Background: Health is a core human right. The right of health care includes access to affordable medicines. Affordability of medicines by individual patients in low-income countries is a significant factor influencing access to care and treatment. However, drug prices in low income countries are found to be higher than those in high-income countries. Although the health care system in Jordan is quite advanced in comparison to neighbouring countries, the access to affordable medicines remains problematic. It was reported that almost 80% of the public in Jordan pay for their medications through out-of-pocket payments. High medicine prices are of a great concern to patients and their finances, which can result in poor compliance. Moreover, non-compliance can lead to reduced productivity and increased medical costs. In fact, several studies found that the high out of pocket-costs can be a significant obstacle to medical adherence with prescription medication regimens. Aims: The aim of this thesis is to research medicine prices and policies in Jordan, in order to recommend feasible solutions to make these affordable. To measure the affordability of medicines in Jordan and to assess the extent by which the cost of medicines is high, prices and factors affecting them were compared with the United Kingdom (UK), a high income developed country. Methods: A mixed-method approach was used in this thesis to research medicine prices and policies. The thesis reviewed the relevant literature, followed by reviewing the health care and pharmaceutical systems in both countries and their impact on medicine prices. Quantitative studies to measure the affordability of medicines in Jordan were conducted to assess the extent by which the cost of medicines is high in comparison to the UK and the factors that may affect medicine prices. This was followed by a qualitative study on how and why high unaffordable prices occur in Jordan. Finally, a quantitative survey exploring patients', pharmacists' and prescribing physicians' opinions towards measures that could be used to achieve greater clinical effectiveness and economic efficiency from drug prescribing was conducted. All the findings from the thesis were synthesised to form policy recommendations, designed to ensure affordable medicines for the Jordanian population. Results and discussion: Factors that influence prices of medicines over time were identified. These included; competition, marketing strategies, time in the market, regulations and pricing policy, change of clinical guidelines, epidemiology of disease, change in therapeutic use/value and exchange rate. Although the income per capita is much lower in Jordan (almost 7 fold less) than the one the UK, the studies conducted within this thesis demonstrated that medicine prices were significantly higher in Jordan compared to the UK. Generic medicines are three fold more expensive than the equivalent prices of the same drugs in the UK. However, the difference in prices for many drugs was significantly higher than the 3 fold difference. For example, the average price of pravastatin and amlodipine generics was more than eight fold higher than the UK price. Moreover, the average price of omeprazole, citalopram and fluoxetine generics were around 10 fold higher than the comparable UK price. Additionally, originator brand medicines prices were also found to be 1.5-fold more expensive in Jordan compared to the UK. Many originators were extremely higher than this average. For example, the Jordanian price of misoprostol originator tablets was around 19 times the comparable UK price. The price of ranitidine originator in Jordan was more than seven times the UK price and lansoprasole originator was around 6 times more than the price in the UK. The current pricing policy and its application are believed to be the root causes for the high prices of medicines in Jordan, as revealed by the qualitative interviews. The expected patients' saving by using generic medicines instead of originators in Jordan ranged from 32% up to 74%. The median saving in Jordan was -30.65% compared to - 71.43% in UK. The average savings were 32.68% and 43.54% in both Jordan and UK respectively. This increased to 54.96% in the UK when one outlier was removed. However, the saving calculated in both countries would have been higher if the lowest priced generic was used. An extra saving of 6.86% was identified in Jordan if the lowest priced generics were used for cardiovascular diseases (the calculated saving increased from 32.71% when using the average generic price compared to 39.57% when using the lowest priced generic). The findings also showed a positive attitude of all stakeholders (patients, pharmacists and prescribing physicians) towards generic medications and their willingness and acceptance of strategies that encourage generic utilisation in Jordan such as generic substitution, lnternational. Non-proprietary Name (INN) prescribing and Electronic Prescribing (EP). Such measures will help reduce the high expenditure on drugs in Jordan which accounts for around one-third of the national health care budget. Conclusion: A range of policy measures and changes are required to improve access to medicines in Jordan. Recommendations made included amendments to pharmaceutical policies, better enforcement of the current regulations, encouraging the use of generic medicines by introducing measures such as generic prescribing, generic substitution and public awareness education programs. These changes should result in more affordable medicines in Jordan.

Introduction: Surgical treatment is the cornerstone of the management of colorectal cancer (CRC). This study described the structures of care at Ontario hospitals performing CRC surgery. Methods: Patients diagnosed with CRC undergoing surgery were identified from 2003-2007. Data linkage identified all institutions performing CRC surgery. Multiple hospital level structures were measured. For the final year of our study, the impact of these structures on 30-day mortality was evaluated. Results: 20,784 patients underwent CRC surgery. Each year, between 106 and 109 institutions performed at least one CRC operation. There was variation in hospital level structures of care. After adjustment for patient characteristics, no hospital level structures were independently associated with 30d mortality. Conclusions: Although variation in surgical care and patient outcomes is likely related to variation in processes and structures of care, after adjusting for covariates, our study did not show any significant relationship between hospital level structures and 30-day mortality.

Introduction: Surgical treatment is the cornerstone of the management of colorectal cancer (CRC). This study described the structures of care at Ontario hospitals performing CRC surgery. Methods: Patients diagnosed with CRC undergoing surgery were identified from 2003-2007. Data linkage identified all institutions performing CRC surgery. Multiple hospital level structures were measured. For the final year of our study, the impact of these structures on 30-day mortality was evaluated. Results: 20,784 patients underwent CRC surgery. Each year, between 106 and 109 institutions performed at least one CRC operation. There was variation in hospital level structures of care. After adjustment for patient characteristics, no hospital level structures were independently associated with 30d mortality. Conclusions: Although variation in surgical care and patient outcomes is likely related to variation in processes and structures of care, after adjusting for covariates, our study did not show any significant relationship between hospital level structures and 30-day mortality.

Introduction: The Family Health Team (FHT) is an Ontario-based initiative that aims to provide primary care through multidisciplinary teams of healthcare professionals. Little is known about variability between and within teams, and whether certain organizational characteristics are associated with quality of patient care. Objectives: (1) To describe FHT-level organizational characteristics for seven FHTs in Southeastern Ontario. (2) To examine the role of physician-level organizational characteristics in predicting: (a) Up-to-date colorectal cancer screening and (b) episodic patient-centredness for patients within seven FHTs in Southeastern Ontario. Methods: This study employed linked datasets obtained from surveys of seven FHTs, 115 health care providers (including 41 family physicians) and 998 patients, as well as a chart abstraction. Statistical analyses included performing subject-specific multilevel multivariate modeling. Results: (1) FHTs varied on characteristics including length of time of practice operation, number of patients, existence of personnel policies, team makeup and team climate. (2) (a) Patient uptake of colorectal cancer screening was associated with average duration of regular routine visit OR=0.88 per minute (95% CI 0.83-0.94), patient gender male OR=2.00 (95% CI 1.22-3.28), general checkup in past 2 years OR=9.03 (95% CI 5.18-15.73), travel time less than or equal to 20 minutes OR=1.53 (95% CI 0.94-2.48), and usually see regular provider OR=0.40 (95% CI 0.19–0.87). Patient uptake or physician recommendation of colorectal cancer screening demonstrated similar associations, with the absence of travel time and the addition of team climate (family physician and nurses) OR=5.88 (95% CI 0.98-35.24), patient occupational status employed vs. retired OR=0.49 (95% CI 0.23–1.02), patient occupational status not employed vs. retired OR=0.42 (95% CI 0.16–1.13), and patient smoking status never vs. ever OR=0.59 (95% CI 0.37–0.96). (b) Episodic patient-centredness was associated with patient born in Canada 0.1119 (95% CI -0.0040-0.2278), seeing regular healthcare provider today 0.1449 (95% CI 0.0426-0.2472), physician-patient gender concordance 0.1019 (95% CI 0.0128-0.1910), and appointment length 0.006929 (95% CI 0.003554-0.010304). Discussion: Further research is needed to examine predictors of the quality of patient care at the practice, physician and patient levels. / Thesis (Master, Community Health & Epidemiology) -- Queen's University, 2012-09-27 15:21:12.794

Electronic cigarettes, or e-cigarettes, are devices that allow users to inhale an aerosol, which contains chemical additives. E-cigarettes are becoming common for nicotine delivery in addition to traditional cigarettes. The goal of this study was to determine how college students perceive e-cigarettes, how often college students use e-cigarettes, and how they view e-cigarettes compared to tobacco cigarettes. This was accomplished through sending a survey built on Qualtrics to UCF students via Knights Email. This survey included questions about demographics, perceptions, and usage of e-cigarettes. The collected data was downloaded into SPSS and analyzed to compare data among different groups. The demographics of the participants reflected the overall student demographics at UCF including age, ethnicity, and academic status, which allowed for the results to be related to the university population. A little over half of the students who participated in this study have tried e-cigarettes. Those who use e-cigarettes reported that the availability of variety of flavors was the most attractive reason for them. Most participants believe e-cigarettes to be equal in harm or less harmful than tobacco cigarettes. Gender, major, and work status differences were observed in survey responses related to use of e-cigarettes and perception of potential harm. The results of the study provide valuable information that can be used in health education programs about e-cigarettes. The results also support the need for future studies to assess the health impact of e-cigarettes on the physiological functions of lungs and other tissues and compare that to tobacco cigarette damage.

Dissatisfaction amongst US physicians has been steadily increasing over the past few decades as health care reform changes the practice of medicine (Hoff, Young, Xiang, & Raver, 2015; Rosenstein, & Mudge-Riley, 2010). In 2008, physician dissatisfaction rates had increased to 19% (Mazaurenko & Menachemi, 2012). By 2012, 42% of physicians voiced dissatisfaction, with family medicine reporting most likely to be dissatisfied (Sorrell & Jennings, 2014). One factor that could affect physician career dissatisfaction/satisfaction that has not been studied is collaborative relationships with other healthcare providers, such as nurse practitioners. This study used secondary quantitative data from the National Survey of Primary Care Physicians and Nurse Practitioners (2012). Logistic regression was used to analyze the relationship of nurse practitioner collaboration and the other independent variables with the dependent variable of physician career satisfaction. In order to address the research goals the independent variables of primary interest were as follows 1) whether PCPs work with NPs in their office; 2) what the quality of the PCP relationship is with the NPs; 3) what is the share of work performed by NPs. Descriptive statistics and binary logistic regressions were run to test the significance of the three hypotheses. Analysis yielded many observational results on the PCPs descriptively but did not show any significant results on the proposed hypotheses regarding PCP career satisfaction. However, one of the greatest strengths of this study was the attempt to bridge the gaps of knowledge regarding PCP and NP collaboration and physician career satisfaction. The fact that results were not significant does not negate the need for further studies on this issue, especially since no other studies exist. In conducting future research, obtaining a larger sample of PCPs, including PCPs who work with NPs, would be an important step in correcting some of the limitations of this study. The lack of significant results also raises further questions regarding the difference between career and job satisfaction with the latter referring to the current work environment rather than the cumulative career experience.

The purpose of this study was to better understand the relationship between elements of patient-centered care and patient/provider comfort with conversing about food insecurity and related social determinants of health. A mixed methods study was conducted. Patients and healthcare providers were surveyed on their experiences with patient-centered care and comfort discussing food insecurity and related social concerns. Telephone interviews were conducted to gain a richer understanding of the concepts under investigation. In the survey and telephone interviews, both samples were also asked about changes in communication during COVID-19 times. Quantitative findings show that patient involvement in care and cultural sensitivity are two important patient-centered variables that positively impact patient comfort being screened for food insecurity. Qualitative findings support this inference, and also denote the importance of other patient-centered care elements, such as empathy, trust, and effective communication. For healthcare providers, process-oriented variables, such as having food insecurity screenings built into the patient history assessment and sufficient training administering screenings were important factors that facilitated comfort screening patients for food insecurity and related concerns. Both populations stated several changes in communication resulting from COVID-19. For example, both samples noted an increase in communication through various channels. However, this increased communication did not necessarily reflect an increase in quality of communication. Patients described quicker and less personal interactions with healthcare providers. Providers observed increased difficulty in conveying empathy and support through nonverbal cues because of wearing masks and communicating through computer screens. The findings of this study provide important implications for healthcare practitioners and community organizations that aim to increase screenings for food insecurity in outpatient medical settings and highlight additional challenges that may be faced resulting from COVID-19.

Opioid-related deaths have increased rapidly over the last couple of decades due to the overprescribing of prescription opioids and the availability of illicit drugs from family members, friends, or street dealers. To address this crisis, this research will attempt to identify how health literacy levels affect knowledge, attitudes, and behaviors. Hence, this study is informed by the Knowledge-Attitude-Behavior (KAB) Model. The KAB model is used to determine the influence of knowledge and attitudes on behaviors, which includes prescription drugs, illicit drugs, and fentanyl. This dissertation aims to explore the relationships between health literacy, knowledge, attitude, and behavior for opioids (prescription and illicit). This study will also explore how these relationships differ by socioeconomic status and demographics. This study used a survey methodology to engage college students from a southeastern university as the participants of this study. The findings of this study show there is an association between health literacy and the KAB model. Additionally, there is an association between the components of the model and gender, ethnicity, and lifetime behavior, which supports what is found in the literature. The results from this study will be useful for opioid researchers and public health organizations so opioid-related information is disseminated in a plain language format to the public. The dissemination of information is significant because it will guide the opioid knowledge of college students and can essentially influence their behavior.

Diabetes Miletus (DM) is one of the major health problems in the United States. Despite all efforts made to combat this disease, its incidence and prevalence are steadily increasing. One of the common and serious side effects of treatment among people with diabetes is hypoglycemia (HG), where the level of blood glucose falls below the optimum level. Episodes of HG vary in their severity. Nevertheless, many require medical assistance and are usually associated with higher utilization of healthcare resources such as frequent emergency department visits and physician visits. Additionally, patients who experience HG frequently have poor outcomes such as higher rates for morbidities and mortality. Although many studies have been conducted to explore the risk factors associated with HG as well as others that looked into the level of healthcare utilization and outcomes among patients with HG, most of these studies failed to establish a theoretical foundation and integrate a comprehensive list of personal risk factors. Therefore, this study aimed to employ Andersen's health Behavior Model of health care utilization (BM) as a framework to examine the problems of HG. This holistic approach facilitates enumerating predictors and examining differential risks of the predisposing (P), enabling (E) and need-for-care (N) factors influencing HG and their effects on utilization (U) and outcomes (O). The population derived from the national inpatient sample of the Healthcare Cost and Utilization Project (HCUP) database and included all non-pregnant adult diabetic patients admitted to hospitals' Emergency Departments (EDs) with a diagnosis of HG from 2012-2014. Based on the BM framework, different factors influencing HG utilization and outcome were grouped under the P, E, or N component. Utilization was measured by patients' length of stay (LoS) in the hospital and the total charges incurred for the stay. Outcome was assessed based on the severity ranging from mortality (the worst), severe complications, mild complications, to no complications (the best). Structural Equation Modeling (SEM) followed by Decision Tree Regression (DTREG) were performed. SEM helped in testing multiple hypotheses developed in the study as well as exploring the direct and indirect impact of different risk factors on utilization and outcome. The results of the analysis show that N is the most influential component of predictors of U and O. This is parallel to what was repeatedly found in different studies that employed the BM. Regarding the other two components, P was found to have some effect on O, while E influences the total charge. Interaction effects of predictors were noted between some components, which indicate the indirect effect of these components on U and O. Subsequently, DTREG analysis was conducted to further explore the probability of the different predictor variables on LoS, total charge, and outcome. Results of this study revealed that the presence of renal disease and DM complications among HG patients play a key role in predicting U and O. Furthermore, age, socio-economic status (SES), and the geographical location of the patients were also found to be vital factors in determining the variability in U and O among HG patients. In conclusion, findings of this study lend support to the use of the BM approach to health services use and outcomes and provide some practical applications for healthcare providers in terms of using the predictive model for targeting patient subgroups (HG patients) for interventions among diabetic patients. Moreover, policy implications, particularly related to the Central Florida area, for decision makers regarding how to approach the growing problem of DM can be drawn from the study results.

The control of proliferation, differentiation and survival of normal and malignant haemopoietic cells is under the control of a wide range of different factors. These include cell:cell interactions, immune regulatory factors, hormonal influences, and local environmental influences. However, the way in which these factors combine to regulate the dynamics of the leukaemic cell are poorly understood. One of the main problems in conducting these experiments is the logistical difficulty in comparing multiple variables. For example, to design an experiment to simulate and study a biological system that involves 13 factors each at 3 different levels requires 1,594,323 experimental runs. Taguchi methods, on the other hand, use orthogonal arrays to create smaller, less costly experiments that have a high rate of reproducibility. A study involving 13 factors at 3 different concentrations can be conducted with only 27 experimental runs. The use of Taguchi methods in the discipline of life scienceis in its very early stages, as very limited number of experiments in this field have been designed and analysed according to the Taguchi methodology. This study was thus set to investigate the suitability of Taguchi methods to study a biological problem with multiple factors involved and poorly understood mechanisms.