Bakgrund: Aktivitetsbalans är ett kärnbegrepp inom arbetsterapi och kan definieras som en subjektiv upplevelse av rätt mängd och rätt variation mellan olika aktiviteter. Forskning har visat att aktivitetsbalans är en viktig faktor för hälsa och välbefinnande. Däremot finns ingen tidigare forskning gällande aktivitetsbalans hos läkare och sjuksköterskor inom slutenvård som författarna till studien kunde hitta. Syfte: Att beskriva den självskattade aktivitetsbalansen hos läkare och sjuksköterskor inom slutenvård. Metod: En kvantitativ studie med insamlat datamaterial från en webbenkätundersökning med självskattningsinstrumentet Occupational Balance Questionnaire (OBQ) samt kompletterande bakgrundsfrågor. I studien deltog sammanlagt 100 läkare och sjuksköterskor från olika slutenvårdsavdelningar i Sverige. Resultat: Det mest utmärkande resultatet var att ungefär två tredjedelar av hela urvalsgruppen inte var nöjda med sin mängd och variation av aktiviteter i vardagen. Utifrån enskild yrkesgrupp visade resultatet även att läkare var mindre nöjda med sina aktiviteter i vardagen än sjuksköterskor. Slutsats: Läkare och sjuksköterskor upplevde svårigheter att uppnå aktivitetsbalans i vardagen och därför behövs hälsofrämjande insatser av bland annat arbetsterapeuter. Vidare forskning med större population behövs göras med målgruppen läkare och sjuksköterskor inom slutenvård.

This study aims to examine to what extent Dutch GPs are at risk for burnout, and to identify personal, professional and practice related characteristics that are associated with high burn out scores. In the extant literature, physicians are identified as professionals who are high risk for burnout. In the past decade, working conditions for general practitioners (GPs) in the Netherlands have changed for the worse. There are no recent data on GP burnout in the Netherlands. Although much is known in the literature about factors that are associated with burnout and the role job demands and resources play in getting burned out, the extent to which these findings apply in the context of Dutch GPs is unknown. This study is designed as a quantitative, survey based, empirical study. An invitation to complete an online survey was sent to 4,000 GPs in the Netherlands, of whom close to 1,300 participated in this study (33% response rate). The data were analysed using IBM SPSS 22.0. The data analysis consisted of a descriptive analysis of the data with an emphasis on the outcome of burnout measurements, as well as an inferential analysis of the data with an emphasis on the association between respondents’ characteristics and burnout measurements. The results from this study indicate, that one in seven practicing Dutch GPs could be classified as burned out with fulltime working GPs reporting an average working week of 62 hours. According to the findings, the amount of hours worked per week is the most important determinant of emotional exhaustion. Variation in emotional exhaustion, depersonalisation and professional efficacy can to a large extent be explained by variation in demands (administrative burden, work-home conflict, psychological job demands) and resources (decision latitude, co-worker support and home support). Increased job demands are predominantly associated with emotional exhaustion, while a scarcity of resources predominantly leads to increased depersonalisation and reduced professional efficacy. The findings demonstrate, that a bigger job size, more hours worked and a more responsible position held, are associated with higher experienced demands, which is in turn associated with unfavourable burnout scores, particularly increased emotional exhaustion. Working in a group setting, being professionally active outside of one’s own practice and being in a relationship were found to be associated with increased resources, which is in turn associated with favourable burnout scores, particularly decreased depersonalisation and increased professional efficacy. Based on the findings of this study, three recommendations for government bodies, healthcare providers and other healthcare stakeholders were formulated: 1) Reduce the length of the working week, predominantly by reducing the number of allocated patients per GP. This recommendation implies an increase in the GP workforce; 2) Undertake a comprehensive analysis of the quantity, type and purpose of administrative duties currently performed by GPs and trim unnecessary paperwork and bureaucracy within the GP practice and 3) Increase co-worker support, either within the GP practice or by using the existing collegiate support infrastructure.

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Background. In the United States, adolescents are the age group least likely to be aware of their HIV infection and linked to care in a timely manner, contributing to disproportionately low rates of viral suppression and increased risk of transmitting HIV to others. A major barrier to health care for adolescents relates to confidentiality concerns, such as fears that parent/guardian consent will be required or that parents, guardians, or others will be informed of test results. This suggests that state laws related to confidentiality in sexual and reproductive health services could influence their HIV testing practices. Guided by Andersen’s Behavioral Model of Health Services Use, this dissertation utilizes a large, representative sample of sexually active high school students from the 2019 state-level Youth Risk Behavior Surveillance System (YRBSS) to investigate the potential impact of five state-level confidentiality-relevant laws on U.S. adolescents’ HIV testing practices. Methods. Data on HIV testing and individual characteristics (i.e., potential individual-level confounders/covariates) were aggregated from 25 states that participated in the 2019 state-level YRBSS. Data on contextual characteristics (i.e., potential state-level confounders/covariates) were obtained from the United States Census Bureau and the Behavior Risk Factor Surveillance System. Information about state-level confidentiality-relevant laws was compiled from the Guttmacher Institute and the Center for HIV Law and Policy to create five variables indicating whether state laws were confidentiality-promoting at the time of the 2019 state-level YRBSS. Multilevel logistic regression was used to test the following hypotheses: 1. After adjusting for individual and contextual characteristics, confidentiality-promoting state laws will be positively associated with HIV testing among sexually active U.S. high school students, such that odds of self-reported lifetime HIV testing will be significantly higher when states (a) explicitly allow minors to consent to HIV testing, (b) do not have age of consent requirements, (c) do not permit parental/guardian notification, (d) protect the confidentiality of minors insured as dependents, and (e) do not have HIV-specific criminal laws that require disclosure to sexual and/or needle-sharing partners, as compared to states with non-confidentiality-promoting laws. 2. After adjusting for individual and contextual characteristics, sex will moderate the relationship between state-level confidentiality-relevant laws and HIV testing among sexually active U.S. high school students, such that associations between confidentiality-promoting state laws and self-reported lifetime HIV testing will significantly differ between males and females. 3. After adjusting for individual and contextual characteristics, young men who have sex with men (YMSM) status will moderate the relationship between state-level confidentiality-relevant laws and HIV testing among sexually active male high school students, such that associations between confidentiality-promoting state laws and lifetime HIV testing will be significantly stronger among males who report same-sex sexual contact than among males who report opposite-sex sexual contact only. Results. Findings supported the first hypothesis that parental notification not being permitted would be positively associated with HIV testing among sexually active U.S. high school students. After adjusting for individual (i.e., sex, grade level, race/ethnicity, sexual identity) and contextual (i.e., percentage of the state population aged 25 and older with a high school diploma or higher, median household income, lifetime HIV testing among adults) characteristics, odds of self-reported lifetime HIV testing were significantly higher in states that do not permit parent/guardian notification (adjusted odds ratio [aOR]: 1.07; 95% confidence interval [CI]: 1.04-1.11; p<.001) than in states that allow health care providers to inform parents or guardians that their child is seeking or receiving STI services. However, results did not support the hypothesis that the other confidentiality-promoting state laws would be positively associated with HIV testing among sexually active U.S. high school students; as compared to states with non-confidentiality-promoting laws, odds of self-reported lifetime HIV testing were significantly lower in states that explicitly allow minors to consent to HIV testing, do not have age requirements to consent to HIV testing, and do not have HIV-specific criminal laws that require disclosure. Results supported the second hypothesis that sex would moderate the relationship between state-level confidentiality-relevant laws and HIV testing among sexually active U.S. high school students, as associations between confidentiality-promoting state laws and lifetime HIV testing differed significantly between males and females. After adjusting for individual and contextual characteristics, the effects of living in a state without age requirements or HIV-specific criminal laws with disclosure requirements on lifetime HIV testing for females were 1.53 (CI: 1.07-2.20; p=.020) and 1.56 (CI: 1.16-2.10; p=.003) times those of males, respectively. Meanwhile, the effects of state laws that explicitly allow minors to consent to HIV testing, do not permit parental notification, and protect the confidentiality of minors insured as dependents on lifetime HIV testing for females were 0.73 (CI: 0.55-0.96; p=.025), 0.72 (CI: 0.52-0.99; p=.043), and 0.66 (CI: 0.48-0.90; p=.008) times those of males, respectively. Analyses with these data failed to reject the null hypothesis for the third [alternative] hypothesis that associations between confidentiality-promoting state laws and self-reported lifetime HIV testing would be significantly stronger among sexually active males who report same-sex sexual contact than among males who report opposite-sex sexual contact only. Conclusions. Findings provide evidence that parental notification not being permitted is associated with significantly increased odds of lifetime HIV testing among sexually active U.S. adolescents, and that sex differentially affects associations between state-level confidentiality-relevant laws and sexually active U.S. adolescents’ HIV testing practices. Parental/guardian notification not being permitted may increase access to and utilization of HIV testing among sexually active U.S. adolescents. Furthermore, confidentiality-promoting laws – particularly those that explicitly include HIV testing in the package of STI services to which minors may consent, do not permit health care providers to notify parents/guardians that their child is seeking or receiving STI services, and protect the confidentiality of minors insured as dependents – may facilitate access to and utilization of HIV testing for sexually active male adolescents. Altogether, this dissertation provides compelling preliminary evidence for efforts to better understand and address structural determinants of HIV and HIV prevention among sexually active U.S. adolescents. Results underscore the need for a comprehensive, multi-level approach to adolescent HIV prevention that goes beyond a focus on reducing individual-level risk factors to increase protective factors at the structural level (e.g., confidentiality-promoting state laws). To address HIV-related health inequities among young people in the United States, advocates must fight for the passage of state laws that protect adolescents’ right to confidential sexual and reproductive health care.

<p>Please insert 2 pages into the main thesis - page 39 and page 40</p> <p>- 2 separate PDF attachments will be included plus the main thesis.</p> / <p><strong>Background:</strong></p> <p><strong> </strong> Academic detailing (AD) provides evidence-based education to healthcare professionals in their practice setting and has been found to improve knowledge and prescribing in many situations. Personalized academic detailing (PAD) is a new initiative by the Hamilton Family Health Team (FHT) in which pharmacists integrated within the FHT provide an AD service to prescribers in their office.</p> <p><strong>Objective: </strong></p> <p>To describe and determine the feasibility of a smoking cessation (SC) PAD program.</p> <p><strong>Methods:</strong></p> <p>Design: Descriptive retrospective cohort pilot project</p> <p>Setting: Primary Care Setting</p> <p>Participants: FHT pharmacists, physicians, nurse practitioners (NPs) and their patients</p> <p>Intervention:</p> <p>Pharmacists receive basic AD training and education (upskilling) on SC; and provide education to clinicians</p> <p><strong>Feasibility Criteria for success:</strong> <ol> <li>PAD coordinator time to train pharmacists <40 >hours</li> <li>Average time for upskilling <20 >hours</li> <li>Average time for PAD session are <60 minutes and><30 minutes for initial and follow-up>visits, respectively</li> <li>Percentage of clinicians detailed within 3 and 6 months are >50% and >70%, respectively</li> <li>Number of new SC referrals to the pharmacist at 3 and 6 months are >5 patients/1.0 full-time equivalent (FTE) pharmacist and >10 patients/1.0 FTE pharmacist, respectively.</li> </ol></p> <p><strong>Results:</strong></p> <p>Eight pharmacists (5.8 FTE) received basic AD training and upskilling on SC PAD. Consent was obtained from 48/54 (88.9%) physicians and 9/10 (90.0%) NPs.</p> <p>The PAD coordinator training time was 29.1 hours. The median time for upskilling was 3.1 hours. The median time for PAD session was 15 and 5 minutes for an initial visit and follow-up visit, respectively. The number of clinicians detailed within 3 and 6 months were 50/64 (78.1%) and 57/64 (89.1%), respectively. The number of new SC referrals at 3 and 6 months was 66 and 200 patients, respectively.</p> <p><strong>Conclusion:</strong></p> <p>This pilot study showed that the main study is feasible with respect to the management, resources, process and scientific components.</p> / Master of Science (MSc)

This dissertation includes four papers— two conceptual and two empirical— on universal health coverage introduced in global health as a policy concept to improve access to health care. The conceptual papers review the selection process for the Sustainable Development Goal indicator on universal health coverage and propose parameters to guide an evaluation framework for universal health coverage. The first two papers show that including participants from as many sections of the health sector and policy community is recommended in policy formulation and evaluation, and recognize that decision-making might be slower as a result. While the first two papers focus on the third Sustainable Development Goal to achieve universal health coverage, the following two empirical papers focus on the sixth Millennium Development Goal which committed to provide universal access to treatment and care for people living with HIV. The first empirical paper shows how physicians in six Eastern Caribbean countries (Antigua and Barbuda, Dominica, Grenada, St. Kitts and Nevis, St. Lucia and St. Vincent and the Grenadines) cope with the lack of resources for treatment and care. Access was implemented broadly emphasizing the availability of HIV treatment and care while ensuring that everyone who needed antiretrovirals did not incur out-of-pocket costs. In most cases, this meant receiving care in the public system which was mostly centralized and where people living with HIV had concerns about their privacy being compromised in societies where HIV stigma was prevalent. The second empirical paper shows that in St. Lucia, third-line antiretrovirals could be unaffordable to as much as 98 % of the population, depending on how affordability is measured. The papers collectively demonstrate how the Millennium Development Goals provided an opportunity for policy learning by comparing the implementation of universal access for HIV treatment and care with universal health coverage in the Sustainable Development Goals. / Thesis / Doctor of Philosophy (PhD) / The dissertation recognizes the challenges with defining and measuring universal health coverage and with providing access to treatment and care for human immunodeficiency virus (HIV) in the Eastern Caribbean. The first conceptual paper documents the process of selecting indicators for universal health coverage in the Sustainable Development Goals. The second conceptual paper advances recommendations for evaluating universal health coverage. The following two studies then empirically assess the challenges with access to health care for people living with HIV in the Eastern Caribbean. The third paper shows how physicians cope with the lack of appropriate resources and highlights the issue of privacy for patients. The fourth paper uses data from St. Lucia to assess the affordability of antiretrovirals and highlights the difficulties of measuring financial affordability.