Includes bibliographical references (leaves 33-37). / Hypertension is one of the major causes of death in developed and underdeveloped nations. Essential hypertension and obesity may have their inception in childhood, with little data in African children to support these findings. Objectives were to determine the prevalence of overweight and hypertension in rural children in South Africa. Additionally, the association between fat-patterning ratios and blood pressure was investigated.

Rwanda has been rolling-out free antiretroviral treatment (ART) since 2004. This scale up could only be realised through significantly increased funding to the HIV/AIDS sub-account. Funding grew from US$9 million in 2003 to US$43 million in 2004 (UNAIDS, 2006b) and has continued to grow since this time given increased grants from GFATM and PEPFAR. Although international funding has been pivotal in the initiation of ART roll-out in resource poor settings, national programmes must look inwards for long term sustainability. This raises the question of whether the country will be able to sustain this level of funding once these grants cease ot are significantly reduced. This question could be answered to a large extent if one knew the lifetime costs of providing ART in Rwanda and the capacity of the country to raise domestic revenue. Unfortunately the body of evidence on unit and lifetime costs for providing ART in Rwanda is nonexistent. The study aimed to determine the economic costs of scaling up ART in Rwanda. Costing from the provider's perspective was undertaken based on data from 3,310 patients in 3 ART sites. The health care utilisation and cost data obtained, supplemented by appropriate secondary data, were used to estimate the cost perpatient period and lifetime costs. These were then used to model the costs of scaling up and to explore the financial sustainability of ART in Rwanda.

Background: The United States is experiencing a primary care physician shortage that will grow in the next decade as demand for primary care services is projected to increase. The growth in physician, Nurse Practitioner, and Physician Assistant supply alone will not be adequate to meet the demand for primary care services by 2020. Creating pharmacist-inclusive collaborative care teams for outpatient clinical care can help alleviate this health care delivery shortage. Methods: A qualitative mixed-methods case study was conducted in Tucson, Arizona to determine the supports and structures behind the Pharmacy-Based Diabetes Management Program (PBDMP) at El Rio Community Health Center. Using key informant interviews from El Rio, other outpatient clinical pharmacy programs (OCPPs), and the Tucson Accountable Care Organization, coupled with Lean Management brainstorming group sessions, the study elicited information about how the experience of El Rio with the PBDMP can inform nationwide development and implementation guidelines for other OCPPs. Results: The PBDMP at El Rio provides a blueprint for other programs interested in creating an OCPP. Key contributing factors to program success within El Rio and the other OCPPs interviewed included a focus on six key practices. Challenges inhibiting success were pharmacist provider status and reimbursement of clinical services provided. Translation: Three public health practice products were developed as a framework to provide future OCPPs interested in implementing a pharmacist-inclusive practice model: 1) implementation guidelines, 2) a self-assessment outpatient clinical pharmacy program worksheet for clinics looking to create or expand an OCPP, and 3) a student management decision case study. Conclusion: This study demonstrates the value of considering all potential members of a care team for diabetes care management. The decision by a clinic to create an OCPP should be based on team-based approaches to patient-centered chronic disease care management. Clinics looking to participate in a CDTM model OCPP need to identify if organizational transformation is needed for program buy-in and consider relational coordination between clinical roles as a major component of the coordinated work needed for a successful OCPP.

BACKGROUND: The CDC estimates that asthma affects over 7 million American children. Children that live in urban settings bear more of the asthma burden in regards to morbidity and mortality than their suburban and rural counterparts. Theories as to the cause of this disparity are varied and complex. There is consensus that some interaction of home and outdoor exposures coupled with a genetic predisposition to make urban children more at risk for suffering asthma symptoms. Objective: The CARES (Childhood Asthma Resolution of Environmental Symptoms) pilot study seeks to investigate the role home environment play in urban childhood asthma by measuring asthma symptoms before and after a 2 week stay at a residential summer camp in the suburban Duxbury, MA. METHODS: Asthma Control Tests^TM were administered to campers at the start and end of their 2 week stay at camp. These results were correlated with demographic information that parents supplied during enrollment. ACT score improvements were tested for significance against particular polled home exposures or demographics. RESULTS: 53 campers enrolled in the pilot study with 96% completing induction and follow-up. While both age groups saw a general increase of ACT scores during their stay at camp (p=.009 and p=.006), there was no significant difference of ACT score increase between groups that had a particular exposure (e.g. smoker in the home) and those that did not (p=.275 and p=.945). Conclusion: While we cannot attribute the general asthma improvement seen in Participants to a particular exposure or demographic status, this pilot study highlighted important ideas for future investigations with more statistical power that may give us better answers to the cause of increased urban asthma burden among children.

The aging U.S. population accompanied by the increases in the number of residents permanently living in institutionalized facilities (including nursing homes and correctional facilities) has a created a need for health care providers that are adequately trained to provide them with comprehensive care. This has subsequently created a need for more oral health providers that are trained to serve this population. This study aims to determine the overall oral health status of populations living in two specified institutionalized settings: nursing homes and state prisons within the US. A broad assessment of the common challenges in providing Oral Health Care to these groups along with the disparities that affect them disproportionately may improve the future care provided to them. As well as potentially improve the training and motivation of more oral health professionals to meet their needs. In order to adequately assess this challenge, several research studies at both nursing homes and a state prison in the US were identified and analyzed. According to the CDC, the estimated number of people in the US utilizing nursing facilities is expected to increase from 15 million in 2000 to 27 million by 2050. This also includes alternative residential care places and home care services so for the purposes of this analysis, we will only consider the provision of care in institutions from nursing homes. And as of 2013, there were 15,700 Medicare certified nursing homes in the U.S. It’s no secret that aging baby boomers are and will result in a much older U.S. over the next decade. According to CDC’s review on Long-term Care Services in the U.S.: 2013, the number of Americans in the U.S. over the age of 65 is expected to double (from 40.2 million to 88.5 million) from 2010 to 2050 This population group is more likely to need long-term care services in the areas of health, personal care, and general support because of their limited capacity for self-care; specifically oral health care. Xerostomia, commonly referred to as “dry mouth,” edentualism, and overall poor oral hygiene were among the most common concerns among elderly patients in nursing home. But with the increase of natural teeth retention into older age, there has been a subsequent increase in the risk of periodontal disease and tooth decay (Friedman et al., 2014). The US Federal Bureau of Prisons (FBOP) is the largest correctional jurisdiction in the US and is made up of 119 prisons and over 216,000 prisoners. While healthcare is under the direction of a Chief Medical Officer, oral healthcare is controlled by a chief dentist who further delegate the duties to regional chief dentists. But despite a highly organized division of health care within correctional facilities, inmates still have a severe compromised oral health due to drug abuse. This usage results in increased instances of dental disease and pain that often go unnoticed among this institutionalized population. Whether or not there will be enough qualified dental providers to fill the needs of this group remains an important issue for current and future oral health professionals.

The FDA approved pre-exposure prophylaxis (PrEP) with Truvada® in 2012 as the first drug to reduce the risk of HIV infection among uninfected individuals (FDA 2012). There is a strong scientific base for its effectiveness among uninfected heterosexual individuals who engage in sexual intercourse with HIV-infected partners. Studies further reveal no significant differences by HIV-infection status in regard to childbearing motivations or future pregnancy motivations (Finocchario-Kessler 2012). Historically, serodiscordant couples comprised of an HIV-positive male and HIV-negative female have faced challenges to accessible, affordable options for safe conception. Assisted reproductive technologies (ART) are often prohibitively expensive and also largely inaccessible to this population. The CDC suggests PrEP as another reproductive option for these couples to reduce the risk of sexual HIV acquisition during periconception and pregnancy. Truvada® for PrEP, however, is also costly and may provide only modest additional prevention benefits to serodiscordant couples in which the HIV-infected partner is already on anti-retroviral therapy with suppressed HIV viremia. cART for the infected partner is recommended regardless of conception plans due to proven health benefits for people living with HIV (PLHIV). However, there is also a prevention benefit to the non-infected partner when the HIV-positive partner is on cART, with a relative risk reduction of 96% (Cohen et al. 2011). While Truvada® for PrEP is potentially a more accessible option for these couples compared to assisted reproductive technology services, adoption of PrEP has been slow among providers. In addition to better understanding the impact of PrEP when the male partner is consistently on cART, it is also critical to understand the barriers to prescribing Truvada® for this indication. There is also insufficient information on the ability of HIV-serodiscordant couples to access other reproductive options outside of PrEP. Whether for the purpose of risk reduction or for supported fertility, serodiscordant couples should have access to the same spectrum of reproductive services as non-HIV affected couples. The overall research question this thesis addressed was: What are the access and cost implications for HIV serodiscordant couples seeking conception services in the United States? To address these issues, I used the following methods: (1) a cross-sectional survey of infectious disease, internal medicine, and family medicine providers to determine prescribing behaviors and perceptions of PrEP utilization; results analyzed using multivariable regression modeling; (2) “secret shopper” methodology whereby a physician and “patient” carried out scripted phone calls to fertility clinics to gauge a more realistic picture of access; results analyzed using McNemar tests to assess marginal homogeneity and chi square goodness of fit; and (3) cost effectiveness analysis using a Markov state-transition model to project long-term clinical outcomes, costs, and cost-effectiveness of different HIV prevention strategies for serodiscordant couples seeking conception. / 2018-12-08T00:00:00Z

BACKGROUND: The World Health Organization predicts that by 2030 there will be a shortage of more than 14 million healthcare workers. Fifty years ago, to help address the growing demand for medical providers, the United States created a new medical profession, the Physician Assistant. Since 2000, several other countries including Australia, Canada, Germany, Great Britain, India, Israel, Ireland, New Zealand, Saudi Arabia, Scotland, South Africa, and The Netherlands have developed or are developing their own PA-like profession. LITERATURE REVIEW FINDINGS: This thesis contains a comprehensive literature review, composed largely of small pilot and qualitative studies, which summarizes the introduction and expansion of the PA profession in each country. The literature review highlights that around the globe the PA profession is unified by similar condensed medical education and training. However, there is presently a lack of literature on the current roles and tasks of PAs in each country. PROPOSED PROJECT: This thesis proposes a qualitative study to identify each country’s motivation for PA professional development, current scope of practice of PAs and future directions for the PA profession. CONCLUSIONS: The results will be analyzed to reveal correlations, as well as unifying themes and characteristics that are shared among all PAs globally. SIGNIFICANCE: The compiled data will illuminate an emerging profession that is helping to alleviate the healthcare workforce shortage.

In response to persistent shortages of primary care physicians, researchers have suggested increased use of non-physician providers to mitigate the consequences of the strained supply of physicians. As more health care systems implement a team-based approach in treating patients, better understanding the pattern of team care and its effects on outcomes and cost is critical in transitioning away from physician-centric care. This dissertation focuses on the prescribing component of care to explore the effects of team medication management on prescribing patterns, clinical outcomes, and care costs in Veterans with diabetes. In Chapter 2 I examine the outpatient prescribing patterns of oral antidiabetic drugs (OADs) over a 2-year period among patients who receive sole-provider prescribing or team-based prescribing. I find that team-prescribing patients receive significantly more sulfonylureas and metformin/sulfonyl urea combinations, suggesting that team prescribing may respond to patients’ needs quicker and intensify treatment earlier by switching or augmenting the initial medication. To determine the effect of prescribing modality on health outcomes, I compare mean changes in diabetes-related lab measures between the sole-provider models and team-prescribing models in Study 2. I perform 2-stage least squares regression to estimate the change in outcome measures from baseline to follow-up and find that while patients receiving NP prescribing achieve significantly greater reductions in glucose level compared to those receiving physician prescribing, the differences in HbA1c, glucose, and LDL reductions between team prescribing patients and sole-provider patients are insignificant. In Study 3 I explore the effect of prescribing model on health care costs. I use generalized linear modeling to estimate mean total outpatient cost among patients managed under different prescribing models. In addition, I perform logistic regression to estimate the likelihood of incurring any inpatient cost. I find no significant differences in mean outpatient cost or the likelihood of incurring any inpatient cost between sole-provider prescribing and team prescribing, suggesting that prescribing modality may not be associated with care costs. Evidence from this dissertation suggests that while team prescribing appears to provide more responsive medication management, it does not result in significant improvements in health outcomes or affect overall care costs. / 2019-10-23T00:00:00Z

BACKGROUND: The Indian healthcare system is undergoing rapid change. While the country seeks to provide universal health coverage (UHC), aspirations for UHC require linkage with non-government providers (including charitable providers) who provide 60-70% of patient care. One of the largest groups of charitable providers in India are Mission Hospitals, whose historic role of healthcare delivery to the poor and underserved is challenged by external and internal pressures. This study explored the main challenges facing mission hospitals, their response to those challenges, and the role they might play in healthcare delivery going forward. METHODS: The study employed interdisciplinary, mixed methodology to assess the top challenges and responses between 2010-2017. The theory of everyday resilience was used to categorize challenges as chronic stresses or acute shocks and explore features of resilience in responses to challenges along with the underlying capabilities that enable resilience responses. The study included site visits to 11 mission hospital facilities, 5 mission hospital associations, and 83 key informant interviews. Interviews were thematically analyzed using NVivo and triangulated with other study data. RESULTS AND DISCUSSION: Mission hospitals were impacted by social, political, and health system changes. Most challenges operated as “stressors”, for example, strained governance structures and human resource shortages. “Shocks” included major changes in health policy and increasing competition from for-profit providers. In response, some mission hospitals exhibited traits of everyday resilience, traversing between absorptive, adaptive, and transformative strategies. Among mission hospitals that appeared to be successfully navigating challenges, three core capacities were present: 1) cognitive capacity, understanding the challenge and developing appropriate response strategies; 2) behavioral capacity, having agency to deploy context-specific response; and 3) contextual capacity, having adequate resources, including hardware (money, people, infrastructure) and, importantly, software (e.g. values, relationships, networks), to exercise the first two capacities. CONCLUSION: While mission hospitals face a series of internal challenges, many exhibit features of everyday resilience and retain strong commitment to population health and service to the poor. These features make them potentially strong partners in the realization of UHC, in addition to continued or expanded provision of services that complement government efforts. / 2021-02-20T00:00:00Z

BACKGROUND: Women account for 19% of new HIV diagnoses in the United States, with women of color (WOC) comprising 83% of this group. Pre-exposure prophylaxis (PrEP) is a safe and effective method of HIV prevention for women. Yet, prescribing to WOC remains disproportionately low, leaving a major gap in HIV prevention options for this population. The purpose of this study was to examine PrEP implementation barriers and facilitators in a high HIV incidence setting in order to identify strategies to better provide comprehensive HIV prevention options for WOC. METHODS: This study used a case study approach with qualitative data collection to examine PrEP implementation for WOC as it happened in the “real world” in three clinical settings: a community-based clinic, a pediatric emergency department, and a Federally Qualified Health Center. Guided by the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) implementation science framework, two rounds of semi-structured interviews were conducted with clinical staff and providers. Data analysis was completed according to the five steps of the Framework Method. RESULTS: By the end of the one-year implementation period, only three WOC had been prescribed PrEP out of the targeted 387. Staff cited support of PrEP provision among staff and leadership, PrEP alignment with their clinics’ missions, having a centralized PrEP coordinator, and relationships with other implementing sites and within the local community as implementation facilitators. Despite these supportive factors, staff reported time limitations, resistance to PrEP prescribing, discomfort with PrEP counseling, and managing different and changing priorities across clinic departments as implementation barriers. CONCLUSION: Though the clinics seemed well-positioned for PrEP implementation, significant challenges impeded their success. To successfully provide PrEP to women, implementation should include clarifying staff roles and responsibilities, engaging staff and providers through ongoing and targeted feedback, and ensuring care is focused on women’s needs and experiences. The HIV epidemic can only be fought by utilizing all available HIV prevention tools in combination with HIV treatment, delivered with consideration of the local context and population. Specific practice recommendations identified will support clinics as they provide PrEP to WOC.