Healthcare choice: Discourses, perceptions, experiences and practices

Policy discourse shaped by neoliberal ideology, with its emphasis on marketisation and competition, has highlighted the importance of choice in the context of healthcare and health systems globally. Yet, evidence about how so-called consumers perceive and experience healthcare choice is in short supply and limited to specific healthcare systems, primarily in the Global North. This special issue aims to explore how choice is perceived and utilised in the context of different systems of healthcare throughout the world, where choice, at least in policy and organisational terms, has been embedded for some time. The articles are divided into those emphasising: embodiment and the meaning of choice; social processes associated with choice; the uncertainties, risks and trust involved in making choices; and issues of access and inequality associated with enacting choice. These sociological studies reveal complexities not always captured in policy discourse and suggest that the commodification of healthcare is particularly problematic

MULTI-DIMENSIONAL PROFILING OF CYBER THREATS FOR LARGE-SCALE NETWORKS

Current multi-domain command and control computer networks require significant oversight to ensure acceptable levels of security. Firewalls are the proactive security management tool at the network’s edge to determine malicious and benign traffic classes. This work aims to develop machine learning algorithms through deep learning and semi-supervised clustering, to enable the profiling of potential threats through network traffic analysis within large-scale networks. This research accomplishes these objectives by analyzing enterprise network data at the packet level using deep learning to classify traffic patterns. In addition, this work examines the efficacy of several machine learning model types and multiple imbalanced data handling techniques. This work also incorporates packet streams for identifying and classifying user behaviors. Tests of the packet classification models demonstrated that deep learning is sensitive to malicious traffic but underperforms in identifying allowed traffic compared to traditional algorithms. However, imbalanced data handling techniques provide performance benefits to some deep learning models. Conversely, semi-supervised clustering accurately identified and classified multiple user behaviors. These models provide an automated tool to learn and predict future traffic patterns. Applying these techniques within large-scale networks detect abnormalities faster and gives network operators greater awareness of user traffic.Outstanding ThesisCaptain, United States Marine CorpsApproved for public release. Distribution is unlimited

Trust, regulatory processes and NICE decision-making: Appraising cost-effectiveness models through appraising people and systems.

This article presents an ethnographic study of regulatory decision-making regarding the cost-effectiveness of expensive medicines at the National Institute for Health and Care Excellence (NICE) in England. We explored trust as one important mechanism by which problems of complexity and uncertainty were resolved. Existing studies note the salience of trust for regulatory decisions, by which the appraisal of people becomes a proxy for appraising technologies themselves. Although such (dis)trust in manufacturers was one important influence, we describe a more intricate web of (dis)trust relations also involving various expert advisors, fellow committee members and committee Chairs. Within these complex chains of relations, we found examples of both more blind-acquiescent and more critical-investigative forms of trust as well as, at times, pronounced distrust. Difficulties in overcoming uncertainty through other means obliged trust in some contexts, although not in others. (Dis)trust was constructed through inferences involving abstract systems alongside actors’ oral and written presentations-of-self. Systemic features and ‘forced options’ to trust indicate potential insidious processes of regulatory capture

Prevalence and associated factors in burnout and psychological morbidity among substance misuse professionals

<p>Abstract</p> <p>Background</p> <p>Studies of psychological stress among substance misuse professionals rarely describe the nature of burnout and psychological morbidity. The main aim of this study was to determine the extent, pattern and predictors of psychological morbidity and burnout among substance misuse professionals.</p> <p>Methods</p> <p>This study was a cross-sectional mail survey of 194 clinical staff of substance misuse services in the former South Thames region of England, using the General Health Questionnaire (GHQ-12) the Maslach Burnout Inventory (MBI) as measures of psychological morbidity and burnout, respectively.</p> <p>Results</p> <p>Rates of psychological morbidity (82%: 95% CI = 76–87) and burnout (high emotional exhaustion – 33% [27–40]; high depersonalisation – 17% [12–23]; and diminished personal accomplishment – 36% [29–43]) were relatively high in the study sample. High levels of alienation and tension (job stressors) predicted emotional exhaustion and depersonalisation (burnout) but not psychological morbidity. Diminished personal accomplishment was associated with higher levels of psychological morbidity</p> <p>Conclusion</p> <p>In the sample of substance misuse professionals studied, rates of psychological morbidity and burnout were high, suggesting a higher level of vulnerability than in other health professionals. Furthermore, pathways to psychological morbidity and burnout are partially related. Therefore, targeted response is required to manage stress, burnout and psychological morbidity among substance misuse professionals. Such a response should be integral to workforce development.</p

Ethnicity and attitudes to deceased kidney donation: a survey in Barbados and comparison with Black Caribbean people in the United Kingdom

<p>Abstract</p> <p>Background</p> <p>Black minority ethnic groups in the UK have relatively low rates of deceased donation and report a higher prevalence of beliefs that are regarded as barriers to donation. However there is little data from migrants' countries of origin. This paper examines community attitudes to deceased kidney donation in Barbados and compares the findings with a survey conducted in a disadvantaged multi-ethnic area of south London.</p> <p>Methods</p> <p>Questionnaires were administered at four public health centres in Barbados and at three private general practices. Adjusted odds ratios were calculated to compare attitudinal responses with a prior survey of 328 Caribbean and 808 White respondents in south London.</p> <p>Results</p> <p>Questionnaires were completed by 327 respondents in Barbados (93% response); 42% men and 58% women, with a mean age of 40.4 years (SD 12.6). The main religious groups were Anglican (29%) and Pentecostal (24%). Educational levels ranged from 18% not completing 5th form to 12% with university education. Attitudes to the notion of organ donation were favourable, with 73% willing to donate their kidneys after their death and only 5% definitely against this. Most preferred an opt-in system of donation. Responses to nine attitudinal questions identified 18% as having no concerns and 9% as having 4 or more concerns. The highest level of concern (43%) was for lack of confidence that medical teams would try as hard to save the life of a person who has agreed to donate organs. There was no significant association between age, gender, education or religion and attitudinal barriers, but greater knowledge of donation had some positive effect on attitudes. Comparison of attitudes to donation in south London and Barbados (adjusting for gender, age, level of education, employment status) indicated that a significantly higher proportion of the south London Caribbean respondents identified attitudinal barriers to donation.</p> <p>Conclusions</p> <p>Community attitudes in Barbados are favourable to deceased donation based on a system of informed consent. Comparison with south London data supports the hypothesis that the relatively high prevalence of negative attitudes to deceased donation among disadvantaged ethnic minorities in high income countries may reflect feelings of marginalisation and lack of belonging.</p

CD4 Deficit and Tuberculosis Risk Persist With Delayed Antiretroviral Therapy: 5-Year Data From CIPRA HT-001

SETTING: Port-au-Prince, Haiti. OBJECTIVE: To determine long-term effects of early vs. delayed initiation of antiretroviral therapy (ART) on immune recovery and tuberculosis (TB) risk in human immunodeficiency virus (HIV) infected individuals. DESIGN: Open-label randomized controlled trial of immediate ART in HIV-infected adults with CD4 counts between 200 and 350 cells/mm(3) vs. deferring ART until the CD4 count was \u3c200 cells/mm(3). The primary comparisons were CD4 counts over time and risk for incident TB, with 5 years of follow-up. RESULTS: A total of 816 participants were enrolled, with 408 in each treatment arm. The early treatment group started ART within 2 weeks, while the deferred treatment group started ART a median of 1.3 years after enrollment. After 5 years, the mean CD4 count in the early treatment group was significantly higher than in the deferred treatment group (496 cells/mm(3), 95% confidence interval [CI] 477-515 vs. 373 cells/mm(3), 95%CI 357-389; P \u3c 0.0001). TB risk was higher in the deferred treatment group (unadjusted HR 2.41, 95%CI 1.56-3.74; P \u3c 0.0001) and strongly correlated with lower CD4 counts in time-dependent multivariate analysis. CONCLUSION: Delays in ART initiation for HIV-infected adults with CD4 counts of 200-350 cells/mm(3) can result in long-term immune dysfunction and persistent increased risk for TB. TRIAL REGISTRATION: ClinicalTrials.gov NCT00120510

Beyond price: individuals' accounts of deciding to pay for private healthcare treatment in the UK

<p>Abstract</p> <p>Background</p> <p>Delivering appropriate and affordable healthcare is a concern across the globe. As countries grapple with the issue of delivering healthcare with finite resources and populations continue to age, more health-related care services or treatments may become an optional 'extra' to be purchased privately. It is timely to consider how, and to what extent, the individual can act as both a 'patient' and a 'consumer'. In the UK the majority of healthcare treatments are free at the point of delivery. However, increasingly some healthcare treatments are being made available via the private healthcare market. Drawing from insights from healthcare policy and social sciences, this paper uses the exemplar of private dental implant treatment provision in the UK to examine what factors people considered when deciding whether or not to pay for a costly healthcare treatment for a non-fatal condition.</p> <p>Methods</p> <p>Qualitative interviews with people (n = 27) who considered paying for dental implants treatments in the UK. Data collection and analysis processes followed the principles of the constant comparative methods, and thematic analysis was facilitated through the use of NVivo qualitative data software.</p> <p>Results</p> <p>Decisions to pay for private healthcare treatments are not simply determined by price. Decisions are mediated by: the perceived 'status' of the healthcare treatment as either functional or aesthetic; how the individual determines and values their 'need' for the treatment; and, the impact the expenditure may have on themselves and others. Choosing a private healthcare provider is sometimes determined simply by personal rapport or extant clinical relationship, or based on the recommendation of others.</p> <p>Conclusions</p> <p>As private healthcare markets expand to provide more 'non-essential' services, patients need to develop new skills and to be supported in their new role as consumers.</p

Dynamic Operation of a Heat Exchanger in a Thermally Integrated Photovoltaic Electrolyzer

The outdoor operation of an up scaled thermally photovoltaic electrolyzer PV EC , constructed using a heat exchanger HE made of low cost materials, compared to its nonintegrated counterpart to quantify heat transfer and its effects, is studied. Thermal coupling of the PV and EC can reduce the difference between their temperatures, benefitting device performance. Such devices can produce hydrogen at rooftop installations of small to medium sized nonindustrial buildings. The devices are tested outdoors using automated real time monitoring. Under amp; 8776;880 amp; 8201;W amp; 8201;m amp; 8722;2 peak irradiance, they produced hydrogen at amp; 8776;120 and amp; 8776;110 amp; 8201;mL amp; 8201;min amp; 8722;1 rate with and without HE, respectively, corresponding to about 8.5 and 7.8 solar to hydrogen efficiencies. During about 700 amp; 8201;h of testing, the HE is beneficial at over amp; 8776;500 amp; 8201;W amp; 8201;m amp; 8722;2 due to cyclic device operation. Under lower irradiance levels, pumping previously heated electrolyte through the HE increases the PV and reduces the electrolyte temperature, reducing the device performance. The HE increases the cumulative hydrogen production amp; 8776;800 amp; 8201;L from both devices , so even relatively modest heat transfer rates can improve the PV EC operation. Improving the HE should further increase the benefits, but additional measures may be needed to maximize the hydrogen productio

Interaction among general practitioners age and patient load in the prediction of job strain, decision latitude and perception of job demands. A Cross-sectional study

BACKGROUND: It is widely recognized and accepted that job strain adversely impacts the workforce. Individual responses to stressful situations can vary greatly and it has been shown that certain people are more likely to experience high levels of stress in their job than others. Studies highlighted that there can be age differences in job strain perception. METHODS: Cross-sectional postal survey of 300 Lithuanian general practitioners. Psychosocial stress was investigated with a questionnaire based on the Reeder scale. Job demands were investigated with the Karasek scale. The analysis included descriptive statistics; logistic regression beta coefficients to find out predictors and interactions between characteristics and predictors. RESULTS: Response rate was 66% (N = 197). Logistic regression as significant predictors for job strain assigned – duration of work in primary care; for job demands- age and duration of working in primary care; for decision latitude- age and patient load. The interactions with regard to job strain showed that GP's age and job strain are negatively associated to a low patient load. Lower decision latitude for older GP age is strongly related to higher patient load. Job demands and GP age are slightly positively related at low patient load. CONCLUSIONS: Lithuanian GP's have high patient load and are at risk of stress, they have high job demands and low decision latitude. Older GP's perceive less strain, lower job demands and higher decision latitude in case of low patient load. Young GP's decision latitude has week association to patient load. Regarding to the changes in patient load younger GP's perceive it more sensitively as changes in job demands