Dissertations / Theses on the topic 'Public health – Economic aspects – Honduras'

Bipolar disorder (BD) is one of the leading causes of disability worldwide and has a detrimental impact on health-related quality of life (HRQoL), and personal and social functioning. Despite this, there is insufficient knowledge of the costs, HRQoL implications relevant to BD, and the cost-effectiveness of current treatments for BD in the UK. This thesis aims to inform decisions about local and national service provision by applying a variety of health economic tools to build an economic case for BD. First, economic evaluations of BD management strategies are systematically reviewed. A cost-of-illness study is then conducted to estimate the societal burden of BD in the UK and explore the factors that drive variations in these costs. The appropriateness of applying the EQ-5D-3L outcome measure in BD is assessed, and the feasibility of mapping disease-specific measures to the EQ-5D-3L is explored. Finally, a cost-utility analysis (CUA) is conducted to bring together evidence on the costs and outcomes associated with alternative psychological interventions in BD management. This thesis makes critical contributions to multiple research domains, informing the allocation of scarce healthcare resources in this context. There is a sheer dearth of evidence on cost-effectiveness strategies for the long-term management of BD in the UK, especially the evidence for psychological therapies is limited. The annual societal costs associated with BD in the UK are estimated to be £5.14 billion, demonstrating the significant economic burden associated with this disease. The EQ-5D-3L instrument is found to be useful in measuring HRQoL in BD patients who predominantly experience depressive symptoms but is not sensitive enough to detect changes in individuals with mania. More psychometric evidence is therefore required before this instrument can be widely applied in economic evaluations of BD-related interventions. Finally, the CUA indicates that a novel structured psychoeducation intervention in individuals on remote mood monitoring in the UK is not cost-effective.

The aim of operations management in health care is to enhance the provision of services to patients and to decrease costs. Overall worldwide health care expenditures represent around 10.5% of the global GDP and are projected to increase at an annual rate of 5.3% from 2015 to 2017 [74]. In order to investigate how to curb health care costs, I study the English NHS, a health care system that provided universal care to around 54 million people in 2014 [243]. The NHS has launched many initiatives to improve the performance of hospital operations such as the "QIPP" program, which has the objective to save £20 billion of costs by 2015 [98]. Given this framework, this research aims to contribute to the theory that is guiding these operational changes, using data on all admissions to hospitals and focussing on the inguinal hernia, one of the most common surgical procedures [86]. In the next chapters, this research describes inguinal hernia care delivery in the English NHS, examines the impact of spillovers and complementarities on costs, and investigates the effects of length of stay reduction on risk of re-admission and risk of death. The findings of this thesis indicate that one of the possible problems in the delivery of inguinal hernia care in the NHS is the decrease in the number of elective operations performed and the increase in readmission rates. They also clarify how decisions on allocation of resources can affect hospital expenditures by showing that loss in focus can increase health care costs and by pointing out that there is little evidence to support the theory of spillovers and complementarities in the surgical context. Finally, the results of this research can be used to suggest the logic of a policy to decrease length of stay that can inform hospital decisions and can decrease hospital costs.

The broad aim of this thesis on ‘Health Economic aspects in the management of Chronic Obstructive Pulmonary Disease’ (COPD) was to study the natural history of the disease in order to inform the conceptualisation and development of a new economic model. Existing economic evaluations for COPD were critiqued and information on the natural history of the disease gathered though literature searches and analyses of two large datasets, a COPD randomised controlled trial called TORCH and a general population observational dataset called the Renfrew/Paisley (MIDSPAN) study. Particular attention was paid to identifying the COPD population using different diagnostic criteria. The elicitation of utility estimates under a number of circumstances was considered. A regression based prediction model was conceptualised and developed. Significant contributions of this thesis include, but are not limited to: a NICE COPD cohort were identified who were found to be at higher risk of all-cause and COPD mortality than a GOLD defined cohort; a mapping equation was successfully developed that predicts the EQ-5D from the SGRQ; and an entirely new concept for modelling COPD was developed that uses a series of regression equations to predict cost and effect based on lung function, symptoms and exacerbations and weighted by survival probability in order to generate a model with one arm representing current treatment and a second arm representing a comparator treatment. The thesis successfully combined information gathered throughout the period of research on the natural history of COPD with treatment effects in a novel way in order to conceptualise and develop a new economic model for COPD.

Introduction: There is an increasing need for economic evaluation of public health interventions to ensure efficient allocation of resources. Outcomes of such interventions often consists of health and non-health and do not fit in the conventional economic evaluation of quality-adjusted life year (QALY) framework. A cost-benefit analysis (CBA) could be appropriate but has concerns of assigning monetary values to health outcomes. Questions remain on how to consider the broad outcomes of a public health intervention in an economic evaluation. Objective: This thesis aimed to develop an integrated approach for an economic evaluation of a public health intervention that combines the standard cost-utility analysis (CUA) for health outcomes with the stated preference discrete choice experiment (SPDCE) approach for non-health outcomes on a single monetary metric. Methods: A natural experiment of the Woods In and Around Towns (WIAT) study in Scotland was used for empirical analysis. Costs were assessed using a top-down approach based on resources used. A difference-in-differences (DiD) approach was used to establish the impact. A CUA valued the health outcomes in terms of QALYs while a previously developed conceptual model of the WIAT was used to identify the SPDCE attributes and levels for the non-health outcomes. The WIAT study questionnaire was mapped to the SPDCE which generated relative willingness to pay (WTP) values from a general Scottish population. The WTP estimates were applied to the changes or improvements in the attributes and levels resulting from the intervention. A net monetary benefit (NMB) framework was then used to combine the CUA with the SPDCE on the same monetary scale, effectively deriving a CBA. Results: The WIAT interventions were of low cost despite the base case DiD analysis showing a statistically insignificant effect for interventions. The incremental cost-effective ratios (ICERs) for the interventions revealed that they were cost-effective. The probabilistic sensitivity analysis (PSA) showed that the physical intervention was 73% likely to be cost-effective at WTP of £20,000 and £30,000. The combined physical and social interventions had 74% and 75% likelihood of being cost-effective at WTP of £20,00 and £30,000, respectively. There was a great deal of uncertainty around QALY results. Overall, the integrated approach revealed that the WIAT interventions were cost-beneficial in terms of both health and non-health outcomes. Conclusion: This thesis has proposed and demonstrated the integrated approach that combines the conventional QALY framework with the SPDCE on a single monetary scale, hence a broader economic evaluative space particularly suitable for an economic evaluation of a public health intervention.

Background: Population health interventions by their nature affect an entire population and are typically delivered outwith of health services and within the community, such as in schools. An example of such interventions are those that aim to improve children’s social and emotional wellbeing, which have demonstrated effectiveness in the short-term and potentially the long-term. However, challenges arise when conducting economic evaluations of population health interventions, most notably the difficulties of identifying, measuring, and valuing broader intersectoral costs, health, and non-health outcomes. Economic evaluation in an education context is relatively novel, but could provide decision-makers with information to help them make transparent and consistent decisions about how to allocate limited funds. This thesis examined the role for economic evaluation in school-based interventions and sought to determine appropriate methods for its implementation in addition to examining appropriate child-focused outcome measures. Thus, the overarching research question asked, ‘How should the cost-effectiveness of school-based, population health interventions aimed at children be determined?’ Methods: A mixed methods approach to this thesis was used: (i) a systematic literature review and narrative synthesis to determine which evaluation methods (economic and non-economic) are currently being used in school-based population health interventions; (ii) a case study to illustrate an economic evaluation (including cost-utility and cost-effectiveness analysis) of a school-based intervention to reflect on the advantages and disadvantages for decision making in this context; and (iii) an exploration of outcome measures (through mapping validation) for valuing child health and social and emotional wellbeing in school-based programmes to support future evaluation work in this context. Data for the economic evaluation and mapping validation study were available from a cluster randomised controlled trial of the Roots of Empathy programme in Northern Ireland (Ref: 10/3006/02). Results: The systematic review found that the methods currently being utilised to evaluate school programmes are varied (including economic evaluation, cost only, and effectiveness only studies), with poor quality reporting for the economic evaluations. Of the few cost-utility analyses in school-based settings identified, none had directly measured health-related quality of life using child measures or values. The case study cost-utility analysis using Child Health Utility 9D of a school-based intervention was found to be cost-effective from the National Health Service perspective with an incremental cost-effectiveness ratio of £11,000 per quality-adjusted life year (confidence interval: -£95,500 to £147,000), however the wide confidence interval demonstrates considerable uncertainty. This uncertainty is likely due to a lack of statistically significant effect that remained at the 36-month follow-up. Cost-effectiveness analysis using child behavioural descriptive measure, the Strengths and Difficulties Questionnaire, resulted in an incremental cost-effectiveness ratio of £197 per unit decrease in total difficulties score (confidence interval: £77 to £471). The Strengths and Difficulties Questionnaire is suitable for measuring social and emotional wellbeing, but is less advantageous for cost-effectiveness decision-making as no consensus has been reached as to what a clinically meaningful change in score represents, nor has a cost-effectiveness threshold been defined. It remains uncertain how these cost-effectiveness results will be interpreted in an education decision-making context where cost-effectiveness thresholds have not been set up. The mapping validation study validated a mapping algorithm to convert the Strengths and Difficulties Questionnaire into child health utility. Using this algorithm provides an option for valuing incremental changes in health-related quality of life against a generally accepted cost-effectiveness threshold from a health service perspective. Conclusions: Given the findings from the various aspects of work undertaken for this thesis to address population health issues, this thesis identified cost-benefit analysis as currently the most comprehensive method for determining the value for money of school-based public health interventions. Cost-benefit analysis incorporates monetary valuation of multisector outcomes in a final net benefit/loss result allowing clear, consistent, decision-making criteria to be set. Other methods such as cost-consequence analysis, cost-utility analysis, and multi-criteria decision analysis may also be suitable depending on the decision-making context and problem. This thesis demonstrates a lack of clear decision-making criteria in place for funding allocation decisions in education (e.g. education specific cost-effectiveness thresholds). Furthermore, there is no equitable method currently in place for apportioning the cost of funding public health interventions that generate benefits for multiple sectors. From a health service perspective, directly measuring child health utility using the Child Health Utility 9D is preferred as it is the only preference-based measure developed specifically for children and valued by young people. Mean child health utility can be predicted by mapping from the Strengths and Difficulties Questionnaire. This affords the opportunity to estimate longer-term utility by utilising long-term cohort data that routinely collects the Strengths and Difficulties Questionnaire, as long-term cost-effectiveness of school-based preventive programmes is an area in need of further research. The school setting plays an important role in shaping our young people’s futures. Economic evaluation of school-based population health interventions is justified, as schools need to maximise their existing resources in order to give children the best start in life.

By the early 21st Century further amendment to the Constitution has been necessitated by Ireland’s membership of the European Union, which has involved the cession of a degree of sovereignty and the subordination of national law to European law. A significant amendment was effected pursuant to the Good Friday Agreement, when Ireland removed its territorial claim to Northern Ireland and replaced it with the principle of unity by consent.Today’s Irish law due to the pandemic conditions of its development is on the way to its own improvement to regulate social relations effectively and protect the interests of their participants.

The main questions of this thesis are how a period of in utero malnutrition can impact the health of young children and their later development, and how job promotions can affect health. In the first chapter I analyse to what extent the South-East Asian financial crisis affected the height of Indonesian children who had in utero exposure to the crisis. I find that they are significantly shorter than children who were exposed at later ages. There is a large difference in effect for urban and rural children. This finding helps attribute the detrimental health effects to the crisis and not other events which occurred during the period of analysis. The second chapter exploits the exogenous shock of the crisis to analyse how early childhood height causes later cognitive development. I argue that this question should be analysed using instrumental variables. The results show a large and significant effect of early childhood height on cognitive ability and the use of instrumental variables changes the results significantly compared to OLS with or without fixed effects. Lastly, I analyse how on the job promotions of British civil servants affect health. In a cross-section, the direction of causality is almost certainly two-way. I argue that the use of individual fixed effects will alleviate this concern. The results show a large, positive effect of a job promotion on health in the subsequent survey phase.

In being philosophically based this thesis is concerned with understanding the human condition with particular reference to matters of meaning and how these find expression in systems of government and social policy. This study is based on the premise that concepts determine how the world is viewed and people use a variety of conceptual schemes to answer different classes of questions. Scientific endeavour is based in a scheme that enables questions about the material world to be answered. It cannot however answer classes of questions related to many features of human lives as its methods necessitate the development and use of abstractions and generalisations that are ill-equipped by design to determine what is important to people and what motivates and satisfies them. Therefore, the reality of any particular individual or group cannot be adequately understood in scientific terms. The thesis examines the scientific conceptual framework and minimalist abstractions of the medical model and the quasi-scientific conceptual frameworks of economics and identifies their conceptual limits. It shows that if the medical model is assumed to provide a complete representation of realities in health and is uncritically used as the basis of medical practice it has the potential to overlook the patient as a person and distance medical practice from its social roots which can lead to adverse outcomes for both clinical practice and medicine itself. It also observes that the economic scheme has conceptual limits that create their own distorted representations of reality. A similar dislocation in the meaning of people�s lives occurs when abstractions are made by adopting concepts from other schemes based in science, such as the medical model, without any awareness of their conceptual limits. Further distortions occur when these other accounts are turned into economic ones. Not only is the patient as a person overlooked, so is the patient as an entity. In light of these observations the thesis examines health reforms that have taken place in New Zealand, whereby the economic scheme has been given dominance in the development of public policy and set the parameters for rationality and what can acceptably be said. It shows that in not recognising features of meaning these parameters have led to health sector reforms that have had unintended and adverse consequences for clinical practice, as shown in the particular case of reforms of maternity services. Furthermore these reforms have severed the health sector from its social roots and moral frameworks and created barriers between it and government so that health sector problems that cannot be understood using economic parameters cannot be addressed in forums where public policy is developed.

Background and Rationale: Urban regeneration programmes are well placed to address social inequalities, and improve residents' quality of life and thus, are increasingly regarded a form of population health intervention. Within such programmes, the central role of communities is becoming increasingly recognised as important, with policy makers highlighting the need for activities that foster community empowerment and community involvement in programmes’ delivery. A motivating factor for this emphasis on community empowerment is the envisaged health gains it can produce. Existing literature has demonstrated that community empowerment is linked to positive health (specifically mental health) however, little is known about this link within an urban regeneration context and the value of allocating resources to foster community empowerment as an outcome of urban regeneration programmes. Previous attempts to value community empowerment as an outcome of urban regenerations have failed to fully capture and measure this complex, multi-faceted outcome or its theorised links to health. This thesis crosses disciplines, addressing issues of public health, urban planning and health economics. However, as outlined in Chapter 1, its leading discipline is health economics, drawing on methodology from the field to make a contribution to the evolving focus of public health economic evaluation. Specifically, the thesis demonstrates how health economic methodology can be adapted or expanded upon to aid the challenges researchers face when trying to identify, measure and value complex, non-health outcomes (such as community empowerment) for inclusion in economic evaluations of population health interventions (such as urban regeneration), which, as discussed at length in Chapter 5, present numerous challenges for techniques previously used solely within the health sector, and commonly in controlled settings (randomised controlled trials). Methods: The thesis initially outlines the policy context of the study (community empowerment in urban regeneration), defines what is meant by community empowerment and the study’s overall health economics focus in Chapter 1. Chapter 2 continues this introduction to the study’s context by highlighting how community empowerment relates to other concepts, whether it is viewed as an outcome or a process and how this impacts on efforts of measuring the concept and through a rapid scoping review, summarises what is known in the current evidence base on community empowerment and its links to health. It clearly highlights that community empowerment is a context specific concept and that in order to identify, measure and value it within an urban regeneration context, investigation of its specific, quantifiable ‘elements’ within this context must be identified. This is presented in Chapters 3 and 4. Firstly, a systematic review with narrative synthesis was then conducted (Chapter 3) to identify whether urban regeneration interventions can lead to a sense of empowerment and key community empowerment elements within this context. Then in Chapter 4, analyses of cross-sectional data from Glasgow’s GoWell neighbourhoods regeneration study (n=4254) was used to further test the causal relationship between community empowerment and self-reported health. The final part of the thesis (Chapters 5-8), firmly centres these initial findings into the health economics focus of the thesis to demonstrate how discrete choice experiments could be used to value a non-health outcome such as community empowerment for future inclusion in economic evaluations of population health interventions. It outlines the challenges of conducting economic evaluations of population health interventions and the importance of health economics as a discipline for decision-makers (Chapter 5). Then in Chapters 6-8 it presents the conceptualisation, design and results of a UK representative population discrete choice experiment survey (n=311) and how its results can value community empowerment as a potential outcome (using the payment vehicle ‘time’) for use in economic evaluation of population health interventions within urban regeneration. Results: The thesis identifies that community empowerment can result from urban regeneration interventions and that there are specific community empowerment ‘elements’ within this context which can be used to start conceptualising how to measure and value this concept and its links to health. The thesis also demonstrated that this was not always a positive relationship between urban regeneration and community empowerment and that a sense of disempowerment could be felt by the affected communities. These elements were sense of inclusion, sense of belonging, residents’ time commitment, a sense of trust in stakeholders, availability of stakeholder help and support and, availability of information about the regeneration programme (Chapters 2-3). Regression analysis of the GoWell data (Chapter 4) highlighted significant associations between community empowerment and improved general health and mental wellbeing. The discrete choice experiment’s (shown in Chapters 6-8) mixed logit model analyses demonstrated that there is an overall value for community empowerment activities within urban regeneration. The general populations respondents strongest preferences were shown for the delivery of community empowerment activities which require less time commitment, offer opportunities to participate, fully explain decision making processes, increase social interactions with their neighbours, have help and support from stakeholders and, keep them informed of the regeneration programme. Respondents’ strongest preferences were for delivery of community empowerment attributes that increase sense of belonging and feeling informed about the regeneration programme. Conclusions: The thesis provides valuations for attributes of community empowerment which can be used to inform future resource allocation decisions related to the cost-effectiveness of community empowerment generating activities as part of the delivery of urban regeneration programmes. Progress on the application of economic evaluation methodology to public health has been challenging, thwarted by complexities due to broad ranging costs and outcomes that are not readily suited to established economic evaluation techniques. The thesis contributes to the growing field of public health economic evaluation by highlighting the use of stated preference techniques, specifically discrete choice experiment methodology as a tool for measuring and eliciting values for the non-health outcomes of population health interventions for inclusion in economic evaluations. Failure to capture and include all benefits or costs of these multi-sector interventions which seek to look beyond health gains could lead to under or over estimation of their value and total effectiveness. This could ultimately result in poor investment decisions. To conclude, this study has contributed to current evidence by providing a means for identifying, measuring and valuing community empowerment both as an outcome in its own right and as an interim surrogate outcome linked to health. Thus, it has begun to address and tackle the research gaps identified in previous studies (outlined in Section 1.2.2). It has valued individual elements of CE within urban regeneration programmes which can be used by policy makers for decisions regarding future investment in CE and has further evidenced claims that community empowerment is linked to health within this context. Therefore, the thesis is able to recommend investment for community empowerment promoting activities in the delivery of urban regeneration programmes as a pathway to mental health gains.

Thesis submitted in partial fulfilment of the requirements for the degree Master of Technology in Environmental Management In the Faculty of Applied Sciences Department of Environmental and Occupational Studies At the Cape Peninsula University of Technology
Rivers, lakes and streams are the only way people encounter water sources in urban areas. Human endeavours have consequently deteriorated the environmental quality provided by river systems thus rivers are supporting a fraction of their original biodiversity and abundance. Urban streams are highly valuable and sensitive systems which, can be assessed by means of impacts of urban catchment and pathway influences. Many of the problems associated with environmental quality and management of urban watercourses are as a result of poor public perception. Advances in river assessment and management has come about through the recognition that water resource problems involve biological, physical and chemical components and more recently the addition of social and economic aspects. Social public participation is therefore achieved by studying and acting on people’s values, behaviours and perceptions of environmental quality. The main aim of this research was to identify whether a difference in socio-economic status is an influential factor in people’s perception of environmental quality. The objectives of the research were to determine whether the Elsieskraal River has a perceived low environmental relevance and quality (health and aesthetics), to determine what sensitizes people about issues relating to the natural environment and to identify people’s uses and perceptions of the Elsieskraal River corridor and its importance to the enjoyment as a recreational space. The study used a qualitative approach to obtain the data using the focus group technique. The purposive sample of participants from Pinelands and Thornton were the population that this study sought to investigate. Two focus group discussions; one in each study area was conducted. The results of this study found both similarities and differences in people’s perceptions of the Elsieskraal River between the two different socioeconomic urban communities. The perceived observation that the Elsieskraal River was a canal and not a river set the foundation for the envisaged low environmental quality the river so acquired. The majority overall environmental quality scores for the attributes of aquatic life, vegetation and water quality were found to be lower than they were scientifically found to be. Two clear avenues concerning environmental information sourcing and sensitization to the public was found. Politicians and government officials were unreliable to relay environmental information of a trustworthy nature. Community newspapers were a useful tool to present theevidence of information concerning the status of the natural environment especially at a local level. Three themes namely safety, maintenance and facilities and community attachment emerged on the importance of the Elsieskraal River as a recreational space. It is recommended that further studies should examine the perceptions of other similar rivers in the urban environment, both natural and canalised within Cape Town and the greater South Africa. The findings can assist environmental managers, planners and educators identify the gaps between the scientific environmental conditions and what people’s perceived awareness and knowledge about environmental quality are (factual versus perceived). It is also recommended that emphasis and support from local authorities must be given to non-governmental organisations (NGO’s) and adjacent property owners to aid in mobilising people into “ownership of rivers” within their communities to enhance their value and utilisation.

In 1995, the Taiwanese government introduced the Case Payment Scheme (CPS) to initiate a prospective payment method for diagnosis-related groups under the National Health Insurance (NHI) programme. The aim of the CPS was to rectify the supplier induced demand caused by the fee-for-service plan and to improve the efficiency of health services. However, this scheme created a dual reimbursement system for the NHI, under which, some services were reimbursed on the basis of claims for fees, while others were bundled together and paid a fixed rate per discharge. This study examines changes in hospital behaviour in this context based on the assumption that hospitals have incentives to maximise the profits from both payment plans. The aim is to quantify the effects of reimbursement changes on different dimensions of the delivery of health care. This research also evaluates the global budget programme which has changed the budget allocation mechanism within the hospital sector since 2002. Empirical investigations were carried out for all the hospitals contracted into the NHI over the period 1998-2004. To model hospital behaviour, this study employs different econometric methods, including instrumental variables, panel data model, semiparametric estimation, seemingly unrelated regressions and limited dependent variable models. The results suggest that hospitals react to the shift toward the dual payment system by selecting patients, altering treatment patterns, changing the case mix and adjusting treatment intensity. Policymakers do not appear to have anticipated these phenomena. These findings indicate that there could be fundamental problems in the parallel use of retrospective and prospective payments, due to the improper reimbursement incentives embodied within the system. As mixed payment systems have been adopted around the world, this research has implications for existing and future reimbursement reforms.

Recent health care reforms within Saudi Arabia have advocated use of economic evaluation in health care decision making. Little research has, however, considered the use of economic evaluation to set priorities in rentier state settings. This thesis explores the nature of the rentier state and the basis of health care priority setting, and conducts a systematic review of the use of economic evaluation in priority setting. The thesis uses in-depth qualitative research to explore health care priority setting and use of economic evaluation in Saudi Arabia. Qualitative data comprised 22 in-depth interviews with decision makers at the national and district levels, 3 focus groups, and one meeting observation. Data collection and analysis were conducted iteratively using constant comparison. Findings show that contextual factors have a great influence on the decision making process and that the use of economic evaluation is still very limited. There appeared to be two types of barriers to the use of economic evaluation: decision context-related barriers and barriers relating to the production of economic evaluation data. Incorporating economic evaluation into the health care decision making process in Saudi Arabia is proving to be complex and contextual factors have more influence on priority decisions than economic evaluation.

Aim: Empathy is widely regarded as an important attribute of healthcare professionals, and has been linked to higher patient satisfaction, enablement, and some health outcomes. The ‘mechanism of action’ of clinical empathy is not well understood. An ‘effect model’ of empathic communication in the clinical encounter has been proposed by Neumann et al (2009). In this model, clinician empathy is seen as having a positive effect in encouraging patients to tell more about their symptoms and concerns (for example, by picking up on emotional cues and responding in an encouraging way). This can result in ‘affective-oriented effects’ (such as the patient feeling listened to and understood) or ‘cognitive/action-oriented effects’ which include the clinician collecting more detailed information (medical and psychosocial), gaining a more accurate perception of the problem (and possible diagnosis) and enhanced understanding and responses to the patients’ individual needs. Such responses may include Self-Management Support of various kinds, which help enable the patients to better manage their condition(s), leading to improved outcomes. Recent Government policy in Scotland has focused on Self-Management Support and Anticipatory Care as key priorities in primary care, in response to the rise in chronic disease and health inequalities. However, the amount and type of Self-Management Support and Anticipatory Care that occurs in routine consultations in primary care is not known, nor their relationship with empathy and patient enablement. Thus the ‘effect model’ of empathy as proposed by Neumann, which postulates a relationship between empathy, Self-Management Support, and outcomes in the consultation remains largely theoretical. The aim of this thesis was to examine the relationships between patients’ perceptions of doctors’ empathy, patient enablement, health outcomes and the amount and the type of Self-Management Support (including Anticipatory Care) in general practice consultations. Due to the wide health inequalities that exist in Scotland, and the continuing operation of the ‘inverse care law’, a comparison was made between consultations in areas of high or low socio-economic deprivation to establish whether the relationships varied by deprivation. The thesis had the following research objectives; • To assess the nature, type and frequency of Self-Management Support (including Anticipatory Care) in general practice consultations in high and low deprivation groups • To determine whether patients’ perceptions of GP empathy is related to Self-Management Support (including Anticipatory Care) in consultations in high and low deprivation groups • To explore the effects of Self-Management Support (including Anticipatory Care) on patient enablement and health outcomes in high and low deprivation groups • To assess patients’ perception of empathy in terms of the nature, type, and frequency of emotional Cues and responses by GPs rated as high or low in empathy by their patients in consultations in high and low deprivation groups Methods: The research objectives were investigated by a secondary analysis of data collected between 2006-2008 by Mercer and colleagues in the Section of General Practice and Primary Care at the University of Glasgow. These data were collected as part of a research project in general practice in areas of high and low deprivation funded by the Chief Scientist Office of the Scottish Government. The research produced database, includes 659 videoed baseline consultations, with patient rated experience measures, including the Consultation and Relational Empathy (CARE) Measure, the Patient Enablement Instrument (PEI) and outcomes (self-reported symptom change and well-being) at 1 month post-consultation available on 499 patients. An observer-rated method of assessing Self-Management Support and Anticipatory Care was sought from the literature to answer objectives 1-3. However, there were a lack of validated observer-rated tools available that were specifically designed to measure these constructs. As such, the Davis Observation Code was identified as a validated system of coding primary care consultations across a broad range of consultation components which included items deemed to relate to Self-Management Support and Anticipatory Care. The process of selecting the Davis coding system, and the rejection of alternative coding systems is discussed in detail in Chapter 5. The Davis coding system was also considered feasible given the large size of the database. Self-Management Support and Anticipatory Care were then measured by using combinations of seven codes deemed relevant to Self-Management Support within the consultation setting. Four additional codes were added to the Davis system, in order to include tasks relevant to UK general practice consultations. These additional codes were not part of Self-Management Support or Anticipatory Care but were added to achieve a complete coding system of activities within the consultations. The Verona coding system measured emotional cues, concerns and health provider responses that were observed within the consultations. As such, this system was used to answer objective 4. The choice of this system reflected a desire to use an observer-rated measure to help ‘validate’ the patient-rated empathy measure (the CARE Measure) in terms of the first part of the Neumann et al (2009) model, i.e. eliciting concerns and symptoms, separate from the cognitive/action oriented effects relating to Self-Management Support. Results: Reliability of the objective coding systems Preliminary work was carried out on both coding systems in order to establish reliability in the application of the codes. This was a lengthy process, involving several cycles of coding by two coders (the author and one of her supervisors) but resulted in acceptably high levels of inter-rater reliability (kappa > 0.7 for the Davis coding system, and > 0.9 for the Verona coding system). Objective 1: The nature, type and frequency of Self-Management Support (including Anticipatory Care) in general practice consultations in high and low deprivation groups In both the high and low deprivation groups, time was predominantly allocated to gaining information about the patient’s complaint, conducting physical examinations and planning treatment. There was no difference observed in the amount of Self-Management Support overall in the consultations between high and low deprivation areas. However, there were significant differences in the nature, type and frequency of certain aspects of Self-Management Support, with significantly more Anticipatory Care in the consultations in the high deprivation areas. The results also showed that patients in the high deprivation group tended to experience a more direct biomedical focused consultation that featured practical tasks such as physical examinations and discussion of substance misuse. In the low deprivation group, a biopsychosocial approach was more common, which involved more time spent within the consultation discussing treatment effects, compliance or discussing how previous interventions had impacted on the patient’s health. For both groups, little time was allocated to gathering family information or counselling, answering patient questions or discussing health knowledge. Objective 2: Patients’ perception of GP empathy and relationship with Self-Management Support (including Anticipatory Care) in consultations in high and low deprivation areas. The relationship between empathy and Self-Management Support was explored using the Consultation and Relational Empathy Measure (CARE) and the Davis observation code respectively. Potential confounding variables were taken into account. Patients' perceptions of their GP's empathy were significantly associated with Self-Management Support in the low deprivation group, but not the high deprivation group.

The aim of this thesis is to help the RM industry avoid misguidedly investing in technologies that are unlikely to be cost-effective and reimbursed by healthcare providers. Health economics provides the tools to demonstrate value for money. These tools are typically used by healthcare providers to drive demand side decisions. However, they can be used by manufacturers to inform the supply side. I propose a simple approach, termed the headroom method. This ‘back of the envelope’ calculation is based on estimates of effectiveness of the proposed treatment towards the upper end of the plausible range. The method can be used either to inform an intuitive decision to continue or abandon development, or as a screening test to decide if more elaborate models are justified. One problem I encountered was the development of technologies without clearly defining the clinical problem. In particular, the marginal gain in benefit over alternative treatments is frequently overlooked. A large part of this thesis is therefore concerned with the clinical epidemiology of the conditions at which treatment is targeted. In this way, it was found, for example, the headroom for health gain from new treatment for inguinal hernia was much smaller than that for incisional hernias.

A crucial contemporary public health issue is the construction and contestation of the relevance of the natural world to human health. Taking a critical approach, this thesis examines how the natural environment as a health determinant is positioned in relation to the 'social' within social epidemiological studies of health, illness and disease. Using conceptual and empirical forms of enquiry, this study shows how current constructions of natural environmental health drivers contour public health practice in the UK and that by challenging the limits of existing structures, innovative responses emerge, which can generate new frameworks for health policy and practice. Having identified a lacuna in research on the 'natural' environment in medical sociology, this inductive qualitative research project brings into conversation the findings from extensive desk and field research. Specially, a study of the elaboration of environmental health discourses within the UK public health policy arena and disciplinary wide discourse analyses of key academic journals are read together to describe the discursive practices shaping environmental public health work in the UK. Linking theory to practice, data from in-depth interviews with sixty health professionals working on health and the environment in the UK and internationally are used to investigate how public health practitioners produce the environment within their work remits. The research breaks ground for further social scientific studies of health and the environment and in particular substantiates the call for an extended notion of the 'environment' using ecological principles. Methodologically, the interdisciplinary reach of this research draws attention to the tensions that arise when working across the medical, natural and social sciences. Practical and philosophical questions about the challenge of expanding the sociological imagination in the contemporary moment are also considered. Empirically, to medical sociology the 'EcoBioPsychoSocial' framework is offered as a tool for studying health at the nexus between the 'social' and the 'natural environment.' Finally, the ways informal public health institutions are serving as 'invisible' forces impeding the uptake of prevention oriented environmental health policies are findings offered to the health policy arena.

Consumer choice has become a key reform trend in the provision of public services in Western European welfare states. Research on the welfare effects of choice reforms – including greater provider choice for the individual and competition between providers – has largely focused on economic evaluations of the extrinsic (outcome) effects of choice, thereby leaving its intrinsic, or procedural, value unexplored. The overarching objective of this thesis is to investigate the welfare effects of choice in the provision of health and long-term care (LTC) and their implications for equity. The thesis utilises the subjective well-being approach – incorporating both procedural and outcome utility from choice – to measure welfare effects based on quantitative analysis of survey data. Welfare effects and equity implications are examined in relation to: competition in health care in the English National Health System (NHS); choice of care package in the German long-term care system; and individual preferences and views of choice as a priority in the provision of health care in three NHS countries. The thesis argues that both service characteristics – extent of competition, information availability, technical complexity – and individual capabilities – ability to process information, capacity to manage transaction costs, availability of private support – influence the benefits that individuals derive from choice. Results suggest that choice policies have an overall positive welfare effect in both health and long-term care. However, while direct evidence of outcome improvements is found, the empirical analysis only finds indirect evidence of procedural utility. Middle class characteristics, primarily income and education, are found to have a positive influence on the benefits of choice, amounting to evidence of inequitable facets of choice policies. The middle class further exhibits preferences for choice over and above other characteristics of health care systems. Overall, this thesis advocates a holistic approach to the analysis of choice, incorporating its procedural value and paying particular attention to the equity implications of the choice situation, information processing and differences in available options as well as preferences for choice.

Development aid in most of the developing countries can sometimes compromise the principles of public service broadcasting (PSB). This may be true when reflected against the tension between donor financed programmes in Malawi and the mandate of Television Malawi (TVM). Although the donor intentions are noble, the strings attached to the funding are sometimes retrogressive to the role of PSBs. A case in point is how donors dictate terms on the HIV/Aids communication strategies at TVM. Producers receive money from donors with strings attached on how the money should be used and accounted for. If producers deviate they are sanctioned through withholding funding, shifting schedules and reducing the funding frequency. The donors also dictate who to interview on what subject, how to conduct capacity building. Some scholars have researched much on the impact of commercialisation of the media. This study is a departure from these traditional interferences; it interrogates the interest of philanthropy tendencies by international donors in the three chosen HIV/Aids programmes broadcast by TVM. The study investigates the extent of pressure exerted by donors on the producers of HIV/Aids programmes in Malawi. Thus, the study seeks to illicit specifics in the power relationship between the donor and the producer hence the study employs the political economy of development aid as applied to the public service broadcasting and communication for development. The study employed qualitative research methods and techniques (in-depth interviews, case study and document analysis). The study reveals how donor ideologies dominate the Aids messages-content output of the texts constructed. The study argues that cultural alienation of the Malawian audiences retards efforts of donors in combating HIV infection rate.

Thesis (MA)--Stellenbosch University, 2005.
ENGLISH ABSTRACT: This thesis is an explanatory study into civil society's increased influence in global governance. More specifically this situation is examined by looking at the generic medicine debate that came in the wake of the passing of the Medicines and Related Substances Act by the South African government in 1997. This debate gained worldwide attention and touched some of the prevailing inequalities between the developed world and the developing world in our globalised society. The research question that is addressed here is to what extent did civil society influence the signing of the Doha Declaration of the TRIPS Agreement and Public Health by the members of the World Trade Organisation (WTO) in 2001? In doing so, this thesis looks at the role of the US government, the South African government, the pharmaceutical industry, the WTO's TRIPS Agreement and civil society in the form of nongovernmental organisations like Treatment Action Campaign (TAC), Oxfam and Medecines Sans Frontieres (MSF). The study applies a constructivist approach in order to analyse how civil society used global advocacy networks to inform and communicate the normative concerns regarding South Africa and developing countries' lack of access to HIVand AIDS drugs. Moreover, it examines how civil society's use of moral authority challenged the regulative power of the WTO. The study concludes that civil society played a vital role in influencing the WTO member states' decision to sign the Doha Declaration on the TRIPS Agreement and Public Health. However, it was not only civil society's ability to set the agenda concerning the HIV/AIDS pandemic, but also the content of the normative concerns themselves that help explain its success. Consequently, the study further concludes that civil society's success in this specific case must be seen in light of its growing influence in challenging global governance.
AFRIKAANSE OPSOMMING: Hierdie tesis is 'n verduidelikende studie van die burgerlike samelewing se groeiende invloed in globale regering. Hierdie situasie word meer spesifiek ondersoek deur te kyk na die generiese medisyne debat wat gevoer is na die Suid-Afrikaanse Regering die Medisyne en Verwante Stowwe Wet van 1997 goedgekeur het. Hierdie debat het wêreldwye aandag geniet en het geraak aan sommige van die bestaande ongelykhede wat daar heers tussen die ontwikkelde en ontwikkelende wêreld in die geglobaliseerde samelewing. Die navorsingsvraag wat hier aangespreek word is tot watter mate die burgerlike samelewing die ondertekening van die Doha Verklaring van die TRIPS Ooreenkoms en Publieke Gesondheid deur lede van die Wêreld Handelsorganisasie (WHO) in 2001 beïnvloed het. Deur dit te doen, sal hierdie tesis kyk na die rol van die Amerikaanse regering, die Suid- Afrikaanse regering, die farmaseutiese bedryf, die WHO se TRIPS Ooreenkoms en die burgerlike samelewing in die vorm van nie-regerings organisasies soos die Treatment Action Campaign (TAC), Oxfam en Medecines Sans Frontieres (MSF). Die studie maak gebruik van 'n konstruktiwistiese benadering om 'n analise te doen van hoe die burgerlike samelewing globale ondersteunings netwerke gebruik het om die normatiewe besorgdhede wat heers oor die tekorte in Suid-Afrika en die ontwikkelende lande ten opsigte van toegang tot MIV en VIGS medisyne, toe te lig en te verkondig. Verder ondersoek die studie hoe die gebruik deur die burgerlike samelewing van morele gesag die regulerende mag van die WHO uitgedaag het. Die studie kom tot die gevolgtrekking dat die bugerlike samelewing 'n uiters belangrike rol gespeel het in die WHO lidlande se besluit om die Doha Verklaring van die TRIPS Ooreenkoms en Publieke Gesondheid te onderteken. Dit was egter nie net die burgerlike samelewing se vermoë om die agenda daar te stel ten opsigte van die MIV/VIGS pandemie nie, maar ook die inhoud van die normatiewe besorgdhede self wat bygedra het om hierdie sukses te verduidelik. Gevolglik kom die studie tot die verdere gevolgtrekking dat die burgerlike samelewing se sukses in hierdie spesifieke geval gesien kan word in die lig van sy groeiende invloed in die uitdaging van globale mag en gesag.

Economics has become a dominant framework for analysing problems in public health and health care and for proposing policy solutions. A separate subdiscipline of health economics has grown out of the welfare economics tradition to develop specific methods for economic inquiry into health care issues. The encroachment of economics into health care and public health has not occurred without consternation from within the health field. Part of the reason for this concern arises from a mismatch between the worldview of public health and that of mainstream economics. However, this mismatch is largely unexamined, and there has been limited attempt to address the mismatch and to propose alternative approaches to economic questions in public health. This thesis examines the project of public health in some detail, making reference to the consensus documents of the World Health Organization that set out the values base of public health and define its approach and some of its activities. Public health is a collective activity, mostly undertaken outside of markets and is primarily concerned with impacts on populations. It is inherently political and focuses on populations as its unit of analysis. This contrasts to the approach of mainstream economics, which presumes that economic decisions are primarily private decisions and focuses on individuals as its unit of analysis. The differing worldviews constitute an impasse between mainstream economics and this view of public health. The solutions of neo-classical economics are often at odds with the public health approach. An alternative view of economics, from the heterodox Institutional School may provide an alternative approach to economic questions in public health. In contrast to neoclassical economics, it claims to be holistic and not to engage in methodological individualism and to be explicitly concerned with questions of power. The case studies of role of government and ageing as a public health issue provide a lens through which the neoclassical approach can be examined and contrasted to the public health approach. These case studies are based on reports written for Australian governments by neoclassical economists. The two case studies are then inspected from an institutional perspective to examine whether this approach does indeed generate explanations and solutions that are more compatible with a public health approach. Other insights into the reports that can be gained from an institutional perspective are also discussed.
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Thesis (Ph.D.) -- School of Population Health and Clinical Practice, 2007.

Economics has become a dominant framework for analysing problems in public health and health care and for proposing policy solutions. A separate subdiscipline of health economics has grown out of the welfare economics tradition to develop specific methods for economic inquiry into health care issues. The encroachment of economics into health care and public health has not occurred without consternation from within the health field. Part of the reason for this concern arises from a mismatch between the worldview of public health and that of mainstream economics. However, this mismatch is largely unexamined, and there has been limited attempt to address the mismatch and to propose alternative approaches to economic questions in public health. This thesis examines the project of public health in some detail, making reference to the consensus documents of the World Health Organization that set out the values base of public health and define its approach and some of its activities. Public health is a collective activity, mostly undertaken outside of markets and is primarily concerned with impacts on populations. It is inherently political and focuses on populations as its unit of analysis. This contrasts to the approach of mainstream economics, which presumes that economic decisions are primarily private decisions and focuses on individuals as its unit of analysis. The differing worldviews constitute an impasse between mainstream economics and this view of public health. The solutions of neo-classical economics are often at odds with the public health approach. An alternative view of economics, from the heterodox Institutional School may provide an alternative approach to economic questions in public health. In contrast to neoclassical economics, it claims to be holistic and not to engage in methodological individualism and to be explicitly concerned with questions of power. The case studies of role of government and ageing as a public health issue provide a lens through which the neoclassical approach can be examined and contrasted to the public health approach. These case studies are based on reports written for Australian governments by neoclassical economists. The two case studies are then inspected from an institutional perspective to examine whether this approach does indeed generate explanations and solutions that are more compatible with a public health approach. Other insights into the reports that can be gained from an institutional perspective are also discussed.
Thesis (Ph.D.) -- School of Population Health and Clinical Practice, 2007.

This dissertation examines topics related to development, environment and health in developing countries using empirical methods. In the first chapter, I study how developing countries can increase enforcement to reduce subsidy leakage in public programs, by investing in the state capacity to target program beneficiaries. This chapter further attempts to understand how the formal sector and black market respond to a policy that reduces diversion of a subsidized commodity. I explore these questions using the case of a Unique ID-based direct fuel subsidy transfer policy in India. Second chapter focuses on the health and wealth trade off near mineral mining operations in developing countries. Using extensive data on mining, health outcomes and assets from 44 developing countries, this study quantifies the wealth gain and adverse health impact of mineral mining. With a number of empirical strategies, this study shows that, despite high wealth gains, how heavy metal mining significantly increases the level of anemia in women and stunting in children living near mines. In the third chapter, I estimate demand for a water quality diagnostic product -- arsenic testing, when it is offered at a price. I further look into various aspects related to selection, learning and households behavioral response to the information. This study is based on a field experiment in Bihar, India.

This dissertation examined whether or not microcredit, the provision of small loans to people usually excluded from mainstream financial institutions, demonstrably improved health for typical borrowers in Indonesia. The underlying idea behind microcredit is that loans will increase borrowers’ income and lead to positive changes in their lives, including their health. However, microcredit may actually be harmful to borrowers’ health because of stress associated with repayment obligations, extra working hours needed to start a business and tensions caused by shifting power dynamics in the household. Moreover, for some borrowers, a loan may facilitate increased spending on so-called temptation goods that are damaging to health, such as tobacco and processed foods. Previous research has not adequately explored these competing positive and negative pathways linking microcredit and health. The project consisted of three parts: a systematic review and two empirical papers. The systematic review synthesized the scientific literature related to individual microcredit loans, health-related temptation spending, psychological stress and self-reported health outcomes in adults. The empirical papers estimated the causal effect of microcredit on household expenditures on tobacco and processed foods, and individual psychological distress and self-rated health. Both empirical papers used data from the Indonesia Family Life Survey, a longitudinal study that followed more than 7,000 households over 21 years. After adjusting for confounding, people living in borrowing households had levels of psychological distress and self-rated health that were similar to people living in non-borrowing households. These predominantly null findings were relatively robust across multiple models. Microcredit households did spend substantially more money on tobacco than non-borrowers. This difference was driven by households with male borrowers. Still, tobacco spending ultimately did not affect health outcomes. Based on empirical evidence from this dissertation along with findings from other studies, policymakers and practitioners should recalibrate their high expectations of microcredit as a socially transformative intervention. At the same time, fears about the unintended health consequences of microcredit may have been exaggerated. Reliance on longitudinal data generated insights into microcredit and health that could not be established from randomized controlled trials.

In recent years, studies have linked various structural and environmental factors to disproportionately increased rates of morbidity, mortality, and adverse health outcomes in low-income racial and ethnic minority neighborhoods. Among the adverse health outcomes, is the constraint on the ability to access and afford a healthy diet. While local food systems play a significant role in influencing urban health and well-being outcomes, they also present an opportunity to develop community-based assets and resilience. By identifying limitations and successes in current food system literature and practice, this report examines how a more comprehensive approach to equitable community health and wellness can be achieved and sustained. Effective disparity reduction relies on cross-sectoral partnerships that not only promote food equity, but also provide participatory social, economic, and educational opportunities to marginalized communities.
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This dissertation discusses three questions of development and environmental economics. First, it assesses the impact of mineral mining on the health and wealth of households in local communities across 44 developing countries, using micro data. Secondly, it presents evidence from a randomized controlled trial on the cost-shared provision of well-water tests for arsenic. Finally, it analyzes measurement error in a satellite night light data product widely used in development research, and investigates the scope for using the data in very high spatial resolution.

Over the past decade, chronic illnesses have increased significantly in developing regions around the world, with implications for health service provision. Research shows that morbidity follows a social gradient in many countries around the world. Though various studies highlight the importance of socioeconomic status as a predictor of a person’s morbidity and mortality experience, there is a dearth of data and literature in the South African context. This study aimed to address this gap by examining the association between socioeconomic status and diabetes and hypertension among participants aged 35 years and older. This was achieved by undertaking the analysis of secondary data from the National Income Dynamic Study. The findings of the study reveal that there is a significant relationship between socioeconomic factors and chronic health outcomes of individuals. People with lower levels of education were more likely to have a chronic illness than those with higher levels of education. However, interestingly the lowest rates of prevalence were found in the unemployed category in South Africa. This draws attention to the need for further research on employment and chronic disease prevalence. An important finding of the study was the relatively higher prevalence of chronic conditions in rural areas and among the Black/African population. This data suggests that changes in lifestyle and behavior in the context of globalization and urbanization may be contributing to changes in the health profile of these communities. Policy makers need to acknowledge that chronic diseases are no longer the preserve of the wealthy with diseases such as diabetes and hypertension evident across all sectors of South African society. By addressing the causes of chronic conditions policies and programs can aim to prevent the emergence of future epidemics. In the long-term, sustainable progress will only be achieved with greater attention directed towards the socioeconomic factors underlying the health profile of the country.
Thesis (M.A.)-University of KwaZulu-Natal, Durban, 2011.

Immunisation is a cost-effective public health intervention that contributes to the attainment of the Sustainable Development Goals (SDGs). About 40% of children under the age of five years die from vaccine-preventable diseases in Nigeria. Routine immunisation has been quite low in Nigeria, where national coverage is estimated to be 33%, according to a 2016–2017 survey. This empirical research was aimed at determining the key socio-economic and gender determinants of immunisation in the Federal Capital Territory (FCT), identifying gaps and proffering solutions. Mixed methods of data collection and analysis were used. Data were gathered from several secondary sources and from 11 key informants using semi-structured interviews and 501 household and 26 health-facility surveys using questionnaires mounted on Open Data Kit. Lot quality assurance sampling and probability to population size methodology were used to size the samples and identify survey locations. Odds ratio analysis and logistic regression analysis were conducted to gauge the statistical association between the determinants and the coverage of immunisation. The main finding that was reached on the basis of the documents reviewed and the feedback received from the key informants was that they were gender blind at worst and gender neural at best. Most of the current strategies give little attention to socio-economic and gender barriers. Over 40 immunisation variables were identified. The analysis, particularly using the 2x2 odds ratio, yielded mixed results. The majority of the variables exhibited a close statistical association as far as immunisation indices were concerned. These variables included urban residency, married couples, literacy, birth at a health facility, antenatal care experience, vaccination card possession, immunisation knowledge, child health information, non-farming earnings, socio-economic status and tolerance of spouse beating. On the other hand, variables that were found to have no statistical significance included sex, marital status, marriage type, age, religion, tetanus toxoid (TT) vaccination and adequacy of income. Immunisation and gender are intertwined, particularly because of mothers’ biological and social attachment to their children. At the same time, conducting vaccination avails the opportunity to access almost all households. Moreover, it is important to recognise that socio-economic and gender determinants are not totally in control of one ministry. Single agenda interventions will not produce the desired result. A paradigm shift and the concerted effort of various sectors and partners are required. Therefore, the Nigerian government should galvanise the relevant stakeholders to bring gender and socio-economic variables into the mainstream throughout the immunisation ecosystem and to implement integrated development initiatives by prioritising vulnerable communities.
Ugonyo yindlela engcono yokungenela kwezempilo yabantu engathela esivivaneni ekufinyeleleni izinhloso zentuthuko eqhubekela phambili ezaziwa ngelokuthi yi- Sustainable Development Goals (SDGs). Cishe izingane ezifinyelela ku 40% ezingaphansi kweminyaka emihlanu zibulawa yizifo ezivimbelekayo ngomgcabo emitholampilo eNigeria. Ukugonya njalo kusezingeni eliphansi eNigeria, laphokhona ukwengamela kuzwelonke kulinganiselwa ku 33%, ngokuya kocwaningo olwenziwe phakathi kuka 2016-2017. Ucwaningo lokuthola ubufakazi lwalunenhloso yokubona imithelela yezesimo sabantu nomnotho (socio-economic) kanye nobulili ngokugonya kwi-Federal Capital Territory (FCT) ukubona amagebe kanye nokutholakala kwezixazululo. Amamethodi axubene okuqokelela ulwazi kanye nohlaziyo kwasetshenziswa. Ulwazi lwaqokelelwa ngokufunda imithombo yemibhalo (secondary sources) kanye nakubantu ababalulekile abanolwazi (key informants) abangu 11 ngokusebenzisa ama-semi-structured interview kanye nemizi engu 501 kanye namasurvey amafasilithi ezempilo angu 26 ngokusebenzisa uhla lwemibuzo yamaquestionnaire ebifakelwe kwi-Open Data Kit. Kwasetshenziswa nemethodi ye-Lot quality assurance sampling ne-probability, ngemethodoloji yobuningi babantu, ukwenza usayizi wamasampuli kanye nokubona izindawo okumele kwenziwe kuzo ama-survey. Kwenziwa nohlaziyo lwe-Odds ratio analysis kanye ne-logisic regression analysis ukubona ukuhambelana kwamastatistiki phakathi kwezinto eziwumthelela kanye nokunaba kongamelo lokwenziwa kogonyo. Okukhulu okutholakele ngokulandela amadokhumende okufundwe kuwo, kanye nezimpendulo ezivela kulabo abanolwazi ababalulekile (key informants) kube wukuthi bekungaboneleli ubulili (gender blind) kanti futhi bekungachemile ngokulandela ubulili (gender neutral) ngezinga elibi nangokungcono kakhulu. Amasu amaningi amanje awanakekeli kakhulu izihibe ezimayelana nabantu nezomnotho kanye nezobulili. Kwaphawulwa cishe izinto ezehlukene zama-variable ezingu 40 mayelana nogonyo. Uhlaziyo, ikakhulukazi ngokusebenzisa i 2x2 odds ratio, lwaveza imiphumela exubene. Ezinto zama-variable ehlukene eziningi zikhombise ukuhlobana phakathi kwamastatistiki mayelana namaindices ogonyo. Lama variable, abandakanye ukuhlala emadolobheni, abantu abashadile, ikhono lokubhala nokufunda, ukuzalwa kwezingane kumafasilithi ezempilo, izipiliyoni zonakekelo lwengane ngaphambi kokuzalwa, ukuba nekhadi lomgcabo ix wasemitholampilo, ulwazi ngogonyo, ulwazi ngempilo yengane, ukuthola imali ngemisebenzi engeyona eyokulima, isimo sabantu mayelana nezomnotho, kanye nokuqinisela ukuhlukunyezwa ngokushaywa kwabesimame. Kanti ngakolunye uhlangothi, ama-variable atholakale engenakho ukubaluleka ngokwamastatistiki, abandakanya ubulili, isimo ngokomendo, inhlobo yomendo, iminyaka yobudala, inkolo, umgcabo we-tetanus toxoid (TT), kanye nokwenela kwengeniso lemali. Ugonyo kanye nobulili kuyangenelana nokuhambelana, ikakhulukazi ngenxa yokusondelana komama kanye nezingane zabo. Ngaso leso sikhathi, ukwenziwa kogonyo kuhlinzeka ngethuba lokufinyelela cishe kuwo yonke imizi eminingi. Nangaphezu kwalokho, kubalulekile ukwamukela ukuthi isimo sabantu mayelana nezomnotho kanye nobulili kuyizinto ezinomthelela, azinalo ulawulo oluphelele kumnyango kangqongqoshe owodwa. Ungenelo ngento eyodwa ngeke kwaveza imiphumela efiswayo. Ukugudluka ngokomqondo (paradigm shift), kanye nemizamo eqhubekela phambili yemikhakha ehlukene kanye nabasebenzisani kuyadingeka. Ngakho-ke uhulumeni waseNigeria, kumele agqugquzele ababambiqhaza abafanele ukuhlanganisa nokufaka emkhakheni ofanele izinto ezimayelana nabantu nomnotho kanye nobulili, kuyo yonke inqubo yokusebenzisana kwemikhakha okumele isebenzisane nehlangene ukusebenza ngokulandela inqubo yentuthuko ehlangane ngokubonelela imiphakathi ekwizimo ezibucayi
Development Studies
D. Phil. (Development Studies)

This dissertation examines three health insurance eligibility policies and their impact on reproductive health outcomes for low-income women of reproductive age. The first paper examines the effects of expanded eligibility for Medicaid under the Affordable Care Act (ACA), on fertility among low-income women of childbearing age. The second paper explores the effect of presumptive eligibility policies in Medicaid for pregnant women on access to prenatal care and health insurance coverage. Finally, the third paper exploits state-level differences in eligibility for public versus private insurance under the ACA, and the effects on perinatal coverage patterns, childbirth outcomes, and access to care.

This dissertation examines the political economy of HIV biomedical prevention research—largely designed in the global North but conducted in the global South—and its implications for people of diverse genders and sexualities. As a recognized global leader in HIV biomedical prevention research among people categorized as men who have sex with men (MSM) and transgender women, Peru offers a key site in which to explore the increasing focus on gender and sexual identity as a strategic area for extractive research practices. This phenomenon has become particularly visible in the epidemic’s 4th decade, which has emphasized the pursuit of biomedical prevention strategies. Building on nine years of previous experience working inside HIV biomedical prevention studies, this project involved 24 months of ethnographic research, including participant observation; 110 interviews with scientists, study staff, and research subjects; 10 focus groups; and analyses of relevant scientific publications. This study presents four key findings. First, US and Peruvian researchers’ historical and continued entanglement primed Peru to become a hotbed of HIV biomedical prevention research. In this context, population categories imported from the global North have served as powerful tools to sustain a booming local research market, which produces data that aligns with the global demands of the HIV industry. Second, on the ground, research begets more research rather than institutionalized HIV prevention technologies, creating a sustained enterprise in which issues of compensation, value, and labor shape the science. The commodification of gender and sexually diverse identities operates here in two ways: as a mechanism to access particular kinds of bodies and associated HIV risk data, and as a mechanism by which to claim expertise in the HIV prevention research industry for both researchers and community members. Third, Peruvians classified as MSM and transgender women are afforded only temporary access to cutting-edge strategies to prevent HIV, limited to study participation. The result is a sustained pool of people in need of HIV care primed to support the HIV biomedical research economy. Finally, this project illuminates a key paradox within the industry’s contemporary focus on gender and sexual diversity in HIV prevention science. This focus creates the impression that progressive health politics marked the field, while obscuring and absolving ongoing forms of exploitation and unequal gains embedded within it.

The researcher investigated the knowledge, attitudes and experiences of people living with the Human Immunodeficiency Virus (HIV) towards antiretroviral treatment (ART) and who are accessing antiretroviral treatment at a public health clinic in Limpopo, South Africa. A qualitative method was used. The research findings revealed five themes: experiences, social support, knowledge, attitudes, unemployment and economic themes of the study. Factors reported influencing optimum adherence were the inability of the patients to take medication at work, laziness of the patients to collect medication, unemployment, economic hardship, poverty and lack of knowledge of employers regarding HIV/AIDS.
Health Studies
M.A. (Social Behaviour Studies in HIV and AIDS)

The aim of the study was to offer solutions for the enhancement of Indonesia’s HIV and AIDS policy and to suggest future possibilities. In the process, the gendered nature of the epidemic was explored. In light of the relatively lower rates of employment among Indonesian women, this study also sought to gain insights into the possible reasons for many women appearing to be attached to domesticity. In the first phase of the study, interviews with stakeholders in HIV and AIDS prevention were conducted, followed by a Delphi exercise involving 23 HIV and AIDS experts. In the second phase, 28 women from various ethnicities were interviewed, including those in polygamous and contract marriages. The overall results were interpreted through the lens of complexity theory. Fewer than half of the proposed objectives were approved by the experts in the Delphi round. These were interventions mainly aimed at the risk groups while most objectives relating to education about HIV and AIDS and safer sex for the general public failed to obtain consensus. Reasons for the lack of consensus were differences in perceptions associated with human rights, moral reasoning, the unfeasibility of certain statements and personal conviction about the control of the epidemic. Emphasis on men’s and women’s innate characteristics; men’s role as breadwinner; women’s primary role as wife, mother and educator of their children; and unplanned pregnancies emerged as major themes from the qualitative phase. While the adat and Islam revival movements may have endorsed the ideals of the New Order state ideology, Javanese rituals regarded as violating Islam teachings were abandoned. Ignorance about safer sex and HIV and AIDS was also established. Interpretation of the results through the lens of complexity theory revealed that the national HIV and AIDS policy needs to encompass interventions for the general population, which would include comprehensive sex education in schools and media campaigns focusing on women. It was found that women’s vulnerability to HIV and their penchant for domesticity appear to be associated with their perceived primary role as wife and mother, as promoted by the adat-based New Order state ideology.
Sociology
D. Litt. et Phil. (Sociology)

Indiana University-Purdue University Indianapolis (IUPUI)
Existing zakat research reports little information about the living conditions of Indonesian zakat recipients. This study examined the perceptions of zakat recipients at Rumah Zakat, a charitable institution, in Yogyakarta. Semi-structured interviews solicited seven economic empowerment and seven socio-health program respondents’ narratives. This data collection method incorporating multiple approaches to data analysis, including phenomenology, revealed that economic empowerment respondents with more education and spousal support could better subsist after utilizing Rumah Zakat’s interest-free loans. And, compared to individual efforts or group support, spousal support helped significantly with business growth. These respondents typically earned incomes above the national standard of poverty. As their businesses grew, four respondents planned to employ the jobless. In the socio-health program, respondents had minimal education and incomes that fell below the national standard of poverty. A Rumah Zakat clinic gave these respondents four to five years of free health care services; it also facilitated collaborative learning. Although the services lowered their expenses, three respondents requested food distribution in addition to health care. Respondents benefiting from both programs reported a significant positive impact on their home economies, health, and social lives. Thus, an integrative program offering assistance with micro-credits, health care, food security, and education would better serve the poor.

Farm workers in South Africa have limited access to health care and health-related information. In this qualitative study, the implementation of a workplace HIV/AIDS policy was evaluated using data gathered through interviews and observation. It was found that, although the farm workers were knowledgeable about HIV and AIDS, this knowledge was insufficient. It was found that the lives of farm workers are deeply affected by HIV and AIDS. It is also suggested that the agricultural sector is not yet able to deal effectively with HIV and AIDS and that, in this regard, urgent planning is needed in respect of HIV and AIDS policies and interventions
Social Work
M.A. (Social Behaviour Studies in HIV/AIDS)