Context: Partnerships are emerging as critically important vehicles for addressing health in local communities. Coalitions involving local health departments can be viewed as the embodiment of a local public health system. Although it is known that these networks are heavily involved in assessment and community planning activities, limited studies have evaluated whether health coalitions are functioning at an optimal capacity. Objective: This study assesses the extent to which health coalitions met or exceeded expectations for building functional capacity within their respective networks. Design: An evaluative framework was developed focusing on 8 functional characteristics of coalitions previously identified by Erwin and Mills. Twenty-nine indicators were identified that served as "proxy" measures of functional capacity within health coalitions. Setting and Participants: Ninety-three County Health Councils (CoHCs) in Tennessee. Main Outcome Measure(s): Diverse member representation; formal rules, roles, and procedures; open, frequent interpersonal communication; task-focused climate; council leadership; resources; active member participation; and external linkages were assessed to determine the level of functionality of CoHCs. Scores across all CoHCs were analyzed using descriptive statistics such as frequency distributions, measures of central tendency, and measures of variability. Data were analyzed using SAS 9.3. Results: Of 68 CoHCs (73% response rate), the total mean score for the level of functional characteristics was 30.5 (median= 30.5; SD = 6.3; range, 18-44). Of the 8 functional characteristics, CoHCs met or exceeded all indicators associated with council leadership, tasked-focused climate, and external linkages. Lowest scores were for having a written communications plan, written priorities or goals, and opportunities for training. Conclusion: This study advances the research on health coalitions by establishing a process for quantifying the functionality of health coalitions. Future studies will be conducted to examine the association between health coalition functional capacity, local health departments' community health assessment and planning efforts, and changes in community health status.

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archives@tulane.edu / Public health finance is still a relatively young field and, as such, many questions have yet to be asked—and answered. To date, few have examine how specific revenue streams—alone or in combination—shape local health departments’ (LHD) resources and capacity to accomplish their public health missions. Given ongoing policy conversations about financing for public health, it’s important for researchers to rigorously examine the and the potential costs and benefits associated with different revenue sources. Introduction Chapter: The central thesis for the body of work encapsulated by this dissertation is simple: where money comes from matters. This chapter critically examines published evidence and theory linking public health financing mechanisms and their interactions to LHD operations, outputs, and even outcomes. The chapter also introduces situates the specific research questions addressed in this dissertation within a broader conceptual framework. Paper 1: The first paper examines the relationship between revenue diversification and revenue volatility among Washington State LHDs. Using fixed effects linear regression models and revenue data reported during 1998-2014 by all LHDs operating in Washington State, the paper finds little evidence to suggest revenue diversification is significantly associated with revenue volatility. Paper 2: The second paper evaluates whether available revenue sources differentially effected the scope of programs provided by Washington State LHDs between 2000 and 2011. Using two measures of program scope and both linear and non-linear fixed effects panel regression models, the paper finds that only funding received from federal Medicaid was consistently and significantly associated with both measures of program scope. Paper 3: The third paper examines changes in total LHD expenditures in Washington State between 2006 and 2013 following introduction of a new state funding program to support core public health services and infrastructure. Using a pre-post design regression model to evaluate changes in LHD expenditures, the paper finds overall spending among LHDs significantly increased with receipt of the new state funds in the first years of the program. However, those increases were not sustained over the longer term Conclusion Chapter: The final chapter reviews findings from the three papers and discusses their implications for public health policy, practice, finance, and research. / 1 / Abigail Hope Viall

Yes / Understanding patients' perspective to get an insight into cancer, and how best the public health systems can battle with this disease is the way forward in this current world. This study aimed to explore patients' knowledge about common cancers, barriers to assessing cancer information and cancer preventative approaches in Fiji. The study used a qualitative method approach that was conducted among patients who attended Special Outpatients (SOPD) at the four selected health centres in Lautoka Subdivision, Fiji from 1st March to 30th April 2021. A semi-structured open-ended questionnaire was used to guide in-depth interviews. These audio recordings were transcribed and analysed using thematic analysis. All interview transcripts were read and similar words and phrases were assigned numbers which were grouped together to identify themes and sub themes. Twenty-eight patients took part in the in-depth interview and the responses were grouped into four themes including; cancer knowledge, diagnosis of cancer in a close friend/family, barriers of communication and optimizing cancer awareness. Patients' awareness about common cancers and cancer risk factors was low. Many barriers for cancer screening were highlighted including stigmatization, fear, worry, death, lack of information, herbal medicine use, lack of resources and delay in diagnosis. Awareness strategies highlighted by participants included community outreach programs, house to house visits, opportunistic screening, engagement of community health care workers and the concept of a cancer hub centre. It is evident that there is a range of views from patients towards cancer and it is important to understand these perceptions to better guide public health interventions concerning cancer. This puts more focus on the need to invest more in information, education, and communication material for public campaigns that target a variety of people for a wider reach.

Background: With recent emphasis on creating a stronger, more patient-centred, health system in Ontario, there remains no clear definition of a “public health” system, hindering the ability to integrate preventive public health and health care practices. This study aims to describe public health systems and initiate a research agenda for this field. Methods: A critical interpretive synthesis of the literature was conducted using six electronic databases. In addition, data extraction, coding and analysis followed a best-fit framework analysis method. Initial codes were based on two current leading health systems and policy classification schemes: health systems arrangements (based on governance, financial and delivery arrangements) and the 3I+E framework for health policy formulation (institutions, interests, ideas and external factors). New codes were developed as guided by the data. A constant comparative method was used to develop concepts and to further link these into themes. Additional documents were identified to fill conceptual gaps. Results: 5,933 unique documents were identified and 338 documents met the inclusion criteria. 81 documents were purposively sampled for full-text review and 58 of these were included in this study. Nine documents were found to help fill conceptual gaps. Generally, public health systems can be defined using traditional healthcare systems and policy frameworks. There was also a strong emphasis on identifying and standardizing the roles and functions of public health. Partnerships (community and multi-sectoral) are common features within and between components of public health systems. A public health system framework and a model of a population health system were conceptualized. Discussion: Understanding public health systems can help strengthen these systems and further integrate preventive public health and primary care services. Systems are influenced by organizational and contextual factors that need to be explored to improve population health. A research agenda is proposed to move this field forward. / Thesis / Master of Public Health (MPH)

Rural counties in the United States vary drastically on metrics related to socioeconomic status and dominant economic industry as well as health behaviors and outcomes. This study sought to understand the underlying structural reasons why some rural counties have better or worse than expected health outcomes using a positive deviance (PD) approach. The study aimed to: 1) create an area deprivation index and divide counties into quartiles using the index; 2) identify positive, negative, and non-deviant counties using health outcome metrics; 3) analyze differences between deviance on a variety of local public health system metrics; and 4) analyze differences between deviance on a variety of health service system metrics. All data were secondary, with data on public health systems derived from NACCHO’s 2016 National Profile of Local Health Departments (LHDs) and data on healthcare systems derived from HRSA’s 2016-2017 Area Health Resource File. Multivariate analysis, nonparametric analysis, and multinomial logistic regression were conducted. Results indicated that public health systems in positive deviant counties were more likely to have their next year’s budget exceed their current budget compared to negative and non-deviant counties. Public health systems in negative deviant counties had much lower rates of completed community health assessments, community health improvement plans, and strategic plans. LHDs overseen by their local government were 6.20 (p=.001) times more likely to be positive deviant, and negative deviant counties were much less likely (OR=0.12, pp 17.28 physicians per 10,000 population), while negative deviant counties were less likely (OR=.35, pp=.38) compared to non-deviant counties. Future research should continue using the PD approach for population-level studies and seek to understand which components of local public health and healthcare systems are associated with better population health.

<p>The purpose of this study was to explore and describe the experiences of academic and decision-maker researchers participating in a public health integrated knowledge translation (IKT) and exchange program of research in Ontario and British Columbia. This research sought to identify structures and processes that acted as enablers or barriers for all partners on a research team as they engaged in collaborative research. The researcher answered the following research questions: <em>What are the experiences of academics and decision-makers participating in the first two years of an integrated knowledge translation program of research?</em> <em>What structures and processes positively and negatively influence the engagement of partners on the collaborative research team?</em> Through answering these two questions the research contributes relatively new knowledge in the form of strategies for engaging academics and decision-makers engaging in collaborative public health systems and services research.</p> <p>A qualitative descriptive approach was used to gain a contextual understanding of experiences of participants in the IKT research program. Twelve semi-structured, one-on-one interviews were conducted with academic and decision-maker researchers working in British Columbia universities and Health Authorities. Qualitative content analysis of transcripts was used to explore and identify concepts emerging from the data.</p> <p>Data analysis identified IKT processes and concepts that encompass and underlie a collaborative research team. An overarching systems approach is used to examine the evolution of the collaborative team. Themes are presented in relation to IKT engagement concepts identified from the literature as well as those that emerged from analysis including: establishing and maintaining relationships, communication, capacity building, multidirectional knowledge sharing, and multidisciplinary capacity.</p> <p>By examining experiences of research partners representing both academia and decision and policy-making, this research contributes new knowledge about strategies to support collaborative health services research which can subsequently strengthen the Canadian public health systems and services research agenda.</p> / Master of Science in Nursing (MSN)

Philosophiae Doctor - PhD (School of Public Health) / South Africa has an estimated two million documented and undocumented immigrants. In addition, Statistics South Africa (2014) notes very significant internal migration. This mobile population is affected by chronic communicable and non-communicable diseases such as TB, HIV, and diabetes, although it has a Constitutional right to health and healthcare. Their quality of healthcare and disease control also affects the general population and the burden on the health system can be increased by inadequately managed chronic conditions as well as acute health care needs. Access to healthcare and continuity of care reflect both patient agency and the health system. Community Health Workers (CHWs) play an important role in linking communities and patients to health services and vice versa. The aim of this study was to understand how agricultural migrants in the Cape Winelands District of Western Cape Province of South Africa navigated the healthcare system to access healthcare services including securing continuity of care, and in particular the role of CHWs in this process, in order to inform policy and practice.

As características e conceitos dos sistemas complexos adaptativos (SCA) e a dinâmica de sistemas podem ser utilizados como ferramentas altamente efetivas para analisar a organização de um sistema de saúde. Várias das propriedades dos SCA são relevantes para este propósito especialmente a emergência de padrões auto-organizativos. Os objetivos são descrever os fluxos intermunicipais de gestantes para a resolução da gravidez visando compreender os fatores que influenciam estes deslocamentos considerando os recursos hierárquicos disponíveis e propor modelos explicativos da regionalização ao cuidado ligado à gravidez e ao parto e à regulação do sistema. Esta pesquisa aplicou conceitos de sistemas complexos adaptativos para estudo dos fluxos de gestantes entre municípios no sistema de atenção ao parto e puerpério na região de Ribeirão Preto- São Paulo determinando as áreas de captação de pacientes e fatores que influenciam deslocamentos. Para isto foram construídas matrizes de origem-destino das gestantes que tiveram a resolução da gravidez na área do Departamento Regional de Saúde XIII (DRS XIII) sediado em Ribeirão Preto no ano de 2012. Foram utilizadas ferramentas ligadas ao fluxo de altas disponíveis no Observatório Regional de Atenção Hospitalar, aplicando modelos de interação espacial e análise de redes para determinar a suficiência das regiões e sub-regiões para a realização dos procedimentos selecionados e explorar os fatores determinantes dos deslocamentos de pacientes. Em 2012, os hospitais de Ribeirão Preto (sede da DRS XIII) receberam 3807 internações por parto de fora do município, das quais 597 foram provenientes de 114 municípios fora da jurisdição do DRS XIII. Observou-se que 25 % das pacientes se deslocaram a outro município para a resolução da gravidez, percorrendo uma distancia média ponderada de 27 km. Os fluxos de pacientes mostram uma alta concentração em Ribeirão Preto e Sertãozinho, embora grande parte dos casos derivados não requeriam serviços de alta complexidade. O DRS XIIII é suficiente como região para a resolução destes casos e se comporta como um importador de pacientes de uma região mais ampla que compreende ao menos 60 municípios. Vários municípios do DRS XIII também têm serviços suficientes para as necessidades de sua população. O sistema de regulação do estado e do DRS XIII e as preferências dos pacientes, famílias e médicos são determinantes mais importantes dos fluxos que as distancias geográficas. A evolução da demografia e epidemiologia, da geografia política e organizacional do SUS, da oferta de serviços e os comportamentos e preferências dos agentes (usuários, médicos e outros) devem ser analisadas em conjunto como sistemas dinâmicos para compreensão dos fluxos de pacientes e assim reformular as redes de serviços para responder melhor às necessidades da assistência materna e puerperal na região coberta pelo DRS III. / The characteristics and concepts of complex adaptive systems (CAS) and system dynamics can be used as highly effective tools to analyze the organization of a health system. Several of the properties of an CAS are relevant to this purpose, especially the emergence of self-organizing patterns. Objectives: To describe the intermunicipal flows of pregnant women at the end of the pregnancy, in order to understand the factors that influence these displacements considering the available hierarchical resources and propose explanatory models of the regionalization of care related to pregnancy, delivery and regulation of the system. This research applied concepts of complex adaptive systems to study the flows of pregnant women among municipalities in the maternal care system in the Ribeirão Preto - São Paulo region, determining the catchment areas of patients and analyzing the factors that influence their displacement. For this purpose, the research gathered origin-destination matrices of the pregnant women who had the pregnancy resolution in the area of the Regional Health Department XIII (DRS XIII), based in Ribeirão Preto, for the year 2012. The tools used for these matrices were built in the discharge-flow utility available at the Hospital Regional Observatory webpage. Using spatial interaction models and network analysis it was possible to determine the sufficiency of regions and sub-regions to perform the selected procedures and to explore the determinants of patient travel. In 2012, maternity hospitals in Ribeirão Preto (headquarters of DRS XIII) received 3807 hospitalizations related to deliveries coming from outside the municipality, of which 597 came from 114 municipalities outside the jurisdiction of DRS XIII. It was observed that 25% of the patients moved to another municipality for the events related to the end of the pregnancy, traveling a weighted average distance of 27 km. Patient flows show a high concentration in Ribeirão Preto and Sertãozinho, although a majority of the derived cases did not require services of high complexity. DRS XIIII is sufficient as a region to resolve these cases and behaves as an net importer of patients from a wider region comprising at least 60 municipalities. Several municipalities of DRS XIII also have sufficient services for the needs of their population. The system of regulation of the state and DRS XIII and the preferences of patients, families and doctors are more important determinants of flows than geographical distances. The evolution of demography and epidemiology, the political and organizational geography of the SUS, the service offerings and the behaviors and preferences of the agents (users, doctors and others) should be analyzed together as dynamic systems for understanding patient flows allowing to redesign the service networks to better respond to the needs of maternal and child care in the region covered by DRS XIII.

O Brasil possui um sistema de saúde com cobertura universal (Sistema Único de Saúde- SUS) defendendo a saúde como um direito de todos os cidadãos e dever do estado. Apesar deste sistema público universal, o sistema de saúde brasileiro é composto por um mix público-privado que favorece cobertura duplicada aos serviços de saúde para a parcela da população com posse de plano privado de saúde. Um quarto dos brasileiros possui plano privado de saúde e, portanto, tem acesso duplicado aos serviços de saúde. A posse de plano privado de saúde e o uso dos serviços médicos e odontológicos precisam ser analisados neste contexto. Os objetivos desta tese são analisar as tendências no uso dos serviços de saúde médicos e odontológicos e verificar sua relação com a posse de planos privados de saúde. Os resultados desta tese estão organizados em dois manuscritos. O primeiro manuscrito “The relationship between private health plans and use of dental and medical health services among Brazilians: a cross-sectional study, 2008” teve por objetivo descrever o uso de serviços de saúde médico e odontológico de acordo com o tipo de serviço utilizado (público, privado ou por plano privado de saúde) e analisar o efeito do cadastro na Estratégia de Saúde da Família (ESF). Neste estudo foram analisados 391.868 indivíduos provenientes do banco da Pesquisa Nacional de Amostra Domiciliar (PNAD) de 2008. Como esperado, indivíduos sem plano privado de saúde utilizaram mais o serviço público, enquanto aqueles com plano utilizaram mais os serviços do seu plano. Ainda, os indivíduos com plano privado de saúde tendem a utilizar mais os serviços de saúde. Por outro lado, estar cadastrado em ESF aumenta o uso do serviço público e reduz o uso do privado e do plano entre os indivíduos sem plano e aumenta a chance de usar qualquer serviço entre aqueles que têm plano. Assim, políticas para a expansão da ESF devem ser incentivadas e a posse de plano privado precisa ser monitorada e regulada para evitar gastos desnecessários em saúde e o aumento das iniqüidades no acesso, principalmente em países com sistema universal de saúde. O segundo manuscrito “Tendências no uso de serviços de saúde médicos e odontológicos e a relação com nível educacional e posse de plano privado de saúde no Brasil, 1998 a 2013” teve como objetivo analisar as tendências no uso de serviços de saúde médico e odontológicos por adultos no Brasil entre 1998 e 2013 em relação à posse de planos privados de saúde e nível educacional. Foram analisados 760.678 indivíduos oriundos dos bancos de dados nacionais da PNAD de 1998, 2003, 2008 e da Pesquisa Nacional de Saúde de 2013. Adultos (18 a 59 anos) com posse de plano privado de saúde apresentaram chance maior de usar os serviços de saúde comparados àqueles sem plano em todos os anos analisados. No entanto, houve tendência de diminuição do uso dos serviços médicos entre indivíduos com posse de plano privado de 1998 para 2013. Em relação ao uso dos serviços odontológicos, o declínio foi observado de 2003 para 2013. O percentual de adultos com plano privado para assistência médica diminuiu de 24,9% para 22,2%, enquanto a tendência de posse de plano exclusivamente odontológico aumentou de 1,0% para 6,3% de 1998 para 2013. Tendência de aumento no uso de serviços de saúde, médico e odontológico, entre adultos sem plano privado de saúde também foi verificada. Acompanhar as tendências na posse de planos privados e no uso dos serviços, bem como avaliar o estado de saúde e o tipo de serviço utilizado (público, pagamento direto do bolso ou através do plano) são necessários para auxiliar o estado na regulação dos planos e evitar o aumento das iniquidades no acesso e uso dos serviços entre os cidadãos. / Brazil has a health care system with universal coverage (Unified Health System, or SUS) advocating health as a right to all citizens and a duty of the state. Despite this universal public system, the Brazilian health system is composed of a public-private mix that favors doubled coverage for part of the population with private health plan. About a quarter of Brazilians has private health insurance and therefore has duplicate access to health services. The private health plan possession and the use of medical and dental services need to be analyzed in this context. The objectives of this thesis are to analyze trends in possession of private health plans and verify their relation to the use of medical and dental health services. The results this thesis is organized in two manuscripts. The first manuscript "The relationship between private health plans and use of dental and medical health services among Brazilians: a cross-sectional study, 2008" aimed to describe the use of medical and dental health services according to the type of service used (public, private or private health plan) and assess the effect of being registered in the Family Health Strategy (ESF). This study analyzed 391,868 individuals from the 2008 National Household Survey (PNAD). As expected, individuals without private health plan used more public health services, while those with private health plan tend to use more their plan. Overall, those with private health plan tend to use more the health services. On the other hand, being registered in ESF increased the use of public service and reduced the use of private service among individuals without private health plan, and increased the chance to use any service among those with plan. Thus, policies for expanding ESF should be encouraged and private health plans need to be monitored and regulated to avoid unnecessary expenses on health and increasing inequities in access, especially in countries with universal health systems. The second manuscript " Trends in use of dental and medical services and its association with education and having private health plan in Brazil, 1998 to 2013" aimed to analyze trends in use of medical and dental health services among Brazilian adults between 1998 and 2013 in relation to private health plans and educational level. The sample included 760,678 individuals from the PNAD in the years 1998, 2003, 2008 and the National Health Survey in 2013. Adults (18-59 year-old) with private health plan were more likely to use health services compared to those without a plan in every years analyzed. However, there was a trend of decrease in the use of medical services among adults with private health plan from 1998 to 2013. In relation to the use of dental services, a decrease was observed from 2003 to 2013. The percentage of individuals with medical plans has decreased from 24.9% to 22.2%, while the trend in exclusively dental private plan has increased from 1.0% to 6.3% from 1998 to 2013. Trend the increase to use health services between adults without private health plan was found in medical and dental service. Monitoring trends in the private health plan possession, and health services use, and to assess the health conditions and the type of service used (public, private out-of-pocket or through the plan) are important for the state regulation and to avoid increasing inequities in access and use of health services among citizens.