This descriptive study was conducted in the State of Bahrain using: firstly, a questionnaire for students in the final year of their school education, together with a similar questionnaire for their parents, teachers and all Bahraini health promoters; secondly, focus group interviews; thirdly, hazard analyses critical control point (HACCP) model and a checklist to assess schools' canteen, and finally, an evaluation of school's textbooks and health education materials. The study was designed to answer three principal research questions: 1. Do Bahrainis have appropriate knowledge, healthy beliefs and opinions which will empower them to control food poisoning; 2. Are the canteen environments and the practices within the canteens supportive to health; 3. Do school textbooks and health education materials empower the community in food safety? This study describes for the first time the knowledge, attitudes, beliefs of students, parents, teachers, and health promoters in food safety and HACCP in schools and TLMs and linked these three areas to suggest empowering control measures. The results of this study indicate that future health promotion programmes should start at primary school level and teachers need to be further trained in environmental health issues. Canteen environment, and practices need to be further addressed by authorities. Particular attention should be focused on the critical control points which are the time of preparation, transportation, storage and temperature control during display of foods. There is a need for providing appropriate resources which influence learning and community empowerment. Recommendations also suggested the implementation of the Ottawa Charter for Health Promotion which mobilises all the community, resources and the media.

No description available.

This thesis explores the tensions between policy and practice in community participation in Health Improvement Programmes (HImPs). The HImP is used as a vehicle through which partnership working and public participation is health planning in the ‘new NHS’ may be explained, The literature review discusses key theories and models of community participation, power and policy implementation which informed the development of my key research questions and strategy. A review of the global, national and local influences upon a community participation in health planning is supplemented with primary research in the form of a detailed case study of one locality’s response to the national requirement to involve the public in the development of their HImP. A multi-method case study was employed using the following methods of data collection: observation, interviews, questionnaires and documentary analysis. The research presented identifies a number of issues as significant in affecting a locality’s approach to public participation, including: power; the organisational cultures(s) within the HImP partnership; the attitudes and capacity of those charged with developing participatory activities; and the impact of national priorities on local flexibility to respond to community identified priorities. The application of Alford’s (1975) structural interests theory to the findings provides a useful framework for assessing power relations and understanding why the HImP fails to represent community interests in the way that had been hoped. A number of recommendations are made to facilitate participation in health planning in the future, including: the need to address the national culture of risk avoidance; the need for better training in public participation skills for personnel charged with developing participatory opportunities; and the need for a mandatory performance framework related to community participation as a mechanism to ensure that participation issues are given the same attention as other nationally monitored issues.

There have been a considerable number of studies that have examined the potential benefits of companies investing in corporate fitness (CF) programmes and the results have been well publicised. However, in the UK, little research has investigated the development, implementation and management of CF and how this has impacted upon programmes and their effectiveness. The aim of this thesis was to begin to fill this void of research and understanding and to examine whether CF is regarded as an initiative that contributes to organisational success. Therefore, the management of CF was evaluated so its role within corporate philosophy and its relevance to research on business management could be assessed. The research analysed the perceptions of both users (n=149) and non-users (n=122) of CF, through two separate questionnaires, that sought to gain both qualitative and quantitative information. To examine the experiences and perceptions of individuals working within CF, semi-structured, qualitative interviews (n=25) with CF consultants (n=7), managers (n= 11), company representatives (n=5), a member of the Health Development Agency (n= I), and a member of the Association of Workplace Health Promotion (n= I) were also conducted. In addition, a group discussion was held between key CF industry figures to discuss further issues raised during the interviews. The results indicated that CF has become increasingly popular amongst employees and prevalent within companies, arguably as a result of general changes in attitude towards health, fitness, and lifestyle. CF has begun to develop a more holistic approach to health and fitness and has been commonly rebranded 'Corporate Wellness' (CW). However, CW is not significantly different from CF and the effectiveness of programmes in positively impacting upon the majority of the workforce is doubtful. CW tends not have a high profile within companies and providers are restricted from developing more effective management and marketing practices, partly due to a lack of resources. In addition, companies fear that instead of improving work performance, through improved well-being, employee productivity could actually deteriorate as individuals spend less time working. Currently, companies lack an understanding of the role CW plays within the workplace and, as a result, programmes lack direction and do not have any clear objectives. The future of CW, as a beneficial initiative, will be dependent upon the development of effective management strategies that will encourage company-wide participation and demonstrate that its associated benefits are a reality. In conclusion, the research suggests that CW is predominantly used as a perk for those individuals who have an interest in health and fitness. Consequently, contrary to previous research, the evidence indicates that CW, in the UK, is not an essential initiative within corporate management.

Thesis (Ph. D.)--University of Sydney, 2005. / Title from title screen (viewed 10 October, 2007). Submitted in fulfilment of the requirements for the degree of Doctor of Philosophy to the Faculty of Education and Social Work. Includes bibliography. Also issued in print.

Background and Importance: There has been much debate recently over rapidly growing drug expenditures. Cancer medicines, in particular, have driven new brand spending over recent years, and US oncological expenditures have risen faster than for many other disease areas, in part because of rapidly growing drug prices, as well as increased rates of use. Objective: In the face of ongoing debates on how to reasonably control growth in pharmaceutical spending, while also providing patients with the best possible care, this thesis sets out to help address the question of whether growing pharmaceutical expenditures are providing value-for-money to patients and society. Novelty and Empirical Contributions: This thesis is based in part on a systematic review with narrative synthesis of English-language HTA appraisals of the comparative clinical risks and benefits of new cancer medicines, as well as on the novel use of methods to generate comparative evidence on their use and cost. Adapting established methods, these data are then used to examine existing questions over whether growing expenditures are worth the cost to patients and society. This thesis makes five major contributions to the literature on value-based spending on cancer medicines: 1) approximately one in three newly licensed cancer medicines provide no known overall survival benefit, while one in five provide no known overall survival, quality of life, or safety benefit; 2) novel use of methodologies to model treatment course and duration reveals that cancer drug use and costs vary greatly between individual medicines, and across Australia, France, the UK, and the US; 3) the monetized value of survival gains attributable to cancer drug innovation, net of growth in cancer drug spending, varies across individual medicines, and, at a country-level, remains unambiguously positive in Australia, France, and the UK, but negative in the US; 4) spending on new cancer medicines is often only weakly associated with their clinical benefits; and 5) the strength of this association nevertheless varies across countries, with the UK demonstrating the strongest evidence of value-based spending on new cancer medicines. Clinical and Policy Implications: Findings from this thesis provide a resource for valuebased clinical decision-making by patients and physicians. Moreover, growing expenditures on cancer medicines may only weakly be associated with meaningful clinical benefits, though the extent to which this is true differs across countries. These findings highlight the important role that health policy can have in encouraging valuebased cancer drug spending. In particular, it is argued that managed access schemes promoting access and evidence development, as well as the use of value-based spending policies, can help expedite access to new treatments, incentivize the development of clinically meaningful medicines, and rationalize growing cancer drug expenditures. Future Research Directions: The comparative clinical risks and benefits from new cancer medicines using real-world data, and how they compare with trial-based results; how evidence on the comparative impact from new treatments is measured, weighted, and rewarded in decision-making by regulators and payers; and how it is effectively linked through policy and regulation to cancer drug spending.

From 28 October 1999 to 26 September 2000 Mbeki publically endorsed the position of ‘denialist’ AIDS scientists – a marginal group who oppose the claim that HIV causes AIDS – and used their views as the basis for a policy of not providing ARVs (antiretrovirals – the treatment that prevents HIV from replicating) via the public health system. This policy persisted until 2004, with severe consequences – best estimates indicate that it resulted in 171,000 avoidable new infections and 343,000 deaths over the 1999 – 2002 period. I use this case to address two questions. First, is it reasonable for policy makers to consult non-mainstream scientists in the process of policy development? Second, can they be held personally morally responsible for the consequences of having done so when things go very badly wrong? I begin by providing a motivation for why philosophers should be interested in real-world cases. Having justified the philosophical “methodology” of this thesis, I move on to describing the specific case of South African AIDS denialism in the early 2000s. I then take a chronological step back in order to assess the rationality of accepting HIV as the sole cause of AIDS in 1984, when the virus was first identified. I argue that it was rational, but that some explanatory power was lost when other competing accounts of the disease’s aetiology were discarded. I argue that this explanatory loss can be accounted for by re-considering the way causation is understood in biomedicine and epidemiology. Having settled the scientific issues of the case, I then move on to the question of moral responsibility. I specifically look at when an agent can be held morally responsible for their ignorance, and the role of suppressed disagreement in the production of that ignorance.

Cardiovascular disease (CVD) is the biggest killer of people in western civilisation. Age is a significant risk factor for the development for CVD, and treatments and therapies to address this increased risk are crucial to quality of life and longevity. Exercise is one such intervention which has been shown to reduce CVD risk. Age is also associated with endothelial dysfunction, reduced angiogenic capabilities, and reduced ability to repair the vessel wall. Circulating angiogenic cells (CACs) are a subset of circulating cells which assist in the repair and growth of the vasculature and in the maintenance of endothelial function. Reductions in these cells are observed in those with vascular disease compared to age-matched healthy controls. Exercise may reduce CVD risk by improvements in number and/or function of these CACs. Data was collected from human volunteers of various ages, cardiorespiratory fitness (CRF) levels and latent viral infection history status to investigate the effects of chronological age, CRF, viral serology and other lifestyle factors, such as sedentary behaviours and exercise on CACs. The levels of CACs in these volunteers were measured using four colour flow cytometry using various monoclonal antibodies specific to cell surface markers that are used to identify specific subsets of these CACs. In addition, the response to acute exercise of a specific subset of these CACs, termed ‘angiogenic T-cells' (TANG) were investigated, in a group of well-trained males aged 20-40 years, using a strenuous submaximal exercise bout. Advancing age was associated with a decline in various subsets of CACs, including bone marrow-derived CD34+ progenitors, putative endothelial progenitor cells (EPCs) and also TANG cells. Individuals with a higher CRF were more likely to have higher circulating numbers of TANG cells, particularly in the CD4+ subset. CRF did not appear to modulate CD34+ progenitors or EPC subsets. Increasing sitting time was associated with reduction in TANG cells, but after correcting for the effects of fitness, sitting time no longer negatively affected the circulating number of these cells. Acute exercise was a powerful stimulus for increasing the number of TANG cells (140% increase), potentially through an SDF-1:CXCR4-dependent mechanism, but more studies are required to investigate this. Latent CMV infection was associated with higher number of TANG cells (CD8+), but only in 18-40 year old individuals, and not in an older age group (41-65 year old). The significance of this has yet to be understood. In conclusion, advancing age may contribute to increased CVD risk partly due to the observed reductions in angiogenic cells circulating in the peripheral compartment. Maintaining a high CRF may attenuate this CVD reduction by modulating TANG cell number, but potentially not CD34+ progenitor or EPC subsets. Acute exercise may offer a short window for vascular adaptation through the mobilisation of TANG cells into the circulation.

During the past decade, the Mexican government launched an ambitious expansion of public health insurance through the Seguro Popular programme (SP). As a result, health care access was legislated as citizens’ entitlement, a generous benefit package was offered, and public health expenditure was significantly increased. In 2011, the programme had reached 52 million affiliates. However, there is limited evidence on its effects on a number of outcomes and their distribution. This thesis analyses three aspects that are key to evaluate health system performance. Specifically, using quasi-experimental methods and recent distributional measures of pure health, it examines the effect of universal insurance coverage on infant mortality, non-medical consumption, and health inequalities. Drawing on municipality-level data, the first article finds that the programme led to a 3.9 per cent decrease in infant and neonatal mortality. These reductions were concentrated in more populated, urban, and less marginalised municipalities, however, probably because this type of municipalities have been traditionally better equipped and are thus better prepared to offer all the interventions from the benefit package. Based on data from the Mexican Family Life Survey (MxFLS), the second article shows that unexpected health events such as accidents and deterioration in physical capacity are associated with large declines in non-medical consumption. Social security seems to provide protection against both types of shocks, but endogeneity-corrected estimates show that the SP only protects consumption against accidents. This suggests that income losses associated with disability shocks for which the programme does not offer protection, are likely larger than medical care expenditures, and poses the question of whether other social security benefits, such as disability insurance, should also be extended. Finally, the third article analyses the distribution of health in the context of the SP implementation. Unlike traditional studies, pure health inequality and mobility are analysed using a recently developed class of indices appropriate for categorical data. If a downward-looking definition of status is employed, the distribution of health appears stable, but if an upward-looking definition is adopted, a significant increase in inequality is observed. Evidence of strong persistence in health was also found. This lack of improvement in the health distribution suggests that factors other than health insurance coverage, such as institutional performance, are more important determinants of health inequalities. Overall, this thesis finds important health effects from extending health insurance coverage but limited effects on economic welfare and the distribution of health status across the entire population.

Introduction: Current evaluation approaches for new medical technologies are problematic for a plethora of reasons relating to measuring their expected costs and consequences, but also due to hurdles in turning assessed information into coverage decisions. Most adopted methodologies focus on a limited number of value dimensions, despite the fact that the value of new medicines is multi-dimensional in nature. Explicit elicitation of social value tradeoffs is not possible and decision-makers may adopt intuitive or heuristic modes for simplification purposes, based on ad hoc procedures that might lead to arbitrary decisions. Objectives: The objective of the present thesis is to develop and empirically test a methodological framework that can be used to assess the overall value of new medical technologies by explicitly capturing multiple aspects of value while allowing for their tradeoffs, through the incorporation of decision-makers’ preferences in a structured and transparent way. The research hypothesis is that Multiple Criteria Decision Analysis (MCDA) can provide a methodological option for the evaluation of new medicines in the context of Health Technology Assessment (HTA), to support decision-making and contribute to more efficient resource allocation. Methods and Empirical Evidence: The first paper proposes a conceptual methodological process, based on multi-attribute value theory (MAVT) methods comprising five distinct phases, outlining the stages involved in each phase and discusses their relevance in the HTA context. The second paper conducts a systematic literature review and expert consultation in order to investigate the practices, processes and policies of value-assessment for new medicines across eight European countries and identifies the evaluation criteria employed and how these inform coverage recommendations as part of HTA. The third paper develops a MAVT value framework for HTA, incorporating a generic value tree for new medicines composed from different levels of criteria that fall under five value domains (i.e. therapeutic, safety, burden of disease, innovation and socio-economic), together with a selection of scoring, weighting and aggregating techniques. In the fourth and fifth papers, the value framework is tested empirically by conducting two real-world case studies: in the first, the value tree is adapted for the evaluation of second-line biological treatments for metastatic colorectal cancer (mCRC) patients having received prior oxaliplatin-based chemotherapy; in the second, the value tree is conditioned for the evaluation of third-line treatments for metastatic castrate resistant prostate cancer (mCRPC) patients having received prior docetaxel chemotherapy. Both case studies were informed by decision conferences with relevant expert panels. In the mCRC decision conference multiple stakeholders participated reflecting the composition of the English National Institute for Health and Care Excellence (NICE) technology appraisal committees, whereas in the mCRPC decision conference a group of evaluators participated from the Swedish Dental and Pharmaceutical Benefits Agency (TLV), thereby adopting the TLV decision-making perspective. Policy Implications: The value scores produced from the MCDA process reflect a more comprehensive benefit metric that embeds the preferences of stakeholders and decisionsmakers across a number of explicit evaluation criteria. The incorporation of alternative treatments’ purchasing costs can then be used to derive incremental cost value ratios based on which the treatments can be ranked on ‘value-for-money’ grounds, reflecting their incremental cost relative to incremental value. Conclusion: The MCDA value framework developed can aid HTA decision-makers by allowing them to explicitly consider multiple criteria and their relative importance, enabling them to understand and incorporate their own preferences and value trade-offs in a constructed and transparent way. It can be turned into a flexible decision tool for resource allocation purposes in the coverage of new medicines by payers but could also be adapted for other decision-making contexts along their development, regulation and use.