Background: Increasing breastfeeding rates is a longstanding goal of health policy in England. Rationale for this is premised upon the health benefits to both mother and child conferred by exclusive breastfeeding. Current UK Infant Feeding Policy (IFP) derives from international guidelines incorporating the Baby Friendly Initiative (BFI) that promote exclusive breastfeeding. Such ‘evidence informed policy formation’ is emblematic of the current context of health policymaking. However, the impact of current IFP upon women and healthcare professionals is under researched. Aim: This study explores the impact of IFP upon Women, Midwives and Heads of Midwifery services in England and considers the implications for maternity services. Methodology: A qualitative design used semi-structured interviews to determine the experiences and views of IFP with eight Heads of Midwifery and eight Midwives. Six women underwent three interviews exploring their infant feeding journeys at: 8 months pregnant, 1 month and 6 months’ post-partum. Data were analysed using Colaizzi’s phenomenological method. Findings: Three key themes arose contributing towards understanding the context of IFP: Being with IFP, Discourses of Self-Determination and The Emotion work of Compliance. For Midwives: The socio-political context of health and health-care system policy is multifarious but contains identifiable spheres relating to current IFP. Midwives do not appear to actively engage in the political process of this type of policy generation. For Mothers: Infant feeding remains emotionally fraught territory. Three key themes arose from the first interview: Adopting a Stance, Formulating a Vision and Processing the Dialogues of Infant Feeding. The second interview engendered three more key themes termed: Being with the Reality of Infant Feeding, Regaining Selfhood and Seeking Companions. Discussion and Conclusion: Foucault’s analyses of power and governmentality were used to explore the ‘Art of Midwifery’ vs the ‘Art of Governance’. Lack of holism and neoliberal agendas dominating current IFP may be detrimental to maternity service provision as they compromise decisional autonomy for women and clinical autonomy for midwives.

Diabetes is a long-term condition which causes significant public health concern in view of its increasing prevalence and associated morbidity. Notwithstanding this, effective management has been shown to prevent or delay the onset of diabetes complications, thereby improving prognosis. Diabetes has a high self-management demand. This involves behaviour modification together with psycho-social adjustments required to overcome challenges with integrating diabetes management in one’s life. Such challenges often originate from the socio-cultural context and it is recognised that support for diabetes self-management should target these challenges. The purpose of this study was therefore to explore how Maltese individuals with Type 2 diabetes believe they can be supported to manage their condition, as well as to examine whether, and if so how such views may be shaped by the Maltese socio-cultural environment. The study used a qualitative design guided by a Grounded Theory approach. Data were collected by in-depth focus group and one-to-one interviews, carried out amongst 52 adults with Type 2 diabetes recruited from an outpatient hospital clinic and community-based diabetes clinics in Malta. A total of six focus groups and twelve one-to-one interviews were conducted. Theoretical sampling was used and data analysis involved constant comparison of data, together with conceptualising and organising the data into categories. Generated categories were linked by exploring relationships between them, in the process of developing a substantive theory. The emergent theory describes how participants viewed diabetes self-management as involving the implementation of skills in thought and behavioural management. These skills were found to be key to coping and consisted of flexibility, proactive management, stress management and developing a positive mind-set towards diabetes. Furthermore, the theory outlines how aspects of Maltese culture, including those related to stigma, family, food and health services were seen to influence diabetes self-management directly, or through their impact on the development of such skills. A basic social process emerged representing individuals’ movement across the coping continuum, characterising transition to a higher/lower level of coping, during particular episodes in life. This process reinforced the identified relationship between the socio-cultural context and patient’s agency, demonstrating how such movement coincided with negative/positive experiences of socio-cultural influence. These findings have contributed new knowledge about the relationship between culture and diabetes-related coping. They suggest that patients may be supported in managing their diabetes by addressing cultural factors which influence the development of specific self-management skills. In Malta, this may involve new ways of delivering culturally sensitive care and education.

Background and objectives - Addressing ethical issues in health technology assessment (HTA) can increase transparency and accountability of the HTA process and lead to better-informed healthcare decisions. Despite its importance, integration of ethics into HTA remains challenging. The objective of this thesis was to develop a process-based framework to support ethical evaluations in HTA and increase their applicability. Methods - Project 1: A systematic literature review was conducted with the purpose of identifying and mapping the methodological features of the existing frameworks for ethics in HTA. Project 2: A systematic literature review and an international survey of HTA agencies were conducted to explore how ethical evaluations may be encouraged or discouraged in the HTA practice. Project 3: A procedural framework was drafted based on the operational features of the identified guidance documents as well as barriers and facilitators for incorporating ethics into HTA. Project 4: The framework was applied to a hypothetical case study, with the aim of helping HTA practitioners touch on key points of the steps outlined by the proposed framework. Results - Project 1: The identified ethical frameworks vary in their purpose, philosophical approach, structure, and comprehensiveness. The review results suggest that the choice of a method for collection and analysis of ethical data depends on the context, purpose of analysis, and availability of resources. Project 2: The results of this study emphasize the importance of simplification of ethics methodology and development of good practice guidelines in HTA, as well as capacity-building for engaging HTA practitioners in ethical analyses. Project 3: The proposed framework consists of an algorithmic flowchart, showing different steps of an ethical evaluation throughout the HTA process; a stepwise guide, which focuses on the tasks and potential questions that are required to be addressed at each step; and a list of some commonly recommended tools to facilitate the evaluation process. Project 4: The case study outlines the key tasks, recommended by the framework, and provides examples of process outputs that could be considered when attempting to perform an ethical evaluation. Conclusions - The outputs of this thesis can be used to support and promote a more consistent practice of ethical evaluation among HTA professionals. However, further validation of the proposed framework is required to establish its utility for HTA practice. / Dissertation / Doctor of Philosophy (PhD)

The present diploma thesis strives to promote the importance of information technologies and their implementation in the health care sector. In the introductory chapter the thesis gives an account of the development of the information technologies and information systems (IT/IS) in the CR and in the world. Further the thesis gives an introduction to some of the strategic documents supporting the development of IT/IS in the health care sector, and institutions and organisations active in the research and development of IT/IS in the CR are listed. Further to this, the thesis informs on particular IT/IS products dealing with the health care topics. The thesis also gives insight into the issue of hospital information systems (HIS) and analyses some of the health care information systems operating in the CZ and elsewhere. The criteria of selection an appropriate information system (IS) for a particular health care centre are further analysed. The following part of the thesis deals with implementing a new IS to the health care centre and its possible pitfalls, and gives recommendations as to making the transition as smooth as possible. The concluding chapter contains a case study focusing on implementing changes to the e-requisition form used by the Teaching Hospital in Pilsen. Based on this case study,...

As a contraceptive technology, women’s sterilization is a medical event that is uniquely situated in relation to the dominant discursive link between women and reproduction. Intended as a contraceptive option that permanently ends a woman’s potential ability to sexually reproduce, women’s sterilization presents a significant point for exploring the discursive formation of femininity, and how the concepts thereof relate to broader questions of access, control, and regulation of sterilization and the female sterilization patient. This study uses a Foucauldian feminist theory of discourse to explore such questions in a qualitative discourse analysis of women’s sterilization, from both a historical perspective and from within contemporary medical texts. Sterilization has had a particularly tumultuous history in the provision of reproductive healthcare for women; situated within public health and welfare discourse that differentiates the “unfit” from the “fit” reproducers, women have been forcibly sterilized under classist and racist eugenic programs, while subtle yet coercive forms of sterilization abuse continue to occur as inequality of reproductive healthcare access is an ongoing issue for immigrant women, poor women, and women of colour. In light of this historical analysis, as well as the impact of feminist and bioethics discourse upon contemporary medical practice, an analysis of medical texts further explores the association of women with reproduction in the discursive form of the sterilization patient. This study argues that the sterilization patient is situated within a discourse of ideal femininity, associated with normalized forms of mothering, sexuality, and family structure. Given the historical link between the discursive “fit” reproducer, these concepts have continued implications for women’s experience of accessing sterilization as a contraceptive option. / Thesis (Master, Sociology) -- Queen's University, 2007-07-17 17:09:15.595

To fill a gap in the literature and to better inform decision making in oncology, this doctoral thesis investigates the role and impact of analytical methods in the economic evaluation of oncology medications through three main chapters which have been recently published. Chapter 2 presents a systematic literature survey of published economic evaluations in oncology over a 10-year period in order to identify, examine, and describe analytical methods that have been utilized (published in Pharmacoeconomics Open in 2021). This chapter demonstrated that greater detail in reporting of extrapolation methods, statistical techniques, and validation procedures is needed in order to conform with best practices outlined in existing economic evaluation guidelines. Chapter 3 complements the work of chapter 2 but takes a different perspective through an examination of the methods reported in economic evaluations published by HTA agencies in Canada, the UK, and Australia (published in Current Oncology in 2022). This chapter revealed significant reporting discrepancies across the agencies and concluded that common standards for reporting the results of HTAs should be implemented. Building on chapters 2 and 3, chapter 4 provides a model-based health technology re-assessment of an oncology drug approved on the basis of interim trial data using recently published long-term follow up data (published in Current Oncology in 2023). The findings from this chapter highlight the importance of transparency in the reporting of methods, the impact of using a life-cycle approach to HTA, and demonstrate the existence of a tradeoff between clinical/economic uncertainty and the value of the incremental cost-effectiveness ratio (ICER). The final chapter provides the overall conclusions of the research and presents avenues for future research. / Thesis / Doctor of Philosophy (PhD)

Ökad kostnadsutveckling inom offentlig hälso- och sjukvård och en ökad en efterfråga dess tjänster har uppmärksammat behov av prioriteringar för resursfördelning, inte minst för avancerad medicinteknisk utrustning. Användning av olika beslutsunderlag kan bidra till lättare prioritering och mer kostnadseffektiva investeringsbeslut i den svenska hälso- och sjukvården. / Increased expenses in the public health care, combined with an increased demand of its services, have led to a higher demand for resource prioritization, not least for advanced medical equipment. Using different types of supporting information enables better prioritizing and more cost-effective investment decisions in Swedish public health care.

When the Swedish National IT Strategy for Health and Social Care was introduced in 2006, intensive work started in implementing Information Systems (IS) in Swedish healthcare organizations. To follow up on the requests for more research with a combined socio-technical focus on challenges, the overall aim of this thesis was to identify social challenges when implementing IS in a Swedish healthcare organization. Furthermore, the aim was to understand the impact of identified social challenges when implementing IS in this context by putting them in an interdisciplinary Applied Health Technology theoretical framework. Institutional ethnography and phenomenological hermeneutics influenced the study design. Study 1 aimed to investigate different meanings of accessibility when implementing Health Information Technology in everyday work practice. The results indicate that accessibility depends on working routines, social structures and patient relationship. When an IT strategy and interaction in everyday work use the same word in different ways there will be consequences. Study 2 sets out to describe experience-based reflections on discharge planning as narrated by nursing staff in primary healthcare, along with their concerns about how the introduction of video conferencing might influence the discharge planning situation. It was found that there is a need for improvement in communication and understanding between nursing staff at the hospital and in primary healthcare. The aim of study 3 was to explore social challenges when implementing IS in everyday work in a nursing context. Power (changing the existing hierarchy, alienation), Professional identity (calling on hold, expert becomes novice, changed routines), and Encounter (ignorant introductions, preconceived notions) were categories presented in the findings. The aim of study 4 was to explore and obtain a deeper understanding of how identified social challenges have an influence on the implementation process of IS, based on healthcare staff’s experiences on micro, meso and macro levels of Swedish Healthcare organizations. It was found that the challenges were related to the steps of putting into practice, making IS a part of everyday work routine and establishing an identity in the implementation process. In the thesis’s discussion, social challenges when implementing IS in Swedish healthcare organizations and how they might be met and dealt with constructively are further reflected upon in relation to the interdisciplinary theoretical framework and as possible consequences of the modernity-era. This thesis contributes to the starting up of a discussion of how ingrained professional characteristics are important to feel secure of being part of an established profession. If the characteristics are questioned, the whole professional performance is threatened. One consequence of this insight is the reinforcement of the realization that a basic understanding of IS and IS implementation processes in healthcare organizations needs to be integrated in to the construction of professional identity of nurses already from the start in nursing education.

O Sistema Único de Saúde no Brasil (SUS) proporciona a incorporação de muitas tecnologias na área médica e, por conseguinte, pode estar exercendo um papel indireto na produção de conhecimento que não está sendo considerado como uma de suas qualidades. Objetivo: analisar se a incorporação de tecnologias pelo Sistema Único de Saúde no Brasil, mais especificamente fármacos, está associada a um aumento da produção de conhecimento científico nacional sobre estas tecnologias. Material e métodos: Trata-se de um estudo descritivo onde foram selecionados alguns fármacos distribuídos pelo Ministério da Saúde. Utilizando o PubMed analisou-se a produção de conhecimento no Brasil e em outros países do mundo sobre estas tecnologias. Comparou-se a posição do Brasil no ranking da produção científica mundial nos 3 anos antes da incorporação dos fármacos pelo SUS com a posição do Brasil no 4º, 5º e 6º anos após a incorporação destas tecnologias. Esta comparação foi feita utilizando teste não paramétrico de Wilcoxon. Resultados: a posição do Brasil no ranking da produção científica das tecnologias farmacológicas melhora para 70 das 90 tecnologias avaliadas. A posição geral média do Brasil passa de 68º para 45º após a incorporação (p < 0,0001). Conclusão: a incorporação de tecnologias farmacológicas pelo SUS está associada a um aumento da produção de conhecimento nacional sobre estas tecnologias / The Brazilian National Health System (SUS) is responsible for the incorporation of many health technologies, and thus, it could be having an indirect function in the scientific production that has not been considered as one of its qualities. Objective: to evaluate if the technologies incorporation by SUS is associated with an increment in national scientific production about those technologies. Material and methods: This is a descriptive study where it was selected some medications (pharmacologic technologies) that are offered by SUS. The PubMed database was used for the search of Brazilian and other countries scientific production about these technologies. The Brazilian international ranking position in the 3 years before SUS incorporation was compared with the position in the 4th, 5th and 6th years after the incorporation. Wilcoxon nonparametric test was used to perform this comparison. Results: the Brazilian international ranking position improves for 70 of the 90 technologies evaluated. The mean Brazilian ranking position went from 68th to 45th after incorporation (p < 0.0001). Conclusion: the incorporation of pharmacologic technologies by SUS is associated with an increment in the national knowledge production about these technologies

A Avaliação Tecnológica em Saúde (ATS) é uma sistemática que avalia os impactos clínicos, sociais e econômicos das tecnologias em saúde e tem como finalidade auxiliar os gestores na tomada de decisão quanto ao desenvolvimento, incorporação e descontinuação destas tecnologias. Agências de ATS têm destacado a importância da existência de métodos que visem padronizar e implantar esta sistemática em diferentes contextos. Assim, o objetivo geral desta tese é propor procedimentos para apoiar a avaliação tecnológica de equipamentos médico-hospitalares, por meio de uma pesquisa construtiva (Constructive Research) aplicada à terapia de hemodiálise. Os procedimentos propostos compõem um modelo adaptado do EuroScan, modelo desenvolvido por agências Europeias e indicado como boa prática pelo Ministério da Saúde do Brasil. Também são procedimentos ajustados às necessidades de pesquisadores de centros regionais de avaliação de equipamentos médico-hospitalares. Inicialmente, foi desenvolvida uma coleta de dados sobre os problemas de desenvolvimento e incorporação das tecnologias da saúde por meio de duas fontes: uma revisão sistemática de literatura sobre oportunidades de melhorias do EuroScan no mundo e discussões com pesquisadores no país. A partir destas investigações foi proposto um modelo preliminar de ATS, aplicado para o domínio Operacional e de Inovação na hemodiálise. Finalmente a aplicação foi validada e examinada por especialistas para a geração de um modelo final. Os principais procedimentos resultantes foram: (i) validação da relevância das avaliações para novos desenvolvimentos e incorporações tecnológicas do ponto de vista de diferentes especialistas, integrando diferentes áreas do conhecimento na ATS; (ii) operação de Observatórios Tecnológicos, auxiliando na definição das tecnologias e domínios a serem avaliadas; (iii) definição de técnicas para análise dos domínios de ATS, como o uso de séries temporais e o Technology Roadmap (TRM) para previsões sobre o futuro das inovações e o uso das dimensões da usabilidade e de incidentes críticos de riscos para os aspectos operacionais; e (iv) integração das diretrizes de ATS no Brasil em um único modelo, amparando pesquisadores não relacionados a saúde na compreensão sobre ATS e no desenvolvimento ágil de novos estudos tanto para equipamentos emergentes como em uso. Já a avaliação dos domínios selecionados para a hemodiálise resultou: (i) na identificação de um crescimento médio anual de 7% dos indicadores da terapia; (ii) no diagnóstico de usabilidade de máquinas eficazes, porém com possibilidades de gerarem maior satisfação aos usuários quanto: ao espaço entre elas, a redução dos desperdícios de água e materiais, aos planos de manutenção para evitar temperaturas elevadas, a capacitação visando mais atenção e treinamento para tarefas de apoio e aos aspectos de display (realimentação de dados e visualização); e (iii) na consolidação entre profissionais sobre um futuro promissor, para os próximos 10 anos no Brasil, da assistência homecare com máquinas de hemodiálise portáteis, mais seguras e sustentáveis. / The Health Technology Assessment (HTA) is a systematic evaluation of clinical, social and economic impacts of health technologies aiming to assist managers in the decision making process related to the development, consolidation and discontinuation of these technologies. HTA agencies have been highlighting the importance of methods to standardize and apply this systematic evaluation in different contexts. Thus, the general objective of this thesis is to propose procedures to support the technology assessment of medical-hospital equipment through a constructive research applied to hemodialysis therapy. The proposed procedures compose a EuroScan adapted model, which was developed by European agencies and is recommended as a good practice by the Brazilian Ministry of Health, and also are procedures adjusted to the needs of researchers in regional centers of medical equipment assessment. Initially, a data collection on the problems of developing and incorporating health technologies was carried out using two sources: a systematic review of the literature on opportunities to improve the EuroScan around the world and discussions with Brazilian researchers. Based on these investigations, it was proposed a preliminary HTA model applied to the hemodialysis’ Operational and Innovation domain. The application of the model was reviewed and evaluated by experts to produce a final version. The main resulting procedures were: (i) to validate the importance of assessments for new technological developments and incorporations considering the point of view of different experts from diverse knowledge areas; (ii) to operate Technological Observatories, assisting to define the technologies and domains to be evaluated; (iii) to set techniques for the analysis of HTA domains such as the use of time series and the Technology Roadmap (TRM) to make predictions about the future of innovations and the use of usability dimensions and critical incidents of risks to the operational aspects; and (iv) to integrate HTA Brazilian guidelines in a single model, supporting researchers not related to health in the understanding of HTA and fast development of new studies for both emerging and in use equipment. The assessment of the domains selected for hemodialysis led to: (i) the identification of an annual growth in therapy indicators (7% in average); (ii) the usability diagnosis of efficient machines, however with the potential to generate greater user satisfaction considering: distance between machines, reduction in the waste of water and materials, maintenance plans to avoid high temperatures, training aiming more attention to supporting tasks as well as focus on display aspects (data feedback and visualization); and (iii) the consolidation among professionals of a future, for the next 10 years in Brazil, based on homecare with portable machines, safer and more sustainable.