This study explores the global health diplomacy phenomenon by focusing on how and why health is integrated into foreign policy. Over the last decade or so, precipitated primarily by a growing concern about the need to strengthen global health security and deliver on the Millennium Development Goals, foreign policymakers have been paying more attention to health as a foreign policy concern and several countries have adopted formal global health policy positions and/or strategies. To elucidate a deeper and clearer understanding of how and why health is integrated into foreign policy, this thesis used a case study research design that incorporated literature and document review and interviews with twenty informants to conduct an in-depth analysis of the United Kingdom’s (UK) Health is Global: A UK Government Strategy 2008-13. Health is Global represents the first example of a formal national global health strategy developed using a multi-stakeholder process. Briefer background case reviews of three nations that are leaders in global health diplomacy - Brazil, Norway and Switzerland, were also conducted to inform the analysis of the in-depth case. Policy analysis included categorizing data into five areas: context (why?), content (what?), actors (who?), process (how?) and impact (so what?). The Multiple Streams Model of Policymaking and Fidler’s health and foreign policy conceptualizations - revolution, remediation and regression - were used to analyze the findings. Based on this analysis, the primary reason that the countries examined have decided to focus more on global health is self-interest - to protect national and international security and their economic interests. Investing in global health was also seen as a way to enhance a state’s international reputation. In terms of self-interest, Brazil was an outlier, however. International solidarity and health as a human right have been the driving forces behind its long-term investment in development cooperation to date. Investing in health for normative reasons was also a prevalent through weaker theme in the UK, Swiss and Norwegian cases. The study highlighted the critical role that policy entrepreneurs who cross the domains of international relations and health play in the global health policymaking process. In regards to advancing a conceptual understanding of global health diplomacy, the findings propose that the whole-of-government global health policymaking process is a form of global health diplomacy. The thesis elucidated factors that underpin this process as well as lessons for other nations, in particular, Canada. While ascertaining the impact of national global health strategies was not the main objective of this thesis, the study provided an initial look at the impact of these policy instruments and processes. Such impacts include better collaboration across government actors leading to enhanced policy coherence and a more strategic focus on global health. Finally, some have argued of late that the global health revolution is over due to the current world economic crisis. Considering the level of interest in whole-of-government global health strategies and the ever growing and sophisticated world-wide global health policy community, based on this thesis, the global health revolution is alive and well.

Research confirms that breastfeeding disparities persist and that lactation consultants play a key role in reducing them. However, there continues to be a limited availability of International Board Certified Lactation Consultants (IBCLCs) in the US with racial minorities in particular facing persistent barriers in the certification process. Through semi-structured interviews with 36 IBCLCs across the US, this study takes a systematic look at breastfeeding disparities through the lens of the IBCLC. Specifically, this study addresses barriers to certification and employment discrimination faced by IBCLCs of color, race-based discrimination against patients, and the ways in which IBCLCs work to both medicalize and demedicalize breastfeeding. Each of these areas can impact breastfeeding equity, and each help to reveal the ways in which race, class, gender and medicine shape views and practices related to lactation and motherhood. Cost and the increasingly university-focused approach of the IBCLC certification process are found to be significant barrier for participants. Race-based discrimination during the certification process and in the workplace is also an ongoing and persistent reality that affects participant’s relationships with patients and coworkers and their ability to secure workplace resources and to advance in their careers. IBCLCs report instances of race-based discrimination against patients such as unequal care provided to patients of color and overt racist remarks said in front of or behind patient’s backs. Finally IBCLCs are found to demedicalize breastfeeding, but they often lack the authority to change breastfeeding policies. They also engage in other work that medicalizes breastfeeding and perpetuate the idea that mothers are anxiety-prone patients in need of professional intervention.

Low-income groups have greater potential to gain from incorporating health promotion into daily living using bike-share to increase physical activity and expand transport options. The potential is unmet because of socioeconomics and access. Disproportionate uptake of bike-share by higher income individuals widens the gaps in health equity and transportation equity as bike-share use over-represents males with more resources, less need, and lower health risk. The Prescribe a Bike (RxBike) program, a key focus of this study, is a partnership between primary care providers (PCPs) at an urban safety net hospital and the city’s existing income-based, subsidized bike-share membership. Three studies using quantitative and qualitative methods were performed to: examine utilization of bike-share by Boston residents among subsidized and non-subsidized members; examine perceived attributes of the RxBike program by Boston Medical Center (BMC) PCPs; and evaluate BMC patient referrals. The overarching conceptual model uses elements of theories from health services and organizational behavior, in a public health framework. Analysis of Boston resident utilization at the trip-level (2012-2015) demonstrated overall ridership was increasingly by males and residents of more advantaged neighborhoods. Subsidized members had significantly higher likelihood of living in neighborhoods with socioeconomic and health disadvantage, and less gender disparity when compared to non-subsidized members. The impact was minimal because subsidized members made only 7.17% of trips. The survey of PCPs revealed mismatch between highly favorable opinion of RxBike appropriateness and lower intent to refer. Female gender and not being an urban biker predicted lower likelihood of intent to refer. Examination of open-ended survey comments mirrored quantitative data and expanded on the range of provider biking safety concerns in Boston. From 2013-2015, 27 BMC providers made only 72 referrals to RxBike. Patients referred had high cardiovascular health risk, resided in neighborhoods with extremely high levels of disadvantage, and in neighborhoods without meaningful access to bike-share kiosks. Overall, the subsidized membership extends reach of bike-share to residents of neighborhoods with more health and socioeconomic risk than the rest of the city; RxBike has strong potential to impact this vulnerable population. The most critical matters for program success are safety and neighborhood access.

Human papilloma virus (HPV) is the most common viral infection of the reproductive tract and a well-established cause of cervical, anal, and oropharyngeal cancers in both women and men worldwide. Despite data that supports HPV vaccine as an effective measure to prevent such cancers, vaccine uptake has not been optimal in many countries. In the United States (US) for example, rates have stagnated over the past few years and only one-third of adolescents are fully immunized, in contrast to other adolescent vaccines such as Tdap and meningococcal that have double the rates of uptake. Current approaches to HPV vaccine education and delivery have not been successful at improving immunization rates. In this article we propose the implementation of a child rights, social justice, and health equity-based approach to HPV vaccine policy. This approach would promote youth’s participation in medical decision-making and advance policies that allow for independent consent to HPV vaccination. We postulate that by empowering youth to be involved in issues pertaining to their health and well-being, they will be more likely to explore and discuss information about HPV with others, and be able to make informed decisions related to HPV vaccine.

Set in 2000, with a completion date of 2015, the deadline for the Millennium Development Goals is approaching, at which time a new global development infrastructure will become operational. Unsurprisingly, the discussions on goals, topics, priorities and monitoring and evaluation are gaining momentum. But this is a critical juncture. Over a decade of development programming offers a unique opportunity to reflect on its structure, function and purpose in a contemporary global context. This article examines the topic from an analytical health perspective and identifies universal health equity as an operational and analytical priority to encourage attention to the root causes of unnecessary and unfair illness and disease from the perspectives of those for whom the issues have most direct relevance.

This study explores the global health diplomacy phenomenon by focusing on how and why health is integrated into foreign policy. Over the last decade or so, precipitated primarily by a growing concern about the need to strengthen global health security and deliver on the Millennium Development Goals, foreign policymakers have been paying more attention to health as a foreign policy concern and several countries have adopted formal global health policy positions and/or strategies. To elucidate a deeper and clearer understanding of how and why health is integrated into foreign policy, this thesis used a case study research design that incorporated literature and document review and interviews with twenty informants to conduct an in-depth analysis of the United Kingdom’s (UK) Health is Global: A UK Government Strategy 2008-13. Health is Global represents the first example of a formal national global health strategy developed using a multi-stakeholder process. Briefer background case reviews of three nations that are leaders in global health diplomacy - Brazil, Norway and Switzerland, were also conducted to inform the analysis of the in-depth case. Policy analysis included categorizing data into five areas: context (why?), content (what?), actors (who?), process (how?) and impact (so what?). The Multiple Streams Model of Policymaking and Fidler’s health and foreign policy conceptualizations - revolution, remediation and regression - were used to analyze the findings. Based on this analysis, the primary reason that the countries examined have decided to focus more on global health is self-interest - to protect national and international security and their economic interests. Investing in global health was also seen as a way to enhance a state’s international reputation. In terms of self-interest, Brazil was an outlier, however. International solidarity and health as a human right have been the driving forces behind its long-term investment in development cooperation to date. Investing in health for normative reasons was also a prevalent through weaker theme in the UK, Swiss and Norwegian cases. The study highlighted the critical role that policy entrepreneurs who cross the domains of international relations and health play in the global health policymaking process. In regards to advancing a conceptual understanding of global health diplomacy, the findings propose that the whole-of-government global health policymaking process is a form of global health diplomacy. The thesis elucidated factors that underpin this process as well as lessons for other nations, in particular, Canada. While ascertaining the impact of national global health strategies was not the main objective of this thesis, the study provided an initial look at the impact of these policy instruments and processes. Such impacts include better collaboration across government actors leading to enhanced policy coherence and a more strategic focus on global health. Finally, some have argued of late that the global health revolution is over due to the current world economic crisis. Considering the level of interest in whole-of-government global health strategies and the ever growing and sophisticated world-wide global health policy community, based on this thesis, the global health revolution is alive and well.

Introduction: Despite Colombia having adopted a health system based on an insurance market, Bogota in 2004, as part of a left-wing government (elected for first time in the city), decided to implement a Primary Health Care (PHC) strategy to improve quality of life, level of population health and reduce health inequities. The PHC strategy has been implemented through the HomeHealth program by three consecutive governments over the last eight years in the context of continuous political tension stemming from differences between national and district health policies. This thesis is an attempt to provide a better understanding of the overall experience of implementing a PHC strategy in the context of a market-oriented health care system. The research aimed to evaluate results of the PHC strategy through the intervention of the Home Health program and to identify factors that have enabled or limited the on-going PHC implementation process in Bogota. Methods: This study used a combination of quantitative and qualitative methods. A descriptive analysis was performed to assess direct results of the PHC strategy in terms of progress in the Home Health program coverage and increases in health personnel ratios reaching out to poor and vulnerable groups in Bogota. A cross sectional analysis was carried out to evaluate qualities of the delivery of PHC services through the attainment of PHC essential dimensions in the network of first-level public health care facilities. An ecological analysis was performed to estimate the contribution of the PHC strategy, through the Home Health program, to improve child health outcomes and to reduce health inequalities. A qualitative multiple case study was conducted to identify contextual factors that have enabled or limited the on-going PHC implementation process in Bogota. Results: The descriptive analysis showed a notable initial increase and rapid expansion in the development of the PHC strategy between 2004 and 2007, followed by a period of slower growth and stagnation between 2007 and 2010. The cross-sectional analysis suggested that the Home Health program could be helping to improve the performance of first-level public health care facilities. Ratings assigned to PHC dimensions by different participants pointed out the need to strengthen family focus, community orientation, financial resources distribution, and accessibility. The ecological analysis showed that localities with high PHC coverage had a lower risk of under-five mortality, infant mortality and acute malnutrition as well as a higher probability of being vaccinated than low PHC coverage localities. The belonging to a high-coverage locality was significantly associated with risk reductions of under-five mortality (13.8%) and infant mortality by pneumonia (37.5%) as well as increases in the probability of being vaccinated for DPT (4.9%). Concentration curves and concentration indices indicated inequality reductions in all child indicators betwen 2003 and 2007. In 2007 (period after implementation), the PHC strategy was associated with a reduction in the effect of the inequality that affected disadvantaged localities in under-five mortality (24%), infant mortality rate (19%), acute malnutrition (7%) and DPT vaccination coverage (20%). The main facilitators of the results achieved so far by the PHC strategy were all related to the commitment and good will of actors at different levels. Longterm political commitment, support by local mayors and hospital managers, organized communities historically active in the process of social participation, as well as extramural work carried out by community health workers and health care teams were highly valued. Barriers to the implementation included the structure of the national health system itself, lack of a stable funding source, unsatisfactory working conditions, lack of competencies among health workers regarding family focus and community orientation, and limited involvement of institutions outside the health sector in generating intersectoral responses and promoting community participation. Conclusion: Despite adverse contextual conditions and limitations imposed by the Colombian health system itself, Bogota’s initiative of a PHC strategy has helped to improve the performance of first-level public health care facilities in the essential dimensions of PHC and has also contributed to improvement of child health outcomes and reduction of health inequalities associated with socioeconomic and living conditions. Significant efforts are required to overcome the market approach of the national health system. Structural changes to social policies at the national and district level are needed if the PHC strategy is expected to achieve its full potential. Specific interventions must be designed to have well-trained and motivated human resources, as well as to establish available and stable financial resources for the PHC strategy.

The hospice social movement, which emerged as a new social movement based on the ideals of providing a more humane and natural approach towards death, illness, and grief, led to the creation of community-based hospice programs across Canada. This single case study explored the factors that influenced the life course of a small, community-based hospice (Hospice Orillia) from its beginning in 1987 to 2017. A preliminary timeline was created through a review of secondary data sources which identified milestones, events and individuals who were in leadership roles in the organization. This information was then used to recruit nine key informants who participated in semi-structured interviews. Through thematic analysis, the interviews identified that the organization’s geographic location, its relationship to the formal health care system, its ability to access funding, and issues regarding advocacy and awareness all played key roles in how it developed over the years, leading to its eventual decline. / Graduate

For her MPH thesis research, Alex Kent conducted secondary analysis of data from the Equity Lens in Public Health (ELPH) research program to explore whether and how Indigenous health equity is prioritized within one regional health authority [HA100] in British Columbia’s public health system. Her thesis addresses the question: How has Indigenous health equity been identified and prioritized within HA100 as reflected in core documents and plans as well as interviews with key decision makers in the health authority? Using the Xpey’ Relational Environments Framework, a theoretical framework designed by Drs. Charlotte Loppie and Jeannine Carriere, Alex identifies and discusses the physical and theoretical settings where Indigenous health equity is and is not manifested in the public health system. Her findings highlight a number of examples of how HA100 has implemented successful strategies aimed at enhancing Indigenous health equity as well as several areas for improvement across the relational environments. Alex concludes that improving Indigenous health equity through human, non-human and symbolic interactions in institution, system and community settings appears to be a current priority for HA100; whereas reconciling historical relationships and creating equitable social, cultural and political conditions that promote optimal health and wellbeing for Indigenous peoples is positioned as a long-term and indirect goal. / Graduate

This study explores the global health diplomacy phenomenon by focusing on how and why health is integrated into foreign policy. Over the last decade or so, precipitated primarily by a growing concern about the need to strengthen global health security and deliver on the Millennium Development Goals, foreign policymakers have been paying more attention to health as a foreign policy concern and several countries have adopted formal global health policy positions and/or strategies. To elucidate a deeper and clearer understanding of how and why health is integrated into foreign policy, this thesis used a case study research design that incorporated literature and document review and interviews with twenty informants to conduct an in-depth analysis of the United Kingdom’s (UK) Health is Global: A UK Government Strategy 2008-13. Health is Global represents the first example of a formal national global health strategy developed using a multi-stakeholder process. Briefer background case reviews of three nations that are leaders in global health diplomacy - Brazil, Norway and Switzerland, were also conducted to inform the analysis of the in-depth case. Policy analysis included categorizing data into five areas: context (why?), content (what?), actors (who?), process (how?) and impact (so what?). The Multiple Streams Model of Policymaking and Fidler’s health and foreign policy conceptualizations - revolution, remediation and regression - were used to analyze the findings. Based on this analysis, the primary reason that the countries examined have decided to focus more on global health is self-interest - to protect national and international security and their economic interests. Investing in global health was also seen as a way to enhance a state’s international reputation. In terms of self-interest, Brazil was an outlier, however. International solidarity and health as a human right have been the driving forces behind its long-term investment in development cooperation to date. Investing in health for normative reasons was also a prevalent through weaker theme in the UK, Swiss and Norwegian cases. The study highlighted the critical role that policy entrepreneurs who cross the domains of international relations and health play in the global health policymaking process. In regards to advancing a conceptual understanding of global health diplomacy, the findings propose that the whole-of-government global health policymaking process is a form of global health diplomacy. The thesis elucidated factors that underpin this process as well as lessons for other nations, in particular, Canada. While ascertaining the impact of national global health strategies was not the main objective of this thesis, the study provided an initial look at the impact of these policy instruments and processes. Such impacts include better collaboration across government actors leading to enhanced policy coherence and a more strategic focus on global health. Finally, some have argued of late that the global health revolution is over due to the current world economic crisis. Considering the level of interest in whole-of-government global health strategies and the ever growing and sophisticated world-wide global health policy community, based on this thesis, the global health revolution is alive and well.