<p>Evidence briefs are an innovative and promising approach to synthesizing the best available research evidence to support evidence-informed health policymaking in low- and middle-income countries. Unfortunately, despite their increased use, little work has been undertaken to understand how the contexts in which briefs are prepared and the issues that they address influence the ways in which policymakers and stakeholders view them. Furthermore, there have been few efforts to determine whether and how evidence briefs influence the policy processes related to the priority policy issues for which they are prepared. This thesis begins to address these issues through four manuscripts that use a range of methods and approaches to develop a deeper understanding of briefs and their use, as well as the ways in which they can be evaluated in low- and middle-income countries. Taken together the chapters present: 1) the development of a theoretical framework through a systematic review that highlights how factors related to contexts and issues can influence policymakers’ and stakeholders’ views about evidence briefs and their design features; 2) results from a survey conducted across six countries that provide insights into how policymakers, stakeholders and researchers who have read evidence briefs view them and their design features; 3) an approach to operationalizing factors related to contexts and issues as variables for use in quantitative analyses of evidence briefs; and 4) four case studies that explain how evidence briefs prepared for priority policy issues in low- and middle-income countries influenced the policy processes related to these issues. These chapters constitute substantive, methodological and disciplinary contributions to the field of health systems research, and in particular about how to support its use in efforts to strengthen health systems. They also support the continued use and evaluation of evidence briefs in efforts to strengthen health systems in low- and middle-income countries.</p> / Doctor of Philosophy (PhD)

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This work investigates the uses of the Internet and email in health care and specifically focuses on the use of these technologies in the management and support of patients following kidney transplantation. Health information websites are recognised to differ widely in quality and reliability of their content. This has led to the development of various codes of conduct and rating tools to assess the quality of health websites. However, the validity and reliability of these rating tools and their applicability to different health websites also varies. In principle, rating tools should be available to consumers, require a limited number of elements to be assessed, be assessable in all elements, be readable and be able to gauge the readability and consistency of information provided from a patient's view point. This study addresses the design and evaluation of a patient-centred transplant online service consisting of a website and e-mail communication. The website focuses on providing health education to patients so that they can conveniently obtain useful clinical information, as needed in home or workplace settings. The online service was assessed for its acceptability and usefulness from patient's perspectives and for its efficacy in reducing patient's needs to contact primary or secondary care services regarding day-to-day health issues. The online service was purpose built, informed by a framework developed during this study. The framework can be used by transplant clinicians to develop and maintain their websites. Work to inform the framework included an evaluation of the quality of information found in kidney and liver transplantation websites. This evaluation used both expert reviews, based on a weighted hformation Scoring (IS) system and involving clinicians in the assessment, and user evaluations where patient's Internet use, and their suggestions about, and interest in, transplant websites were elicited. The use of email in answering health related questions in the group of the patients who took part in the study was also evaluated. Whilst the hflernet has made it possible for patients and their families to access vast quantities of information that previously would have been difficult for anyone but a physician or librarian to obtain, an important finding of the research is the existence currently of many poor quality websites. The results indicate overall that readily accessible Internet websites for liver or kidney transplantation patients provide a large quantity of, but poor quality, material. Based on surveys of patients needs, the study reported in this thesis highlights the fact that transplant websites should include information about life style in addition to purely medical-related topics. Incorporation of web tools, like email, is shown to effectively help solve many of the daily health problems of patients with organ transplantation. The transplant online service developed as a part of this study showed high levels of patient acceptability and effectively helped reduce the need for patients to access primary or secondary care. The results of this research support the potential of online services as an innovative approach for patient-centred care in organ transplantation.

Global studies investigating scaling-up of mental health services have highlighted mental health policy development and implementation as a priority area, especially in low- and middle-income countries. This research aimed to investigate Malaysia's National Mental Health Policy (NMHP) development and implementation and explore the barriers and facilitators to mental health care from multi-stakeholder point of view. This study, consisting of two main parts, adopted the situation analysis model from the Global Mental Health Lancet 2011 Series. Part One details the current mental health plans and development of the NMHP with data obtained via semi-structured interview, consultation observation, and government documents analysis. Part Two investigates key stakeholder perceptions and/or experiences gained through semi-structured interviews with 54 participants across five main stakeholder groups: policymakers, service providers, NGOs, service users, and caregivers. These were analysed using content analysis and the Framework Method respectively. Six categories of types of mental health plans emerged: (1) 'action plans', (2) 'education and training', (3) 'operational', (4) 'community psychiatry', (5) 'promotion', and (6) 'NGO'. Further, stakeholders identified seven key areas in relation to mental health care: (1) 'barriers to mental health care', (2) 'suggestions for improvement', (3) 'awareness and knowledge on mental health', (4) 'facilitators to mental health care', (5) 'impact of mental illness', (6) 'duty of care', and (7) 'cultural spiritual or ethnic influence'. Findings indicate the extent to which the NMHP objectives and goals were achieved between 2009 and 2016. Issues around attitude, resources, and awareness are most pressing to address. Facilitating factors, as well as suggestions for improvements, were uncovered too. Further important considerations in providing care in Malaysia revolve around raising awareness and knowledge, cultural appropriateness, and the roles of family, friends and even NGOs. This study concludes with proposed needs- and asset-based recommendations for future national mental health policy development.

This thesis explores in which ways and why research informs and influences the public policy making process, and the extent to which existing theories and models add to our understanding of this. Since the late 1990s, the UK government has aspired to evidence-based policy making, particularly policy that is informed by research on what works. In practice, there are many barriers to this aspiration and the instrumental research use of 'what works' knowledge seems relatively rare. Existing research utilisation models offer some insights into why this is the case but they are not well supported by empirical evidence and they tend to underplay the complexities of the policy making process. Additional insights are provided by the literature on the policy process, but this does not pay much attention to research use. This thesis thus combines these perspectives. The thesis is guided by a conceptual framework that combines insights from the advocacy coalition framework (ACF), the stages heuristic, the research utilisation typology, practical rationality and the epistemic communities framework. Two qualitative case studies of Scottish national mental health policy making are considered using this conceptual framework: a suicide prevention policy and a review of mental health law. Data analysis combines 23 in-depth interviews and extensive document review. The ACF is used as a heuristic device to focus on aspects of the policy sub-system that are key to understanding research use. The findings demonstrate that despite limited research evidence on what works in mental health, research was used in the agenda setting and formulation stages of the policy making process, enriching the process and influencing policy sub-system dynamics. Five types of research use are identified; they do not occur in isolation but are layered and interlinked, and are at times contingent on one another. Research use is found to be bound up with the ways in which those involved in the policy making process work with others who share or oppose their policy beliefs, using similar or different knowledge bases. Research influenced policy beliefs, which in turn influenced policy making behaviour. Discussion of research enabled the inclusion, consideration and appreciation of new and different policy positions. It empowered weaker coalitions as well as cementing coalition dominance. It influenced policy direction and encouraged innovation and policy learning. The findings indicate that the current common usage of three categories of research use (instrumental, conceptual and political) may be too crude; real benefit was gained from applying Weiss' original seven research use types. Combining Weiss' research utilisation typology with the ACF deepened understanding of how research influences the policy making process. The findings only partially support the ACF hypotheses concerning research use, and they highlight weaknesses in a number of the ACF's assumptions and definitions. In terms of policy implications, the findings indicate a need to broaden governments' view of research use from an almost exclusive focus on the problem-solving use of 'what works' research knowledge to a wider appreciation of the ways in which research contributes to and enhances policy making.

This thesis focuses on how health care policies affect the labor supply of physicians and beneficiaries. Further, I examine how the labor supply responses of physicians vary based on the level of competition. In the first chapter, I focus on the labor supply response of physicians to two large public health insurance expansions, the State Children’s Health Insurance Program (SCHIP) and the Affordable Care Act (ACA). These insurance programs have significantly increased the number of patients with public health insurance and the demand for medical services, but it is not clear whether providers will supply additional services for newly-insured patients. In response to the introduction of SCHIP, my estimates suggest that physicians reallocate their total working hours between patient care and non-patient care activities. The size of the impact was greater in areas with high level of physician concentration prior to the expansion. Physicians in high concentration areas tend to decrease time spent on direct patient care, but increase hours on non-direct patient care. In response to the ACA, physicians’ working hours did not increase, but working hours and the probability of being employed increased for registered nurses. This suggests that physicians might utilize other healthcare providers to accommodate increases in demand for medical services after the expansion. In the second chapter, we analyzed the impact of expanding Medicaid on health insurance coverage and labor market outcomes. Expansions of public health insurance have the potential to reduce the uninsured rate, but also to reduce coverage through employer-sponsored insurance (ESI), reduce labor supply, and increase job mobility. In January 2014, twenty-five states expanded Medicaid as part of the Affordable Care Act to low-income parents and childless adults. We compare the changes in insurance coverage and labor market outcomes over time of adults in states that expanded Medicaid and in states that did not. Our estimates suggest that the recent expansion significantly increased Medicaid coverage with little decrease in ESI. Overall, the expansion did not impact labor market outcomes, including labor force participation, employment, and hours worked. In the third chapter, I examined the impact of competition among dentists on the labor supply of dentists. I focus on how dentists’ working hours will changes when the level of competition increases by examining the effect of the National Health Service Corps (NHSC). The NHSC was created to increase the supply of rural physicians, which might increase the competition in rural areas. I examine the number of dentists (extensive margins of labor supply) and the change in the working hours of dentists (intensive margins of labor supply) in response to the increased level of physician competition. I found that 1 percent increase in NHSC-approved sites increases 5.4% increases in the number of providers and 0.2% of competition in a rural county. In addition, I found that there is a positive relationship between the number of NHSC-approved sites and providers’ working hours. If the competition among dentists increases about 1, then working hours of providers increase about 6 hours per week.

This paper examines how regulations since Roe v. Wade and anti-choice activism affect low income women's access to abortion.

The central objective of this study is to examine the factors that have influenced the evolution of the drug patenting regulatory framework in Canada from 1965 to 2005. The principal focus is on the extent to which in formulating that regulatory framework the Canadian federal government has been influenced by domestic and international interests and forces. In examining the domestic interests and forces attention is devoted to the financial interests of the two sectoral associations representing the patented and generic drug manufacturers and the economic and political interests of the governing and opposition parties. In examining the international interests and forces the focus is both on the emergence of international institutions and agreements and on the interests of various countries and drug companies located therein which wanted to ensure that Canadas regulatory framework would not have an adverse effect on them. This study reveals that there was three relatively distinct phases in the evolution of Canadas drug patenting regulatory framework and that each was influenced primarily by different sets of factors. The first phase which lasted from 1965 to 1991 was influenced entirely by domestic interests and forces produced by a highly charged political debate over reduced patent protection and drug price restrictions on the one hand, and increased patent protection and economic development on the other. The second phase, which lasted from 1992 to 2001, consisted largely of international forces. This included the emergence of new international institutions and agreements such as the World Trade Organization and the North American Free Trade Agreement, which created new intellectual property obligations for Canada and provided for even longer periods of patent protection than what had already existed. The third phase which began 2002 and continues to the present day, consists of a combination of domestic and international forces which attempt to reconcile domestic issues such as price restriction and economic development with international issues such as allowing Third World countries an opportunity to import drugs at reasonable prices. The Government of Canadas response to all of these pressures has predominantly reflected the objectives of patented drug manufacturers.

The central objective of this study is to examine the factors that have influenced the evolution of the drug patenting regulatory framework in Canada from 1965 to 2005. The principal focus is on the extent to which in formulating that regulatory framework the Canadian federal government has been influenced by domestic and international interests and forces. In examining the domestic interests and forces attention is devoted to the financial interests of the two sectoral associations representing the patented and generic drug manufacturers and the economic and political interests of the governing and opposition parties. In examining the international interests and forces the focus is both on the emergence of international institutions and agreements and on the interests of various countries and drug companies located therein which wanted to ensure that Canadas regulatory framework would not have an adverse effect on them. This study reveals that there was three relatively distinct phases in the evolution of Canadas drug patenting regulatory framework and that each was influenced primarily by different sets of factors. The first phase which lasted from 1965 to 1991 was influenced entirely by domestic interests and forces produced by a highly charged political debate over reduced patent protection and drug price restrictions on the one hand, and increased patent protection and economic development on the other. The second phase, which lasted from 1992 to 2001, consisted largely of international forces. This included the emergence of new international institutions and agreements such as the World Trade Organization and the North American Free Trade Agreement, which created new intellectual property obligations for Canada and provided for even longer periods of patent protection than what had already existed. The third phase which began 2002 and continues to the present day, consists of a combination of domestic and international forces which attempt to reconcile domestic issues such as price restriction and economic development with international issues such as allowing Third World countries an opportunity to import drugs at reasonable prices. The Government of Canadas response to all of these pressures has predominantly reflected the objectives of patented drug manufacturers.

Plain packaging can arguably reduce the appeal of cigarette packages and deter people from smoking. In this study, a 1 (brand type) X 4 (levels of plain packages) betweensubject design was utilized. The method used was an internet survey. 220 adult smokers and non-smokers from Halifax Regional Municipality (HRM) rated packages in terms of their brand imagery characteristics and answered a single multiple choice question to test their recall of the health warning on their package. According to the results of a MANOVA test and a bivariate logistic regression test of perception attributes, the association between plainer packages and the participants’ ratings for some attributes were significant, and ranged from slightly moderate to moderate strength levels of associations. Health warnings recall and plainer packages were also significantly and moderately associated. These associations provide a compelling argument for the need for plain packaging policies as a deterrent for smoking.