Thesis (Ph.D.) -- McMaster University, 2005. / Supervisor: I. L. Bourgeault. Includes bibliographical references.

Thesis (Ph. D.)--University of Washington, 2004. / Vita. Includes bibliographical references (leaves 86-95).

Thesis (Ph. D.)--Case Western Reserve University, 2006. / [School of Medicine] Department of Epidemiology and Biostatistics. Includes bibliographical references. Available online via OhioLINK's ETD Center.

O estudo que se apresenta tem como objeto a Política de Transplante do Estado do Rio de Janeiro e as suas particularidades, visando captar as transformações que este vem sofrendo, especialmente na atualidade, quando se observa importantes transformações na Política de Saúde Brasileira e Estadual. As disputas entre os diferentes projetos de saúde na atualidade o Projeto Privatista e o Projeto de Reforma Sanitária - vem impactando na configuração da política pública de transplante. No caso do Rio de Janeiro, observa-se uma forte tendência de fortalecimento do Projeto Privatista com a criação do Programa Estadual de Transplantes. Repasse maior de recursos financeiros públicos em unidades privadas, a ampliação da oferta de transplantes através de parcerias privadas e a contratação de funcionários por contratos e outros vínculos que não garantem os direitos dos trabalhadores são as principais estratégias que foram adotadas pelo Estado do Rio. Identificar essas estratégias de privatização se torna essencial para a construção de respostas democráticas para combatê-las e fortalecer o SUS. / The study that is presented focuses the policy of the State of Transplantation Rio de Janeiro and its special features , aiming to capture the transformations that this is suffering , especially today , when we observe significant changes in the Brazilian and State Health Policy . Disputes between different health projects today - the privatizing Project and Project Health Reform - has impacted the setting of public policy transplantation. In the case of Rio de Janeiro, there is a strong trend towards the strengthening of the privatized project with the creation of the State Program of Transplantation. Greater transfer of public funds into private units , expanding the supply of transplants through private partnerships and hiring employees for contracts and other links that do not ensure workers' rights are the main strategies that have been adopted by the State of Rio identify these privatization strategies becomes essential for building democratic responses to combat them and strengthen the SUS

Thesis (M.S.H.P.) PLEASE NOTE: Boston University Libraries did not receive an Authorization To Manage form for this thesis or dissertation. It is therefore not openly accessible, though it may be available by request. If you are the author or principal advisor of this work and would like to request open access for it, please contact us at open-help@bu.edu. Thank you. / The Accountable Care Act (ACA) will expand coverage to millions of Americans. Health insurance plans designed to contain costs and incentivize patients may pose risks that deter members from utilizing recommended services despite provisions such as zero-cost-sharing intended to encourage their use. We evaluated trends (from 2007 to 2011) in health insurance plan type and initial colorectal cancer (CRCA) screening per current guidelines. We hypothesized that consumer-directed and high-deductible health plans (CDHP/HDHP) would be associated with decreased and delayed CRCA screening, and a shift toward lower-cost screening options. Using Thomson MarketScan® data, we analyzed commercial claims for 989,038 American adults (prior colectomy or CRCA excluded) over a full three-year period (starting in January of the fiftieth birthday-year) to assess for CRCA screening (colonoscopy, sigmoidoscopy, or stool test). Using logistic regression, we found that CDHP/HDHP members showed increased likelihood of having had any CRCA screening compared to Preferred Provider Organization (PPO) members, in both Massachusetts (Odds Ratio [OR] 2.321, 95% Confidence Interval [CI] 1.788-3.014) and the Nation (OR 1.640, 95% CI 1.602-1.678). Of those screened, CDHP/HDHP patients were more likely to receive colonoscopy than other recommended alternatives compared to PPO (Massachusetts OR 1.289, 95% CI 1.007-1.651; U.S. OR 1.225, 95% CI 1.192-1.259). Using linear regression, we found that CDHP/HDHP patients were only slightly older at screening compared to PPO, and the difference, while statistically significant, was likely too small to be clinically meaningful. We conclude that contrary to our expectations, CDHP/HDHP members have not been deterred from seeking and obtaining appropriate and timely initial CRCA screening, and they have not chosen lower-cost options. These findings may reflect the newly insured effect, although one limitation of this study was the inability to adjust for selection into CDHP/HDHP. Further study should determine whether CDHP/HDHP members subsequently experience unexpected financial burdens related to CRCA screening that affect future utilization of recommended care. In the pursuit of lower costs through better outcomes, attention should be paid to designing simple and affordable plans with easily understandable features that encourage both patients and providers to follow recommended guidelines while considering the cost-effectiveness of available options. / 2031-01-01

Thesis (M.S.H.P.) / BACKGROUND: Dual eligible (DE) patients qualify for Medicare and Medicaid. There are approximately nine million DE patients in the United States, and healthcare costs for this population totaled 319.5 billion dollars in 2011. Behavioral health illness (BHI) is a risk factor for increased healthcare service utilization. The healthcare utilization of adult DE patients <65 years of age with BHI has been studied sparsely. This study sought to describe the adult DE patient population <65 years of age at an urban academic safety net health center and compare hospital and emergency department (ED) utilization of those with and without BHI. METHODS: The study was a secondary analysis of hospital administrative data. Inclusion criteria were patients with Medicare and Medicaid between ages 18 and 65 years, who utilized Boston Medical Center between 1/1/2011 and 1/1/2012. The independent variable was diagnosis of BHI, and the dependent variables were hospital admission and ED utilization. Chi-square and Wilcoxon rank-sum tests were used for descriptive statistics on categorical and continuous variables, respectively. Greedy propensity-score matching without replacement with a caliper distance of half of a standard deviation was used to control for confounding factors. Rate ratios (RR) and confidence intervals (CI) were determined after matching and after adjusting for those variables that remained significantly different after matching. RESULTS: Pre-propensity-score matched data showed significant differences in age, sex, race/ethnicity, marital status, education, employment, physical comorbidities, and Charlson Comorbidity Index score. Post-propensity-score matched analysis found significant differences in sex, Hispanic race, and other education and employment status. As compared to those patients without BHI, patients with BHI had RR 2.07 (CI: 1.81- 2.38) (p<.0001) of hospital admission and a RR 1.61 (CI:1.46-1.77) (p<.0001) of ED utilization. After adjustment, RR for hospital admission and ED utilization remained significantly different and even increased slightly, RR 2.14 (CI: 1.87-2.46) (p<.0001) and RR 1.64 (CI:1.49-1.81) (p<.0001), respectively. CONCLUSION: As compared to DE patients without BHI, those with BHI had significantly more hospital admission and ED utilization, even after controlling for confounding factors. Results suggest interventions for decreasing healthcare services utilization in this population should focus on those DE patients with mental health illness. / 2031-01-01

Thesis (M.S.H.P.) PLEASE NOTE: Boston University Libraries did not receive an Authorization To Manage form for this thesis or dissertation. It is therefore not openly accessible, though it may be available by request. If you are the author or principal advisor of this work and would like to request open access for it, please contact us at open-help@bu.edu. Thank you. / IMPORTANCE: With greater access to health care through health care reform it is important to know if quality of care for similar complaints differs across clinical settings. OBJECTIVE: Develop and pilot a chart review instrument to measure quality of care for patients presenting with urethritis and vaginitis. METHODS: List of sexually transmitted infection (STI) quality of care measures was reviewed by a panel of five STI experts representing Emergency Department (ED), Obstetrics/Gynecology (Ob/Gyn), Family Medicine (FM), Primary Care (PC) and Infectious Disease. Panel members grouped each measure into “standard” or “exceeds standard of care” in evaluation and management of male patients with penile discharge/dysuria or female patients with vaginal discharge. The chart review instrument was piloted on 50 charts per gender from the STI Clinic and matched charts, by patient presenting complaint, age, gender, and visit date, from PC, FM, ED, and Ob/Gyn (for vaginal discharge) in the same large safety-net hospital in Massachusetts. RESULTS: Twenty-four and 34 final measures in male and female patients, respectively, were selected on plurality of expert panel member’s categorization into “standard of care”. Measures were grouped into 7 clinical domains: history, examination, laboratory testing, additional screening, assessment, treatment, and counseling. Performance on the 7 domains ranged from 3.16-4.36 on male patients and 3.17-4.40 on female patients, with the highest scores in the STI Clinic. However, each clinical setting had particular documentation strengths and weaknesses: STI Clinic scored higher on laboratory testing, additional screening, and counseling, but scored lower on examination and assessment; ED scored higher on examination and treatment; PC and FM scored higher on laboratory testing for male patients and on examination and treatment for female patients; Ob/Gyn scored higher on treatment. All sites other than the STI Clinic scored poorly on additional screening and counseling. CONCLUSIONS: An instrument to discern standard of care and identify strengths and weaknesses in specific domains of clinical documentation for patients presenting with STI complaints can be rapidly developed and implemented to evaluate quality of care across care settings. Further research is needed on whether these findings can be integrated into site-specific quality improvement processes and linked to cost analyses. / 2031-01-01

Background Malnutrition is a major risk factor of infant mortality in India. Policies targeting poverty and food insecurity may reduce infant malnutrition. The Mahatma Gandhi National Rural Employment Guarantee Act (MGNREGA), a wage-for employment policy of the Indian Government, targets deprivation and food insecurity in rural households. MGNREGA could prevent infant malnutrition by improving household food security or increase the risk of malnutrition by reducing the time devoted to infant care if mothers are employed. This study analyzed the effect and the pathways of effect of households' and mothers' participation in MGNREGA on infant malnutrition. Methods A community based mixed methods study using cross-sectional survey and focus group discussions (FGDs) was conducted in Dungarpur district of Rajasthan, India. Cross-sectional study included 528 households with 1,056 participants who were infants 1 to <12 months and their mothers/caregivers. Selected households were divided into MGNREGA-households and non-MGNREGA-households based on participation in MGNREGA between August-2010 and September-20ll. Anthropometric indicators of infant malnutrition-underweight, stunting, and wasting (WHO criteria) were the outcomes. Eleven FGDs with 62 mothers were conducted. Results Of 528 households, 281 participated in MGNREGA (53%). Mothers were employed in 51 (18%) households. Prevalence of wasting was 39%, stunting 24%, and underweight 50%. Households participating in MGNREGA were less likely to have wasted infants (OR 0' 57, 95% Cl 0•37-0'89; p=O'014) and underweight infants (OR 0'48,95% Cl 0•30-0'76; p=0'002) than non-participating households. Stunting did not differ significantly between groups. Although MGNREGA reduced starvation, it did not confer food security to the participating households because of lower than standard wages and delayed payments. Results from path analysis did not support an effect through household food security and infant feeding, but suggested a pathway of effect through birth-weight. Mothers' employment had no significant effect on the outcomes in the cross-sectional study, but the qualitative study indicated that it could compromise infant feeding and care. Conclusion Participation in MGNREGA was associated with reduced infant malnutrition possibly mediated indirectly via improved birth-weight rather than improved infant feeding. Providing child care facilities at worksites could mitigate the negative effects of mother's participation in MGNREGA. Further, improving mothers' knowledge of appropriate feeding practices in conjunction with providing employment (to address deprivation and food insecurity) is key in the efforts to reduce infant malnutrition.

Submitted by Raniere Barreto (raniere.barros@ufvjm.edu.br) on 2018-05-07T19:25:48Z No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) sandra_neres_santos.pdf: 2035812 bytes, checksum: d8607072d59b5a797fcc1096c55a4bdb (MD5) / Approved for entry into archive by Rodrigo Martins Cruz (rodrigo.cruz@ufvjm.edu.br) on 2018-05-14T14:31:36Z (GMT) No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) sandra_neres_santos.pdf: 2035812 bytes, checksum: d8607072d59b5a797fcc1096c55a4bdb (MD5) / Made available in DSpace on 2018-05-14T14:31:36Z (GMT). No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) sandra_neres_santos.pdf: 2035812 bytes, checksum: d8607072d59b5a797fcc1096c55a4bdb (MD5) Previous issue date: 2017 / O objetivo desta disserta??o ? analisar a pol?tica de sa?de, o Estado e o sistema capitalista e seu processo hist?rico. Esse processo ? resultado de lutas e conquistas realizadas pela classe trabalhadora e as contradi??es que s?o intensificadas em conson?ncia com os interesses capitalistas. Analisa-se antes e depois da institui??o da Pol?tica de Sa?de como direito por meio da Constitui??o Federal de 1988 e os reflexos atuais. Utilizou-se uma pesquisa bibliogr?fica descritiva qualitativa. As bibliografias mostram como as conquistas sociais se tornam letra morta diante do que preconiza e da efetividade desses servi?os, processo este marcado por intensas investidas neoliberais a partir da d?cada de 1990. ? reconhec?vel o avan?o legal de 1988 e outras leis que visam o aperfei?oamento. Em contrapartida, muitas s?o as ambiguidades vivenciadas, precariza??o do p?blico versus o crescente n?mero de setores privados. A sa?de ? universal, mas nem todos a acessam como lhe ? de direito, de maneira que se faz necess?ria a judicializa??o na luta pelo direito ? sa?de. Relacionar essa precariza??o dos servi?os p?blicos com a expans?o exacerbada do capitalismo indagamos para compreender o papel do Estado. O contexto da d?cada de 1990 com o processo de contrarreforma, tendencialmente fortalece essas rela??es de mercado capitalista. Eleva-se a mercantiliza??o da sa?de via planos de sa?de que s?o bem seletivos e a qualidade do acesso ? medida pelas condi??es de pagar. Nessa perspectiva, percebe-se que as contradi??es s?o inerentes e cont?nuas, a reprodu??o capitalista sempre ser? dependente do Estado burgu?s que potencializa os interesses privados em detrimento da precariza??o do p?blico, por meio de concess?es, isen??es fiscais; e parcela da popula??o que usa os servi?os privados depende dos servi?os p?blicos; ou seja, n?o h? aparta??o total dessas inst?ncias privados e p?blico. Nessa l?gica, as pol?ticas que comp?em a seguridade social s?o afetadas e se torna um arranjo. Para acessar a previd?ncia, se faz necess?ria a contribui??o estar vinculada ao mercado de trabalho, a sa?de ? universal, mas diante do discurso privado a qualidade ser? melhor se for paga e a assist?ncia social ? a pol?tica que ir? amparar e assistir ?queles que est?o fora do mercado de trabalho que, consequentemente, n?o poder? acessar a previd?ncia e essa sa?de privada, e, que, para a l?gica capitalista ? um grande aliado nesse processo de acumula??o capitalista. ? a parcela da sociedade que continuar? ? margem da cobertura dessas pol?ticas sociais, e, possivelmente, se submeter? aos ditames e condi??es desumanas na busca pela sobreviv?ncia, as quais s?o rela??es de depend?ncia criadas e mantidas pelo capitalismo. A pol?tica de sa?de tem sido uma ?rea de forte interesse para investimentos privados e os setores influentes econ?micos t?m investido em planos de sa?de, mas com aux?lio do Estado potencializador das a??es privadas, que s?o refor?adas pelos organismos internacionais, (FMI, BIRD, BM); enquanto no setor p?blico, fortalece interven??es pontuais e burocratizadas. Essa realidade se perpetua, pois, antes da institui??o legal do direito, o acesso era restrito aos que estivessem inseridos no mercado de trabalho, para algumas categorias profissionais. A historicidade dial?tica apresenta como as rela??es em sociedade est?o culturalmente impregnadas pela depend?ncia impositiva, e o sistema capitalista usa desse mecanismo para sua reprodu??o. / Disserta??o (Mestrado Profissional) ? Programa de P?s-Gradua??o em Tecnologia, Sa?de e Sociedade, Universidade Federal dos Vales do Jequitinhonha e Mucuri, 2017. / The aim of this dissertation is to analyze health policy, the state and the capitalist system and its historical process. This process is the result of struggles and achievements carried out by the working class and as contradictions that are integrated in within capitalist interests. It is analyzed before and after the institution of the Health Policy as a right through the Federal Constitution of 1988 and the current reflexes. Qualitative descriptive bibliographic research was used. As bibliographies show how social achievements become irrelevant in front of what it advocates and the effectiveness of services, a process marked by intense neo-liberal efforts since 1990. It is recognized as legal progress of 1988 and other laws focus on improvement. In contrast, many are like experienced ambiguities, public precariousness versus the growing number of private sectors. Health is universal, but not everyone is approached as the right, in the way that a judicialization is necessary in the fight for the right to health. To relate this precariousness of public services with an exacerbated expansion of capitalism, we inquire into the paper document. The context of the 1990s with the process of counter-reform tends to strengthen these capitalist market relations. The commodification of health is raised through health plans that are very selective and a quality of access is measured by the conditions of payment. In this perspective, it is perceived that as contradictions are inherent and continuous, capitalist reproduction will always be dependent on the bourgeois state that potentialize private interests to the detriment of the precariousness of the public, through concessions, tax exemptions; And part of the population that uses private services depending on public services; That is, there is no total apportionment of private and public instances. In this logic, as policies that make up social security are affected and becomes an arrangement. To access social security, if a guarantee is needed for the labor market, a health and universal, but before the private speech, a better quality and better if to pay and social assistance is a policy that will support and watch what? Labor market that, consequently, we cannot access private pension and health, and that, for capitalist logic and a great ally in the process of capitalist accumulation. It is a part of society that continues with the margin of cover, is likely to submit to the dictates and inhuman conditions in the quest for survival, as are dependency relations created and maintained by capitalism. A health policy has a strong area of interest for private investors and the influential economic sectors that have invested in health plans, but with the aid of the State, which is reinforced by the international organizations (IMF, IBRD, WB); While in the public sector, it strengthens punctual and bureaucratic interventions. This reality is perpetuated, because before the legal institution of law, access was restricted to those who were included in the labor market, for some professional categories. A dialectical historicity shows how relations in society are culturally impregnated by tax dependence, and the capitalist system uses that mechanism for its reproduction.

Aim Despite the country's explicit political goal to establish equivalent living conditions across Germany, significant inequality continues to exist. We argue that premature mortality is an excellent proxy variable for testing the claim of equivalent living conditions since the root causes of premature death are socioeconomic. Subject and methods We analyse variation in premature mortality across Germany's 402 districts and cities in 2014. Results Premature mortality spatially clusters among geographically contiguous and proximate districts/cities and is higher in more urban places as well as in districts/cities located further north and in former East Germany. We demonstrate that, first, socioeconomic factors account for 62% of the cross-sectional variation in years of potential life lost and 70% of the variation in the premature mortality rate. Second, we show that these socioeconomic factors either entirely or almost fully eliminate the systematic spatial patterns that exist in premature mortality. Conclusion On its own, fiscal redistribution, the centrepiece of how Germany aspires to establish its political goal, cannot generate equivalent living conditions in the absence of a comprehensive set of economic and social policies at all levels of political administration, tackling the disparities in socioeconomic factors that collectively result in highly unequal living conditions.