Is public health policy based on scholarly evidence? With the manifold variables that policy makers must consider, is evidence-based policy even realistic? While strategies exist to translate research into policy, a need to understand better how that can play out in real-life remains. Using interviews from informants occupying a range of positions, and considering the atmosphere created by media reports, this study examines the case of smoking privileges at East Coast Forensic Hospital. After a patient committed murder while on leave, apparently to smoke, public pressure over public safety, a relative lack of relevant scholarship, ethical considerations, and the divergent voices of stakeholders created challenging circumstances for policy makers. Through the use of case study methodology, this project identifies the kinds of information that are employed in the creation or modification of policy and offers insights concerning how the influences exerted on policy makers determine how information is employed.

The perceived level of self-determination in health care in four First Nations communities in Canada is examined through a multiple case study approach. Twenty-three participants from federal, provincial and First Nations governments as well as health care professionals in the communities of Blood Tribe, Lac La Ronge, Garden Hill and Wasagamack First Nations provided insight into the diversity of perception of self-determination in First Nations health care. The difference in definition between Aboriginal and the federal and provincial governments is a factor in the varying perceptions of the level of control First Nations communities have over their health care system. Participants from the four First Nations communities perceived their level of self-determination over their health care system to be much lower than the level perceived by provincial and federal government participants. The organization and delivery of health care is based on the location of the community, the availability of the human resources, the level of communication, the amount of community resources, and the ability to self-manage. The socio-political history including impact of contact, residential schools, and integration of Aboriginal worldview are factors in the organization and delivery of health care as well as the perceived level of self-determination that the community sees. The duration and intensity of contact influences how health care is organized as the communities become more familiarized with the biomedical model that most Canadians use. Having a holistic health care system that includes acknowledging the socio-political history, culture, language, worldview and traditional medicines is important to the four First Nations communities, but this has not been fully embraced in any of the communities. Despite their differences, all four communities are working toward self-determination that hopefully would result in an ‘ideal’ First Nations health care system which is holistic, cultural, spiritual, and interdisciplinary and ultimately lead to full management of the health care system.

The perceived level of self-determination in health care in four First Nations communities in Canada is examined through a multiple case study approach. Twenty-three participants from federal, provincial and First Nations governments as well as health care professionals in the communities of Blood Tribe, Lac La Ronge, Garden Hill and Wasagamack First Nations provided insight into the diversity of perception of self-determination in First Nations health care. The difference in definition between Aboriginal and the federal and provincial governments is a factor in the varying perceptions of the level of control First Nations communities have over their health care system. Participants from the four First Nations communities perceived their level of self-determination over their health care system to be much lower than the level perceived by provincial and federal government participants. The organization and delivery of health care is based on the location of the community, the availability of the human resources, the level of communication, the amount of community resources, and the ability to self-manage. The socio-political history including impact of contact, residential schools, and integration of Aboriginal worldview are factors in the organization and delivery of health care as well as the perceived level of self-determination that the community sees. The duration and intensity of contact influences how health care is organized as the communities become more familiarized with the biomedical model that most Canadians use. Having a holistic health care system that includes acknowledging the socio-political history, culture, language, worldview and traditional medicines is important to the four First Nations communities, but this has not been fully embraced in any of the communities. Despite their differences, all four communities are working toward self-determination that hopefully would result in an ‘ideal’ First Nations health care system which is holistic, cultural, spiritual, and interdisciplinary and ultimately lead to full management of the health care system.

This thesis is a transdisciplinary study aimed at exploring the role of race, racism and stress as determinants of health for indigenous populations and other oppressedethnoracial groups. Commencing with an analysis of continuing racialisation in health research, it is shown that there is no consistent evidence that oppressed ethnoracial groups, who suffer disproportionately from type 2 diabetes, are especially genetically susceptible to this disease. Continued attribution of ethnoracial differences in health to genetics highlights the need to be attentive to both environmental and genetic risk factors operating within and between ethnoracial groups. This exploration of racialisation is followed by a theoretical examination of racism as a health risk factor. This includes a comprehensive definition of racism, a diagrammaticrepresentation of the aetiological relationship between racism and health and an examination of the dimensions across which perceived racism can be operationalised.An empirical review of 138 quantitative population-based studies of self-reported racism as a determinant of health reveals that self-reported racism is related to ill-health(particularly mental health) for oppressed ethnoracial groups after adjustment for a range of confounders. This review also highlights a number of limitations in thisnascent field of research. This thesis then attempts to clarify the plethora of conceptual approaches used in thestudy of stress and health as a first step towards comprehending how stress interacts with both racism and health. A review of the empirical association between stress and chronic disease for fourth world indigenous populations and African Americans was also conducted. This review, which located 65 studies, found that a range of chronic diseases (especially chronic mental conditions) were associated with psychosocial stress. Utilising the conceptual work on operationalising racism discussed above, an instrument was developed to measure racism and its correlates as experienced by Indigenous Australians. This instrument demonstrated good face, content, psychometric andconvergent validity in a pilot study involving 312 Indigenous Australians. The majority of participants in this study (70%) reported some experience of inter-personal racism, with this exposure most commonly reported in employment and public settings, from service providers and from other Indigenous people. Strong and consistent associations were found between racism and chronic stress as well as between racism and depression (CES-D), poor/fair self-assessed health status/poor general mental health (SF-12) and a marker of CVD risk (homocysteine), respectively. There was also evidence that the association between inter-personal racism and poor mental health outcomes was ediated by somatic and inner-directed disempowered reactions to racism as well as by chronic stress and a range of psychosocial characteristics. To conclude this thesis, an examination of approaches to addressing racism forIndigenous Australians is undertaken. The theoretical issues pertinent to the study of anti-racism are discussed along with empirical findings from social psychology oneffective approaches to anti-racism. Recommendations for implementing these approaches through institutional and legal policies are also presented. Strategies for engendering political will to combat racism in the current neo-liberal capitalist climate are also briefly considered.

Thèse (Ph.D.)--Université Laval, 1999. / Comprend des réf. bibliogr.

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2008. / CD-ROM: Titel från titelskärmbild. Även utgiven som CD-ROM.

Thesis (M.B.A.)--University of Hong Kong, 1995.

Este trabalho toma como objeto as práticas de atenção à saúde desenvolvidas na rede básica de serviços de saúde voltadas para a juventude. O objetivo geral foi analisar as práticas de saúde específicas para a juventude na rede básica de serviços de saúde da Supervisão Técnica de Saúde Butantã, região Centro-Oeste do município de São Paulo, tomando por referência as políticas públicas brasileiras nessa área. Fundamentando-se no campo da Saúde Coletiva, a juventude é compreendida como uma categoria social, o que submete compreensões centradas nas mudanças biológicas a análises mais amplas, enfatizando a existência de várias juventudes, a depender da inserção de classe social dos jovens. Para isso, identificou-se as práticas de saúde específicas para a juventude a partir dos depoimentos dos trabalhadores e analisou-se a tendência dessas práticas frente às políticas públicas brasileiras, em especial aos programas de saúde (federal, estadual e municipal) da juventude. Dessa forma, os trabalhadores constituíram os sujeitos dessa pesquisa. Utilizou-se a entrevista semi-estruturada como técnica para a coleta dos dados e a análise temática como estratégia para a apreensão da realidade. A análise permitiu elencar categorias empíricas - como o setor saúde percebe a juventude, como o setor saúde percebe o processo saúde-doença, como o setor saúde percebe a questão da educação, como o setor saúde percebe os seus problemas, como deveria ser a resposta do setor saúde frente aos seus problemas, o que os serviços de saúde estão oferecendo para a juventude e quando a juventude procura o serviço de saúde – que foram respondidas sob a ótica dos trabalhadores entrevistados. A análise mostrou que além de poucas, as práticas específicas para a juventude são intermitentes e de natureza casuística, dependendo da “boa vontade” dos trabalhadores para o seu desenvolvimento. Sua tendência frente às políticas públicas brasileiras voltadas para a juventude revela a ausência de um sistema de referência uniforme entre os serviços de saúde da rede básica. Para a superação dessas limitações será necessário o reconhecimento das necessidades de saúde da juventude pelos distritos de saúde do município de São Paulo, em especial pela Supervisão Técnica de Saúde Butantã, tomando-as sob a visão da saúde coletiva, ou seja, respeitando a concepção da determinação social do processo saúde-doença, para que definitivamente possa se implementar um programa em nível distrital. Além disso, é imprescindível o apoio dos gestores dos vários níveis de governo e principalmente das chefias imediatas dos trabalhadores executores das práticas de saúde / This research comprises health practices developed in the public health department, specifically towards young people. The main target was to analyse health practices on young people at the public health department of Health Technical Supervision of Butantã Area, a central-west area of the city of São Paulo, taking as reference the Brazilian public politics in this area. Taking theoretical considerations from the Collective Health field, young people are taken as a social category, which causes the research to be centered from biological changes to wider analyses, emphasizing the existence of different groups of young people, according to their social class. For this reason, it identified specific health practices on young people and analysed the tendency of these practices towards Brazilian public politics, specially the youth health program (federal, state and municipal). This way the workers constitute the subject of this research. A pre-stablished interview was used to collect data and the theme analysis as strategy for reality apprehension. The analysis permitted some empirical categories to be listed – how health department sees young people, how health department sees the health-disease process, how health department sees their own matters, how health department sees their own problems, how health department should face their own problems, what health service has been offering young people and when young people look for health service assistance. The analysis showed that young people practices in basic health services are not only low-numbered, but also unsteady and casual, counting on their workers’ willingness to develop it. Their tendency towards Brazilian public politics for young people shows the absence of a straight-guidelined system between health service and health basic system. Overcoming these limitation there requires acknowledgement of young people’s needs for young-people health care by the community districts of São Paulo, especially by those of Health Technical Supervision of Butantã, taking note of the insight of Collective Health, in other words, respecting the social conception of determination of the health-disease process, so that a district-level program can be definitely implanted. Also the support by various levels of government officials is essential, especially by those in charge of the health-department offices

Este trabalho faz uma abordagem pouco explorada dos indicadores de saÃde, em especial da âMortalidade Infantil": uma reflexÃo sobre a sua âidentidadeâ como indicador de saÃde. Respaldado em um estudo que mescla a leitura epistemolÃgica com a antropolÃgica, procuramos analisar sobre que processos a diminuiÃÃo da taxa de mortalidade infantil no CearÃ, perÃodo de 1993 a 1997, se estabelece como indicador de saÃde. Para tal empreendimento lanÃamos mÃo de uma breve recuperaÃÃo histÃrica dos fundamentos conceituais desse indicador e, atravÃs de uma pesquisa de campo com base na metodologia qualitativa, a partir de situaÃÃes vivenciadas nos municÃpios de Itapajà e Ipueiras, procuramos explicitar os processos que levaram à diminuiÃÃo da Taxa de Mortalidade Infantil (TMI) no CearÃ. Os resultados encontrados revelam que a mortalidade infantil, como indicador de saÃde, nÃo se trata de parÃmetro estÃtico e fixo; seu valor e poder de revelar mudanÃas nas condiÃÃes de saÃde e de vida das populaÃÃes vÃm se modificando com a histÃria, o tempo e o lugar, a depender de transformaÃÃes sociais, polÃticas e tecnolÃgicas. No CearÃ, no perÃodo em estudo, ela nÃo representou mudanÃas significativas na saÃde da populaÃÃo ou mesmo na saÃde da crianÃa, mas, basicamente, avanÃos tecnolÃgicos, cuidados primÃrios e seletivos de saÃde, especificamente de assistÃncia à crianÃa de atà 1 ano de idade. Verificamos ainda que em ambos os municÃpios, tanto no de maior quanto no de menor diminuiÃÃo da TMI, foram aplicados o mesmo modelo e igual metodologia para a sua reduÃÃo, ocorrendo a maior diferenÃa entre os municÃpios apenas na forma organizada e prioritÃria de sua implantaÃÃo. Os relatos colhidos evidenciam que o modelo terapÃutico implantado, embora de baixo custo e "eficaz", nÃo à dotado de sustentabilidade, haja vista trazer consigo grandes distorÃÃes educativas, pedagÃgicas e atà de financiamento, tornando-o cada vez mais difÃcil de ser aplicado e sustentado, aparentemente em um misto de origem ideolÃgica, polÃtica e organizacional. As conclusÃes desse estudo apontam para a urgÃncia de uma revisÃo do modelo de intervenÃÃo e da metodologia utilizada para a diminuiÃÃo da TMI, no CearÃ, com o intuito de abolir suas distorÃÃes e muni-la de sustentabilidade. / This paper presents an approach underexplored health indicators , especially the " Infant Mortality " : a reflection on your " identity " as a health indicator . Backed in a study that merges the epistemological reading with anthropological , about which we analyzed processes to decrease the infant mortality rate in Cearà , the period from 1993 to 1997 , is established as a health indicator . for this project we used a brief recovery hysterical conceptual foundations of this indicator and , through a field research based on qualitative methodology , from situations experienced in the municipalities of Itapajà and Ipueiras , we explain the processes that led to the decline of Infant Mortality Rate ( IMR ) in Cearà . These results show that the infant mortality as a health indicator , not parameter is static and fixed , their value and power to reveal changes in health and life of the people have been changing with the story , the time and place , depending on the social, political and technological . Cearà in the period study , it did not represent significant changes in population health or the health of the child, but basically , technological advances , and selective primary care health , specifically for child care for up to 1 year old. verified although in both municipalities , both in higher and in lower decrease in IMR , we applied the same model and the same methodology to reduce it , the biggest difference occurring between the municipalities only in an organized manner and priority of its implementation . reports show that harvested therapeutic model deployed , although inexpensive and " effective " , is not endowed with sustainability , considering bring large distortions educational , pedagogical and even financing , making it increasingly difficult to be implemented and sustained , apparently in a mixed origin ideological , political and organizational . findings of this study point to the urgent need for a review of the intervention model and methodology used for the reduction of IMR in Cearà , with the aim of abolishing its distortions and muni her sustainability .

The health care industry’s involvement with biosimilar policies suggests that building coalitions and reducing opposition are critical factors for interest group success. As government decision-makers wrestle with how to handle a perplexing category of prescription drugs, companies and patient groups alike receive ample opportunities to contribute to the policymaking process. When stakeholders in the biosimilar arena – including manufacturers, physicians, and patients – unite, we see that the United States government takes steps toward fixing the policy problem. This occurred most recently with policies about biosimilar drug coverage under Medicare Part D and reimbursement under Medicare Part B. In both cases, stakeholders took a united stance and consequently faced no opposition. On the contrary, internal industry disputes between brand and biosimilar manufacturers about patent exclusivity laws and interchangeability rules revealed the nuances of biosimilar policy and the challenge that regulators face when they receive mixed messages. Across all of their efforts, biosimilar stakeholders pursued numerous strategies which may have contributed to their successes. They focused on niche issues and used their lobbying expertise to actively submit comments, testify in hearings, and meet with government officials; however, the differentiating tactic between the industry’s successes and failures was whether they formed coalitions. By coming together, stakeholders lowered their chances of facing opposition. A closer analysis of the politics of biosimilars illustrates that when they present a united front to lawmakers, interest groups reduce the likelihood of opposition and successfully influence policy change.