This paper will examine specific processes involved within the decision-making process of how to allocate limited health care resources. I will start by discussing how in order to compare and differentiate between health states, we have created ranking systems, based on the health state’s impact on people’s quality of life, which health states need more care, and which can be most effectively treated. We evaluate impact on quality of life by assigning quality weights to years of life lived with that health state, which we call quality-adjusted life years, or QALYs. Next, I will discuss the problems with assigning quality weights to health states; specifically, the disability paradox, meaning the distinct differences between quality weights assigned by non-patients versus patients. After that, I will explain how depression defies the trend of the disability paradox, and causes our prior arguments about why patients and non-patients rate health states different to contradict themselves., This leads me to suggest that we should consider a different way of deciding between different quality weights. I examine the arguments for choosing higher or lower quality weights, and conclude that because we have a moral imperative to provide health care resources to those in need, particularly those who are disadvantaged, we should take the lower quality weights and err on the side of overspending on health states. Ultimately, this will create the greatest change in funding for health states like depression that go against the disability paradox. Finally, I address the economic trade-offs we have to consider if we make the decision to spend more on treating health states.

Licentiatavhandling (sammanfattning) Skara : Sveriges lantbruksuniversitet, 2005. / Härtill 2 uppsatser.

Global health is an emerging concern in a rapidly changing world in which health issues transcend international borders. This study developed and validated a new self-report questionnaire to assess self-perceived global health competencies among international medical students and how they are influenced by international clinical experiences. A tool consisted of two scales and four subscales with moderate internal consistency. Comparisons between participants who completed retrospective pretest (after the intervention retrospectively) and those who completed traditional pretest (before the intervention) revealed that those participants who completed the questionnaires retrospectively provided lower pretest scores, suggesting that response-shift bias had occurred. Significant increases in scores after international clinical experience were reported for the majority of global health competency measures in IFMSA group. Linear regression identified participant’s age, gross national income (GNI) of country of medical studies, GNI of the country visited, duration of international clinical experience and years of medical school completed, as significant predictors of global health scores. This study contributes valuable information about the newly developed global health competencies measurement tool.

Philosophiae Doctor - PhD / Headache disorders constitute a public-health problem which impacts on individuals and society. The functional limitation and psychosocial restriction, caused by chronic headache, may be a more reliable indication of the severity of the disorder than the pain intensity and temporal headache pattern itself. Evaluation of all these parameters may improve health care for individuals suffering from chronic headache. The ultimate purpose of this study was to develop and validate a multidimensional questionnaire to assess the severity and impact of headache in individuals suffering from chronic headache. The study was carried out in six phases, each stage building on the previous ones. A quantitative retrospective review of 450 patients' clinical files was executed to identify the elements of complaint of these patients. This was followed by a literature review of existing headache-related health measures and construction of a theoretical framework for the study. A questionnaire was developed based on these findings. This questionnaire was then tested for face and content validity in a chronic headache population sample (n=60) and physiotherapists working with these patients (n=18). The questionnaire was further refined by a small qualitative study, making use of small group discussions (n=10). After the suggested modifications were made, the Multidimensional Chronic Headache Questionnaire (MCHQ) was tested for stability in a group of chronic headache patients (n=21), who completed the questionnaire twice with a one-week intervening period with no intervention. It was then tested for responsiveness, where patients completed the questionnaire prior to, and after, an episode of treatment. The Wilcoxon Signed Rank Sum Test was used to detect significant differences (and hence responsiveness). Lastly, all the MCHQ's (n=148) that were completed during the course of the study were analised to establish the homogeneity of item content (Chronbach alpha values), and the construct validity of the instrument in terms of item structure (exploratory factor analysis). The retrospective review of patients' perceptions of the severity and impact of their chronic headache indicated that many of the patients experienced moderate to severe limitation of function and psychosocial restriction. Although many domains of headache-related health were represented in published questionnaires reviewed for this study, no instrument that assesses both the perceived severity and a wide range of impact was found. The MCHQ was developed from this study to measure these parameters. The items in the questionnaire were based on the retrospective study and existing questionnaires utilised in the chronic headache population. The face and content validity of the first draft of the instrument was found to be good. The stability of the questionnaire was very good, with Pearson's correlation coefficients of greater than 0.9334 for all repeated items. Responsiveness was very good, with all items found to be responsive to change (with probability values of p<O.OOOI for all but 3 items; these being effect of analgesics, triggering factors and impact on relationships). Homogeneity of item content was good (alpha values all >0.6647), and preliminary construct validity was suggested by demonstration of eight distinct factors that were clearly interpretable (one in the severity and seven in the impact domain). These suggested that severity is unidimensional, and that seven dimensions of impact are assessed in the MCHQ (functional limitations, two emotional dimensions, relationship restrictions, and three headache trigger dimensions). Positive linear correlations between severity and impact suggested that the higher the severity, the more severe the impact on the individual's quality of life (r=0.5183; p<.OOOI). These tests suggested preliminary construct validity for the questionnaire. The researcher concluded that severe and frequent headache has a considerable impact on the individual and that the multiple facets of headache-related health can be measured appropriately using this instrument. The Multidimensional Chronic Headache Questionnaire is a new instrument to assess headache-related health in terms of both severity and multidimensional impact on individuals, which can be utilised in a once-off health assessment as well as an outcome measure for therapy.

O surgimento de novas tecnologias em saúde e a diversidade dos modelos assistenciais tornou necessária a investigação sobre a qualidade dos cuidados médicos e dos serviços de saúde, especialmente na atenção primária. O Primary Care Assessment Tool (PCATool) foi desenvolvido para medir a presença e extensão dos atributos da Atenção Primária à Saúde (APS) nas perspectivas de usuários, profissionais e gestores. Esse instrumento foi elaborado considerando o quadro conceitual baseado nos atributos essenciais - acesso de primeiro contato, longitudinalidade, integralidade e coordenação; e derivados - orientação familiar, orientação comunitária e competência cultural. Na literatura internacional os atributos da APS são reconhecidos como eixo estruturante do processo de atenção, associados à qualidade dos serviços, à efetividade e a eficiência de suas intervenções. O objetivo deste estudo foi avaliar a validade e a fidedignidade do PCATool na versão profissionais, traduzido e adaptado para o Brasil, em um estudo transversal com 340 profissionais médicos e enfermeiros dos serviços públicos de APS em Porto Alegre. Foram avaliadas a validade fatorial, a consistência interna e a estabilidade no tempo. Na análise fatorial exploratória foram retidos 9 fatores, explicando aproximadamente 75% da variação total. A avaliação da consistência interna mostrou alfa de Cronbach variando de 0,28 a 0,90. Estabilidade temporal foi observada para todos os atributos à exceção de orientação familiar (p < 0,05). Os atributos da APS foram captados pelos primeiros nove fatores na análise fatorial, identificando-se, assim, a natureza multidimensional do instrumento e conceitual do fenômeno. Essa avaliação sugere que o instrumento é útil para a mensuração da qualidade dos serviços de saúde de atenção primária, na perspectiva dos profissionais de saúde. Pode ser utilizado tanto para identificação, monitoramento e avaliação dos atributos da APS nos serviços de saúde, quanto para estudos comparativos. / The emergence of new technologies in healthcare and the variety of assistance models has created a need for assessing the quality of healthcare services, especially primary healthcare services. The Primary Care Assessment Tool (PCATool) was developed in order to measure the presence and extension of Primary Care attributes from the perspective of the users, healthcare professionals, and managers. This tool was formulated by considering the conceptual framework based on primary attributes (first contact access, longitudinally, integrity and coordination) and secondary attributes (family counseling, community counseling and cultural competence). In the international literature, Primary Healthcare attributes are recognized as the structural axis of the attention process associated with the quality of services, effectiveness and efficiency of its intervention. The objective of the present study was to assess the validity and reliability of the PCATool from the perspective of healthcare professionals, translated and adapted for the Brazilian context. Therefore, a crosssectional study of 340 healthcare professionals within the public Primary Healthcare service in Porto Alegre was carried out. Factorial validity as well as internal consistency and stability over time were assessed. Nine factors were retained in the exploratory factorial analysis explaining approximately 75% of the total variation. These factors are identified with the Primary Healthcare attributes characterizing the multidimensional nature of the tool and the conceptual nature of the phenomenon. For internal consistency assessment, Cronbach's alpha coefficient estimates ranged from 0.28 to 0.90. Temporal stability was observed for all attributes but family counseling (p<0.05). The results of this assessment suggest that the PCATool can be useful to measure the quality of the Primary Healthcare services from the perspective of healthcare professionals. The tool can be used either for identification, monitoring and assessment of the Primary Healthcare attributes within healthcare services or comparative studies. / Telemedicina

O surgimento de novas tecnologias em saúde e a diversidade dos modelos assistenciais tornou necessária a investigação sobre a qualidade dos cuidados médicos e dos serviços de saúde, especialmente na atenção primária. O Primary Care Assessment Tool (PCATool) foi desenvolvido para medir a presença e extensão dos atributos da Atenção Primária à Saúde (APS) nas perspectivas de usuários, profissionais e gestores. Esse instrumento foi elaborado considerando o quadro conceitual baseado nos atributos essenciais - acesso de primeiro contato, longitudinalidade, integralidade e coordenação; e derivados - orientação familiar, orientação comunitária e competência cultural. Na literatura internacional os atributos da APS são reconhecidos como eixo estruturante do processo de atenção, associados à qualidade dos serviços, à efetividade e a eficiência de suas intervenções. O objetivo deste estudo foi avaliar a validade e a fidedignidade do PCATool na versão profissionais, traduzido e adaptado para o Brasil, em um estudo transversal com 340 profissionais médicos e enfermeiros dos serviços públicos de APS em Porto Alegre. Foram avaliadas a validade fatorial, a consistência interna e a estabilidade no tempo. Na análise fatorial exploratória foram retidos 9 fatores, explicando aproximadamente 75% da variação total. A avaliação da consistência interna mostrou alfa de Cronbach variando de 0,28 a 0,90. Estabilidade temporal foi observada para todos os atributos à exceção de orientação familiar (p < 0,05). Os atributos da APS foram captados pelos primeiros nove fatores na análise fatorial, identificando-se, assim, a natureza multidimensional do instrumento e conceitual do fenômeno. Essa avaliação sugere que o instrumento é útil para a mensuração da qualidade dos serviços de saúde de atenção primária, na perspectiva dos profissionais de saúde. Pode ser utilizado tanto para identificação, monitoramento e avaliação dos atributos da APS nos serviços de saúde, quanto para estudos comparativos. / The emergence of new technologies in healthcare and the variety of assistance models has created a need for assessing the quality of healthcare services, especially primary healthcare services. The Primary Care Assessment Tool (PCATool) was developed in order to measure the presence and extension of Primary Care attributes from the perspective of the users, healthcare professionals, and managers. This tool was formulated by considering the conceptual framework based on primary attributes (first contact access, longitudinally, integrity and coordination) and secondary attributes (family counseling, community counseling and cultural competence). In the international literature, Primary Healthcare attributes are recognized as the structural axis of the attention process associated with the quality of services, effectiveness and efficiency of its intervention. The objective of the present study was to assess the validity and reliability of the PCATool from the perspective of healthcare professionals, translated and adapted for the Brazilian context. Therefore, a crosssectional study of 340 healthcare professionals within the public Primary Healthcare service in Porto Alegre was carried out. Factorial validity as well as internal consistency and stability over time were assessed. Nine factors were retained in the exploratory factorial analysis explaining approximately 75% of the total variation. These factors are identified with the Primary Healthcare attributes characterizing the multidimensional nature of the tool and the conceptual nature of the phenomenon. For internal consistency assessment, Cronbach's alpha coefficient estimates ranged from 0.28 to 0.90. Temporal stability was observed for all attributes but family counseling (p<0.05). The results of this assessment suggest that the PCATool can be useful to measure the quality of the Primary Healthcare services from the perspective of healthcare professionals. The tool can be used either for identification, monitoring and assessment of the Primary Healthcare attributes within healthcare services or comparative studies. / Telemedicina

O surgimento de novas tecnologias em saúde e a diversidade dos modelos assistenciais tornou necessária a investigação sobre a qualidade dos cuidados médicos e dos serviços de saúde, especialmente na atenção primária. O Primary Care Assessment Tool (PCATool) foi desenvolvido para medir a presença e extensão dos atributos da Atenção Primária à Saúde (APS) nas perspectivas de usuários, profissionais e gestores. Esse instrumento foi elaborado considerando o quadro conceitual baseado nos atributos essenciais - acesso de primeiro contato, longitudinalidade, integralidade e coordenação; e derivados - orientação familiar, orientação comunitária e competência cultural. Na literatura internacional os atributos da APS são reconhecidos como eixo estruturante do processo de atenção, associados à qualidade dos serviços, à efetividade e a eficiência de suas intervenções. O objetivo deste estudo foi avaliar a validade e a fidedignidade do PCATool na versão profissionais, traduzido e adaptado para o Brasil, em um estudo transversal com 340 profissionais médicos e enfermeiros dos serviços públicos de APS em Porto Alegre. Foram avaliadas a validade fatorial, a consistência interna e a estabilidade no tempo. Na análise fatorial exploratória foram retidos 9 fatores, explicando aproximadamente 75% da variação total. A avaliação da consistência interna mostrou alfa de Cronbach variando de 0,28 a 0,90. Estabilidade temporal foi observada para todos os atributos à exceção de orientação familiar (p < 0,05). Os atributos da APS foram captados pelos primeiros nove fatores na análise fatorial, identificando-se, assim, a natureza multidimensional do instrumento e conceitual do fenômeno. Essa avaliação sugere que o instrumento é útil para a mensuração da qualidade dos serviços de saúde de atenção primária, na perspectiva dos profissionais de saúde. Pode ser utilizado tanto para identificação, monitoramento e avaliação dos atributos da APS nos serviços de saúde, quanto para estudos comparativos. / The emergence of new technologies in healthcare and the variety of assistance models has created a need for assessing the quality of healthcare services, especially primary healthcare services. The Primary Care Assessment Tool (PCATool) was developed in order to measure the presence and extension of Primary Care attributes from the perspective of the users, healthcare professionals, and managers. This tool was formulated by considering the conceptual framework based on primary attributes (first contact access, longitudinally, integrity and coordination) and secondary attributes (family counseling, community counseling and cultural competence). In the international literature, Primary Healthcare attributes are recognized as the structural axis of the attention process associated with the quality of services, effectiveness and efficiency of its intervention. The objective of the present study was to assess the validity and reliability of the PCATool from the perspective of healthcare professionals, translated and adapted for the Brazilian context. Therefore, a crosssectional study of 340 healthcare professionals within the public Primary Healthcare service in Porto Alegre was carried out. Factorial validity as well as internal consistency and stability over time were assessed. Nine factors were retained in the exploratory factorial analysis explaining approximately 75% of the total variation. These factors are identified with the Primary Healthcare attributes characterizing the multidimensional nature of the tool and the conceptual nature of the phenomenon. For internal consistency assessment, Cronbach's alpha coefficient estimates ranged from 0.28 to 0.90. Temporal stability was observed for all attributes but family counseling (p<0.05). The results of this assessment suggest that the PCATool can be useful to measure the quality of the Primary Healthcare services from the perspective of healthcare professionals. The tool can be used either for identification, monitoring and assessment of the Primary Healthcare attributes within healthcare services or comparative studies. / Telemedicina

Measurement problems in terms of different understanding of the meaning, concepts and implications of survey questions as well as tendencies to different response-sets (e.g. acquiescence or social desirability) are reoccurring problems in comparative migration research. Cultural factors, time-varying effects and survey design lead to response biases. It could be shown that depending on the region of origin, migrants tend to extreme or centred responding behaviour. Macroscale changes in attitudes towards disclosure of personal information influence acquiescent biases. Therefore, the question arises whether the presence of measurement equivalence can be assumed, especially within instruments regarding subjective feelings, when comparing migrant and native populations. The aim of the study is to test for intercultural and longitudinal equivalence of the Health Short Form 12 - items scale (SF -12), trying to answer the question whether this instrument is useful to compare health of migrants and native Germans over time. The study contributes to the ongoing discussion on measurement equivalence of the SF -12 by including variables concerning integration and assimilation, employment, family status and varying types of migration and years since migration to the analysis. Using a Multiple Group Structural Equation Modelling approach analyzing longitudinal data of the German Socioeconomic Panel (SOEP), we test the validity and measurement equivalence (configural, metric and scalar invariance) of the latent construct ‘health’ over time and between (non-)migration groups. In addition, different item functioning can be detected for a series of covariates. The study concludes in recommending a reduced version of the SF-12 to improve the avoidance of measurement artefacts when comparing the health of migrants and native Germans.