The disparity in life expectancy between Indigenous and non-Indigenous populations, including within high-income countries, is driven by a heightened risk of cardio-metabolic diseases. The current study recruited independent panels of experts in Indigenous cardio-metabolic health from Australia, New Zealand and the United States, in order to establish local consensus opinion and initiate dialogue on appropriate prevention strategies. Therefore, a three-round Delphi process was used to consolidate and compare the opinions of 60 experts, 20 from each country. Round one, the experts were asked twelve open-ended questions across six domains: (i) prevention; (ii) consultation; (iii) educational resources; (iv) societal issues; (v) workforce issues; (vi) culture and family. Round two, the experts completed a structured questionnaire based on results from the first round, in which they ranked items according to their importance. Final round, the experts were asked to re-rank the same items after receiving summary feedback about the rank ordering from the previous round. Several themes emerged common to all three countries: (i) socio-economic and education inequalities should be addressed; (ii) educational, behaviour change and prevention strategies should address physical environmental determinants and be responsive to the local context, including being culturally appropriate; and (iii) cultural appropriateness can be achieved through consultation with Indigenous communities, cultural competency training, use of Indigenous health workers, and use of appropriate role models. These findings highlight several key priorities that can be used to initiate dialogue on appropriate prevention strategies. Such strategies should be contextualized to the local Indigenous populations.

According to the World Health Organisation, obesity is an epidemic of the 21st century. It is most certainly a serious risk to the health of the individual in question, markedly lowering their quality of life. The Czech Republic is the fourth most obese country in Europe, with 5-10 % of child obesity present. This paper explores the development of child obesity and its potential root causes that might contribute to it. The analysis is supported by data from a study by the State Health Institute, which was carried out over 4 phases in 18 cities in the Czech Republic. Quantitative research was used in the analytical part of this paper. The data was processed within the SPSS programme, using the method of statistical analysis of contingency tables and binary logistical regression analysis for testing previously established working hypotheses. The results of the analysis have shown that the rate of obesity grew across the four phases, except only in the youngest group of participants. An analysis of the various contributory factors to obesity has highlighted age and place of residence as being the most influential. The highest number of obese children was found in the regions of Karlovy Vary and Ustí nad Labem, which could be due to the socioeconomic and environmental factors in these areas. In...

Screening to detect diseases early is attractive as it can improve the prognosis and decrease costs, but it is often a problematic concept and there are several pitfalls. Many healthy individuals have to be investigated to avoid a disease in a few, which results in a dilemma because to save a few, many are exposed to a procedure that could potentially harm them. Other examples of problems associated with screening are latent diseases and over-treating. The question of optimal design of a screening program is another source of uncertainty for decision-makers, as a screening program may potentially be implemented in very different ways. This highlights the need for structured analyses that weigh benefits against the harms and costs that occur as consequences of the screening. The aim of this thesis is, therefore, to explore, develop and implement methods for health economic evaluations of screening programs. This is done to identify problems and suggest solutions to improve future evaluations and in extension policy making. This aim was analysed using decision analytic cost-effectiveness analyses constructed as Markov models. These are well-suited for this task given the sequential management approach where all relevant data are unlikely to come from a single source of evidence. The input data were in this thesis obtained from the published literature and were complemented with data from Swedish registries and the included case studies. The case studies were two different types of screening programs; a program of screening for unknown atrial fibrillation and a program to detect colorectal cancer early. Further, the implementation of treatment with thrombectomy and novel oral anticoagulants were used to illustrate how factors outside the screening program itself have an impact on the evaluations. As shown by the result of the performed analyses, the major contribution of this thesis was that it provided a simple and systematic approach for the economic evaluation of multiple screening designs to identify an optimal design. In both the included case studies, the screening was considered costeffective in detecting the disease; unknown atrial fibrillation and colorectal cancer, respectively. Further, the optimal way to implement these screening programs is dependent on the threshold value for cost-effectiveness in the health care sector and the characteristics of the investigated cohort. This is because it is possible to gain increasingly more health benefits by changing the design of the screening program, but that the change in design also results in higher marginal costs. Additionally, changes in the screening setting were shown to be important as they affect the cost-effectiveness of the screening. This implies that flexible modelling with continuously updated models are necessary for an optimal resource allocation.

Introduktion: Den nyutexaminerade sjuksköterskan har under tre år samlat på sig teoretisk kunskap och ska nu ge sig ut i arbetslivet och ge god och patientsäker vård. Hur första tiden i yrket upplevs har betydelse för hur den kommande rollen som professionell sjuksköterska blir. Syfte:Att beskriva hur nyutexaminerade sjuksköterskor upplever första åretsom legitimerad sjuksköterska. Metod:Litteraturstudie med systematisk datainsamling och urval med tio vetenskapliga artiklar. Resultat:Den första tiden i yrket visade sig innebära nervositet, stress och en känsla av att vara otrygg. De nyutexaminerade sjuksköterskorna upplevde under de första månaderna i yrket en frustration. Detta på grund av brist averfarenhetsbaserad kunskap och att deras prestationer inte matchar med förväntningarna från patienter såväl som kollegor. Slutsatser:För att övergången skall vara tillfredsställande måste många delar fungera under första året. Arbetsintroduktion, handledning och kollegor gjorde stor inverkan på hur första året upplevdes. En vanligt förekommande uppgift är att nyutexaminerade sjuksköterskor upplever brist på klinisk kunskap, denna kunskap utvecklas med hjälp av erfarenhet i yrket. Litteraturstudien visar att nyutexaminerade är i behov av stöd och support för att få en bra start i yrket. Därför anses det vara av vikt att stötta varandra under första tidenför att öka trivseln och undvika att sjuksköterskor slutar

Dentists have traditionally been the sole gatekeepers to the delivery of primary care dental services. Direct Access, a measure that allows Dental Care Professionals to see patients without a referral from a Dentist, is a fundamental change to this long-standing principle. This thesis systematically explores the attitudes of stakeholders across the micro, meso and macro levels of dentistry towards Direct Access in two distinct health care systems, the Netherlands and the UK.Direct Access was introduced in the Netherlands in 2006 and subsequently introduced in the UK in 2013. This study uses a qualitative approach to explore the attitudes towards the introduction of Direct Access in both of these states. It presents the results of semi-structured interviews with 74 participants (individually or as part of a group) including Students, Dental Care Professionals and Dentists at the micro-level, representatives of Professional Associations, Insurers and Dental Schools at the meso-level and Policy Makers at the macro-level. The results of this study show a significant range of attitudes towards Direct Access, but reveal a degree of consensus within individual stakeholder groups towards the reform’s introduction and impact. Dental Care Professionals interpret the introduction of Direct Access as recognition of their capabilities and expect it to primarily benefit patients through access to care and expertise. Dentists were more likely to view the introduction of Direct Access in terms of competition or professional persecution, with the impacts considered from a professional or financial viewpoint. Policy Makers saw potential for Direct Access to realign dental workforces and services to contemporary care needs. Attitudes at the meso level demonstrated the greatest variety and were more influenced by the idiosyncrasies of their respective health care system. In comparing the attitudes towards Direct Access in the Netherlands and the UK there were several differences, such as in the support of the Direct Access by Principal Dentists, however many of these can be explained by differences in healthcare funding and the time difference between the two reforms. Despite these differences stakeholders in both states felt that while Direct Access had the potential to create significant impacts on a range of issues (including professional competition, patient access to care, the reduction of care costs to patients and the state, the redistribution of dental tasks and the remodelling of the dental workforce) it was unlikely to do so in either the Netherlands or the UK. Flaws in the Direct Access regulations, legal obstructions to crucial procedures and imbalances in street-level professional power were perceived to obstruct Direct Access. Rather than revolutionising dental services Direct Access has been implemented selectively in the interest of dental practices.

Through the Colombian Institute for Family Welfare (ICBF), the Colombian government aims to provide comprehensive reintegration for children demobilized from the country’s various armed groups. The reestablishment of rights, including the right to health (guaranteed by the Colombian constitution), is a key factor in successful reintegration. This thesis explores the topic of access to health care and health seeking behavior among former child soldiers in Manizales, Colombia who are over the age of 18 and were previously in the Hogar Tutor program (foster care-based youth reintegration) in Manizales. This thesis utilizes semi-structured interviews (n=9) and body mapping (n=9) with former child soldiers, key-informant interviews, participant observation, and a review of archival and secondary sources, including survey data, which is used to complement this research. This research is focused on understanding the barriers participants are experiencing in accessing health care, how participants understand and experience health and the health care system, and how health is handled within reintegration programs. Findings illustrate the incompatibility of transitional justice and the right to health within a neoliberal health system. This research suggests that former child soldiers face significant barriers in access to health care, experience persistent health conditions related to the conflict, and may be insufficiently aware of their rights as both citizens and victims of the armed conflict. These challenges likely affect the ability of former child soldiers to successfully reintegrate. This thesis provides recommendations for future research, as well as for the implementation of- and changes to- health education efforts within the ICBF and the Colombia Agency for Reintegration (ACR).

Disparate healthcare experiences continue to pose a challenge; vulnerable populations such as low-income and racial and ethnic minorities may not be able to afford or utilize care when needed or receive quality care. The sources of disparities are complex and multi-factorial, which include health care system-level factors such as insurance and health care workforce. It is relatively less known to what extent these contribute to disparities related to a patient’s overall health care experience across three important domains – affordability, utilization and satisfaction with care. This dissertation has three objectives. First, to assess how insurance benefit design affects health care utilization among poorest adults. Second, examine the role of insurance in addressing racial and ethnic disparities in access to preventive care. Finally, examine the role of health care providers in differences related to satisfaction with care among low-income patients. To answer questions posed in this dissertation, two different types of datasets are used: a unique hospital administrative data from a coverage program for low-income adults and 2008-2014 Medical Expenditure Panel Survey (MEPS). To examine the role of insurance and health care providers in disparities related to different outcomes of patient experience, several models are estimated; including mixed effects linear probability and negative binomial regressions, decomposition and multivariate linear probability models. Several efforts are being made to address inequalities through coverage expansions, removal of financial barriers for preventive services and incentivizing health care providers to improve patient satisfaction. The findings suggest that differences in utilization and satisfaction with care continue to persist among low-income and racial and ethnic minorities. However, policy levers and system-level reforms including value-based insurance designs that may curb healthcare costs without shifting the cost burden to poorer adults, continued reforms to expand coverage and improve access to a usual of care, and policy interventions that extend beyond improving workforce diversity and enhance provider skills to elicit patient communication preferences may foster positive patient experiences and ameliorate existing disparities. Improving patient experiences of care will thus require policy efforts with a comprehensive multi-level strategy that targets broad sectors – including payers, health care providers and society at large.

Masters in Public Administration - MPA / Agenda setting is about how some issues get onto the policy agenda for discussion and action why others do not. Drawing critically on the ―policy windows‖ approach of J.W Kingdon (2003) this dissertation will describe and explain the shifting of policy agendas in health with reference to human resources in Zambia between 2000 and 2006. This research explores how and why the issue of human resource shortages in health became prominent on the state‘s agenda in 2005.The research is a qualitative study and data was collected using both primary and secondary sources of data across various stakeholders in the country. It tested the applicability of Kingdon‘s conceptual framework to a case study of Zambian health policy by analysing the degree to which agenda-formation is influenced by such factors as issue definition, the presence of policy alternatives, presidential support, interest group advocacy, media attention, political cycles, and public opinion. The general elections scheduled for the following year, coupled with media attention and strong public action contributed to the selection of the human resource crisis as an issue on the state‘s agenda for serious action. Furthermore, the slow progress on the attainment of the health related Millennium Development Goals and the poor performance of some donor funded programmes necessitated the state to act. Despite some weaknesses, Kingdon‘s multiple streams approach was found to be useful in explaining the agenda-setting of the Human Resources for Health Strategic Plan (2006-2010) in Zambia.

Philosophiae Doctor - PhD / Background: Syphilis transmission remains a global problem with an estimated 12 million people infected each year. Ninety percent of syphilis cases occur in low income countries. Syphilis is a serious source of adverse pregnancy outcomes for both mother and infant. Ideally, syphilis screening should be provided as part of a package of maternal and newborn health-care services. This thesis reports on a pilot intervention study to develop, implement and evaluate a point of care test for syphilis in antenatal care services in rural Burkina Faso. Methods: This study used a pre post intervention mixed methods quasi-experimental design with a group of health facilities offering ANC services (primary health centers in rural area) as the sampling units. This study was conducted in three phases, which consisted of a situational analysis using qualitative methods (Phase 1), selecting an appropriate test through evaluating 4 candidate tests and the participatory design and implementation of an intervention that included onsite training, provision of supplies and medicines, quality control and supervision (Phase 2), and an evaluation combining review of record tools, interviews, time motion study and estimating incremental costs (Phase 3). The conceptual framework draws on multilevel assessment (MLA), policy triangle framework, MRC framework for designing complex interventions and the Normalization Process Model (NPM). Methods included document review, seventy five interviews were conducted with health providers, district managers, facility managers, traditional healers, pregnant women, community health workers, and Non-Governmental Organizations (NGO) managers in phase I and fourteen in phase III, non-participant observation, time-motion study, incremental cost analysis, and sensitivity, specificity and ease of use analysis of four candidate point-of care tests. Data were collected between 2012 and 2014. Qualitative data were analyzed through thematic analysis supported by Nvivo software. Quantitative data were analyzed through descriptive statistics such as frequency, mean and median supported by SPSS. Findings: Phase I identified barriers to implementation and uptake of syphilis testing at health provider and community levels. The most important barriers at provider level included fragmentation of services, poor communication between health workers and clients, failure to prescribe syphilis test, and low awareness of syphilis burden. Cost of testing, distance to laboratory and lack of knowledge about syphilis were identified as barriers at community level. Phase II: Alere DetermineTM Syphilis was the most sensitive of the four point-of-care tests evaluated. The components of the intervention were successfully implemented in the selected health facilities. Overall, phase III showed that it is feasible and acceptable to introduce a point of care test for syphilis in antenatal care services at primary health care level using the available staff. The intervention was reported as acceptable, but of 812 pregnant women who came for their first visit 39% were screened during the study period. Rural facilities had higher coverage (66.8%) than the urban ones (25.6%). Quality control found no discordance between the rapid test and TPHA results. The average cost of ANC per unscreened pregnant woman was 3.11 USD (±0.14) vs 5.06 USD (±0.16) per screened woman. The main cost driver was the material costs notably the test itself. The test’s cost is comparable to HIV test costs, but funder support for integrating this additional test is less readily available than for HIV tests. Conclusions: The findings suggested that an intervention that introduces point of care test for syphilis at antenatal care services is feasible, acceptable, and of comparable costs to HIV screening in pregnancy. Nonetheless, instructions and supervision need to be clearer to achieve optimal levels of screening and quality control, and barriers identified by health workers need to be overcome. The point-of care test for syphilis is likely to be acceptable by health workers as a routine service and incorporated as a normal practice in Burkina Faso context. / This research was made financially possible by the UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR); and the African Doctoral Dissertation Research Fellowship (ADDRF 2012) award offered by the African Population and Health Research Center (APHRC) in partnership with the International Development Research Centre (IDRC).

Economic evaluations and network meta-analyses (NMAs) are complex methodologies. Increasing their transparency and accessibility could enhance confidence in the legitimacy of policy decisions informed by these analyses. Four systematic reviews were conducted to understand policymakers’ informational needs and to determine what guidance researchers have on how to present economic evaluations and NMAs. Qualitative interviews were conducted with Canadian policymakers, i.e., knowledge users, to understand barriers and facilitators to using and communicating economic evaluations and NMAs and with individuals in international health technology assessment organizations, i.e. knowledge producers, to explore current approaches to communicating economic evaluations and NMAs. A toolkit for NMAs and economic evaluations was proposed based on an integrated review of these findings and guided by the Knowledge-to-Action framework. Examples of tools were developed and applied to an economic evaluation and NMA of osteoporosis therapies. Systematic reviews and qualitative interviews found that communication approaches that provide robust content, identify contextual factors relevant to policy decisions and enhance clarity were valued. Twelve tools were proposed that enhance communication, education and access to resources for policymakers. Two of these tools were developed: Economic Guidance for Researchers and NMA Guidance for Researchers.