京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第20621号 / 医博第4270号 / 新制||医||1023(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 山下 潤, 教授 木村 剛, 教授 渡邉 大 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

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There is a growing body of literature about public participation in health-system priority setting in different contexts and levels of governance, however, explicit focus on vulnerable populations’ participation is lacking. This dissertation incorporated a mix of methodological approaches to address this gap. First, a scoping review was used to synthesize the literature on priority-setting frameworks to understand whether and how applications of the frameworks involve the public and vulnerable populations in different contexts. Second, an interpretive description study was used to examine stakeholder participation at the district level in a low-income country, Uganda. Third, a qualitative description study design was used to qualitatively assess vulnerable women’s participation in health-system priority setting within a district in Uganda, from the perspectives of both vulnerable women and decision-makers. The research chapters complement and build on one another to make substantive, methodological, and theoretical contributions. Specifically, insights gained from the scoping review demonstrate that while priority-setting frameworks may require participation of all stakeholders, in practice certain stakeholder groups, namely the public and especially vulnerable populations, are not consistently integrated into priority-setting processes. The empirical research provides a rich understanding of the roles of different stakeholders in the priority-setting process and provides explanations about why vulnerable women, as a subset of the public, are not participating. This adds to the evidence base that policy-makers can access to guide future attempts to engage publics in health-system priority setting. These studies collectively contribute to a wider understanding of public’s and vulnerable populations’ participation in health-system priority setting in low-income contexts where health disparities are pronounced, and health resources are especially scarce. Policy-makers should aim to support vulnerable populations’ participation in health-system priority setting. Clear articulation of which vulnerable populations should participate and how they should participate can facilitate priority-setting processes. Co-developing participatory methods, frameworks, and guides with vulnerable populations can reinforce their participation and lead to mechanisms of participation that are more responsive to their needs. / Thesis / Doctor of Philosophy (PhD) / Public participation is often considered a cornerstone of fair and legitimate priority setting. Yet, little is known about whether and how the participation of vulnerable populations is operationalized in the field of health-system priority setting. An in-depth understanding of who participates and who does not, and how participation is enabled and/or hindered is essential to ensure that policy-makers can support participation. This dissertation addresses gaps in knowledge through: 1) a literature synthesis examining the operationalization of stakeholder participation within priority-setting frameworks, with specific attention to the publics’ and vulnerable populations’ participation, in cases where the frameworks have been applied to health-system priority setting; 2) supportive qualitative evidence on the roles, leverages, and challenges of different stakeholders’ participation in district-level health-system priority setting in Uganda; and 3) examining vulnerable women’s participation within one Ugandan district, specifically outlining barriers to their participation, and solutions to address these barriers and support vulnerable women’s participation in health-system priority setting. Collectively these studies can inform policy-making and development of public participation strategies that specifically target vulnerable populations for participation in health-system priority setting.

Yes / Set in the context of the recent unprecedented upsurge of in-work poverty (IWP) in the UK – which currently exceeds out of work poverty – this article presents an account of the realities of experiencing poverty and being employed. Central issues of low-pay, limited working hours, underemployment and constrained employment opportunities combine to generate severe financial complexities and challenges. This testimony, taken comparatively over a year, reveals the experiences of, not only IWP, but of deep poverty, and having insufficient wages to fulfil the basic essentials of nourishing food and adequate clothing. This article contributes to current academic and social policy debates around low-paid work, IWP, the use of foodbanks and underemployment. New dimensions are offered regarding worker vulnerabilities, given the recent growth of the IWP phenomenon.

How might computer scientists work with communities in facilitating meaningful social change? In this project, we make a case for an approach that builds upon what the individuals and community already have---their assets---rather than emphasizing "user's needs" as typically postulated by human-centered design. We present details of our four-year-long assets-based engagement with an anti-trafficking organization in Nepal and the sex trafficking survivors supported by the organization. We explored the potential role that socio-technical systems and technology designers can play in assisting the survivors to build on their existing assets towards their vision of "dignified reintegration". The research involves three fieldwork and a remote study, each one leveraging carefully tailored socio-technical systems to investigate a design proposition. We present an operationalizable definition of assets and a framework of action to leverage assets in realizing change at an individual and institutional level. We describe the conditions that influenced the possibilities for our interventions and the factors that guided the design of the socio-technical systems. We further highlight how we adapted our methods to the local resources and practices in order to foster a space that promoted comfort and control to the study participants. The detailed account of our approach aims to provide a justification for undertaking slow, incremental steps with the community. / Doctor of Philosophy / Human trafficking survivors face a myriad of challenges in their reintegration journey. Working with an anti-trafficking organization in Nepal, I explored the potential role that technology and technology designers can play in assisting the survivors in their reintegration journey. The research involved three forays into fieldwork and a remote study, each one leveraging carefully tailored activities to investigate the possibilities for the survivors to be in a position of power once they leave the shelter home. The activities included technology such as a specifically tailored web application contextualized around the survivors' existing strengths but also involved non-digital components such as collectively envisioning broader possibilities and alternative futures and discussing ways in which the survivors could engage with local actors to mitigate societal problems they had seen near their homes. In all these activities, I adapted local practices and materials to promote a safe space for the survivors to participate from within their realm of comfort. This dissertation illuminates a potential pathway to engage in long-term community-based research with vulnerable populations. In particular, it makes a case for an approach that builds upon what the individuals and community already have, that is, their assets. The work illuminates ways to identify and build upon assets to support the survivors. Using the work, we make a case for undertaking slow, incremental steps as part of assets-based engagement with communities. The work emphasizes the need for technology developers to understand their responsibilities and carefully contemplate what elements of a situation or design allow ethical intervention. Finally, the work emphasizes the need for developers to be cognizant of how design of technology is tied up with the larger, multi-level system in which technology use is embedded.

In the United States, there were 36,560 traffic-related fatalities in 2018, of which 20% were pedestrians, bicyclists, and other vulnerable road users (VRUs) [1]. Vulnerable road users are non-vehicle occupants who, because they are not enclosed in a vehicle, are at higher risk of injury in traffic crashes. While overall traffic fatalities in the US have been decreasing, pedestrian and bicyclist fatalities have been trending upward. Vehicle-based active safety features could avoid or mitigate crashes with VRUs, but are highly dependent on the ability to detect a VRU with enough time or distance. This work presents methods to examine the characteristics of vehicle-pedestrian and vehicle-bicycle crashes and near-crashes using a variety of data sources, assess the potential effectiveness of Automatic Emergency Braking (AEB) in avoiding and mitigating VRU crashes through modeling and simulation, and estimate the future benefits of AEB for VRU safety in the United States. Additionally, active safety features are most effective when behavior of VRUs can be anticipated, however, the behavior of pedestrians and bicyclists is notoriously unpredictable. Therefore, an approach to examine and categorize pedestrian behavior in response to near-crashes and crashes events is presented. Overall, findings suggest that AEB has great potential to avoid and mitigate collisions with pedestrians and bicyclists, but it cannot avoid all crashes even when an idealized AEB system is assumed. Most pedestrians and bicyclists were found to be visible for at least one second prior to the crash, but obstructions, the unpredictability of VRUs, and adverse weather/lighting conditions still pose challenges in avoiding and mitigating crashes with VRUs. / Doctor of Philosophy / In the United States, there were 36,560 traffic-related fatalities in 2018, of which 20% were pedestrians, bicyclists, and other vulnerable road users (VRUs) [1]. Vulnerable road users are non-vehicle occupants who, because they are not enclosed in a vehicle, are at higher risk of injury in traffic crashes. While overall traffic fatalities in the US have been decreasing, pedestrian and bicyclist fatalities are trending upward. Vehicle-based countermeasures, such as Automatic Emergency Braking (AEB), could avoid or mitigate crashes with VRUs, but are highly dependent on the ability to detect a VRU with enough time or distance. My work presents methods to examine the characteristics of vehicle-pedestrian and vehicle-bicycle crashes and near-crashes using a variety of data sources, assess the potential effectiveness of AEB in avoiding and mitigating VRU crashes through modeling and simulation, and estimate the future benefits of AEB for VRU safety in the United States. Additionally, crash avoidance technologies are most effective when behavior of VRUs can be anticipated, however, the behavior of pedestrians and bicyclists is notoriously unpredictable. Therefore, I examined and categorized pedestrian behavior in response to near-crashes and crashes events. Overall, we found that AEB has great potential to avoid and mitigate collisions with pedestrians and bicyclists, but it cannot avoid all crashes even when assuming an idealized AEB system. Most pedestrians and bicyclists were found to be visible for at least one second prior to the crash, but obstructions, the unpredictability of VRUs, and adverse weather/lighting conditions still pose challenges in avoiding and mitigating crashes with VRUs.

Individuals with Social Anxiety Disorder (SAD) are typically perceived by others as shy, submissive, or risk-averse. However, recent work has identified an understudied subtype within SAD characterized by high levels of anger and high-risk or novelty-seeking impulsive behaviors. Interestingly, this subtype bears conceptual similarities with prior accounts of vulnerable narcissism. For example, both are associated with concerns regarding self-presentation and how they are perceived by others. The angry-impulsive subtype and vulnerable narcissism may further share similar etiologic origins and similar associations with self-reported anger, impulsivity, and anxiety-related characteristics. However, despite these key similarities no prior work has systematically evaluated the common and potentially distinguishing factors within and between these conceptually similar but diagnostically distinct groups. For example, cognitive features such as fear of negative evaluation and interpersonal rivalry could be distinguishing features of SAD and vulnerable narcissism, although the utility of these distinguishing features to clarify the differential diagnosis remains unknown. Accordingly, the purpose of this study was to utilize a person-centered analytic approach (latent profile analysis; LPA) to empirically establish whether vulnerable narcissistic traits exist within high anger, risk-prone individuals who are also socially anxious, or alternatively whether specific features of each disorder can be used to disambiguate them empirically. Results of this work supported the existence of the angry impulsive socially anxious subtype and supported a relationship between that group and vulnerable narcissistic traits. These findings have implications for treatment selection among affected individuals and may further clarify why prior work evaluating interventions for adults with SAD and angry impulsive features has been met with only limited success. / M.S. / Individuals with Social Anxiety Disorder (SAD) are typically perceived by others as shy, submissive, or risk-averse. However, recent work has identified an understudied subtype within SAD characterized by high levels of anger and high-risk or novelty-seeking impulsive behaviors. Interestingly, this subtype has conceptual similarities with descriptions of vulnerable narcissism. For example, both are associated with concerns regarding self-presentation and how they are perceived by others. The angry-impulsive subtype and vulnerable narcissism may further share similar origins and similar associations with self-reported anger, impulsivity, and anxiety-related characteristics. However, despite these key similarities no prior work has evaluated the common and potentially distinctive factors within and between these distinct groups. For example, features such as fear of negative evaluation and interpersonal rivalry could be distinguishing features of SAD and vulnerable narcissism, although the utility of these differentiating features to clarify the differential diagnosis is unknown. Accordingly, the purpose of this study was to utilize a person-centered analytic approach (latent profile analysis; LPA) to establish whether vulnerable narcissistic traits exist within high anger, risk-prone individuals who are also socially anxious, or whether specific features of each disorder can be used to differentiate them. Results of this work supported the existence of the angry impulsive socially anxious subtype and supported a relationship between that group and vulnerable narcissistic traits. These findings have implications for treatment selection among affected individuals and may further clarify why prior work evaluating interventions for adults with SAD and angry impulsive features has been met with only limited success.

This study investigated school closures' impact on students from vulnerable populations in elementary classrooms. The research places an emphasis on the importance of an equitable and effective educational system in every community. It highlights the role of formal education in providing opportunities for social advancement and promoting the development of individuals and nations. The impact of the COVID-19 Emergency on access to quality education and the challenges and inequities faced by vulnerable populations are emphasized. This research also discusses the Sustainable Development Goals (SDGs) established by the United Nations in 2015 to ensure inclusive and equitable education for all children worldwide. Data from a large suburban school district is presented to analyze how students perform following school closures and their attempts to prevent achievement gaps. Specifically, the researcher examines how students from minority and low socioeconomic subgroups have been impacted by the COVID-19 Emergency compared to their peers. The analysis demonstrates a significant correlation between race, socioeconomic status and student success on the Florida Standards Assessment. Due to school shutdowns, one can conclude that students from vulnerable populations struggled to access curriculum at the same rate as their non-vulnerable peers. Recommendations are made for mitigating learning loss and for preparing schools to successfully maintain the quality of education in future emergencies.