Beyond Transparency: The Semantics of Rulemaking for an Open Internet

In trying to promote the development of an open Internet, the U.S. Federal Communications Commission (FCC) has primarily tried to encourage network providers to be transparent about their traffic management practices and quality of service prioritization policies. Dominant network operators have successfully challenged this minimalist approach to addressing end-user concerns about the rise of a two-tiered Internet, motivating the FCC to engage in yet another public consultation process to assess its future approach to the problem. This article maps the debate using Natural Language Processing (NLP) tools that allow us to build a systematic picture of the positions of the regulator and groups of private interests trying to shape its decisions. A quantitative linguistic analysis of the content of formal written submissions to the FCC by parties with divergent views helps document how the conceptual model of the regulator evolved during the rulemaking process leading to the FCC February 2015 network neutrality Order. Despite the adoption of a broader substantive basis by the FCC under Title II of the Communications Act, the rule-of-reason approach to substantive interpretation in the Order limits the capacity of the new regulatory framework to protect and promote an open Internet. The evidence suggests the public consultation process is likely to serve as a tool for legitimizing status quo institutional arrangements that allow operators to engage in discriminatory traffic prioritization strategies

Navigation programs for people living with HIV/AIDS who experience homelessness: considerations for assessing performance and costs

Despite the advances in antiretroviral therapy (ART) a disproportionate number of people living with HIV (PLWH) remain limited in their access and use of health care and treatment, including racial/ethnic minorities, persons with mental health and substance use disorders and persons experiencing homelessness or unstable housing. Patient navigation programs have emerged as a potential effective and efficient use of resources to reach and engage these vulnerable populations as part of the HIV service delivery system. This dissertation contains three chapters that aim to identify and assess the performance and mechanisms for navigation programs working with PLWH who experience homelessness and co-occurring substance use and mental health disorders. Study 1, Developing a Reliable and Valid Composite Measure of Effectiveness for HIV Navigation Programs for PLWH who are homeless/unstably housed, describes the development of a multidimensional outcome measure to assess the performance of navigation programs for this population. The composite measure was comprised of seven indicator variables: linkage to care, retention in care and adherence to treatment, patient experience of care, physical and mental health related quality of life and housing stability. Using multivariate analyses, a 3 item measure of retention, adherence, and housing stability was found to have high goodness of fit and strong predictive association with viral suppression. Study 2, Classifying Components of HIV Navigation Programs for PLWH who are homeless/unstably housed, used a latent-class analysis to identify common patterns of activities, modalities of communication, location of work, and staff composition among highest utilizers of services. Results showed that types of activities, work setting and modality of contact were significantly associated with increased retention in care. No difference in activity, staffing patterns, work setting or modality of communication of navigation programs were found on viral suppression rates. Study 3, An Economic Evaluation of HIV Navigation Programs Working with PLWH who are Homeless/Unstably housed assessed costs and net benefits of these navigation programs overall and in subpopulations. Cost utility and net benefit analyses performed indicated that navigation programs for PLWH who are homeless/unstably housed are a potential efficient investment of resources at various willingness-to-pay thresholds. Navigation programs provide a myriad of services for PLWH who are homeless/unstably housed and must be flexible in their approach to address the multiple medical and psychosocial needs of this population. The results of this dissertation provide information for improving the design, measuring performance and costs and benefits of navigation programs as part of the HIV service delivery system for PLWH who experience homelessness.2020-06-30T00:00:00

"They all work...when you stick to them" : a qualitative investigation of dieting, weight loss, and physical exercise, in obese individuals

BackgroundTo explore the extent to which people living with obesity have attempted to lose weight, their attitudes towards dieting, physical exercise and weight loss solutions, why their weight loss attempts have failed, and their opinions about what would be most beneficial to them in their struggle with their weight.MethodQualitative study, using open-ended interviews, of 76 people living with obesity in Victoria, Australia in 2006/7. Individuals with a BMI of 30 or over were recruited using articles in local newspapers, convenience sampling, and at a later stage purposive sampling techniques to diversify the sample. Data analysis was conducted by hand using a constant, comparative method to develop and test analytical categories. Data were interpreted both within team meetings and through providing research participants the chance to comment on the study findings.ResultsWhilst participants repeatedly turned to commercial diets in their weight loss attempts, few had used, or were motivated to participate in physical activity. Friends or family members had introduced most individuals to weight loss techniques. Those who took part in interventions with members of their social network were more likely to report feeling accepted and supported. Participants blamed themselves for being unable to maintain their weight loss or \u27stick\u27 to diets. Whilst diets did not result in sustained weight loss, two thirds of participants felt that dieting was an effective way to lose weight.ConclusionIndividuals with obesity receive numerous instructions about what to do to address their weight, but very few are given appropriate long term guidance or support with which to follow through those instructions. Understanding the positive role of social networks may be particularly important in engaging individuals in physical activity. Public health approaches to obesity must engage and consult with those currently living with obesity, if patterns of social change are to occur

Health behavior change models for HIV prevention and AIDS care: practical recommendations for a multi-level approach

Despite increasing recent emphasis on the social and structural determinants of HIV-related behavior, empirical research and interventions lag behind, partly because of the complexity of social-structural approaches. This article provides a comprehensive and practical review of the diverse literature on multi-level approaches to HIV-related behavior change in the interest of contributing to the ongoing shift to more holistic theory, research, and practice. It has the following specific aims: (1) to provide a comprehensive list of relevant variables/factors related to behavior change at all points on the individual-structural spectrum, (2) to map out and compare the characteristics of important recent multi-level models, (3) to reflect on the challenges of operating with such complex theoretical tools, and (4) to identify next steps and make actionable recommendations. Using a multi-level approach implies incorporating increasing numbers of variables and increasingly context-specific mechanisms, overall producing greater intricacies. We conclude with recommendations on how best to respond to this complexity, which include: using formative research and interdisciplinary collaboration to select the most appropriate levels and variables in a given context; measuring social and institutional variables at the appropriate level to ensure meaningful assessments of multiple levels are made; and conceptualizing intervention and research with reference to theoretical models and mechanisms to facilitate transferability, sustainability, and scalability

REACH: a mixed-methods study to investigate the measurement, prediction and improvement of retention and engagement in outpatient HIV care

BACKGROUND Antiretroviral therapy (ART) benefits individuals living with human immunodeficiency virus (HIV) through reduced morbidity and mortality, and brings public health gains through a reduction in HIV transmission. People living with human immunodeficiency virus (PLWH) need to know their HIV status and engage in HIV care in order for these individual and public health benefits to be realised. OBJECTIVE To explore, describe and understand HIV outpatient attendance in PLWH, in order to develop cost-effective interventions to optimise engagement in care. DESIGN A mixed-methods study incorporating secondary analysis of data from the UK Collaborative HIV Cohort (UK CHIC) study and primary data collection. METHODS Phase 1 – an engagement-in-care (EIC) algorithm was developed to categorise patients as in care or out of care for each month of follow-up. The algorithm was used in group-based trajectory analysis to examine patterns of attendance over time and of the association between the proportion of months in care before ART initiation and post-ART mortality and laboratory test costs. Phase 2 – a cross-sectional survey was conducted among patients attending seven London HIV clinics. Regular attenders (all appointments attended in past year), irregular attenders (one or more appointments missed in past year) and non-attenders (recent absence of ≥ 1 year) were recruited. A ‘retention risk tool’ was developed to identify those at risk of disengaging from care. Individual in-depth interviews and focus groups were conducted with PLWH. Phase 3 – key informant interviews were conducted with HIV service providers. Interventions were developed from the findings of phases 2 and 3. RESULTS Plots from group-based trajectory analysis indicated that four trajectories best fitted the data. Higher EIC is associated with reduced mortality but the association between EIC before starting ART, and post-ART mortality [relative hazard (RH) per 10% increase in EIC 0.29, 95% confidence interval (CI) 0.18 to 0.47] was attenuated after adjustment for fixed covariates and post-ART cluster of differentiation 4 counts and viral loads (RH 0.74, 95% CI 0.42 to 1.30). Small differences were found in pre-ART EIC and the costs of post-ART lab tests. The final model for the retention risk tool included age at diagnosis, having children, recreational drug use, drug/alcohol dependency, insufficient money for basic needs and use of public transport to get to the clinic. Quantitative and qualitative data showed that a range of psychological, social and economic issues were associated with disengagement from care. The negative impact of stigma on attendance was highlighted. Interventions were proposed that support a holistic approach to care including peer support, address stigma by holding clinics in alternative locations and involve training staff to encourage attendance. CONCLUSIONS The study shows the adverse health impacts of disengaging from HIV care and demonstrates the importance of the wider health and social context in managing HIV effectively. Although phase 1 analysis was based on UK data, phases 2 and 3 were limited to London. The interventions proposed are supported by the data but their cost-effectiveness requires testing. Future research is needed to evaluate the interventions, to validate our retention risk tool across populations and settings, and to fully analyse the economic costs of disengaging from HIV care

Effectiveness of interventions to improve the health and housing status of homeless people: a rapid systematic review

Background: Research on interventions to positively impact health and housing status of people who are homeless has received substantially increased attention over the past 5 years. This rapid review examines recent evidence regarding interventions that have been shown to improve the health of homeless people, with particular focus on the effect of these interventions on housing status. Methods: A total of 1,546 articles were identified by a structured search of five electronic databases, a hand search of grey literature and relevant journals, and contact with experts. Two reviewers independently screened the first 10% of titles and abstracts for relevance. Inter-rater reliability was high and as a result only one reviewer screened the remaining titles and abstracts. Articles were included if they were published between January 2004 and December 2009 and examined the effectiveness of an intervention to improve the health or healthcare utilization of people who were homeless, marginally housed, or at risk of homelessness. Two reviewers independently scored all relevant articles for quality. Results: Eighty-four relevant studies were identified; none were of strong quality while ten were rated of moderate quality. For homeless people with mental illness, provision of housing upon hospital discharge was effective in improving sustained housing. For homeless people with substance abuse issues or concurrent disorders, provision of housing was associated with decreased substance use, relapses from periods of substance abstinence, and health services utilization, and increased housing tenure. Abstinent dependent housing was more effective in supporting housing status, substance abstinence, and improved psychiatric outcomes than non-abstinence dependent housing or no housing. Provision of housing also improved health outcomes among homeless populations with HIV. Health promotion programs can decrease risk behaviours among homeless populations. Conclusions: These studies provide important new evidence regarding interventions to improve health, housing status, and access to healthcare for homeless populations. The additional studies included in this current review provide further support for earlier evidence which found that coordinated treatment programs for homeless persons with concurrent mental illness and substance misuse issues usually result in better health and access to healthcare than usual care. This review also provides a synthesis of existing evidence regarding interventions that specifically support homeless populations with HIV.Partial funding for this paper was provided to the Effective Public Health Practice Project by the Region of Peel, Canada