Information and communication technology (ICT) can enhance communication among health care providers which may lead to various health system improvements, such as gains in efficiency. However, there is inadequate evidence regarding the extent to which ICT improves communication among specific groups of health care professionals. This dissertation incorporates a mix of methodological approaches across three interrelated research studies to address this gap. Study 1 consists of a systematic review which suggested that ICT can play an important role in enhancing health care related communication among physicians, but the extent of that benefit is influenced by: 1) the impact of ICT on existing work practices; 2) the availability of adequate resources for ICT implementation and use; and 3) the nature of institutional elements, such as privacy legislation. Study 2 consists of a document analysis that examined guidelines for health information protection when using ICT from the provincial regulatory colleges for physicians. These documents were notable for the considerable variation in the scope and detail of guidance provided, which may result in unequal and inequitable protection of health information across the provinces. Study 3 is a case study that examined the use of a relatively novel form of ICT, smartphones, for communication among postgraduate medical trainees (medical residents). Efficiency and convenience were identified as the main reasons that medical residents use smartphones to communicate health care related information with colleagues. In addition, by applying a neo-institutional perspective, it became clear that medical residents base their smartphone use primarily on normative elements (professional norms; what peers/staff are doing) and cultural-cognitive elements (beliefs/perceptions regarding facilitation of task completion). Regulative elements (guidelines/policies) around smartphone use play a smaller role in shaping behaviour, particularly when they: 1) lack clarity; 2) are not seen as credible/legitimate; or 3) are viewed as cumbersome and do not align with workflow needs. Taken together, these studies provide timely insights regarding the use of ICT by physicians, which can be drawn upon by a variety of decision-makers as efforts to improve health system performance continue. / Thesis / Doctor of Philosophy (PhD) / The goal of this doctoral dissertation was to develop a better understanding of how and why physicians are using information and communication technology (ICT) to exchange health care related information, along with the role of such communication in enhancing health system performance. Findings indicate that physicians use ICT in various circumstances as they perceive it to be more convenient and efficient. However, guidelines for the exchange of health information in digital/electronic format vary by jurisdiction and organization, which may result in different uses of ICT by physicians. Moreover, as these guidelines often lack clarity or are not seen as credible/legitimate, some physicians base their use of ICT primarily on what peers/colleagues are doing or by acting in a manner that they believe facilitates task completion and, hence, patient care. The insights gained from this work can be adopted by decision-makers to improve communication among physicians using ICT and, consequently, health system performance.

OBJECTIVES: The Government of Canada legalized the recreational use of cannabis on October 17th, 2018. Our objectives were to determine the prevalence of Canadians (aged 15 years or older) intending to try or increase their cannabis use following legalization and explore characteristics associated with the intent to try or increase use. METHODS & DATA ANALYSIS: A secondary data analysis was conducted of cross-sectional data from Waves 1–3 of the National Cannabis Survey collected from February to September 2018. All respondents’ data were weighted and bootstrapped multivariable logistic and multinomial regression models were developed. Relative measures of association were reported as adjusted odds ratios (aORs) and relative risk ratios (RRRs), and absolute measures of association as adjusted risk differences (ARDs). RESULTS: Response rates were 51.2% (Wave 1), 51.3% (Wave 2), and 51.6% (Wave 3). An estimated 18.5% (95%CI: 17.6–19.5) of the study population indicated that they intended to try (12.3%) or increase (6.2%) cannabis use following legalization. Our weighted analysis represented 27,808,081 Canadians 15 years of age or older (unweighted n = 17,089). In our adjusted logistic model, being more likely to try or increase cannabis use was associated with younger age (15–24 years versus ≥65; aOR 3.8, 95%CI: 2.6–5.6; ARD 20.1%, 95%CI: 13.9–26.2), cannabis use in the past three months versus not (aOR 3.3, 95%CI: 2.8–3.9; ARD 20.4%, 95%CI: 17.1–23.6),higher income (≥$80,000 versus <$40,000; aOR 1.5, 95%CI: 1.3–1.9; ARD 6.1%, 95%CI: 3.2–9.0), and poor or fair mental health compared to good or excellent mental health (aOR 2.0, 95%CI: 1.6–2.6; ARD 11.5%, 95%CI: 6.7–16.2). CONCLUSIONS: Nearly 1 in 5 respondents reported their intention to try or increase cannabis use post–legalization. Intentions may not lead to actual changes in behaviour and further surveillance of cannabis use can help determine impact of policy change. / Thesis / Master of Public Health (MPH)

No

Yes / New wave public health places an emphasis on exhorting individuals to engage in healthy behaviour with good health being a signifier of virtuous moral standing, whereas poor health is often associated with personal moral failings. In effect, the medical is increasingly being collapsed into the moral. This approach is consistent with other aspects of contemporary neoliberal governance, but it fuels moral panics and creates folk devils. We explore the implications and dysfunctional consequences of this new wave of public health policy in the context of the latest moral panic around obesity.

In the ever-evolving landscape of health systems, citizen advocacy stands as a tool for influencing policy aiming to strengthen health systems. This dissertation delves into the multifaceted nature of health policy advocacy and how citizen advocates can leverage research evidence in addition to the commonly used emotional messaging to influence policy. The first study is a critical interpretive synthesis (CIS), creating a theoretical framework that helps us understand the roles of citizen health policy advocates and their relation to research evidence. The second study is a multiple-case study that examines the approaches taken by citizen-serving NGOs in their advocacy training and whether and how research evidence is incorporated into the training. The third study is a qualitative descriptive study that explores citizens' experiences participating in these training modules and their perceptions of factors affecting the incorporation of research evidence in the training. In Chapter 2, we included 32 publications in the CIS, and four thematic groups were identified, including the roles of citizen health policy advocates, how research evidence could support them and the facilitators and barriers to their use of research evidence. In Chapter 3, we conducted a documentary review of 27 documents and interviewed 16 staff and board members of three organizations that provide advocacy training to citizen advocates. In Chapter 3, we interviewed 14 citizens who participated in the training of the three organizations. v The first study outlined how citizens could use research evidence and its importance to their advocacy roles, while the last two studies provide an understanding of how citizen-serving organizations offer training to citizen advocates and whether, how, and under what conditions they include research evidence in training. / Thesis / Doctor of Philosophy (PhD) / Advocacy is an effective way to influence policies in democratic societies. One of those areas that are influenced by policy advocacy is health systems. Citizens who advocate for improving their health systems often rely on personal emotional messages rather than peer-reviewed research evidence. This dissertation tries to understand why this is the case and how research evidence can support those citizens. We also explore the factors that encourage or hinder citizens from using research evidence in health policy advocacy. We then examine three citizen-serving organizations that support citizens with advocacy training and explore how they support the trainees to use research evidence in advocacy. We also examine the experiences of citizens who participated in those training sessions and how they perceive the utility of research evidence in their advocacy to strengthen their health systems.

Yes / The coronavirus (COVID-19) pandemic coincides with the tenth anniversary of the recognition of the rights to water and sanitation within the United Nations system. Although water, sanitation and hygiene (WASH) remain critical for COVID-19 infection prevention and control, billions of people around the world lack access to basic WASH services in different spheres of life. Mostly affected are people living in vulnerable situations. While the pandemic has significantly impacted regulatory practices and access, key actors in the WASH sector continue to adopt diverse approaches to ensure safety, continuity, and reliability of supply. This chapter explores how COVID-19 influences WASH services and how the rights to water and sanitation can ultimately strengthen resilience to health pandemics? It makes recommendations from the perspective of inclusive development theory, for strengthening WASH sector governance towards ensuring the progressive realization of the rights to water and sanitation during and post the COVID-19 pandemic. Experiences with the coronavirus pandemic illustrate the crucial importance of access to water and sanitation as basic human rights and as necessities for the realization of health, education, food, gender equality, and other human rights (United Nations 2020). Emergent issues, particularly include the high public health risks associated with lack of water and sanitation and the disproportionate burden borne by women and girls, transgendered people, people living in informal settlements, people living with disabilities, the urban poor, migrant workers, workers in the informal sector, people who are sick or living with underlying health conditions, the elderly, school-aged children, and other groups living in vulnerable situations (Banerji 2020; Tan 2020; UNESCO n.d.). These highlight intersecting layers of inequalities in different situations of vulnerability and the interconnectedness of human rights. The pandemic has also demonstrated the imperative of leaving no one behind and ensuring universal access to water and sanitation to achieve sustainable development. From Africa to the Pan-European region, it is a similar picture: there are remarkable inequities in access to water and sanitation based on whether people live in urban or rural areas, whether people are rich or poor, and whether they have any special circumstances which render them vulnerable (Local Burden of Disease WaSH Collaborators 2020; Wang et al. 2019; World Health Organization & UN-Water 2019; United Nations 2020). Furthermore, because of the pandemic, several assumptions and modes of service delivery need to be reexamined to ensure continued suitability for promoting universal access to water and sanitation. It is in light of these realizations that this chapter examines the question: How has COVID-19 influenced water, sanitation and hygiene services and how can the rights to water and sanitation strengthen resilience in health pandemics? This question is addressed from the perspective of inclusive development theory which emphasizes the need to address the social, relational, and ecological aspects of human development (Gupta, Pouw, & Ros-Tonen 2015).

This dissertation begins from a desire to explain situations in which left-wing parties appear to adopt policies that are more typically associated with right-wing thinking. A standard explanation for such behaviour is that relatively weak left-wing parties are drawn to adopt those policies as a way of getting elected — commonly expressed as convergence on the median voter. The puzzle, however, is that this explanation often seems to fall foul of the empirical reality that left-wing parties adopt these policies when they are relatively strong, not weak. The explanation for this advanced here is that parties, seeking to improve outcomes for their constituencies both now and in the future, often operate in political environments which lead them to assign a high probability that today’s policy choices will not survive the predations of government by opposing parties tomorrow. Where this is the case, there is incentive to pursue policies that are less efficient, but which have inbuilt political defence mechanisms: with the main such mechanism focused upon here being the power of organised public sector labour. The effect of partisanship is, therefore, conditioned by expectations about the future political power of parties. Where left-wing parties expect to be weak, they will tend to adopt the highly statist, bureaucratised, nationalised policies that are traditionally associated with the Left as these will tend to embody large amounts of organised labour that will be a counter to future right-wing governments. Where left-wing parties expect to be strong, the costs associated with such policies come to outweigh the benefits, with the result that they do not need to pursue such ‘left-wing’ policies. These ideas are developed heoretically within an institutionalist framework, yielding a synthesis between the historical and rational choice institutionalisms. Empirically, the theoretical framework is applied to the development of welfare states and to the issue of privatisation of state-owned enterprises.

Made available in DSpace on 2016-12-23T14:36:50Z (GMT). No. of bitstreams: 1 Rossana Reis.pdf: 2453531 bytes, checksum: 073553410e861c8a38e91c175293f71b (MD5) Previous issue date: 2009-06-29 / O objetivo deste estudo é identificar como o projeto democrático participativo e o projeto neoliberal atravessam a dinâmica de funcionamento do Fórum de Saúde Mental do Espírito Santo (FSMES) desde seu surgimento em 1999 até 2008/1. O problema de pesquisa é a identificação da tensão entre os dois projetos políticos antagônicos presentes na política de saúde mental brasileira (projeto da reforma psiquiátrica versus projeto privatista, de exclusão dos sujeitos com transtorno mental) tendo como lócus o espaço do FSMES. Foi feita pesquisa documental em sete relatórios de gestão (do período de 2000 a 2007) e em três planos de ação (de 2000-2003; 2004-2007; 2008-2011) da coordenação estadual de saúde mental da Secretaria de Estado da Saúde (SESA), em dez listas de presença dos encontros do FSMES do período de 2005 a 2008, e em um documento do ano de 1995 que versa sobre a proposta de reorientação do modelo de atenção no Estado, naquele ano. Foram realizadas cinco entrevistas semi-estruturadas com atores participantes do FSMES ou informantes-chave sobre esse espaço. E também foi realizada observação sistemática nos encontros do FSMES (no período de 2007 a 2008). O discurso dos entrevistados e o discurso impresso nos documentos indicam uma orientação política-ideológica do FSMES voltada ao processo de reforma psiquiátrica. O FSMES é considerado por seus atores um espaço privilegiado para a saúde mental. O projeto político defendido é o da reforma psiquiátrica. Profissionais e/ou gestores das esferas estadual e municipal são segmentos que continuamente fazem parte desse espaço, enquanto a participação de usuários e da sociedade civil organizada se dá de forma pontual e tímida. No período em análise, os atores atuantes nesse espaço expressaram uma direção de contribuição do espaço do FSMES para o processo de reforma psiquiátrica no Estado. Os entrevistados da pesquisa apontaram avanços na trajetória de existência desse espaço, como: quantidade de pessoas que consegue reunir e temáticas para discussão, relacionando a saúde mental e a saúde de modo geral. Verificam-se também entraves, como: tendência de declínio de realização dos encontros (o que demonstra uma periodicidade instável) e dificuldade em assegurar a participação contínua de usuários. A análise mostra que o FSMES foi construído em uma direção contrahegemônica, defendendo o projeto da reforma psiquiátrica, e está impulsionado a contribuir para o processo de implementação do novo modelo de atenção em saúde mental. Como esse processo não é linear, enfrenta dificuldades que devem ser contextualizadas na conjuntura sócio-política de hegemonia das políticas neoliberais que incentivam a despolitização da sociedade e expressivos investimentos no setor privado. / This study aims at identifying how the democratic-participative and the neoliberal projects have gone through the operating dynamics of the Mental Health Forum of Espírito Santo (FSMES) from its beginning in 1999 to 2008/1. The research problem is to identify the tension between these two main antagonistic political projects present in the Brazilian mental health policies (the psychiatric reform project versus the privatist project excluding subjects with mental disorders) taking place at the FSMES. Documental research was carried out based on seven management reports (from 2000 to 2007); on three action plans (from 2000 to 2003; 2004 to 2007; 2008 to 2011) of the state mental health coordination of SESA State Department of Health; on ten attendance lists of the FSMES meetings between 2005 and 2008; and on a 1995 document about the proposal of reorienting the care model in the state that year. Five semi-structured interviews were carried out with participant actors of the FSMES or key-respondents of this space. Systematic observation of the FSMES meetings (between 2007 and 2008) was also performed. The respondents discourse and the discourse printed on the documents indicate a political and ideological bias of the FSMES towards the psychiatric reform process. FSMES is considered a privileged mental health space by its actors. The political project defended is psychiatric reform. The professionals and/or managers of the state and municipal spheres are segments that continually take part in this space, whereas users and organized civil society s participation is limited and shy. In this period under analysis, the actors in this space made contributions in the FSMES space towards the psychiatric reform process in the state. The respondents in this study reported advances in the history of this space such as: number of people it can gather and discussion topics relating mental health to health care in general. Some obstacles were also identified, such as: tendency to decrease the number of meetings (which shows an instable periodicity) and difficulty to ensure the continuous participation of users. The analysis shows that the FSMES has been built in a counter-hegemonic direction, defending the psychiatric reform project. Also, it is being led to contribute to the process of implementing a new mental health care model. Since this process is not linear, it faces difficulties that should be contextualized in the social-political setting of hegemonic neoliberal policies that encourage both the depoliticization of society and significant investments in the private sector.

Made available in DSpace on 2016-12-23T14:36:51Z (GMT). No. of bitstreams: 1 Dissertacao de Rossana dos Reis.pdf: 2453531 bytes, checksum: ab50e2aa8bccf9fe720f81d5a0094ce5 (MD5) Previous issue date: 2009-06-29 / O objetivo deste estudo é identificar como o projeto democrático participativo e o projeto neoliberal atravessam a dinâmica de funcionamento do Fórum de Saúde Mental do Espírito Santo (FSMES) desde seu surgimento em 1999 até 2008/1. O problema de pesquisa é a identificação da tensão entre os dois projetos políticos antagônicos presentes na política de saúde mental brasileira (projeto da reforma psiquiátrica versus projeto privatista, de exclusão dos sujeitos com transtorno mental) tendo como lócus o espaço do FSMES. Foi feita pesquisa documental em sete relatórios de gestão (do período de 2000 a 2007) e em três planos de ação (de 2000-2003; 2004-2007; 2008-2011) da coordenação estadual de saúde mental da Secretaria de Estado da Saúde (SESA), em dez listas de presença dos encontros do FSMES do período de 2005 a 2008, e em um documento do ano de 1995 que versa sobre a proposta de reorientação do modelo de atenção no Estado, naquele ano. Foram realizadas cinco entrevistas semi-estruturadas com atores participantes do FSMES ou informantes-chave sobre esse espaço. E também foi realizada observação sistemática nos encontros do FSMES (no período de 2007 a 2008). O discurso dos entrevistados e o discurso impresso nos documentos indicam uma orientação política-ideológica do FSMES voltada ao processo de reforma psiquiátrica. O FSMES é considerado por seus atores um espaço privilegiado para a saúde mental. O projeto político defendido é o da reforma psiquiátrica. Profissionais e/ou gestores das esferas estadual e municipal são segmentos que continuamente fazem parte desse espaço, enquanto a participação de usuários e da sociedade civil organizada se dá de forma pontual e tímida. No período em análise, os atores atuantes nesse espaço expressaram uma direção de contribuição do espaço do FSMES para o processo de reforma psiquiátrica no Estado. Os entrevistados da pesquisa apontaram avanços na trajetória de existência desse espaço, como: quantidade de pessoas que consegue reunir e temáticas para discussão, relacionando a saúde mental e a saúde de modo geral. Verificam-se também entraves, como: tendência de declínio de realização dos encontros (o que demonstra uma periodicidade instável) e dificuldade em assegurar a participação contínua de usuários. A análise mostra que o FSMES foi construído em uma direção contrahegemônica, defendendo o projeto da reforma psiquiátrica, e está impulsionado a contribuir para o processo de implementação do novo modelo de atenção em saúde mental. Como esse processo não é linear, enfrenta dificuldades que devem ser contextualizadas na conjuntura sócio-política de hegemonia das políticas neoliberais que incentivam a despolitização da sociedade e expressivos investimentos no setor privado / This study aims at identifying how the democratic-participative and the neoliberal projects have gone through the operating dynamics of the Mental Health Forum of Espírito Santo (FSMES) from its beginning in 1999 to 2008/1. The research problem is to identify the tension between these two main antagonistic political projects present in the Brazilian mental health policies (the psychiatric reform project versus the privatist project excluding subjects with mental disorders) taking place at the FSMES. Documental research was carried out based on seven management reports (from 2000 to 2007); on three action plans (from 2000 to 2003; 2004 to 2007; 2008 to 2011) of the state mental health coordination of SESA State Department of Health; on ten attendance lists of the FSMES meetings between 2005 and 2008; and on a 1995 document about the proposal of reorienting the care model in the state that year. Five semi-structured interviews were carried out with participant actors of the FSMES or key-respondents of this space. Systematic observation of the FSMES meetings (between 2007 and 2008) was also performed. The respondents discourse and the discourse printed on the documents indicate a political and ideological bias of the FSMES towards the psychiatric reform process. FSMES is considered a privileged mental health space by its actors. The political project defended is psychiatric reform. The professionals and/or managers of the state and municipal spheres are segments that continually take part in this space, whereas users and organized civil society s participation is limited and shy. In this period under analysis, the actors in this space made contributions in the FSMES space towards the psychiatric reform process in the state. The respondents in this study reported advances in the history of this space such as: number of people it can gather and discussion topics relating mental health to health care in general. Some obstacles were also identified, such as: tendency to decrease the number of meetings (which shows an instable periodicity) and difficulty to ensure the continuous participation of users. The analysis shows that the FSMES has been built in a counter-hegemonic direction, defending the psychiatric reform project. Also, it is being led to contribute to the process of implementing a new mental health care model. Since this process is not linear, it faces difficulties that should be contextualized in the social-political setting of hegemonic neoliberal policies that encourage both the depoliticization of society and significant investments in the private sector

Introduction: Persistent health inequalities are the focus for much public health policy activity. Understanding the policy response to public health problems, the role of evidence, and the roles and strategies of different actors may help explain this persistence. Research suggests that policy actors often access knowledge through interpersonal relations, but current perspectives in the literature do not analyse relational aspects of finding evidence and influencing policy. Identifying powerful and influential actors (in terms of personal characteristics, strategies, and network properties) offers a method of exploring the policy process and evidence use. Methods: Network data were gathered from a public health policy community in a large urban area in the UK (n = 152, response rate 80%), collecting relational data on perceived power, influence, and sources of evidence about public health policy. Hubs and Authorities analyses were used to identify powerful and influential actors, to test whether powerful and influential actors were also sources of information; and betweenness and Gould-Fernandez brokerage were used to explore the importance of structural position in policy networks. These data were analysed in conjunction with qualitative data from semi-structured interviews (n = 24) carried out with a purposive subsample of network actors. Characteristics of powerful and influential actors, the use of evidence in the policy process, and roles and strategies used to influence policy were analysed using a framework approach, and combined with network data. Results: The most influential actors were mid-level managers in the NHS and local authorities, and to a lesser extent, public health professionals. These actors occupied advantageous positions within the networks, and used strategies (ranging from providing policy content, to finding evidence, to presenting policy options to decision-makers) to influence the policy process. Powerful actors were also sources of information for one another, but providing information did not predict power. Experts, academics and professionals in public health were represented in the networks, but were usually more peripheral and played fewer roles in the policy process. This study presents empirical evidence to support the suggestion that recognition of network structure assists individuals to be influential, and proposes a framework to categorise their activities. Conclusions: In order to influence policy, actors need good relationships with other influential actors, and the skills to exploit these relationships. The relational approach is useful for both identifying powerful and influential people (potential evidence-users) and for exploring how evidence and information reaches them. Identifying powerful and influential actors and describing their strategies for influencing policy provides a new focus for researchers in evidence-based policy, and for those wishing to influence policy. For academics and researchers, this study demonstrates the importance of directly creating ties with decision-makers