Populism is on the rise, anti-globalism, nationalism, and xenophobia run rampant, andtraditional mainstream parties seem unable to curb the tide. Sweden is no exception, eventhough it in some cases seems like it should be, with the populist party the SwedenDemocrats gaining more support by each passing election. In this thesis, the rise of theSweden Democrats and the slow decline of the mainstream Social Democrats and ModerateParty are explored and explained through the use of the term issue alignment. The thesisexamines if the reason for mass migration from the established mainstream parties is due tothe Sweden Democrats being better aligned with voters’ stance on issues and policy.Furthermore, the thesis investigates if the mainstream parties’ voter loss is due to worseningalignment, but not finding any significant decline over time. Similarly, the thesis investigatesif the improving national vote results of the Sweden Democrats are due to improvingalignment between the party and the voters, again, finding no proof for this theory. TheSweden Democrats’ level of issue alignment with voters has not improved consistently overthe period, and similarly, the mainstream parties’ level of issue alignment has not decreasedconsistently over the period.

Kunskapsbidraget från denna studie fokuserar på att medföra en djupare insyn i hurundervisningstiden i matematik i grundsärskolan årskurserna 7-9 fördelas på de femkunskapsområden i det centrala innehållet, samt en kartläggning av möjliga orsaker och syftenmed denna fördelning.Syftet med studien är att öka kunskapen om hur lärare kan fördela undervisningstiden på defem kunskapsområdena i matematik, utifrån det centrala innehållet i grundsärskolans läroplan(Lsär 11), i årskurserna 7-9, och hur fördelningen motiveras.Frågeställningar: Hur fördelar respondenterna undervisningstiden på de fem kunskapsområdena imatematik i grundsärskolan? Hur motiverar dessa respondenter denna fördelning av undervisningstiden?Föreliggande studie har analyserats utifrån ett systemteoretiskt perspektiv på två nivåer. Påden första nivån analyseras helheten och studiens första frågeställning utifrån konstanterna,grundsärskolans styrdokument och den totala undervisningstiden. På den andra nivånanalyseras det insamlade materialet utifrån fem avgränsningar, förberedelse, tid,individualisering, konkreta och grundläggande arbetsområde och elevens självförtroende, tillitoch intresse för matematik.För att få ett varierat och brett resultat på studien, utifrån dess syfte och frågeställningar,användes mixade metoder med både frågeformulär som innehöll en kvantitativ del med slutnafrågor och en kvalitativ del med öppna frågor och intervjuer. Studien har två preciseradefrågeställningar som krävde olika angreppssätt för att kunna nå ett kunskapsbidragande resultat.Resultaten från den halvstrukturerade kvalitativa intervjun och de kvalitativa frågorna ifrågeformuläret förklarade en del av och gav djupare inblick och förståelse för de kvantitativadata som det strukturerade frågeformuläret gav.Det som framkommer i denna studie är att respondenterna fördelar undervisningstiden imatematik i grundsärskolan årskurserna 7-9 ojämnt på de olika kunskapsområdena. Det är storaskillnader och stor spridning på hur respondenterna väljer att fördela sin undervisningstid. Dettaär i enlighet med Skolverkets (2019) riktlinjer, som ger pedagogen mandat att själv bestämmatidsfördelningen efter eget tycke, men med elevens bästa i fokus. I resultatet träder fem avgränsningar fram, till hur respondenterna motiverar sin fördelning av undervisningstiden.Studiens resultat kan sammanfattas med att matematikundervisningen i grundsärskolanårskurserna 7-9, såsom respondenterna presenterar den, är mycket konkret, praktisk ochvardagsnära undervisning som varieras och anpassas efter den enskilde eleven, något som ävenBlom (2003) visar på i sin forskning.Studien kan ge ett kunskapsbidrag i form av ökad insikt och förståelse kring hur och varförrespondenterna väljer att fördela undervisningstiden i matematik i grundsärskolan årskurserna7-9, på det sätt som de gör. Men störst kunskapsbidrag ger föreliggande studie genom att öppnaupp för insyn i det komplexa med att undervisa i matematik i grundsärskolan och knapphetenpå forskning inom detta område.Nyckelord: Centrala innehållet, grundsärskola, IF-diagnos, likvärdig skola, läroplanen förgrundsärskolan (Lsär 11), matematik

Vattenförvaltning inom EU har, enligt EU:s vattendirektiv, som mål att samtliga vattenförekomster ska uppnå god status senast 2027. Sverige är ett av de EU-länder där målet ej har uppnåtts med uppmätt icke-tillfredsställande status i en del vattenförekomster i exempelvis Skåne; en situation som inte beräknas förbättras inom tidsfristen. I Sverige styrs vattenförvaltning lokalt med kommuner och myndigheter som beslutsfattande organ i enlighet med vattenmyndighetens sexårsplan. EU:s vattendirektiv kräver inkludering av intressenter och allmänheten i förvaltningen, vilket har lett till bildandet av vattenorganisationer såsom vattenråd. Dessa har till uppgift att verka som lokalkunskap för särskilda avrinningsområden, där ett nätverk av aktörer bildas för att möjliggöra påverkan av inriktning i vattenförvaltningen. Forskning visar på samarbetsproblematik mellan aktörer i vattenråd, brist på kunskap och intresse bland allmänheten och intressenter samt fall där ekonomiska och sociala mål har prioriterats före ekologiska, vilket har försvårat implementeringen av EU:s vattendirektiv. Syftet med studien är att undersöka hur skånska vattenråd utifrån nuvarande organisationsstruktur och prioriteringar kan bidra mer i arbetet för målet om god vattenstatus enligt EU:s vattendirektiv. Studien utgick från ett strategiskt urval och semistrukturerad intervju-metodik eller fokusgrupper bestående av intervjupersoner med hög expertis. Resultatet analyserades med hjälp av följande teorier: Environmental governance, vattenförvaltning, flernivåstyre, politisk samstämmighet, social inlärningsteori samt reflektiv och reflexiv kommunikation. Studiens resultat visar att de undersökta skånska vattenråden gör vad de kan för att bidra utifrån nuvarande förutsättningar, men att finansieringsbegränsningar, extern påverkan av andra aktörer i avrinningsområdena och brist på samarbete mellan olika nivåer i vattenförvaltningen förhindrar mångas utveckling. Organisatoriskt och prioriteringsmässigt fungerar majoriteten av de undersökta vattenråden väl och visar god potential, men förbättring inom det ovannämnda hade behövts om ett närmande av EU:s vattendirektivs mål skall uppnås i lokala skånska vattenförekomster. / Water management within the EU, according to the EU Water Framework Directive (WFD), has the aim to achieve good water status in all water bodies no later than 2027. Sweden is one EU country where the aim has not been reached, with measured non-satisfactory status in numerous water bodies in Scania for example; a situation not predicted to improve before the deadline. In Sweden, water management is governed locally with municipalities and agencies as decision-makers in accordance with the six-year plan of the water agency. Since the WFD requires stakeholder and public participation, the creation of water organisations such as water councils has been conducted. These act as local knowledge bodies in certain catchment basins, creating a network of actors to enable an influence on the orientation of water management. Research has shown collaboration issues between actors in water councils, a lack of knowledge and interest amongst the public and stakeholders, and cases where economic and social aims have preceded ecological ones. These factors in turn have aggravated the implementation of the WFD. The purpose of this study is to investigate how water councils of Scania, from current organizational structure and prioritizations, have the possibility to increase their contribution towards the aim of the WFD regarding good water status. The study was conducted from a strategic selection and semi-structured interviews or focus groups, including interviewees with high expertise. The result was analyzed using the following theories: Environmental governance, water governance, multi-level governance, policy coherence, social learning and reflective as well as reflexive communication. The results of the study demonstrate a situation where water councils contribute their utmost from current capabilities, yet are prevented to develop further due to financial limitations, external impacts from other actors in catchment basins, and a lack of collaboration between different levels of water management. From an organizational and prioritization point of view, the majority of investigated water councils work well and showcase high potential, with improvements of the aforementioned needed for the approach of the WFD’s aim in local water bodies of Scania.

Manufacturing performance measures the extent to which the manufacturing plant has built capabilities like low cost, high quality, delivery, and flexibility. The importance of identifying drivers of these capabilities has been underscored by many scholars although limited evidence exists so far regarding this issue. The available evidence is also primarily based on data obtained from manufacturing firms operating in developed and emerging economies and not from firms in developing economies. This study, therefore, bridges this gap by exploring key internal and external drivers of manufacturing performance taking evidence from the manufacturing sector of a developing economy - Ethiopia. A quant-emphasis mixed method approach was used along with cross-sectional survey design to gather data and answer the research questions in the study. The unit of analysis is the manufacturing plant, and hence primary data was collected using multidimensional questionnaires at plant level from 197 medium and large scale firms from Addis Ababa and its periphery. Secondary data was obtained from census reports, the country’s Growth and Transformation Plan (GTP), and report on the performance of the Ethiopian economy, which were analyzed qualitatively and the implications to manufacturing performance drawn in the study. A series of scale checks and analyses were made to test unidimensionality, reliability, and validity of measures and then structural equation modeling (SEM) was used to analyze hypothesized relationships. The main finding is that environmental dynamism significantly influences competitive priorities and firm’s strategic orientation, which in turn significantly influence manufacturing decisions. Structural and infrastructural manufacturing decisions eventually significantly influence manufacturing performance when firms place increased emphasis on quality or delivery. The competitive priorities also significantly influence external learning capability of the manufacturing plant, although the influence of strategic orientation on this variable was not significant even at the 0.1 level except in the delivery priority model. Both the competitive priorities and strategic orientation, however, play little role in guiding leadership practices of manufacturing managers. The study further indicates that government support directly influences manufacturing performance, though it does not significantly influence external learning capability. Based on the findings, it is suggested that manufacturing firms should give due attention to what is going on in their external environment and accordingly align their competitive priorities, strategic orientation, and investments in structural and infrastructural resources to enhance plant performance. They should exhaustively utilize the supports provided by government as well. / Business Management / DBL

Approved for public release, distribution is unlimited / This thesis attempts to create a desire for change in DoD's current approach to Network Application Management (NAM). The evolution of NAM into Integrated Network Application Management (INAM) is a crucial component of Network Centric Warfare and achieving Information Superiority and Interoperability. INAM is outlined as three functional requirements, which are Network Awareness, Mission Prioritization linkage to Network Resources, and the Balancing of Service Management. Scenarios play a key role in illustrating the new threats that DoD faces today. These scenarios also identify limitations and challenges to NAM as it exists today. These challenges require significant improvements in flexibility and responsiveness, while providing for wide integration. Trends supporting change are identified in this thesis. Two of the more important trends are the rise of Architectural and Object Oriented Development. Examples such as Training and Testing Enabled Architecture (TENA), Surveillance and Target Acquisition Network (STAN), and Virtual Proving Ground (VPG) are clear examples of these trends. The merging of the Computer Industry's efforts to expand the reach of Operating Systems with the traditional efforts from Network Management is also a trend that is examined. Organizations like Distributed Management Task Force (DMTF) are important to such examinations. Successful change can not be achieved without planning for the transition. This thesis also presents some active transition efforts addressing Network Centric Warfare. TENA, VPG and Naval Postgraduate School's Information Technology Management Master's Program provide three examples of addressing transition in DoD. / Civilian, United States Army Yuma Proving Ground

伴隨著改革開放開始的中國醫療改革由於受到過度市場化的影響，一直在質疑聲中前行。進入21世紀，社會醫療保障制度改革標誌著中國醫改「健康公平」之路的回歸。然而，在公平正義不斷被強調的口號背後，對「健康公平」的理論界定與實證研究仍然相對匱乏。 / 本研究從「弱者優先」的社會公義理論出發，重新將「健康公平」理論界定為「基於社會公義的健康平等」。研究員立於足后實證主義研究範式，綜合運用質化與量化研究方法，結合一手與二手數據分析，以浙江省為研究場域，探索以社會醫療保險改革為核心的醫療福利制度改革，對老年人「健康公平」所造成的影響。最終，確立了「底層健康公平」的價值選擇，並發展了多元健康公平的理論框架。 / 透過量化研究的主要發現，研究員的結論是要將健康公平問題從「機會公平」視角轉換為健康「結果公平」。另一重要的結論是不要單一關注社會醫療保險改革覆蓋面的擴大，更應關注不同保險項目之間福利待遇的公平性。透過多元線性回歸分析，研究員發現了醫療保險改革之後影響老年人健康水平的顯著因素：微觀層面的社會經濟地位與慢性病特徵，宏觀層面的保險因素與中觀層面的社會支持網絡。質化研究的採用將「健康公平」的討論從關注客觀的「健康結果」擴展為利益相關者主觀的公平性體驗。質化研究補充了政策制定者、基層醫生與弱勢老年人各自對「健康公平」的理解，進一步回答了「什麽是健康公平」，確立了本研究的底層視角。 / 混合研究進一步回答了社會醫療保險改革對老人「健康公平」的影響：雖然醫療保險改革提高了老人的「機會公平」，但這只是形式公平，改革在推動「過程公平」與「結果公平」這些實質公平的維度尚待探索。在醫療保險改革之後，進一步的路徑分析評估了「醫療服務使用」作為mediator的作用，呈現了與「健康水平」之間的負向因果關係。交互作用分析表明，如若改變弱勢老年人社群在「健康公平」中的弱勢地位，就需要社會醫療保險改革調節「醫療服務使用」與「健康水平」的關係；且澄清了不同社會醫療保險項目作為moderator的差別：城鎮職工基本醫療保險可以改善使用較多醫療服務的老人的健康水平，而新型農村合作醫療則起到相反的作用。在這些變量之間的關係背後，站在「弱者優先」的底層立場上，深入的質化研究補充了社會醫療保險改革對弱勢老人接受醫療服務與享受醫療福利待遇「過程公平」的缺失與「結果公平」的不足。 / 結合以上量化與質化研究發現，本研究識別出了「健康公平」多維度的影響因素（經濟地位、健康地位、社會關係網絡、身份地位、福利地位），建立了包括機會、結果和過程公平在內的多元的健康公平理論框架。並且綜合討論了「健康公平」理論的反思與重構，混合研究方法在評價醫療保障改革公平性實證研究中運用的可行性，並且倡導在政策制定中改變福利觀念，提出了如何進行公平的「全民醫保」政策改革，以及如何實現「以社區為中心的綜合健康服務與長期照顧體系」的政策創新。 / Along with the reform and opening up, the health reform in China had been continously challenged due to its excessive marketization. As the pioneer of a new round of health reform since 21st century, social health insurance reform reiterated ‘health equity’. Nevertheless, neither theoretical nor empirical studies were abundant behind the slogans for the advancement of equity and justice. / This thesis began with theory of social justice based on ‘give priority to the disadvantaged group’, redefining the concept of ‘health equity’ by ‘health equality on the basis of social justice’. Adopting of the paradigm of post-positivism, researcher chose quantitative-and-qualitative mixed method, and combined analysis of primary data and secondary data. This study has been located in Zhejiang province, intending to explore the impacts of health insurance reform along with health welfare system changes on health equity among the elderly. Researcher finally adopted the value choice of health equity for vulnerable groups, and developed a multi-dimension theoretical framework of ‘health equity’. / From the quantitative research findings, researcher modified the theory of health equity from concerning ‘equal opportunity’ to ‘equal outcome’. This research also contributed to a transition of health insurance studies from emphasis on expansion of ‘insurance coverage’ to the concerns with unequal benefit packages between different social insurance schemes. Multiple linear regression demonstrated significant predictors of older adults’ health outcome after health insurance reform, composing of socio-economic status and chronic disease in the micro-level, health insurance in the macro-level, and social support in the meso-level. Simultaneously, qualitative research explained diversive understandings of ‘health equity’ among policymakers, doctors who provide primary care and vulnerable older adults. The crucial question of ‘what is health equity’ has been answered, and that the ‘give priority to the disadvantaged group’ standpoint being reaffirmed. / Mixed method study further answered the research question of ‘what is impacts of health insurance reform on the health equity among the elderly’: Although health reform improved ‘opportunity equity’ for older adults as a kind of ‘form fairness’, it was still expected to explore other dimensions of ‘essential fairness’, such as ‘process equity’ and ‘result equity’. After health insurance reform, researcher employed path analysis to test mediator effects of ‘healthcare utilization’, which demonstrated negative causal relations with ‘health outcome’. Interaction effect analysis manifested a moderating effect of health insurance reform adjusting the relationship between ‘healthcare utilization’ and ‘health outcome’ with an attempt to improve social status for disadvantaged older groups. Interaction effects of different insurance schemes have been clarified as well: The Basic Medical Insurance for Urban Employees could improve health outcome of the elderly who use more health care services, whereas the New Rural Cooperative Medical Scheme played an opposite function. Under the background of these relations between variables, being standfast in vulnerabe groups’ stand, researcher adopted qualitative data to complement quantitative findings: The lack of ‘process equity’ and the short of ‘outcome equity’ during the process of interpreting accessibility to health care services and utilization. / In this dissertation, researcher also synthetically combined findings in quantitative and qualitative research, identified multiple predict factors of ‘health equity’ (economic status, health status, social networks, identity status and welfare status). All of above mentioned factors jointly composed and enriched multi-dimensional ‘health equity’ theoretical framework (including equitable opportunity, outcome and process). It also profoundly rethought and reconstructed ‘health equity’ theory, and evaluated efficiency and effectiveness of health insurance reform by using mixed research methods. Researcher advocated a transition of welfare ideology in the process of policy making, and recommended an ‘universal health insurance’ reform based on health equity, then initiated a ‘home and community based comprehensive health and long-term care service’ system. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / 劉曉婷. / "2013年3月". / "2013 nian 3 yue". / Thesis (Ph.D.)--Chinese University of Hong Kong, 2013. / Includes bibliographical references (leaves 386-422). / Abstract in Chinese and English. / Liu Xiaoting. / 論文摘要 --- p.I / Abstract --- p.III / 致謝 --- p.VI / Chapter 第一部份 --- 研究背景 --- p.1 / Chapter 第一章 --- 導論 --- p.2 / Chapter 第一節 --- 研究的緣起 --- p.2 / Chapter 一、 --- 醫療改革中的公平性失守 --- p.3 / Chapter 二、 --- 醫改糾偏：重建社會公平的改革共識 --- p.6 / Chapter 三、 --- 聚焦老年人：醫療保障改革中的弱勢社群 --- p.10 / Chapter 四、 --- 研究場域：浙江醫改之路 --- p.12 / Chapter 第二節 --- 研究問題的提出 --- p.16 / Chapter 第三節 --- 研究的目標 --- p.19 / Chapter 一、 --- 從理論上對「健康公平」的界定與發展 --- p.19 / Chapter 二、 --- 從實證研究中識別「弱勢老年人」的社會結構、關係網絡與疾病風險特徵 --- p.20 / Chapter 三、 --- 通過混合研究方法探索醫療保險改革與老人健康公平的因果關係 --- p.21 / Chapter 四、 --- 探索建立「健康公平」研究的理論框架 --- p.21 / Chapter 第四節 --- 本文的結構 --- p.24 / Chapter 第二部份 --- 研究準備 --- p.27 / Chapter 第二章 --- 文獻回顧 --- p.28 / Chapter 第一節 --- 平等與公平 --- p.28 / Chapter 一、 --- 平等的主體與客體 --- p.29 / Chapter 二、 --- 公平的價值選擇 --- p.35 / Chapter 第二節 --- 基於社會公義的健康公平 --- p.41 / Chapter 一、 --- 健康公平的界定 --- p.41 / Chapter 二、 --- 健康公平的實現 --- p.48 / Chapter 三、 --- 底線公平 --- p.53 / Chapter 第三節 --- 醫療保險、醫療服務使用與健康水平的關係 --- p.58 / Chapter 一、 --- 文獻回顧與批評 --- p.58 / Chapter 二、 --- 對老年人健康水平認識的發展 --- p.64 / Chapter 第四節 --- 影響健康公平的社會決定因素 --- p.69 / Chapter 一、 --- 社會結構因素 --- p.69 / Chapter 二、 --- 社會網絡因素 --- p.78 / Chapter 第五節 --- 中國社會醫療保險制度改革 --- p.87 / Chapter 一、 --- 中國傳統醫療保障制度及其缺陷 --- p.87 / Chapter 二、 --- 社會醫療保險的道路選擇與發展 --- p.91 / Chapter 三、 --- 醫療保障制度改革對弱勢社群的排斥 --- p.102 / 本章小結 --- p.107 / Chapter 第三章 --- 方法論與反思 --- p.109 / Chapter 第一節 --- 研究範式：對後實證主義的理解 --- p.109 / Chapter 一、 --- 範式與範式轉移 --- p.109 / Chapter 二、 --- 證偽與後實證主義的運用 --- p.112 / Chapter 三、 --- 研究方法的層次與後實證主義的適用性 --- p.116 / Chapter 第二節 --- 混合研究方法 --- p.118 / Chapter 一、 --- 量化與質化研究各自的優缺點 --- p.118 / Chapter 二、 --- 選擇混合研究方法的理由 --- p.121 / Chapter 第三節 --- 分析單位：結構與能動者 --- p.124 / Chapter 一、 --- 結構與能動者 --- p.124 / Chapter 二、 --- 本研究的分析單位 --- p.128 / Chapter 第四節 --- 研究員的自我反省 --- p.130 / Chapter 一、 --- 對研究員個人社會特徵與經歷的反思 --- p.131 / Chapter 二、 --- 對研究員在學術場域中的位置的反思 --- p.135 / Chapter 三、 --- 對整個研究過程和研究方法的反思 --- p.137 / 本章小結 --- p.141 / Chapter 第四章 --- 研究框架與研究設計 --- p.142 / Chapter 第一節 --- 研究框架 --- p.142 / Chapter 第二節 --- 基本概念界定 --- p.146 / Chapter 一、 --- 社會醫療保險 --- p.146 / Chapter 二、 --- 弱勢老年人 --- p.148 / Chapter 三、 --- 醫療服務使用 --- p.149 / Chapter 四、 --- 健康水平 --- p.150 / Chapter 五、 --- 健康公平 --- p.151 / Chapter 第三節 --- 量化研究設計 --- p.153 / Chapter 一、 --- 研究假設 --- p.153 / Chapter 二、 --- 抽樣方法、問卷調查與二手數據分析 --- p.157 / Chapter 三、 --- 測量問題與分析模型 --- p.165 / Chapter 第四節 --- 質化研究設計 --- p.171 / Chapter 一、 --- 研究假設 --- p.171 / Chapter 二、 --- 樣本選擇與獲得進入 --- p.173 / Chapter 三、 --- 資料收集策略與分析方法 --- p.183 / Chapter 第五節 --- 研究的質素 --- p.190 / Chapter 一、 --- 量化與質化研究方法各自的信效度 --- p.190 / Chapter 二、 --- 混合研究方法的信效度：三角互證法 --- p.192 / 本章小結 --- p.197 / Chapter 第三部份 --- 研究發現 --- p.198 / Chapter 第五章 --- 量化研究發現 --- p.199 / Chapter 第一節 --- 改革前後被訪老人社會特徵的變化 --- p.199 / Chapter 一、 --- 基本特徵 --- p.200 / Chapter 二、 --- 社會經濟地位 --- p.204 / Chapter 三、 --- 社會支持網絡 --- p.208 / Chapter 第二節 --- 被訪老年人的健康水平與醫療服務使用情況 --- p.210 / Chapter 一、 --- 健康水平 --- p.210 / Chapter 二、 --- 醫療服務可及性及使用 --- p.220 / Chapter 第三節 --- 各保險項目參保老年人的健康不平等 --- p.227 / Chapter 一、 --- 各保險項目參保老年人的基本特徵 --- p.228 / Chapter 二、 --- 醫療保險類型與老年人的醫療服務使用 --- p.230 / Chapter 三、 --- 醫療保險類型與老年人的健康水平 --- p.233 / Chapter 第四節 --- 多元線性回歸分析：對健康水平的預測 --- p.236 / Chapter 一、 --- 建立多元線性回歸模型 --- p.239 / Chapter 二、 --- 多元線性回歸分析的結果 --- p.242 / 本章小結 --- p.248 / Chapter 第六章 --- 質化研究發現 --- p.250 / Chapter 第一節 --- 政策制定者：對形式公平與個人責任的強調 --- p.250 / Chapter 第二節 --- 基層醫生：因醫患矛盾和「付出-回報失衡」而產生的弱勢感 --- p.255 / Chapter 第三節 --- 弱勢老人：建立在「比較」基礎上的不公平感 --- p.259 / Chapter 一、 --- 農村老人與城鎮老人比較：社會福利不公平與弱勢地位的惡化 --- p.261 / Chapter 二、 --- 普通老人與離退休干部比較：身份地位差別引發的醫療服務不公平 --- p.264 / Chapter 三、 --- 只享受醫療保險的老人與低保對象比較：究竟誰更加弱勢？ --- p.266 / 本章小結：基於弱者優先的底線公平 --- p.271 / Chapter 第七章 --- 混合研究發現：醫療保險改革如何影響弱勢老人的健康公平 --- p.274 / Chapter 第一節 --- 浙江省社會醫療保障的改革實踐：機會公平 --- p.275 / Chapter 第二節 --- 路徑分析：醫療服務使用與健康水平的關係 --- p.279 / Chapter 一、 --- 醫療服務使用與健康水平的相關分析 --- p.280 / Chapter 二、 --- 路徑模型的建立、修正及結果 --- p.282 / Chapter 三、 --- 戶口-醫療服務使用-健康水平（最終的路徑模型） --- p.294 / Chapter 第三節 --- 交互作用分析：醫療保險的調節作用 --- p.299 / Chapter 一、 --- 「城鎮職工基本醫療保險」作為moderator --- p.299 / Chapter 二、 --- 「新型農村合作醫療」作為moderator --- p.302 / Chapter 第四節 --- 醫療保障制度改革中的過程公平與結果公平 --- p.306 / Chapter 一、 --- 過程公平：部門利益爭奪中「看病貴」問題喜憂參半的改革 --- p.306 / Chapter 二、 --- 結果公平：弱勢老人未被滿足的需要與不足夠的保障 --- p.310 / 本章小結 --- p.316 / Chapter 第四部份 --- 討論與結論 --- p.318 / Chapter 第八章 --- 討論 --- p.319 / Chapter 第一節 --- 「公平性」理論的反思與重構 --- p.319 / Chapter 一、 --- 反思醫療福利改革的理論基礎：對社會公義理論的發展 --- p.320 / Chapter 二、 --- 分析「底層健康公平」的理論機制：階層化身份地位差別的形成與變遷 --- p.325 / Chapter 第二節 --- 傳統微觀影響因素的再認識 --- p.332 / Chapter 一、 --- 健康水平：疾病風險變化與健康水平測量的發展 --- p.332 / Chapter 二、 --- 社會經濟地位：從關注收入轉向關注疾病的經濟負擔 --- p.334 / Chapter 三、 --- 戶籍狀況：影響的消除還是持續？ --- p.336 / Chapter 第三節 --- 結果公平的全民醫療保險制度改革 --- p.339 / Chapter 一、 --- 全民醫療保險的角色反思：從機會公平到結果公平 --- p.339 / Chapter 二、 --- 從醫療服務使用到健康結果：全民醫療保險的新路徑倡導 --- p.341 / Chapter 三、 --- 醫療保險改革與醫藥體制改革的互動 --- p.344 / Chapter 第四節 --- 以社區為中心的綜合健康服務與長期照顧體系初探 --- p.349 / Chapter 一、 --- 社會支持網絡：擴展的視角 --- p.349 / Chapter 二、 --- 美國社區健康中心與長期照顧服務的啟示 --- p.351 / Chapter 三、 --- 對中國建立社區綜合健康服務與長期照顧體系的啟示 --- p.355 / 本章小結 --- p.357 / Chapter 第九章 --- 結論與建議 --- p.359 / Chapter 第一節 --- 結論 --- p.359 / Chapter 一、 --- 「底層健康公平」價值選擇的特殊意涵 --- p.360 / Chapter 二、 --- 混合研究發現「過程公平」與「主觀公平」的重要性 --- p.362 / Chapter 三、 --- 健康公平社會影響因素的新變化與新發現 --- p.363 / Chapter 四、 --- 改革中醫療保險對健康公平的調節作用 --- p.364 / Chapter 第二節 --- 建議 --- p.367 / Chapter 一、 --- 醫療保障政策建議 --- p.367 / Chapter 二、 --- 醫療與醫藥政策的配合：推動「過程公平」的需要 --- p.371 / Chapter 三、 --- 社會醫療保險改革對醫療服務發展的啟示 --- p.373 / Chapter 第三節 --- 貢獻、局限與研究展望 --- p.375 / Chapter 一、 --- 本研究的貢獻 --- p.375 / Chapter 二、 --- 本研究的局限 --- p.379 / Chapter 三、 --- 未來的研究方向 --- p.381 / 結束語 --- p.384 / 參考文獻 --- p.386 / 附錄 --- p.423 / Chapter 附錄1. --- 調查問卷 --- p.423 / Chapter 附錄2. --- 數據使用協議 --- p.441 / Chapter 附錄3. --- 知情同意書 --- p.442 / Chapter 附錄4. --- 訪談提綱 --- p.443

<p>One must consider cost effectiveness when deciding how resources within the health sector should be distributed. Quality adjusted life years (QALYs) are used to measure the value of different medical treatments. QALY is based on utility maximization theory, which suggests that a QALY is always a QALY regardless of who receives it. Therefore, a produced QALY is worth the same regardless of the age or the initial health of the patient. Previous research has shown that these assumptions do not seem to fit the real preferences of individuals. Further, there are different methods of acquiring QALYs that give different outcomes. Two of these methods are Time Trade Off (TTO), in which respondents are confronted with a valuation of health change in time, and Person Trade Off (PTO), where respondents are confronted with a valuation in persons. Arguably, PTO is the preferred method that takes greater account of how individuals wish to allocate the resources of the society. From a distribution perspective focusing on age and initial health status, this paper aims to empirically identify the differences between TTO and PTO considering the measurement of preferences for life quality. The aim is also to examine whether the results obtained are consistent with the theoretical assumptions that are required for the preference to be accepted as a cardinal utility. A quantitative survey was carried out with 58 medical and 61 economics students. Half of the students received PTO and the other half TTO questions. The data collected was analyzed comparing the methods, the two student groups and men against women.</p><p>The results from the survey show that, both with TTO and PTO, respondents on average believe that patients who are at a lower initial health level should be given priority over patients who are at a higher initial health level, and younger patients should be given priority over older patients. No significant differences were seen between PTO and TTO when it came to the age of the patient. Conversely, there was a significant difference between the methods for the valuation based on initial health status of patients. Measured with PTO a treatment for patients who are at a lower initial level is valued 28% higher than a treatment for those patients who are at a higher initial level, while the corresponding figure for TTO was 8%. Between medical students and economic students, there were significant differences in the question of age in the PTO. Between men and women differences were found in both methods.</p> / <p>Kostnadseffektivitet är en av faktorerna som ska tas i beaktande vid beslut om hur resurser inom hälso- och sjukvården ska fördelas. Kvalitetsjusterade levnadsår (QALY) används för att mäta effekten av olika insatser. Måttet baseras på nyttomaximeringsteori vilket leder till att en QALY alltid är en QALY oavsett vem den tillfaller - med andra ord är en QALY som produceras hos en patient lika mycket värd oavsett exempelvis patientens ålder eller initiala tillstånd. Dessa antaganden har i tidigare undersökningar visat sig stämma dåligt med individers preferenser men olika metoder för att ta fram QALY verkar ta olika mycket hänsyn till dem. Två av flera metoder är Time Trade Off (TTO), där respondenter ställs inför en värdering av hälsoförändringar i tid och Person Trade Off (PTO) där respondenter ställs inför en värdering i personer. PTO har påståtts vara en mer rättvisande metod som tar större hänsyn till hur individer vill att samhälleliga resurser ska fördelas. Denna uppsats syftar till att, utifrån ett fördelningsperspektiv med fokus på ålder och initialt hälsotillstånd, empiriskt kartlägga förekomsten av skillnader i preferenser för livskvalitet mätt med PTO respektive TTO, samt att undersöka om de erhållna resultaten överensstämmer med de teoretiska grundantagandena som krävs för att preferenser ska accepteras som kardinala nyttor. För att svara mot syftet utfördes en kvantitativ undersökning på 58 läkar- samt 61 ekonomistudenter. Hälften av studenterna fick PTO-frågor och den andra hälften TTO-frågor. En statistisk bearbetning av insamlad data har gjorts där svaren har jämförts mellan metoderna samt mellan läkar- och ekonomistudenter och kvinnor och män.</p><p>Resultaten från undersökningen visar att både med TTO och PTO anser respondenterna att patienter som befinner sig på en lägre initial nivå ska prioriteras framför patienter som befinner sig på en högre initial nivå samt yngre patienter ska prioriteras framför äldre patienter. Vad gäller hänsyn till patienters ålder uppmättes inga signifikanta skillnader mellan PTO och TTO. Däremot uppmättes en signifikant skillnad mellan metoderna vad gäller hänsyn till initialt hälsotillstånd hos patienter. Mätt med PTO värderas en behandling för de patienter som befinner sig på en lägre initial nivå 28 % högre än en behandling för de patienter som befinner sig på en högre initial nivå medan motsvarande siffra för TTO var 8%. Mellan läkare och ekonomer fanns signifikanta skillnader i frågan gällande ålder i PTO och mellan kvinnor och män återfanns skillnader i båda metoder.</p>

One must consider cost effectiveness when deciding how resources within the health sector should be distributed. Quality adjusted life years (QALYs) are used to measure the value of different medical treatments. QALY is based on utility maximization theory, which suggests that a QALY is always a QALY regardless of who receives it. Therefore, a produced QALY is worth the same regardless of the age or the initial health of the patient. Previous research has shown that these assumptions do not seem to fit the real preferences of individuals. Further, there are different methods of acquiring QALYs that give different outcomes. Two of these methods are Time Trade Off (TTO), in which respondents are confronted with a valuation of health change in time, and Person Trade Off (PTO), where respondents are confronted with a valuation in persons. Arguably, PTO is the preferred method that takes greater account of how individuals wish to allocate the resources of the society. From a distribution perspective focusing on age and initial health status, this paper aims to empirically identify the differences between TTO and PTO considering the measurement of preferences for life quality. The aim is also to examine whether the results obtained are consistent with the theoretical assumptions that are required for the preference to be accepted as a cardinal utility. A quantitative survey was carried out with 58 medical and 61 economics students. Half of the students received PTO and the other half TTO questions. The data collected was analyzed comparing the methods, the two student groups and men against women. The results from the survey show that, both with TTO and PTO, respondents on average believe that patients who are at a lower initial health level should be given priority over patients who are at a higher initial health level, and younger patients should be given priority over older patients. No significant differences were seen between PTO and TTO when it came to the age of the patient. Conversely, there was a significant difference between the methods for the valuation based on initial health status of patients. Measured with PTO a treatment for patients who are at a lower initial level is valued 28% higher than a treatment for those patients who are at a higher initial level, while the corresponding figure for TTO was 8%. Between medical students and economic students, there were significant differences in the question of age in the PTO. Between men and women differences were found in both methods. / Kostnadseffektivitet är en av faktorerna som ska tas i beaktande vid beslut om hur resurser inom hälso- och sjukvården ska fördelas. Kvalitetsjusterade levnadsår (QALY) används för att mäta effekten av olika insatser. Måttet baseras på nyttomaximeringsteori vilket leder till att en QALY alltid är en QALY oavsett vem den tillfaller - med andra ord är en QALY som produceras hos en patient lika mycket värd oavsett exempelvis patientens ålder eller initiala tillstånd. Dessa antaganden har i tidigare undersökningar visat sig stämma dåligt med individers preferenser men olika metoder för att ta fram QALY verkar ta olika mycket hänsyn till dem. Två av flera metoder är Time Trade Off (TTO), där respondenter ställs inför en värdering av hälsoförändringar i tid och Person Trade Off (PTO) där respondenter ställs inför en värdering i personer. PTO har påståtts vara en mer rättvisande metod som tar större hänsyn till hur individer vill att samhälleliga resurser ska fördelas. Denna uppsats syftar till att, utifrån ett fördelningsperspektiv med fokus på ålder och initialt hälsotillstånd, empiriskt kartlägga förekomsten av skillnader i preferenser för livskvalitet mätt med PTO respektive TTO, samt att undersöka om de erhållna resultaten överensstämmer med de teoretiska grundantagandena som krävs för att preferenser ska accepteras som kardinala nyttor. För att svara mot syftet utfördes en kvantitativ undersökning på 58 läkar- samt 61 ekonomistudenter. Hälften av studenterna fick PTO-frågor och den andra hälften TTO-frågor. En statistisk bearbetning av insamlad data har gjorts där svaren har jämförts mellan metoderna samt mellan läkar- och ekonomistudenter och kvinnor och män. Resultaten från undersökningen visar att både med TTO och PTO anser respondenterna att patienter som befinner sig på en lägre initial nivå ska prioriteras framför patienter som befinner sig på en högre initial nivå samt yngre patienter ska prioriteras framför äldre patienter. Vad gäller hänsyn till patienters ålder uppmättes inga signifikanta skillnader mellan PTO och TTO. Däremot uppmättes en signifikant skillnad mellan metoderna vad gäller hänsyn till initialt hälsotillstånd hos patienter. Mätt med PTO värderas en behandling för de patienter som befinner sig på en lägre initial nivå 28 % högre än en behandling för de patienter som befinner sig på en högre initial nivå medan motsvarande siffra för TTO var 8%. Mellan läkare och ekonomer fanns signifikanta skillnader i frågan gällande ålder i PTO och mellan kvinnor och män återfanns skillnader i båda metoder.

From the Proceedings of the 1974 Meetings of the Arizona Section - American Water Resources Assn. and the Hydrology Section - Arizona Academy of Science - April 19-20, 1974, Flagstaff, Arizona / The doctrine of prior appropriation used in the arid western states has encouraged rapid exploitation of our natural water resources. Those who beneficially used the water first, regardless of type of use or efficiency, obtained a perpetual right to always be first. As frontiers for exploiting our natural resources shrink, the Appropriation Doctrine is changing under the stresses of the 1970's. Our water allocations system is changing as new water -use priorities emerge along with changing quality standards. Government at all levels, along with planners and engineers, must understand the institutional and legal constraints put on water development by our historic water rights system so that intelligent decisions can be made in developing and maintaining our natural water resources.

Cette recherche qualitative avait pour but d’explorer le raisonnement clinique d’infirmières de première ligne en CSSS/CLSC lorsqu’elles priorisent leurs interventions auprès de familles vivant en contexte de vulnérabilité dans le cadre du programme des Services intégrés en périnatalité et pour la petite enfance (SIPPE). Il s’agit d’une étude de cas qui comporte un échantillon intentionnel de sept épisodes de soins impliquant deux infirmières auprès de sept familles en période postnatale lorsqu’elles priorisent leurs interventions. La collecte de données a procédé par méthode think aloud, suivie d’entretiens semi-dirigés auprès des infirmières. Une analyse qualitative des données a été effectuée selon des méthodes interprétatives et par comptage de catégories. Ces dernières ont été formulées et mises en relation en s’inspirant de la modélisation du processus de raisonnement clinique de Tanner (2006) ainsi que des stratégies de raisonnement clinique proposés par Fonteyn (1998). Au terme de cette étude, le processus de raisonnement clinique ne semble pas être différent selon le type de priorité d’intervention auprès de familles en contexte de vulnérabilité, particulièrement lorsque nous distinguons la priorité selon un degré d’urgence (prioritaire ou secondaire). Aussi, nous constatons qu’il existe peu de diversité dans les processus de raisonnement clinique mobilisés à travers les sept épisodes de soins; et qu’un processus narratif de raisonnement est fréquent. Si une famille exprime un besoin urgent, l’infirmière y répond prioritairement. Par ailleurs, lorsque des conditions suggèrent un potentiel accru de vulnérabilité des familles, un mode de raisonnement clinique plus systématique, qui comporte une collecte et une mise en relation d’informations afin de formuler une proposition pour soutenir le passage à l’action, semble être mobilisé pour prioriser l’intervention. Il en est ainsi s’il s’agit d’un premier bébé, que la famille n’utilise pas d’autres ressources formelles de soutien. Autrement, s’il s’agit d’un deuxième bébé et que les familles utilisent d’autres ressources, les infirmières tendent plutôt à appliquer une routine d’intervention SIPPE. Aussi, cette recherche témoigne de l’engagement soutenu des infirmières auprès de familles vivant d’importants défis. Il importe toutefois de soutenir le développement d’un répertoire plus varié de processus de raisonnement clinique afin de renforcer leur capacité de prioriser leur intervention qui se déroule dans un contexte de multiples contraintes organisationnelles et interpersonnelles. / The goal of this qualitative study was to explore the clinical reasoning of primary care nurses in CLSC/CSSS when they set priorities for their interventions with vulnerable families as part of the Integrated Perinatal and Early Childhood Services (SIPPE) program. This case study comprises a purposeful sample of seven postnatal care episodes involving two nurses and seven families. Data were collected using the think-aloud method, followed by semi-structured interviews with nurses. Qualitative data analysis was performed using interpretive methods and category counting. The resulting categories and patterns were developed based on Tanner's (2006) model of clinical judgement in nursing and Fonteyn's (1998) clinical reasoning patterns. Study results suggest that clinical reasoning processes do not differ according to the type of priority, whether the situation is more or less urgent. Moreover, there is diversity in the types of clinical reasoning employed within the seven care episodes; and it appears that a narrative reasoning process is favoured. If a family's needs are urgent, nurses prioritize these needs. When conditions indicate that there is greater potential for vulnerability, a more systematic form of clinical reasoning, identified here as «collecting data to form relationships and to present a proposal for action», is used to prioritize interventions. This pattern is more likely when a first child is involved and when the family is less likely to turn to other support resources. Otherwise, if this is a second child and the family uses other resources, the nurse tends to apply routine SIPPE interventions. Finally, our results suggest that a systemic view of a family's living circumstances, rather than keeping the focus on the infant's well-being, could make it more difficult to set intervention priorities. This study highlights nurses' ongoing commitment to families facing significant challenges. However, it is important to support the development of a broader inventory of clinical reasoning processes to bolster nurses' capacity to prioritize interventions that take place in contexts of multiple organizational constraints.