<p>Research has demonstrated repeatedly that income and income distribution are powerful determinants of health. While Ontario public health units are mandated to promote health and reduce health inequities, they have done little to help eliminate poverty, instead focusing on individual behaviours such as smoking, diet, and physical activity – an approach likely to worsen health inequities, rather than mend them. Public health nurses (PHNs) across Canada recognize poverty as a powerful determinant of health, yet have expressed challenges in their ability to take meaningful action to address it (Cohen, 2006b; Reutter & Ford, 1996). The study sought insight into how Ontario public health units can strengthen PHNs socio-political efforts to address the causes of poverty. A qualitative descriptive design was used to explore PHNs’ views, while an <em>Appreciative Inquiry</em> approach was used to draw on participants’ successful past experiences in addressing the causes of poverty and their thoughts for the future. Organizational factors thought to empower PHNs’ socio-political efforts to address the causes of poverty were identified using Kanter’s <em>Structural Theory of Power in Organizations</em> as a starting conceptual framework. Fifteen PHNs participated in face-to-face or telephone interviews. Qualitative content analysis was used to describe participants’ affirmative experiences, empowering organizational attributes, and desired actions and supports for the future. Three overall themes emerged with respect to empowering organizational attributes: authorities within the health unit ‘permit and provide’, active associates ‘help each other out’, and external allies ‘contribute and collaborate’. Factors beyond the health unit that would support anti-poverty work were also identified. Findings suggested that action to address the causes of poverty is within the reach of PHNs, and is consistent with their role and the public health mandate, but requires leadership support and political buy-in in order to maximize its effectiveness.</p> / Master of Science (MSc)

<p><strong>ABSTRACT</strong><strong></strong></p> <p><strong>Background</strong>: Healthcare-associated infections (HAIs) and HAI disease outbreaks present challenges for healthcare facilities. In 2008, a <em>Clostridium difficile</em> outbreak in Ontario resulted in the deaths of 91 patients and raised awareness of HAIs. Over the last 5 years, the outbreak rate has risen dramatically. Traditionally, HAI research has focused on epidemiology, healthcare systems, and the economic burden. Little is known about the impact HAI disease outbreaks have on the work of healthcare professionals.</p> <p><strong>Purpose</strong>: The purpose of this study was to examine the effects of HAI outbreaks on healthcare professionals in a large acute care hospital in Ontario.</p> <p><strong>Methods</strong>:<strong> </strong>A retrospective exploratory case study approach was used, including individual interviews, document analysis, and incidence analysis of HAIs hospital data. The sample was frontline nurses, clinical managers, infection control professionals, and environmental service staff. Document analysis included hospital policies and protocols related to infectious diseases and HAI disease outbreaks.</p> <p><strong>Findings</strong>: The incidence rates of Methicillin-resistant s<em>taphylococcus aureus</em>, <em>Clostridium difficile</em>, and Vancomycin-resistant<em> </em>enterococci<em> </em>have decreased but remained above the provincial benchmarks. The daily work of healthcare professionals was impacted by HAI outbreaks. Nurses experienced workload challenges, time pressures, and increased documentation. Infection control professionals' responsibilities have expanded. The environmental services staffs' cleaning processes have become more intensive. In response, several unique innovations were developed by hospital staff.</p> <p><strong>Conclusion</strong>: The daily work of healthcare professionals at the study site has been affected by HAI outbreaks. Implications for future research include the need to review healthcare professionals’ workloads and evaluate contributing factors to HAI outbreaks.</p> / Master of Science in Nursing (MSN)

Despite demonstrating eating disorder rates equivalent to White women, African American and Asian American women are less likely to seek treatment and are more likely to terminate treatment prematurely. One of the most successful programs for eating disorder prevention has only focused on surface-level cultural adaptations. Prevention literature maintains that deep-structure cultural adaptation (e.g., integrating cultural values and beliefs) can enhance outcomes for ethnic minorities. This dissertation examined the feasibility of Sustainable Adapted Treatments for Eating Disorders (SATED), a pilot intervention that included a culturally- targeted pre-treatment to an eating disorder dissonance-based intervention. A sample of 72 women (ages 18-30) were recruited via the SONA pool, student organizations, and community organizations. In Study 1, 47 women participated in focus groups (i.e., 21 African American women and 26 Asian American women). Grounded theory was used to analyze data, and this data was then used to develop a culturally-informed pre-treatment. Pre-treatment protocols (30- 45 minutes) were developed for both African American and Asian American groups and were refined prior to implementing the intervention. In Study 2, a pilot intervention, 25 women were assigned either to a pre-treatment condition, or 30-45 minute, individualized session (N = 12) or a no pre-treatment condition (N = 13) prior to completing an eating disorder DBI which took place over two 2-hour sessions. Participants completed a battery of questionnaires at baseline, post-intervention, and at 2 to 3-month follow-up. Constructs assessed included eating disorder symptomatology, attitudes towards seeking professional psychological help, and body dissatisfaction. Overall feasibility and acceptability of the pre-treatment and pilot intervention were assessed via triangulation of methods including third-party observations, in-depth interviews, and fidelity checks. Preliminary findings from the questionnaires indicated that there was a general downward trend for eating pathology across both the pre-treatment and no pre- treatment condition, except for eating restraint. Body dissatisfaction decreased for both groups from baseline to post-test, but increased at follow-up. Attitudes towards treatment-seeking increased for both groups from baseline to follow-up. Results may inform feasibility issues that accompany translational research with ethnic minorities and inform a future definitive trial.

This dissertation comprises three discrete empirical papers, with an introductory essay that evaluates the impact of different federal policies on prescription drug prices, utilization, and spending. Two main databases are used: (a) Medicaid State Drug Utilization Data and (b) the Medical Expenditure Panel Survey (MEPS) data. These two databases are designed to track Medicaid drug utilization and overall medical use and expenditures, respectively. The variables of interest in this dissertation are prescription drug price, prescription drug use and spending, and overall drug expenditures. The objective of the first paper (Chapter 2) is to examine whether oncology drug prices have significantly changed because the Medicaid rebate increased under the Patient Protection and Affordable Care Act (ACA). The analytic sample includes top-selling oncology drugs, both branded and generic, over an 8-year time period. The prices of top-selling oncology drugs in 2006 were followed through 2013 to find the extent to which drug prices have changed while controlling for state fixed-effect, package size, type of manufacturer, brand or generic, and drug strength. Thus, this study examines whether and to what extent oncology drug prices have changed after the increase in the Medicaid rebate under the ACA. The second paper’s objective (Chapter 3) is to study whether Medicare Part D has reduced racial disparities in diabetes drug use, coverage, and spending since its implementation in 2006. The analytic sample includes individuals aged 55 years and older who had diabetes from 2001 to 2010. Although the impact of Medicare Part D has been studied from different perspectives, its impact on racial disparities in drug use, coverage, and expenditures among diabetics has not been studied yet. The third paper (Chapter 4) focuses on the association between closing the Medicare doughnut hole and prescription drug utilization and spending for Medicare Part D beneficiaries with chronic diseases through 2013. The objective of the third paper is to determine whether the provisions of the ACA that close the coverage gap have affected prescription drug utilization and out-of-pocket (OOP) spending among Medicare seniors with Part D coverage.

Medicaid expansion under the Affordable Care Act (ACA) facilitates access to care among vulnerable populations, but 21 states have not yet expanded the program. Tennessee’s Medicaid program experienced a dramatic Medicaid contraction when the program disenrolled approximately 170,000 nonelderly adults in 2005. Pre-ACA expansions were associated with better access to and utilization of healthcare services. However, little is known about the effect of these policy changes on improvement in health outcomes for women diagnosed with breast cancer, access to care for cancer survivors, and the effect of generosity and duration of expansion on access to care. This dissertation has three objectives. First, to assess the effects of the Tennesse’s Medicaid disenrollment on stage at diagnosis and delay in surgery for breast cancer among nonelderly women. Second, to compare access to care between cancer survivors living in non-expansion states and survivors living in expansion states. Third, to examine the effect of generosity and duration of the pre-ACA Medicaid expansions on access to and utilization of healthcare services. I use three different types of datasets: the 2002-2008 data from Tennessee Cancer Registry, the 2012 and 2013 Behavioral Risk Factor Surveillance System (BRFSS), and the 2012 Medical Expenditure Panel Survey (MEPS) data. I estimate difference-in-difference models and perform multiple logistic regression models to examine the impact of these policy changes on the different measurement outcomes. While many states are expanding Medicaid eligibility under the Affordable Care Act, there has been discussion among policymakers in some states about reducing eligibility under the Affordable Care Act once full federal funding expires. This study suggests that Medicaid disenrollment leads to later stage at diagnosis for breast cancer patients, indicating negative health impacts of contractions in Medicaid coverage. Prior to the passage of the Affordable Care Act, cancer survivors living in expansion states had better access to care than survivors living in non-expansion states. Failure to expand Medicaid could potentially leave many cancer survivors without access to routine care. The study informs policy makers that, relative to no expansion, moderate or generous expansion is associated with improvement in access to and utilization of healthcare services.

Background – An increase in opioid prescribing has led to an increase in opioid overdoses.1,2 No study has estimated the incremental costs subsequent to an opioid overdose event in prescription opioid users, or the prevalence and costs of overdose events in family members of prescription opioid users and in overdose victims with no identifiable source of prescription opioid. The latter group will be referred to as “others”. Objectives – The first objective of this study was to estimate the prevalence of opioid overdoses in aforementioned groups. The second objective was to estimate the incremental costs and resource utilization associated with opioid overdoses in these groups. Methods – This study is a retrospective analysis using claims data from SelectHealth, a not-for-profit health insurance organization in Utah and southern Idaho. We estimated the prevalence of opioid overdoses in the sample population, as well as in each group, by year. For the cost estimation we collapsed family members and others into one category – “non-medical users”. To estimate costs we used an incremental cost approach whereby we used propensity scores to match cases (patients who suffered from an opioid overdose) to appropriate controls (patients who did not suffer from an opioid overdose) and estimated the direct medical costs incurred in each group in the year following an overdose. Generalized Linear Models were used to estimate incremental costs and resource utilization. Sensitivity analyses were conducted to measure the robustness of the estimates. Results – The prevalence of opioid overdoses increased by 84.8% in prescription opioid users (from 55.6 per 100,000 in 2011 to 102.8 per 100,000 in 2014), increased by 37.9% in family members of prescription opioid users (from 5.9 per 100,000 in 2011 to 8.2 per 100,000 in 2014) and increased by 179.9% in others (from 8.2 per 100,000 in 2011 to 23.1 per 100,000 in 2014). The prevalence of opioid overdoses in acute users increased by 14.7% (from 43.8 per 100,000 in 2011 to 50.3 per 100,000 in 2014) as compared to 165.9% in chronic users (from 187.0 per 100,000 in 2011 to 497.3 per 100,000 in 2014). The incremental direct medical costs per patient per year were estimated to be $65,277 (p-value<0.05) in prescription opioid users who suffered from an overdose and $41,102 (p-value<0.05) in non-medical users who suffered from an overdose. Overdose-specific costs were estimated to be $12,111 for prescription opioid users and $11,070 in non-users. Conclusions – Our study found that the prevalence of opioid overdoses increased steadily from 2011 to 2014 in the sample population. The prevalence of overdoses was much higher in chronic opioid users as compared to acute users. Differences between overdose-specific costs and total incremental costs may suggest that overdoses are associated with substantial costs in addition to costs for the initial treatment of the overdose. While the cost to payers due to overdoses in prescription opioid users is substantial, payers also incur costs from diversion of opioids.

M.A. / The research describes the different methods followed by traditional healers and western professionals in dealing with mental illness. The study is intended to provide an in-depth analysis of the process involved when the mentally ill patient consult a traditional healer in the community and a western professional at the local clinic in Emzinoni. The study also intends to examine whether or not the two approaches can complement each other. In this research, it was found that the mentally ill patient would consult either a traditional healer or a western professional worker. In some cases, when the patient has consulted the traditional healer and his/her condition does not improve, he/she resorts to western medicine. The same applies to the patients, who have consulted a western professional. If his/her condition does not improve, he/she consults the traditional healer. The study showed that patients who are mentally ill do not use medicines from both traditional healers and western professional at the same time. The patient chooses the treatment that makes him/her become better. It was recommended in the study that traditional healers and western professionals should develop a referral system.

A Thesis submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in fulfilment of the requirements for the degree of Doctor of Philosophy December 2015 Johannesburg. / Introduction There has been little published in South Africa regarding quality improvement in health and in particular the involvement of patients in this intervention. There is evidence globally that both quality improvement efforts and particularly the engagement of the users adds value to health services. Three projects were conceived around this core concept as explained below. 1. Systematic review. Patients’ involvement in improvement initiatives: a qualitative systematic review After a search was done of databases, 5121 papers were found to be potentially relevant. After screening and critical appraisal for eligibility, it was found that 31 articles qualified for analysis. These were then assessed using JBI software and 5 categories and 2 metasynthesised findings were documented. In summary, there were enablers and barriers to involving patients. The five categories which lead to these 2 findings were the following: (1) although patient participation in QI is acknowledged and encouraged by many policies and documents globally, it is difficult to implement; (2) there are differing views between patients and providers as to the process; (3) on the positive side, different levels of involvement of patients in QI were demonstrated; 4) practical, appropriate and innovative results emerged; (5) individual or group support and incremental development through skills and enablement contributed towards success 2. The Integration of Non Communicable Chronic Diseases (NCDs) and HIV/Aids and mental health care through the involvement of chronically ill patients using Empowerment Evaluation (EE). At 9 primary care clinics, the process of EE was followed with chronically ill stable patients and appropriate healthcare workers. This was an additional intervention in an ongoing QI cycle on the integration of all chronic illnesses into one model, based on Lean principles. Steps followed were ‘’taking stock’’ ie assessing patients’ and HCWs’ impressions of the services at the clinic in a measured way, creating a vision and using this as a yardstick for the project and then problems and solutions being co-managed by the collaborative team. A total of 37 interventions were discussed and 23 implemented in the time frame. Innovative solutions were implemented and teams were empowered by the potential they experienced. 3. An exploration of childhood nutrition and wellness in a subdistrict by patient inclusivity in QI using experience based codesign (EBCD) with mothers/caregivers of malnourished children . Following the steps of EBCD, staff and patients exposed to health services regarding ill children, were interviewed, feedback was given of the findings separately and then in a combined meeting and co-design teams were created to work with the prioritised quality improvement interventions. Touch points in the system were examined through emotional mapping, video interviews and observations. Within the 10 month period of the project, 38 interventions were identified and 25 accepted and implemented at different levels. Conclusion The methodologies were chosen to fit with the qualitative aspect of the research. There were concrete appropriate improvement outcomes due to the engagement of service users in both the primary care clinics serving chronically ill patients and the paediatric system in one subdistrict eg the flow of patients improved, logistical improvements like direct admissions for very ill children, school and library opportunities for admitted ill children etc occurred. Subjective gains like the acknowledgement of their power role by patients and a flattening of the healthcare worker hierarchy were also experienced in the research. Other findings were that unexpected roleplayers were identified, the timeframe of such QI cycles needs to be considered especially regarding the resilience of patients and resources were not an importatn limitation. However some modifications would have to be considered to make these research approaches common practice. The particular research methodologies have not been published in a South African context before and have also not been used for paediatric or integrated chronic illness research and therefore contribute both content and process information to health systems research in South Africa. / MT2017

With aging populations and rising health care costs, many high-income countries are exploring mobile computing technologies to improve the efficiency and effectiveness of health care provision. These technologies, which underpin the field of pervasive computing, introduce a new model of human–computer interaction. Instead of the scenario where a single user interacts with a desk-bound “personal” computer, pervasive computing envisions a world embedded with small, inexpensive, portable networked devices able to communicate seamlessly with each other. In common with resource-rich countries, the field of pervasive computing has the potential to promote and support healthy population development in middle and low-income countries, and this, therefore, has relevance for South Africa. Current estimates suggest that there are between 28 and 32 million mobile phones in South Africa. This means that around 60% of all South Africans own, or have access to, mobile telecommunication. Over 900 000 km2 of the country is covered by the GSM (Global System for Mobile Communication) network of Vodacom, the largest telecommunications company in the country. Over 90% of South Africa is provided with access to mobile connectivity through shared agreements between the country’s major telecommunications networks. Aims The ubiquity of mobile phones has resulted in their receiving increasing attention from public health researchers. Yet a better understanding of how mobile phones could support health research in South Africa is still an emerging field with many unanswered questions. This thesis attempts to fill some of these gaps in our current knowledge. In particular, the primary aim of this work is to implement and evaluate the use of mobile phones as instruments with which to collect and analyse information for monitoring, evaluation and research in low-resource rural African settings. Methods To investigate this aim, data were gathered from the development, implementation and evaluation of four health surveys in South Africa. Two surveys were conducted with Birth to Twenty, a birth cohort of South African young adults living in Greater Johannesburg. These data were used to better understand the feasibility and data-quality implications of using mobile phones as a tool for the administration of ‘self-administered’ surveys. Two additional surveys, completed in KwaZulu-Natal province, evaluated the same themes of feasibility, acceptability and impact of data quality in mobile-phone-assisted personal (face-to-face) interviews (MPAPI). The first, conducted with 500 HIV-positive pregnant women in eight primary health clinics and 12 interviewers trained to use the mobile-phone survey software, was used to assess the feasibility and acceptability of MPAPI. The final survey compared the difference in data quality achieved by 100 interviewers using either pen and paper, or mobile phones to conduct a short health survey. De Leeuw's conceptual model was used to frame how mode characteristics influence data quality. Results Mobile-phone-assisted interviewing was found to have an impact on the data quality, feasibility and acceptability of health surveys. MPAPI was found to be similar in terms of accuracy and cost to small-scale paper-and-pen interviewing (PAPI) surveys. Time lines and accessibility were improved by the use of MPAPI. Mobile-phone-assisted self-interviewing (MPASI) surveys were found to have a lower survey response but a higher item-completion rate. Acceptability was found to be moderated by technological familiarity and the use patterns of mobile-phone features. Finally, conducting health research using mobile-phone interviews in South Africa was found to be feasible; to reduce the loss of questionnaires, and photocopying and data-entry costs; and to improve the speed at which data becomes available for analysis. Factors that mediated feasibility included the technical expertise of the project management and field staff, the technological know-how of participants, the comprehensiveness of the interviewer training, the mobile communication channel used (e.g., handset-agnostic SMS) and the presence or absence of an interviewer. Conclusion Under the right conditions, mobile-phone-assisted interviewing appears to be a feasible and practical tool for the rapid collection of health information, with data accuracy being the same or better than pen-and-paper interviews. It is argued that these benefits increase as the scale of the survey increases. Improved data can positively influence population health by providing decision makers with more rapid access to accurate data with which to monitor large-scale health systems. Small projects that do not require the rapid availability of data or where staff do not have the appropriate technical proficiencies would be better suited at present to more traditional survey data-collection techniques. Keywords: mobile phones; pervasive computing; mHealth; data collection; survey error

INTRODUÇÃO: A importância de se avaliar sistemas e serviços de saúde: aumento de gastos, avanços tecnológicos, envelhecimento da população, deficiências com as práticas na assistência, iniquidades na alocação de recursos, necessidade de prestação de contas aos órgãos controladores e à sociedade, melhorias e reformas no sistema e serviços de saúde. A avaliação de desempenho de serviços de saúde demonstra parte importante do desempenho do sistema de saúde, permitindo comparações de desempenho de processos e resultados, à medida que os serviços avaliados tenham articulações entre si, e que o desfecho tenha relações com todos os níveis da atenção avaliados. OBJETIVO: avaliar o desempenho dos serviços públicos de saúde de um município paulista de médio porte, no período de 2008 a 2015, quanto a resultados de qualidade nas dimensões do acesso, da efetividade e da adequação de serviços. MATERIAL E MÉTODO: estudo exploratório, com análise descritiva de dados quantitativos. Utilizados indicadores de saúde dos sistemas de informação do Ministério da Saúde, e populacionais do IBGE. Foram distribuídos nas dimensões do acesso, efetividade e adequação, conforme modelo do PROADESS - Metodologia de Avaliação do Desempenho do Sistema de Saúde; para a interpretação do desempenho foi realizada comparação entre o nível municipal e outros três níveis (estado de São Paulo, região Sudeste e Brasil). RESULTADOS: acesso: taxa de internação, cirurgia de revascularização, angioplastia e imunização por tetra/pentavalente demonstraram melhor desempenho dos serviços de saúde municipais em relação aos demais níveis; cobertura Estratégia Saúde da Família e vacinação do idoso contra a gripe demonstraram pior desempenho, porém com tendência de melhora ao longo do tempo. Adequação: consultas de pré-natal do município com melhor desempenho em relação aos demais níveis, e mais próximas do preconizado; histerectomia e partos cesáreos com pior desempenho. Efetividade: mortes em internações por infarto agudo do miocárdio com melhor desempenho para o município; internações por Condições Sensíveis à Atenção Básica, sífilis congênita em menor de um ano e amputação de membros inferiores em diabéticos com pior desempenho municipal em relação aos outros três níveis do estudo. CONCLUSÃO: quanto ao acesso, no conjunto dos indicadores o desempenho foi positivo, com melhor resultado para a atenção hospitalar em relação à atenção básica; quanto à adequação, o desempenho foi desfavorável ao município em comparação com os demais níveis, assim como na efetividade o desempenho municipal também foi inferior aos outros três níveis pesquisados, demonstrando fragilidade na atenção básica da assistência. / INTRODUCTION: The importance of evaluating health systems and services: increased expenditures, technological advances, aging of the population, deficiencies with assistance practices, iniquities in resource allocation, accountability to controlling organs and society, improvements and reforms in the health system and services. The performance evaluation of health services demonstrates an important part of the performance of the health system, allowing comparisons of performance of processes and results, as the services evaluated have articulations among them, and that the outcome has relations with all levels of attention evaluated. OBJECTIVE: to evaluate the performance of public health services in a medium-sized São Paulo municipality, from 2008 to 2015, in terms of quality, access, effectiveness and adequacy of services. MATERIAL AND METHOD: exploratory study, with descriptive analysis of quantitative data. Health indicators of the information systems of the Ministry of Health and of the IBGE population were used. They were distributed in the dimensions of access, effectiveness and adequacy, according to the model of the PROADESS - Methodology for Evaluation of Health System Performance; for the interpretation of the performance was carried out comparison between the municipal level and other three levels (state of São Paulo, Southeast region and Brazil). RESULTS: access: hospitalization rate, revascularization surgery, angioplasty and tetra / pentavalent immunization demonstrated better performance of the municipal health services in relation to the other levels; coverage Family Health Strategy and vaccination of the elderly against influenza showed worse performance, but with a tendency to improve over time. Adequacy: prenatal consultations of the municipality with better performance in relation to the other levels, and closer to that recommended; hysterectomy and cesarean delivery with worse performance. Effectiveness: deaths in hospitalizations due to acute myocardial infarction with better performance for the municipality; hospitalizations for conditions sensitive to primary care, congenital syphilis in less than one year and amputation of lower limbs in diabetics with worse municipal performance in relation to the other three levels of the study. CONCLUSION: with regard to access, in the set of indicators, performance was positive, with a better result for hospital care in relation to primary care; in terms of adequacy, the performance was unfavorable to the municipality in comparison to the other levels, as well as in the effectiveness, the municipal performance was also inferior to the other three levels surveyed, showing weakness in the basic assistance care.