Healthcare agencies and researchers identify several areas in which healthcare disparity affects elder, African-American diabetics including higher rates of diagnosis, higher limb amputation, increased kidney failure, and stroke. While the disparities have been documented, elder, African-American diabetics rarely have been invited into discussions concerning these disparities, research questions, project or program design, and results. They are not asked to be stakeholders in health care or health policy discussions. This study used grounded theory as a participatory action research method to invite elder, African-American, diabetics into the discussion using focus groups. The patient participants then suggested providers they believed to be "successful" in their care who were then interviewed. The analysis suggests that where patient/ provider communication has been peripheral that care and perception of care and patient suffer. Where successful communication was central to the patient/provider relationship, provider preconceptions lessened and patient compliance levels rose. This dissertation offers several downstream, midstream, and upstream recommendations using a patient-focused lens. / Ph. D.

The Hospital Value-Based Purchasing Program (HVBP), created by Section 3001 of the Patient Protection and Affordable Care Act passed in 2010, enacted a major industry shift in Medicare towards "pay for performance," or paying for high marks on a variety quality metrics rather than the traditional reliance on volume of care delivered. This study examines one of these quality metrics in particular: patient satisfaction. The trajectory of this paper begins with an overview of the current focus on patient satisfaction as a modern quality metric in American healthcare, contextualizes this emphasis on satisfaction within the intellectual movement of "patient-centered care," and moves on to a review of the relevant scholarship that attempts to explain the numerous determinants of patient satisfaction scores (with special attention to the inpatient hospital setting), as well as the robust academic debate over whether satisfaction is even an appropriate quality metric at all relative to clinical outcomes in care. The second half of my discourse moves on to more practical applications - first I break down the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey and the impact of its methodology on providers, then the Medicare HVBP program itself and its various directions towards the value-based care model. I conclude with a quantitative analysis of trends in patient satisfaction over time between 1) HVBP-participating providers (as of FY2014) and 2) those providers who have not opted in (including those ineligible to do so). My comparison aims to study the strength of the HVBP incentives to improve patient satisfaction in those subject to the financial incentive relative to those who are not. Additionally, I preface this analysis whether patient satisfaction scores are associated with either clinical process of care scores or outcome scores in the HVBP program. My research questions aim to shed light on the academic debate between patient satisfaction and more traditional clinical outcomes - are they related in the context of FY2014 HVBP? Are the new incentives to improve patient satisfaction actually doing so in a meaningful way among providers newly accountable to these incentives? Finally, in a market defined by zero-sum resources, is there evidence that a financial incentives around patient satisfaction are channeling resources and by extension improvement away from clinical outcome performance? I believe this last question is the true concern of patient satisfaction skeptics, and hope to address it with applicable data. By providing a thorough qualitative grounding in the topic followed by current quantitative analysis, my goal is to create an informed perspective on the use of patient satisfaction as a quality metric in U.S. healthcare, which can be applied meaningfully from policy, provider, and consumer vantage points. With patient satisfaction becoming increasingly more internalized in the value-based care model, these analyses of the initial results in HVBP potentially serve as predictive insight into provider behavior in this area moving forward.

Governance of the healthcare systems is one of the most important challenges forWestern countries. Within this, an accurate assessment of the quality is key to policy makers and public managers, in order to guarantee equity, effectiveness and efficiency. In this thesis, we investigate aspects and methods related to healthcare evaluation by focussing on the healthcare system in Lombardy (Italy), where public and private providers compete with each other, patients are free to choose where to be hospitalized, and a pay-for-performance program was recently implemented. The general aim of this thesis is to highlight the role of statistics within a quality evaluation framework, in the form of advancing the statistical methods used to measure quality, of evaluating the effectiveness of implemented policies, and of testing the effect that mechanisms of competition and cooperation can have on the quality of a healthcare system. We firstly advance a new methodological approach for measuring hospital quality, providing a new tool for managers involved in performance evaluations. Multilevel models are typically used in healthcare, in order to account for the hierarchical structure of the data. These models however do not account for unobserved heterogeneity. We therefore propose an extension of the cluster-weighted models to the multilevel framework and focus in particular on the case of a binary dependent variable, which is common in healthcare. The resulting multilevel logistic cluster-weighted model is shown to perform well in a healthcare evaluation context. Secondly, we evaluate the effectiveness of a pay-for-performance program. Differently from the existent literature, in this thesis we evaluate this program on the basis of five health outcomes and across a wide range of medical conditions. Availability of data pre and post-policy in Lombardy allows us to use a difference-in-differences approach. The statistical model includes multiple dependent outcomes, that allow quantifying the joint effect of the program, and random effects, that account for the heterogeneity of the data at the ward and hospital level. The results show that the policy has overall a positive effect on the hospitals' performance. Thirdly, we study the effect of pro-competition reforms on the hospital quality. In Lombardy, competition between hospitals has been mostly driven by the adoption of a quasi-market system. Our results show that no association exists between hospital quality and competition. We speculate that this may be the result of asymmetric information, i.e. the lack of transparent information provided to citizens about the quality of hospitals. This is bound to reduce the impact of pro-competition reforms on quality and can in part explain the conflicting results found in the literature on this subject. Our results should motivate a public disclosure of quality evaluations. Regardless of the specifics of a system, hospitals are altruistic economic agents and they cooperate in order to improve their quality. In this work, we analyse the effect of cooperation on quality, taking the network of patients' transfers between hospitals as a proxy of their level of cooperation. Using the latest network models, we find that cooperation does lead to an increase in quality and should therefore be encouraged by policy makers.

My study examines the effect of regulatory pressures on the earnings management behavior of nonprofit (i.e., tax-exempt) hospitals. Prior research provides evidence that managers of nonprofit hospitals manage reported earnings to a range just above zero profit in order to conform to regulator low or zero profit expectations. I extend this research by investigating how reported performance on another accounting measure important to regulators, (i.e., charity care), further explains the earnings management behavior of nonprofit hospitals. Specifically, I develop theory to predict that nonprofit hospitals use discretionary accruals to manage positive earnings toward regulator low profit expectations less aggressively when reported performance on charity care is higher than regulator expectations. The intuition behind this prediction is that nonprofit hospital managers can benefit from reporting higher earnings (from profit-based compensation and/or enhanced reputations for operational efficiency), however, they must balance this against the costs of regulatory scrutiny. Results are consistent with my prediction. Further, I validate that my results are not alternatively explained by the mechanical relationship of my test variables, the general hospital economic environment, and/or the specific reporting environment of my sample firms. I do so by comparing the earnings management behavior of nonprofit hospitals to that of for-profit hospitals. Overall, results suggest that nonprofit managers strategically manage earnings higher when their firms are less vulnerable to regulator scrutiny of their reported chairy care. As such, my study contributes to the earnings management literature and has policy implications important to regulators, especially given the current U.S. healthcare environment.

Many nursing theorists consider caring the essence of nursing practice. Yet, the meaning of caring is still elusive in nursing theories. This confusion in conceptualizing caring is exacerbated by the neoliberal socio-political and economic transformations of our societies that infuse nursing practice with economic efficiency values ‒ a condition that threatens the ethical dimensions of nursing. This critical study analyzes nursing actions in home care in Ontario and empirically reconstructs the normative dimensions of care based on nurses’ own perceptions of good care. The findings are used to critique current healthcare transformations through a critical theory of nursing actions. This study is situated in the tradition of the Frankfurt critical school and pursues an emancipatory interest. Axel Honneth’s theory of recognition is the principal theoretical foundation complemented by Jürgen Habermas’ theory of communicative action and the interests of knowledge, in addition to the concepts of phenomenology and corporality. It uses critical ethnography as a methodological approach. Data collection included audiotaped semi-structured open-ended interviews with 18 nurses working for two different home care providers in Ottawa. Analysis demonstrates that the patient must be recognized on three dimensions: love, legal rights, and solidarity. Care is a specific form of communicative action in which patients should participate equally in decision making. Nursing actions comprise a hermeneutic-phenomenological dimension of “deep knowing” that respect the corporal and personal needs of the patient. Healthcare transformations and economic efficiency measures reinforce technical and standardized forms of care, which lead to pathologic practices that neglect patients’ corporal needs, thereby reifying patients. Nursing actions combine both technical and corporal aspects that characterize their “double logic.” This study provides elements for a critical theory of nursing actions. Findings highlight that nurses have a vision of how nursing care should look like, but the reality of home care makes it rather impossible to realize this vision. Economization leads to a systematic violation of multiple dimensions of recognition and to reification. Nurses must resist these social pathologies and this study provides some theoretical tools to engage in this struggle.

'Leaving no one behind' is the slogan for strategies and action plans. Goal 3 of the Agenda aims to "Ensure healthy lives and promote being for all at all ages" which includes sexual and reproductive health. However, it leads ther the policy frameworks are leading to the goal of 'leaving no one behind'. In order to answer the question, migrants' rights is one of them. The construction of the inequalities in the discourse will be

7 ABSTRACT The compulsory vaccination of children has lately become a very actual and frequently discussed topic in the Czech Republic. The public opinion about the compulsory vaccination divide parents on two different groups which are presented by the opinion for or against the vaccination. In my thesis I tried to present the opinion of parents with the different view on the compulsory vaccination. The thesis mainly focuses on the decision-making process by parents. I try to describe how they perceive the compulsory vaccination of their children and what their experience with it is, and how they consequently decide about the realization, changes and rejection of the compulsory vaccination. The main research issue of my work is: What steps parents take when making opinion about the compulsory vaccination and what is happening with parents who decide for or against vaccination. In the theoretical part of my thesis I concentrate on the description of the history of the compulsory vaccination, on the development of system of the vaccination in our country and in the world, on the vaccination schemes and vaccines, the list of vaccinated diseases, the functions of immune system, the model of distribution and payment for the vaccines, the criticism with arguments for and against the vaccination. I summarize the...

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Uninsured and undocumented immigrants risk deportation as well as other social and financial consequences when accessing healthcare in the US. Facing these risks head-on, they do the work necessary to ensure their friends, families, and communities receive medical care. Research at the intersection of linguistic and medical anthropology understands that work to be “communicative care.” Communicative care includes any way that we use language to maintain ourselves. This dissertation utilizes a communicative care framework to demonstrate that immigrant patients are not passive recipients of whatever policymakers determine they deserve; instead, they are structurally competent experts who do communicative care at the institutional and community levels to make a more equitable, accessible, and affordable healthcare system for themselves, their communities, and all patients. The dissertation relies on ethnographic data collected during five years of Philadelphia-based research and fieldwork completed during two overlapping inflection points in the history of US healthcare and immigration – the Trump administration and the COVID-19 pandemic. Ethnographic data includes field notes from longitudinal participant observation, transcriptions of interviews and conversations with undocumented and uninsured Latinx immigrant patients and healthcare professionals, and a corpus of audio-visual materials and policy artifacts. Analysis of this qualitative data revealed that undocumented and uninsured immigrants complete various essential roles within the healthcare system beyond that of the patient. They learn through personal experience what the structural barriers to healthcare are as they navigate through Philadelphia’s patchwork of access points and build lived expertise of sociopolitically constructed inequities. Ultimately, they use this knowledge at the institutional and community level to facilitate access to healthcare in their community. Within the institutional level, they serve as educators and trainers of medical professionals who want to understand the policy-based limitations placed on different patient populations and the clinical strategies needed to improve patient services. At the community level, they serve as advocates who organize and participate in large-scale systems change and representatives for the full ratification of immigrant access to healthcare. This project contributes to anthropological research on two of the most defining sociopolitical issues of the 21st century - immigration and healthcare. Often portrayed as victims and undeserving of our charity, we have yet to fully consider the lived expertise of uninsured and undocumented immigrant patients as we draft responses and solutions to urgent and emerging problems like the simultaneous drop in US life expectancy and rise in healthcare spending. This dissertation recasts immigrant patients as experts who actively engage in healthcare reform through everyday responses to the structural barriers that subvert their access to healthcare and undercut healthcare professionals’ capacity to provide medicine. By illuminating the roles of undocumented and uninsured immigrant patients and the manifestation of their lived expertise across multiple levels of analytic granularity, this project offers new possibilities for future healthcare policies, politics, and practices in and beyond the US. / Anthropology

In the early 2010s, competitive market logic was introduced into healthcare systems so as to achieve rapid improvements. This took place as improvement policies began to emphasize the notion of collaboration as a method of ensuring patient safety across organizational boundaries. This thesis addresses how staff, in their practical improvement work, balance economic values, on the one hand, against meaningful solutions for the patient, on the other. The research interest focuses on the particular interpretations about improvements that emerge in negotiations about change. These interpretations are foundational to the learning that simultaneously takes place. The aim of the thesis is to analyse and explain the pedagogical conditions that take place in improvement practices in a healthcare system in the 2010s. The thesis takes its theoretical point of departure in a pedagogical theory that describes how contextual conditions influence learning processes in a specific practice where communication is foundational for learning. The thesis uses critical discourse analysis as a methodological point of departure and builds on a model of improvement work, namely, the clinical microsystem. The first study consists of a literature review of the microsystem framework. Subsequently, three case studies were conducted at Jönköping county council, Sweden. Discussions of improvements at clinical meetings and improvement coaches’ reflections over their pedagogical approaches provide the empirical data for the case studies. The findings show that market logic gives rise to a number of displacement effects with respect to learning processes. Short-term profits are shown to supersede goals of a more profound development of knowledge. The composition of an improvement practice is of critical importance to the nature of the negotiation that takes place, and thus how the practice comes to successfully challenge things that are taken for granted and the power structures that exist within the practice. Improvement coaches themselves become pedagogical prerequisites under the influence of the prevailing conditions, as they promote different learning organizations. This thesis develops the conceptual framework that is instantiated by the clinical microsystem, and it also contributes to the social constructionist field of improvement science by establishing pedagogical and discursive perspectives on improvement and change. / Bridging the Gaps