month-to-month investigation of LTPA from 3 months prior to conception to 7 months following childbirth. An assessment of 309 pre and postnatal women revealed that LTPA started to decline in the first trimester of pregnancy, continued to decline at a steady rate until childbirth and then increased during the postnatal period. In addition to illustrating the average growth curve, the results from the multi-level moding analyses indicated substantial individual variability around the average growth curve. Future research should identify social cognitive factors that are associated with LTPA during this time of transition. Accordingly, Study 2 investigated psychosocial correlates of LTPA during pregnancy. The study engaged pregnant women in the listing of salient barriers to LTPA at 4 different time points during pregnancy (e.g., pregnancy weeks 18, 24, 30 and 36) and examined if barrier self-efficacy as well as a general measure of exercise self-efficacy were associated with LTPA during pregnancy. A total of 1168 barriers were content analyzed, yielding nine major themes. Hierarchical regression analyses supported both forms of self-efficacy as predictors of LTPA. While Study 2 examined LTPA during pregnancy, Study 3 focused on the postnatal period. The first objective was to identify postnatal women's perceived LTPA barriers and outcome expectations. In general, the barriers reported were consistent with barriers experienced by both asymptomatic and symptomatic populations as well as previous research examining barriers to exercise among postnatal women. The results of the open-ended outcome expectation elicitation generated a large number of physical, psychological and social outcome expectations. Approximately 90% of all outcome expectations listed under each category were classified into four groups. The second objective of Study 3 was to examine if outcome expectation likelihood, exercise self-efficacy and barrier self-efficacy were associated with LTPA. In support of our hypothesis, and consistent with social cognitive theory, self-efficacy was significantly associated with LTPA. For many women engaging in regular LTPA during pregnancy and following the birth of a child is a challenge. The average growth curve results from Study 1 are promising; however the random effects analyses was significant indicating substantial individual variability about the average growth curve. Study 2 and Study 3 identified a number of salient barriers to LTPA which may hinder the initiation and maintenance of regular LTPA. Study 3 also identified salient outcome expectations that may severe a motivational factors to engage in LTPA. The results suggest that self-efficacy represents an important social cognition is linked to higher levels of LTPA in the postnatal period. In conclusion, barrier and exercise self-efficacy may be important targets for intervention efforts to promote LTPA during pregnancy. / Thesis / Doctor of Philosophy (PhD)

The expectation of privacy and confidentiality in health care presents a unique dilemma for public health interests. A great deal of observational health research such as epidemiological studies, disease surveillance, and quality assurance depends on access and use of personal information in the absence of individual consent. Understandably, this raises concerns about personal privacy since sensitive disclosures of information can result in harm such as stigma, discrimination, and loss of socio-economic goods. However, the issue has been largely framed and discussed as a dichotomy: the privacy interest of the individual versus the social interest in research. to individualist paradigm informed by a traditional liberal conception of privacy that emphasizes autonomy drives this dichotomy and inevitably leads to an intractable conflict. In this thesis, I attempt to re-frame the issue by moving away from individualism in shifting the focus towards confidentiality which is relational and founded on trust. I argue that confidentiality is broader than the concern for individual privacy and is thus capable of capturing other relevant interests, such as collective and social interests. I advance a broad conception of confidentiality grounded in a mixed deontic-consequentialist moral framework that can account for respect for persons and social interests. / Thesis / Doctor of Philosophy (PhD)

<p>Multi-faceted interventions that include some form of a clinical information system have been shown to improve primary care physicians' management of chronic diseases. The objective of this pilot study was to assess the feasibility of a cluster randomized controlled trial of a multi-faceted intervention, which includes a clinical information system, to improve the management of the chronic disease of tobacco use by physicians. Feasibility was assessed with respect to the use of a measurement tool (Smoking Status Identification Card) and use of a new smoking cessation management module in the clinical information system.</p> <p>Letters of invitation were sent out to the 65 primary care physicians (in 38 primary care practices) who were subscribed to the web-based clinical information system (P-PROMPT CDMS). Five physicians from 5 primary care practices agree.d to participate, who were stratified and then randomized to the intervention (2 primary care practices) or control group (3 primary care practices).</p> <p>Following the 12-week study period, SSIC completion reached the 90% threshold success criterion in 2 of the 5 primary care practices (one each from the intervention and control group). The intervention group demonstrated basic use of the new smoking cessation management module that reached 21.9% and 19.0% in each of the respective practices, which was below the 30% threshold success criterion. A preliminary evaluation of physician delivery of smoking cessation counselling demonstrated a trend to a higher percentage of Ministry of Health and Long-Term Care (MOHLTC) physician service billing codes submitted among the physicians in the intervention group, which may be indicative of greater smoking cessation counselling.</p> <p>It is concluded that a randomized controlled trial to test a multi-faceted intervention is not feasible with the current study design. Significant modifications to the current study design are required that can potentially be tested prior to progression to a larger trial.</p> / Master of Science (MS)

Background: Compared with typically developing children, children with special needs often struggle with academic and social aspects of school, though certain factors can improve their academic and social developmental trajectory. The objective of this investigation was to explore the association between the developmental health of children with special needs at school-entry, as measured by the Early Development Instrument (EDI), and neighborhood-level SES. To date, the EDI has only been validated for use in typically developing children. Hence, a secondary objective of this investigation was to explore the psychometric properties of the EDI for children with special needs. Methods: The data for this investigation were from the Pan-Canadian database of children’s developmental health at school entry. The psychometric properties of the EDI, including item and domain characteristics, factor structure, and construct validity, were tested for children with special needs. Hierarchical generalized linear models was used to model the association between EDI domain scores and a custom neighborhood SES index. Results: A total of 29,841 (69.8% male) and 29,520 (69.7% male) children with special needs were available for the investigation on the psychometric properties of the EDI and the relationship between EDI outcomes and SES, respectively. The psychometric performance of the EDI in children with special needs was similar to its performance in typically developing children. The EDI was subsequently used to explore the association between developmental outcomes and neighborhood socioeconomic status (SES). All EDI domains were positively correlated with SES, indicating that children in high SES neighborhoods have better developmental outcomes at school entry than those in lower SES neighborhoods. Conclusions: The results of this investigation draw attention to the potential impact of contextual factors on children’s health and have implications for policy development and service planning. These results also indicate that the EDI performs similarly in children with special needs and typically developing children, thus enabling its more extensive use for this population. / Thesis / Master of Science (MSc) / Background: Compared with typically developing children, children with special needs often struggle with academic and social aspects of school, though certain factors can improve their academic and social developmental trajectory. The objective of this investigation was to explore the association between the developmental health of children with special needs at school-entry, as measured by the Early Development Instrument (EDI), and neighborhood-level SES. To date, the EDI has only been validated for use in typically developing children. Hence, a secondary objective of this investigation was to explore the psychometric properties of the EDI for children with special needs. Methods: The data for this investigation were from the Pan-Canadian database of children’s developmental health at school entry. The psychometric properties of the EDI, including item and domain characteristics, factor structure, and construct validity, were tested for children with special needs. Hierarchical generalized linear models was used to model the association between EDI domain scores and a custom neighborhood SES index. Results: A total of 29,841 (69.8% male) and 29,520 (69.7% male) children with special needs were available for the investigation on the psychometric properties of the EDI and the relationship between EDI outcomes and SES, respectively. The psychometric performance of the EDI in children with special needs was similar to its performance in typically developing children. The EDI was subsequently used to explore the association between developmental outcomes and neighborhood socioeconomic status (SES). All EDI domains were positively correlated with SES, indicating that children in high SES neighborhoods have better developmental outcomes at school entry than those in lower SES neighborhoods. Conclusions: The results of this investigation draw attention to the potential impact of contextual factors on children’s health and have implications for policy development and service planning. These results also indicate that the EDI performs similarly in children with special needs and typically developing children, thus enabling its more extensive use for this population.