This thesis is about policy instruments for the regulation of international labour mobility. It focuses on the use of government-to-government agreements on the cross-border movement of nurses, negotiated between source and destination countries. This research is a qualitative case study of agreements signed in the early 2000s between the UK and Spain, South Africa, the Philippines and India. It aims to understand the role of these agreements in British policy as perceived by actors in the destination country. It addresses three questions: 1) What types of agreements did the British government negotiate? 2) Why did the British government negotiate these agreements? and 3) What functions did these agreements perform? Employing the notion of ‘policy tools’ as an organising concept, this thesis’s analytical framework draws on political sociology and the conception of policy instruments as being composed and brought into existence by actors and their power relations in multilevel policy contexts. This study is based on documentary analysis and elite interviews with experts in international organisations, officials in the Department of Health (England), recruitment officers in the source countries, and professional nursing organisations and trade unions in the UK. This thesis argues that government-to-government agreements between the UK and supply countries emerged from a discourse on the ethical recruitment of health workers which was framed in the language of human rights. One of the roles of these agreements was to contain contradictory and conflicting interests between and within institutional actors involved in the international recruitment of nurses on both sides of the migration process. More broadly, the research addresses and advances the discussion of the policy instrumentation approach, and contributes to the understanding of the choice of policy tools and their performance in an ambivalent policy context.

acase@tulane.edu / The Zambian Ministry of Health (MOH) National Malaria Control center (NMCC) adopted artemisinin combination therapy (ACT) as a first-line antimalarial drug for uncomplicated malaria in 2003, and included rapid diagnostic testing (RDT) in its case management guidelines to reduce over-diagnosis of malaria and over-prescription of antimalarials. Prior research has highlighted gaps in the malaria case management process in Zambia, especially in diagnosis and treatment. The first paper of this study aimed to build quality indices or indicators for the four components of malaria case management: assessment, diagnosis, treatment and counseling. The Zambia MOH/NMCC conducted a nationally representative health facility survey in 2011 with the Malaria Control and Evaluation Partnership in Africa. The mean assessment quality (percentage of assessment items correctly completed) rate was 49.9%. The diagnostic quality (concordance with gold standard diagnosis) rate was 82.4%, with 86.9% sensitivity and 79.4% specificity. The treatment quality rate (correct treatment for those needing antimalarials and no treatment for patients not needing it) was 89.6%, and the mean counseling quality (percentage of counseling items correctly completed) rate was 48.6%. The second paper investigated factors association with each of the four components of malaria case management. Supervision was significantly associated with assessment and counseling but not diagnosis and treatment. Health facility managing authority was associated with assessment and diagnosis. Availability of blood tests was associated with correct diagnosis, and diagnosis was strongly associated with treatment. Malaria endemicity and availability of IMCI guidelines were associated with counseling quality. The third paper investigated the associated between counseling and patient recall of treatment regimen, and found that they were associated as hypothesized. The Zambia NMCC has improved the quality of malaria case management over previous years, although it is recommended that more health facility surveys are conducted in order to study the change in health worker performance over time. / 1 / Louie Rosencrans

ABSTRACT Introduction Oral diseases have a severe impact on rural and remote Indigenous communities of Australia with widespread, severe dental caries leading to a significant number of Indigenous children requiring multiple dental extractions under general anaesthesia each year; a scenario rarely seen elsewhere in Australia. This burden of oral disease occurs in these communities in the context of very limited availability of dental personnel and access to oral health care. The rural and remote Indigenous communities of Australia rely on Indigenous Health Workers as key primary health care personnel. Experience in Western Australia and the Northern Territory suggests that the oral health role of these personnel can be developed to improve community oral health and reduce the burden of oral disease in Indigenous communities. The development of the Indigenous Health Worker oral health role is supported by major stakeholders including: the peak Indigenous health organisation, the National Aboriginal Community Controlled Health Organisation; the peak dental health organisation, the Australian Dental Association; and by Australia’s National Oral Health Plan. Yet limited progress has been made in the development of this role. Why? This case study seeks to answer this question through the exploration of the complex, multiple factors influencing the development of the oral health role of Indigenous Health Workers in the Cape York region and so support the development of this role among Indigenous Health Workers. Methodology This research was conducted in accordance with the National Health and Medical Research Council’s Statement and Guidelines for ethical conduct of Indigenous health research. Ongoing consultation took place with key Indigenous health organisations of the region. including Apunipima Cape York Health Council, Gurriny Yealamucka Health Service and the Queensland Aboriginal and Torres Strait Islander Health Worker Training Aboriginal Corporation, to confirm that the research focus was a priority of the communities of the region and to gain input into the design and implementation of the project. With the support of these Indigenous health organisations the study focused on the three communities in which an initial introduction to oral health promotion was provided to Indigenous Health Workers by Queensland Health through its Crocodile Smiles Project. Qualitative methodologies were used with data collection in the region undertaken through semi-structured interviews with 58 health personnel in the remote Indigenous communities of Hopevale, Napranum and Yarrabah; and in the regional centres of Cairns, Cooktown and Weipa. These interviews explored the perceptions of Indigenous Health Workers, dental personnel and their co-workers regarding the priority, characteristics and support needs of the development of the Indigenous Health Worker oral health role in the region. Results Interviews with rural and remote health personnel highlighted the severe impact of oral disease in these communities and on their health services and the high priority given to the development of the Indigenous Health Worker oral health role. These health personnel are seen as key to Indigenous health promotion in the region. Contrasting perspectives were found among rural and remote health personnel regarding the characteristics of an appropriate Indigenous Health Worker oral health role with consistent support being given to the development of the oral health promotion role and varied perspectives found concerning the development of a clinical oral health role. Rural and remote health personnel also highlighted the significant barriers to the development of the Indigenous Health Worker oral health role existing at the clinic and regional levels. Conclusion This study identifies drivers of role development as including oral health needs and oral health skills shortages in rural and remote Indigenous communities of Cape York. Facilitators to role development were found to include: the legislative and policy environment; the support of Indigenous Health Workers and their co-workers; and the policies and plans of Queensland Health and the Indigenous Community Controlled Health Organisations of the region. Significant barriers include: the existing work burden of Health Workers; the lack of clarity of Health Worker role definition; and the difficulties inherent in the development of appropriate inter-professional and cross-cultural training and management support strategies which are able to be implemented in remote settings. The research highlights the complexity of factors to be considered in achieving the system¬wide changes needed to support the development of this role and makes recommendations in the areas of policy, training, management and research to best support the development of this role. In focusing on the development of the oral health role of Indigenous Health Workers the study has examined an area of significance to the Indigenous community using culturally sensitive research methods in remote settings and has addressed a significant though little explored area of dental research – the development of the oral health role of non-dental personnel.

O espaÃo de atuaÃÃo do agente comunitÃrio de saÃde (ACS) tem como foco principal o acompanhamento de mulheres no ciclo gravÃdico-puerperal, cenÃrio em que desenvolve sua aÃÃo comunicativa, cercado pelas relaÃÃes que demarcam a necessidade de articulaÃÃo com a gestante, comunidade e demais profissionais que compÃem a equipe da EstratÃgia SaÃde da FamÃlia. O aumento da detecÃÃo de casos de HIV na vigÃncia da gestaÃÃo evidencia a necessidade de promover acompanhamento que garanta adesÃo ao tratamento e promova o cuidado a essa gestante. Ante a complexidade dessa relaÃÃo, teve-se como objetivo compreender o processo comunicativo do ACS estabelecido durante a abordagem com gestantes e puÃrperas que vivem com o HIV, identificar as estratÃgias que utilizam nesse processo, bem como suas facilidades e dificuldades. Estudo qualitativo, desenvolvido à luz do interacionismo simbÃlico, entrevistando oito ACS que acompanharam gestantes e puÃrperas vivendo com o HIV, no perÃodo de janeiro de 2007 a julho de 2012, no MunicÃpio de CanindÃ- CE. O corpus empÃrico foi categorizado em cinco categorias centrais: 1. Identificando gestante/puerpÃra com HIV na comunidade; 2. Significado do HIV para a ACS; 3. Acompanhamento realizado pela ACS; 4. Desvelando o processo comunicativo da ACS durante a abordagem com gestantes e puÃrperas vivendo com o HIV; 5. InterligaÃÃes com o âmundo da vidaâ. Os resultados obtidos foram analisados conforme a tÃcnica de anÃlise do discurso, com reflexÃes ancoradas no referencial teÃrico de Habermas, Morin e literatura especializada. Identificou-se o fato de que a gestante revela seu status sorolÃgico à ACS em razÃo do vÃnculo constituÃdo e da facilidade de acesso ao serviÃo de saÃde. Por outro lado, o acolhimento humanizado da ACS se relaciona ao sentimento de tristeza atribuÃdo à doenÃa. Apesar de buscarem conceituar Ãtica como guardar sigilo, hà um conflito entre comunicaÃÃo e Ãtica na autocompreensÃo desse conceito na divulgaÃÃo de informaÃÃes na equipe de saÃde. Desenvolvem sua comunicaÃÃo com as mulheres quando descrevem suas orientaÃÃes de forma dinÃmica e ciclica, com base num agir estratÃgico mediante uma imposiÃÃo disfarÃada, induzindo a gestante/puerpÃra a aceitar sua convicÃÃo como vÃlida. Apesar de ser uma estratÃgia que foge do agir comunicativo proposto por Jurgen Habermas, as ACS se sentem felizes por terem a confianÃa das mulheres e pelo fato de representarem uma referÃncia para a comunidade, mas apontam como dificuldades a sobrecarga de trabalho, a ausÃncia de capacitaÃÃes permanentes, a indefiniÃÃo no seu papel e problemas de ordem socioeconÃmica vivenciados pelas gestantes. / The performance space of the community health worker has as its main focus the monitoring of women in pregnancy and childbirth, in that scenario develops his communicative action, surrounded by relations that demarcate the need for coordination with patient, community and other professionals who make up the staff of the Family Health Strategy. Increased detection of HIV in the presence of pregnancy has shown the need for further monitoring to ensure adherence to treatment and care will promote this pregnant. Given the complexity of this relationship, we aimed to understand the communication process established during the Community Health Worker approach with pregnant and postpartum women seropositive for HIV, identify the strategies that you use this process, as well as their strengths and difficulties. Qualitative study, developed in light of symbolic interactionism, interviewing eight Community Health Worker accompanying pregnant and postpartum women seropositive for HIV from January 2007 to July 2012 in the city of CanindÃ-CE. The empirical corpus was categorized into five main categories: 1. Identifying pregnant / postpartum women with HIV in the community; 2. Meaning of HIV to ACS; 3. Monitoring conducted by Community Health Worker; 4. Unveiling the communication process during the ACS approach with pregnant and postpartum women seropositive for HIV; 5. Connections with the "life-world". The results were analyzed according to the technique of discourse analysis, with reflections grounded in the theoretical framework of Habermas, Morin and literature. We identify the pregnant woman reveals his HIV status to Community Health Worker due to the bond built and ease of access to health services. Moreover, the host of humanized Community Health Worker relates to the feeling of sadness attributed to the disease. Despite seek conceptualize ethics as secrecy, there is a conflict between communication and ethics in the selfunderstanding of this concept in the disclosure of information in the health team. Develop your communication with women when describing their orientations in a dynamic and cyclic, based on a strategic action by a levy disguised, inducing pregnant / postpartum women to accept his conviction as valid. Despite being a strategy that avoids the communicative action proposed by Jurgen Habermas, the community health worker are happy to have the confidence of women and because they represent a reference point for the community but the difficulties as work overload, lack of training permanent uncertainty in its role and problems of socio-economic order experienced by pregnant women.

Conselho Nacional de Desenvolvimento CientÃfico e TecnolÃgico / âA mancha visÃvel e o nervo sentidoâ - representaÃÃo social da hansenÃase para agentes comunitÃrios de saÃde objetiva compreender as representaÃÃes sociais sobre a hansenÃase/lepra na prÃtica discursiva das/dos Agentes ComunitÃrios de SaÃde (ACS), identificando crenÃas, valores e tabus que possam estar imbricados no trabalho. Por ser a hansenÃase uma doenÃa mÃtica e estigmatizada, envolta de saberes e prÃticas construÃdas historicamente, acreditamos que as prÃticas da/do ACS tÃm representaÃÃes que, sÃo incorporadas ao seu trabalho. Contextualizamos a evoluÃÃo sÃcio-histÃrica do adoecimento, bem como a elaboraÃÃo ideolÃgica presente no imaginÃrio coletivo dos ACS. Com suporte nos conceitos de ideologia, discurso e poder, verificamos como as representaÃÃes sociais que os sujeitos da pesquisa tÃm acerca da hansenÃase afetam a sua vida. Duas questÃes nortearam este estudo: que representaÃÃes sociais as/os ACS tÃm sobre a hansenÃase/ lepra? E como estas representaÃÃes se imbricam em seu trabalho? Participaram 91 ACS que atuam na EstratÃgia SaÃde da FamÃlia dos MunicÃpios de SÃo Josà de Ribamar (MA), Paragominas (PA), AraguaÃna (TO) e Floriano (PI). A metodologia consistiu na anÃlise temÃtica. Utilizamos a tÃcnica do grupo focal. Do material produzido em campo, estabelecemos o corpus empÃrico, de onde emergiram as categorias/temas (conceitos-imagens). Em cada tema foram divisadas as subcategorias, que se denominou Unidade Representacional (UR). Os conceitos-imagens emergidos foram: 1) lepra X hansenÃase - significados e sentidos; 2) Estigma - a marca do preconceito e da discriminaÃÃo nas prÃticas discursivas; 3) MicropolÃtica na produÃÃo de cuidado a pessoa com hansenÃase; 4) Envolvimento das famÃlias no processo de cuidado; 5) Vivendo/convivendo com a hansenÃase. A pesquisa revelou, dentre outras representaÃÃes, que as/os ACS acreditam na existÃncia de alimentos âreimososâ. Evidenciou-se, tambÃm, culpabilizaÃÃo, do uso de Ãlcool como determinante para o prolongamento da terapia. Constatamos que a lepra e a hansenÃase nÃo se configuram como sinÃnimos, mas sim como duas entidades distintas. Ao termo lepra, cabe o sentido de medo, vergonha e exclusÃo, enquanto hansenÃase adquire o sentido de doenÃa curÃvel. Evidenciamos nos discursos preconceito e prÃticas discriminatÃrias vivenciadas pelas pessoas com hansenÃase, configurando-se em legitimaÃÃo do estigma.

Magister Public Health - MPH / The aim of this research was to describe the role of Community Health Workers, in the Mitanin Programme, in addressing social determinants of health in Chhattisgarh State of India, with the view to identify the pathways for strengthening and making recommendations on this aspect of the CHW’s work for existing or future CHW programmes. A comparative case study design using qualitative research methods was adopted for the study, with the sample comprising of two case studies of action on social determinants by CHWs. The definition of a case was ‘successful action by a CHW (Mitanin) or team of CHWs (Mitanins) on nutrition or violence against women in the village or cluster of villages for which the CHW/s are responsible’. The sampling of the cases followed the ‘replication logic’, that is, examination of similar cases to draw general lessons. Data collection was undertaken through In-depth Individual Interviews and Group Interviews with CHWs, community members and programme staff that participated with the CHWs in, and also benefitted from, their action on social determinants. Respondents were identified through a process of snowball sampling. Seventeen in-depth interviews and ten group interviews (total 27) were conducted as part of the study. A broad conceptual framework of the factors facilitating and constraining the action on social determinants by the CHWs, along with the pathways for action on social determinants by the CHWs, along with the pathways for action on social determinants by CHWs and their role, was developed at the start of the research. The analysis was done using this conceptual framework, which was refined during analysis, resulting in an explanatory framework. The analysis was two-fold. Firstly, both cases were analysed and written up separately and then they were analysed together in order to draw cross case conclusions. Thematic analysis was undertaken. Ethical Clearance was obtained from the UWC Senate Research Committee and permission was obtained from the State Health Resource Center, the body coordinating the Mitanin Programme in Chhattisgarh. A Participant Information Sheet and Informed consent forms for both the individual and the group interviews were prepared and administered. The form for the group interview included a confidentiality-binding clause. The study showed that the Mitanins in Durgkondal and Manendragarh (the Blocks under study) had effectively and successfully addressed the issues of nutrition and xvii violence against women as social determinants, in a manner visualized in the initial programme documents. Despite threats to the autonomy of the programme, pressures to formalise the Mitanin’s role, and backlash from vested interests, such action remained sustained, nearly ten years since the start of the programme.

Obesity is caused by a variety of contributing factors including genetics, behavior, and environment, which contribute to weight gain in children and adults. The obesity epidemic is growing rapidly, predisposing both children and adults to preventable chronic diseases such as heart disease and type 2 diabetes. Obese children often become obese adults, further contributing to the obesity epidemic and its economic consequences including higher healthcare costs and lost productivity. The obesity epidemic also exposes significant health disparities; non-Hispanic Blacks and Hispanics represent a disproportionate number of obese adults and children in the United Community Health Workers (CHWs) are uniquely positioned to support current efforts in the prevention and treatment of childhood obesity. Studies have found CHWs to be effective at increasing healthy behaviors and reducing disparities in cancer screenings for adult minority groups. CHWs can be trained to provide a variety of health services, reducing the burden of healthcare professionals, and reducing cost of care. CHWs provide peer to peer, culturally sensitive health information in an individual’s preferred language. The proposed study is a three-year randomized controlled clinical trial with 262 participants divided equally into two groups, intervention, and control. Non-Hispanic Black and Hispanic children ages 1-5 years old will be recruited from their pediatrician’s offices in the Boston Metropolitan Statistical Area (MSA). Participants will be identified and enrolled by research assistants based on language of care and BMI (body mass index) as recorded in the electronic medical record (EMR). Both groups will receive standard of care treatment throughout the study. The intervention group will additionally receive monthly in-home CHW visits for the first one and a half years. CHWs will take quarterly BMIs and provide education materials on healthy eating and physical activity. The primary outcome is BMI and the secondary outcomes will include healthy behaviors such as average weekly servings of fresh fruits and vegetables. At the end of the study period, all guardians will be given a survey to assess their opinions on the standard of care treatment and CHW interventions. CHWs are an untapped resource in the fight against childhood obesity, reducing health disparities, and the obesity epidemic. However, more research is needed in this area and the proposed study is a step toward proving their efficacy and efficiency. In the United States, the implementation of CHWs over time could make a huge impact on public health by reducing preventable chronic diseases.

Yes / Reliable health information is essential for decision making in the healthcare system. Information management in Kenya was considered the weakest area under the Health Information System pillar mainly due to inadequate health workers capacity. The study therefore aimed at assessing health workers skills and current training needs for information management in the selected healthcare facilities. Cross-section research design was adopted and both purposive sampling technique and censuses were used to establish the study participants. Analysis was done using SPSS version 20 and results were presented in tables, charts and graphs. It was established that capacity building was usually undertaken through on-job trainings i.e. 85.1% (103) health workers had on-job training on filling of data collection tools and only 10% (13) had received formal classroom training on the same. Further, only 9.1% (11) health workers had received information management training while 90.9% (110) had not received such training. Health workers demonstrated below average skills on information management i.e. only 17.4% (21) could check for data accuracy, only 16.5% (20) could compute trends from bar charts and only 16.5% (20) could transform the data they collected into meaningful information for use. The researcher recommended that healthcare facilities management teams develop a competency based framework for defining the desired skill mix for information management and have a yearly Training Needs Assessment for assessing training needs for information management among the health workers.

The social determinants of health continue to impact health disparities among communities living along the U.S.-Mexico border. Because community health workers (CHWs) are recognized for promoting a variety of positive patient-centered health outcomes in their roles as educators and health system navigators, recent inquiry has focused on the role of the CHW in facilitating community-level changes through grassroots advocacy to impact the social determinants of health. Social capital theory, which posits that participation in groups has positive consequences for individuals and the community, is a useful lens through which CHW effectiveness in grassroots advocacy can be measured and replicated. Using quantitative and qualitative methods, this study investigated the social capital characteristics of fifteen CHWs working in border communities who were trained in grassroots advocacy. Participating CHWs reported high baseline levels of social capital, which was assessed using a social capital questionnaire. After one year of engagement in grassroots advocacy, participating CHWs reported statistically significant increases in one measure of bridging social capital (community engagement) and one measure of linking social capita (participation with political/civic leaders). Qualitative interviews with each CHW further explored the role of social capital in their grassroots advocacy, resulting in a social capital model elucidating six activities of CHW-driven grassroots advocacy. The mixed methods results provide measures for assessing CHWs' social capital in their traditional roles and as grassroots advocates, as well as a framework for understanding how CHWs use their social capital to take grassroots action addressing the social determinants of health.

Thesis advisor: Ruth McRoy / Unmet long term care needs are increasingly filled by immigrant home health workers who are primarily female (88%), racial minorities (85%), and from developing countries including Mexico, Caribbean, Philippines, and Africa. The growing numbers of immigrant home health workers are a result of global factors including economic policies, colonial histories with developing countries, and immigration legislation. In addition to macro factors, personal motivations lead migrant home health workers to immigrate and find jobs in the U.S. Once in the U.S., little is known about migrant home health workers' caregiving experiences and work conditions. This study was designed to address this need and explored the personal experiences and viewpoints of the workers. Additionally information on migration histories and work setting was gathered to contextualize caregiving experiences. The study was guided conceptually by caregiving theory on the commodification and devaluation of "care" which can ultimately result in outsourcing care to immigrant women. Qualitative description methods were used to guide the research design, data collection, and analysis of twenty-three semi-structured interviews of female immigrant home health workers in Massachusetts. Interviews focused on three topics: caregiving experiences, reasons for migrating to the U.S., and work conditions. Findings will add to the knowledge base about immigrant home health workers paying particular attention to how workers themselves describe their experience which will in turn inform future policy and program initiatives on inclusion of a multicultural workforce into the long term care system. / Thesis (PhD) — Boston College, 2014. / Submitted to: Boston College. Graduate School of Social Work. / Discipline: Social Work.