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Coming theses from other universities

  • Does health insurance contribute to improving responsiveness of the health system? : the case of elderly in rural Tanzania Author: Paul Joseph Amani Link: http://urn.kb.se/resolve?urn=urn:nbn:se:umu:diva-194699 Publication date: 2022-05-20 07:00

    Background: Financing healthcare in Tanzania has for years depended on out-of-pocket payments. This mechanism has been criticized as being inefficient, contributing to inequity and high cost as well as denying access to healthcare to those most in need, including the elderly in rural areas. Health insurance (HI) was recently introduced as an instrument to enable equitable access to healthcare and thus to improve the responsiveness of the health system. Even though health insurance is expected to bring benefits to those who are insured, there is a lack of specific studies in the country looking at the role of HI in facilitating the health system responsiveness among vulnerable populations of remote areas.

    Aim: The aim of this thesis is to understand if and how health insurance contributes to improving the responsiveness of the healthcare system among the elderly in rural Tanzania. 

    Methods: Four interrelated sub-studies (2 quantitative and 2 qualitative) were conducted in Igunga and Nzega districts of Tabora region between July 2017 and December 2018. The first two sub-studies are based on a household survey using an adapted version of the World Health Organization’s Study on Global Ageing and Adult Health questionnaire. Elderly people aged 60 years and above who had used both outpatient and inpatient healthcare three and twelve months prior to the study, respectively, were interviewed. Whereas in sub-study 1 the focus was to investigate the role of health insurance status on facilitating access to healthcare, sub-study 2 assessed the relationship between health insurance and the health system responsiveness domains. In sub-study 3, interviews with healthcare providers were carried out to capture their perspective regarding the functioning of the health insurance. In the final sub-study 4, focus group discussions with elderly were conducted in order to explore their experience of healthcare, depending on their health insurance status. Crude and adjusted logistic and quantile regression models were applied to analyse the association between health insurance and access to healthcare (sub-study 1) and responsiveness (sub-study 2), respectively. For both sub-studies 3 and 4, qualitative content analysis was used to analyse the data.

    Results: Sub-studies 1 and 2 involved a total of 1899 insured and uninsured elderly, while sub-studies 3 and 4 included 8 health providers and 78 elderlies respectively. Sub-study 1 showed that about 45% of the elderly were insured and HI ownership improved access and utilization of healthcare, both outpatient and inpatient services. In sub-study two, however, health insurance was associated with a lower responsiveness of the healthcare system. In general, all six domains: cleanliness, access, confidentiality, autonomy, communication, and prompt attention were rated high, but three were of concern: waiting time; cleanliness; and communication. Sub-study 3 uncovered several challenges coexisting alongside the provision of insurance benefits and thus contributing to a lower responsiveness. These included shortage of human resources and medical supplies, as well as operational issues related to delays in funding reimbursement. In sub-study 4, the elderly revealed that HI did not meet their expectations, it failed to promote equitable access, provided limited-service benefits and restricted use of services within residential areas. 

    Conclusion: While HI seems to increase the access to and use of healthcare services by the elderly in rural Tanzania, a lower responsiveness by the healthcare system among the insured elderly was reported. Long waiting times, limited-service benefits, restricted use of services within schemes, lack of health workforce in both numbers and skills as well as shortage of medical supplies were important explanations for the lower responsiveness. The results of this thesis, while supporting the national aim of expanding HI in rural areas, also exposed several weaknesses that require immediate attention. There is a need to, first, review the insurance policy to improve its implementation, expand the scope of services coverage, and where possible, to introduce cross-subsidization between the publicly owned schemes; additionally, improvements in the healthcare infrastructure, increasing the number of qualified health workforce and the availability of essential medicines and laboratory services, especially at the primary healthcare facilities, should be prioritized and further investments allocated.

  • Dopamine and the affective-cognitive gradient in the human striatum studied with multimodal brain imaging Author: Filip Grill Link: http://urn.kb.se/resolve?urn=urn:nbn:se:umu:diva-194740 Publication date: 2022-05-20 07:00

    Both dopamine and the dopamine rich brain area, striatum, have been linked to behaviors related to incentives, motor action, and associative processing. Most of the cortex sends projections to the striatum, these connections have been described as a gradient organization representing a repertoire of functional behaviors. Although considerable research efforts have been made on the functions of dopamine, it is still unclear how and when it is released in the striatum in humans and what role it has for everyday behavior.

    The overarching aim of this thesis is to contribute to our understanding of the role of striatal dopamine release during human behaviors relating to incentive, motor, and associative processing. Using a combination of multimodal brain imaging (positron emission tomography and functional magnetic resonance imaging) as well as cognitive modelling this thesis investigates: how a reproducible striatal response to incentives can be divided into behaviorally relevant components relating to affective and cognitive processes, how striatal dopamine release during motor action represent several component processes of behavior, and also provides evidence that striatal dopamine is released during reward prediction errors in humans. The results are consistent with an affective-cognitive gradient in the striatum and suggest that dopamine release into the striatal gradient might facilitate the integration of component processes into complex representations of behavior. The results of this thesis are based on healthy young individuals, however, aberrant dopamine signaling is a hallmark of several psychiatric and neurological diseases making it crucial to further understand the healthy dopamine system.

  • Intervening in a social world : An evaluation of an alcohol prevention programme in a Swedish workplace context Author: Devy Lysandra Elling Link: http://urn.kb.se/resolve?urn=urn:nbn:se:su:diva-203412 Publication date: 2022-05-18 09:00

    A sizeable portion of hazardous alcohol consumers are found in the workforce, suggesting that the workplace could provide opportunities for preventing and reducing hazardous alcohol use at an early stage. One such intervention is the multi-component alcohol prevention programme, ‘APMaT’ (Alcohol Policy and Managers’ skills Training), designed and delivered by Alna, an organisation that provides services to prevent harmful behaviours in Swedish workplaces. This thesis is a programme evaluation of APMaT, assessing its effectiveness through survey data at the managerial and employee levels.

    Study I described the sociodemographic, work-, and health-related characteristics of managers relative to their inclination to intervene and organisational alcohol policy knowledge. Moreover, the association between managers’ inclination to intervene and knowledge about organisational alcohol policy was examined. The number of supervised employees was strongly associated with both the inclination to intervene and alcohol policy knowledge, and a graded positive association was found between managers’ inclination to intervene and alcohol policy knowledge. The findings implied that managerial characteristics may play a role in potential actions to initiate early alcohol interventions.

    Study II evaluated the effectiveness of APMaT, focusing on changes in the inclination to intervene at an early stage among managers at one-year follow-up. The findings suggested that APMaT is somewhat effective in increasing managers’ inclination to initiate an intervention by increasing their confidence in initiating a dialogue with employees, which may increase the likelihood of initiating an intervention at an early stage.

    Study III further assessed the effectiveness of APMaT by examining changes in the risk of hazardous alcohol use among employees at one-year follow-up. The study did not provide strong empirical evidence in support of the effectiveness of APMaT regarding the reduction of hazardous alcohol use within the given follow-up time.

    Given the mixed support for the effectiveness provided by Studies II and III, Study IV described managers’ perceived barriers in the dissemination of their organisational alcohol policy. This dissemination was an important component of APMaT because all managers were expected to facilitate its implementation throughout the workplace. Uncertainties and a variety of perceived organisational obstacles were reported by the managers to have hindered the dissemination of the organisational alcohol policy.

    This thesis highlights the complexity of delivering and implementing an intervention in a complex and dynamic setting, such as the workplace. The findings suggested that the investigated intervention, APMaT, might be effective in changing attitudes among managers, whereas no concrete effects on employees’ hazardous alcohol use could be demonstrated. Nevertheless, the studies contributed with knowledge to the development of prospective workplace prevention programmes.

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