Dissertations / Theses on the topic 'Health system resilience'

En temps de crise sanitaire, les systèmes de santé résilients doivent simultanément répondre à la crise et maintenir la fourniture des services de santé essentiels. Les mesures restrictives prises en réponse à la pandémie de COVID-19 ont probablement affecté négativement l’accès et l’utilisation des services de santé. L’objectif général de cette thèse était d’évaluer l’impact de la pandémie de COVID-19 sur l’accès et l’utilisation des services de prise en charge du VIH/sida, du paludisme et de la tuberculose (maladies prioritaires) en Afrique subsaharienne à partir de l’exemple du Togo. Nous avons décrit l’épidémie de COVID-19 et sa gestion au Togo au moyen d’une revue narrative. Ensuite, nous avons mesuré l’intensité du choc épidémique en population générale et en population adolescente à partir de trois enquêtes de séroprévalence du SARS-CoV-2 conduites en 2021 et 2022. Enfin nous avons décrit l’effet de la pandémie sur l’utilisation des services liés à la lutte contre le VIH/sida, le paludisme et la tuberculose via une approche quasi expérimentale (avant-après). Nous rapportons une séroprévalence élevée de SARS-CoV-2 en population générale en 2021 (65,5% ; intervalle de confiance (IC95%) : 64,3 -66,6) et chez les adolescents de la rue en 2022 (63,5% ; IC95% : 57,8-69,0). Les services de lutte contre le VIH, le paludisme et la tuberculose ont généralement été maintenus au Togo malgré la pandémie de COVID-19. Dans l'ensemble, on a observé une diminution de six des neuf indicateurs inclus. La tendance est restée constante entre les périodes prépandémique et pandémique de la COVID-19 pour tous les indicateurs du paludisme. Ces résultats devraient servir de base pour anticiper les conséquences de futures crises sanitaires liées à des émergences infectieuses au Togo et au-delà en Afrique<br>In times of health crisis, resilient healthcare systems must simultaneously respond to the crisis and maintain the provision of essential health services. Restrictive measures taken in response to the COVID-19 pandemic are likely to have adversely affected access to and use of healthcare services. The overall objective of this thesis was to assess the impact of the COVID-19 pandemic on access to and utilization of services for the management of HIV/AIDS, malaria and tuberculosis (priority diseases) in sub-Saharan Africa, using Togo as an example. We described the COVID-19 epidemic and its management in Togo by means of a narrative review. We then measured the intensity of the epidemic shock in the general and adolescent populations, based on three SARS-CoV-2 seroprevalence surveys conducted in 2021 and 2022. Finally, we described the effect of the pandemic on the use of services related to the fight against HIV/AIDS, malaria and tuberculosis, using a quasi-experimental (before-after) approach. We report a high seroprevalence of SARS-CoV-2 in the general population in 2021 (65.5%; confidence interval (CI95%): 64.3 -66.6) and among street adolescents in 2022 (63.5%; CI95%: 57.8-69.0). HIV, malaria and tuberculosis services were generally maintained in Togo despite the COVID-19 pandemic. Overall, there was a decline in six of the nine indicators included. The trend remained constant between the pre-pandemic and pandemic periods of COVID-19 for all malaria indicators. These results should serve as a basis for anticipating the consequences of future health crises linked to emerging infectious diseases in Togo and beyond in Africa

Research intentionally addressing how leadership attributes and behaviors collectively contributed to the socioecological perspective of organizational resilience were not found. This is a problem for organizations who must hire without benefit of how a collective leadership effect might influence their psychological capital. The purpose of this study was to explore whether or not self-efficacy, psychological empowerment, personal resilience, and leadership style were associated with or predicted organizational resilience among clinical managers in an academic medical center setting. Metatheory of resilience and resiliency was used to frame the study. A quantitative correlational design was used. Self-reported data was collected via the Leader Efficacy Questionnaire, Psychological Empowerment Instrument, Connor and Davidson's Resilience Scale, Multifactor Leadership Questionnaire, and Workplace Resilience Instrument. Intellectual stimulation (rs .480, Ï? .432, p = .00), personal resilience (rs .483, Ï? .465, p = .00), and self-efficacy (rs .522, Ï? .462, p = .00) had the highest statistical correlations to organizational resilience. Negative predictor effects were found for personal resilience and idealized attributes ascribed to self-oriented versus other-oriented resilience qualities, x2(2) = 50.70, p < .01, and p < .05 respectively. Resilience is important for organizational survival and adaptation to the external and internal forces of change. Resilient organizations with available reserves can collaborate with community leaders to optimize the social, environmental, and economic determinants of health foundational for community resilience and positive social change.

Nonlinear and chaotic environmental changes characterize health services organizations as complex adaptive systems in which leaders must exercise non-traditional leadership practices to succeed. Health services leaders who have learned and implemented traditional linear management approaches are ill prepared to lead in complex environments. This study tested complexity and adaptive leadership theories of agility and resilience in complex health systems. The purpose of this quantitative cross-sectional internet-based survey study was to quantify relationships between independent variables of agility and resilience and secondary dependent variables of financial, patient satisfaction, quality and human capital outcomes. The impact of turbulence was also examined. Included sample data were collected from 533 employed healthcare leaders using probability-based systematic proportional random sampling methods and were analyzed through correlation, regression, one-way analysis of variance, t tests, and Hayes PROCESS statistical analytics. Agility correlated with and predicted patient satisfaction outcomes. Resilience independently correlated with and predicted financial performance and patient satisfaction outcomes and augmented the correlation and predictability of agility. Agility and resilience cumulatively predicted financial performance outcomes. Turbulence was related to agility, resilience, financial performance, and patient care quality outcomes and mediated relationships with financial and patient care quality outcomes. Health services leaders may apply these findings to promote social change through the implementation of the agile and resilient leadership approaches necessary to achieve organizational performance outcomes that benefit vulnerable populations.

Pour répondre aux enjeux de la longue vie opérationnelle des systèmes et de l’incertitude de l’environnement, la résilience complète la sûreté de fonctionnement pour prendre en compte les situations imprévisibles, sans précédent : l’objectif est de comprendre la situation pour éviter un accident. La qualité de l’interaction homme-machine est essentielle pour atteindre cet objectif. L’état de l’art présente la résilience des systèmes sociotechniques comme complémentaire à la sécurité. Mettre en œuvre la résilience affecte tant l’architecture système que les processus d’ingénierie système. Enfin, elle affecte aussi l’interaction homme-machine, tant son processus de conception centrée utilisateur, ses modèles utilisateur (persona), que ses modèles d’architecture. Nous avons créé le patron de conception « surveiller et alerter » appliqué à la fonction « éviter » de la résilience, pour donner aux opérateurs la capacité de comprendre la dynamique du système, le conduire à vue face à des situations imprévisibles, sans précédent afin d’éviter la survenue d’un accident. La proposition comprend aussi des processus à mettre en œuvre pour contribuer à la résilience d’un système critique à longue durée de vie. L’application au domaine ferroviaire s’appuie sur l’analyse de rapports d’enquête technique d’accidents. Elle se décline sur le patron de conception « surveiller et alerter » et sur le persona, in fine pour proposer des améliorations des interfaces utilisateur. Des perspectives de recherche complètent le mémoire<br>The long operational lifecycle of systems and the uncertainty of the environment are a great challenge to engineers. Resilience enhances reliability and safety to take into account the unforeseeable situations, without precedent. The goal is to understand the situation to avoid an accident. The quality of the human-machine interaction is the key issue to achieve this goal. The state of the art explains that sociotechnical systems resilience completes safety approach. Implementaing resilience impacts both system architecture and systems engineering processes. At the end, implementing resilience impacts human-computer interaction, user centred design as well as architecture models. We created the design pattern “to monitor and alert” applied to the function “to avoid” of the resilience. Its goal is to give to the operators the capacity to understand the dynamics of the system, to control at sight vis-a-vis unforeseeable situations, in order to avoid an accident. The proposal contents the processes to be implemented to contribute to the resilience of long lifecycle critical systems. The application to the railway domain is based on the analysis of three accident technical reports. It is declined, on the processes to be implemented to contribute to the resilience of a system, on the design pattern “to monitor and alert” for the architecture of a resilient system and to propose improvements of the user interface. Research forecasts supplement the report

Abstract The purpose of this study was to explore the impact of the BP Deepwater Horizon oil spill on students of two coastal Louisiana secondary schools. Bronfenbrenner’s (1979) ecological systems theory was used as a framework to understand how exposure, gender, socioeconomic status, and resilience interact to influence the impact of the spill on students. Cross-sectional questionnaires were administered to 155 high school students in May 2012 and 225 middle school students in January 2013 out of 1247 possible for a return rate of about 30%. Results showed that exposure groups differed significantly on students’ Impact of Event Scale (IES; Horowitz, Wilner, & Alvarez, 1979) scores. Students with high exposure to the oil spill had significantly higher IES scores than those with no exposure and low exposure. Logistic regression results indicated that exposure was a significant predictor of higher IES scores and as exposure increased by 1, students were 1.46 times more likely to experience higher impact. Males were found to have significantly higher IES scores than females, with a low effect size. Students did not differ significantly across resilience levels. In the entire sample, lower-SES students did not score significantly different on IES scores than higher-SES students. However, in the high school significant differences were found between SES groups and SES was a significant predictor of higher IES scores. Implications are provided for counselor educators interested in disaster mental health. Conclusions include suggestions for counselors servicing areas affected by the oil spill and how individual and environmental characteristics of students can influence risk factors. Keywords: Disaster mental health, crisis intervention counseling, ecological systems theory, BP Deepwater Horizon oil spill, secondary school students, resilience, risk factors

Tendo em vista a crescente disseminação de sistemas de gestão da segurança e saúde no trabalho (SGSST), torna-se cada vez mais relevante a necessidade de instrumentos de avaliação da sua eficiência e eficácia. Nesse contexto, esta tese apresenta a proposta de um método de avaliação de sistemas de gestão de segurança e saúde no trabalho (MASST), o qual apresenta duas características inovadoras: a) a conciliação das abordagens estrutural (sistema prescrito), operacional (o que está acontecendo na prática) e por desempenho (resultados de indicadores); b) a adoção do enfoque da engenharia de resiliência (ER) sobre a segurança e saúde. O MASST foi desenvolvido a partir das contribuições da literatura, na qual foram identificados quatro princípios da ER (comprometimento da alta direção, flexibilidade, aprendizagem e consciência), bem como de um estudo de caso exploratório realizado em uma empresa de implementos agrícolas. Com base nisso, foram propostos vinte e sete itens distribuídos ao longo de sete critérios. Cada item possui um conjunto de requisitos que são avaliados com base em três fontes de evidências básicas: entrevistas, análise de documentos e observação direta. O MASST foi validado em um estudo de caso em uma empresa da cadeia automotiva. Os principais resultados revelaram que, no estudo de caso, em uma escala de pontuação de 0% a 100%, nove dentre quatorze itens relacionados à ER obtiveram pontuação entre 0% e 10%. Além disso, o MASST possibilitou a identificação dos pontos positivos do SGSST, a identificação das causas sistêmicas da falta de segurança e a identificação das prioridades de ação em termos de SST. Dentre as limitações do MASST percebidas durante o estudo de caso, salienta-se a necessidade de experiência do auditor acerca de conceitos e princípios da ER, os quais ainda não são amplamente aplicados de modo sistemático no meio industrial.<br>Due to the increasing dissemination of health and safety management systems (HSMS), both academics and practitioners have paid more attention to the assessment of their effectiveness and efficacy. This thesis introduces a method for assessing health and safety management systems (MASST) that has two innovative characteristics: a) it takes into account simultaneously the structural approach (prescribed system), the operational approach (what is really happening on the shop floor) and the performance approach (results of performance indicators); b) it adopts the resilience engineering (RE) perspective on health and safety. The MASST was developed based on both the literature review and an exploratory case study in a heavy machinery manufacturer. The literature review pointed out four major resilience engineering (RE) principles: top management commitment, flexibility, learning and awareness. Then, twenty-seven items grouped into seven major criteria were proposed. Each item encompasses a set of requirements that should be assessed based on three major sources of evidence: interviews, analysis of documents and direct observation. The MASST was tested in a case study that was carried out in a supplier of the automotive industry. The results pointed out that, considering a scale from 0% to 100%, nine out of the fourteen items related to the RE obtained a very low degree, ranging from 0% to 10%. Moreover, the MASST pointed out the positive aspects of the HSMS, identified systemic causes of the lack of safety and identified priorities in terms of health and safety management. The case study results also indicated that one of the main limitations of the MASST concerns the necessity of experienced auditors in terms of RE principles and concepts. This drawback is relevant since the RE perspective on health and safety has not yet been adopted by a large extent in the industry.

Food policy groups (FPG) have emerged in the United States (U.S.) to create healthy, resilient and sustainable food systems. There is a lack of research about FPG in the Commonwealth of Virginia. This M.S. thesis describes a mixed-methods study that investigated the structure, issue framing, activities and priorities of diverse FPG in Virginia to develop a healthy, resilient and sustainable food system framed around three research objectives. Objective one used a scoping review to inventory and visually map the location of Virginia's FPG. Objective two administered a validated, online questionnaire to document activities related to organizational capacity, social capital, context, effectiveness, and community outcomes. Objective three used a semi-structured interview guide to explore stakeholders' views about opportunities and challenges to align diverse FPG priorities and interests. Quantitative data were analyzed using descriptive statistics and qualitative data were transcribed, hand-coded, and analyzed for emergent themes. Results found that 58% of FPG (n=32/55) are located cities around universities (i.e., Richmond, Blacksburg and Charlottesville), and fewer located in rural counties with higher health outcomes. A majority (75%, n=12/16) operated on annual budget less than $50,000. A third (37.5%, n=6/16) reported food system resilience work and 50% (n=8/16) reported sustainability work. Stakeholders (n=11) reported collaboration as a mutual interest and necessary to address systemic challenges and all interviewed FPG (n=11) reported sustainable funding as a major challenge. The results of this study may inform future policies for Virginia's FPG to support a healthy, resilient and sustainable food system at local, state and national levels.<br>Master of Science<br>Since the 1980s, food policy groups (FPG) including councils, networks and coalitions in the United States (U.S.) and other countries have emerged to address food system issues such as food insecurity, food access, diet-related chronic diseases, the environmental impacts agricultural systems, poverty and economic development in communities. In 2016, 411 FPG were active in the U.S. and Canada to create healthy, resilient and sustainable food systems. There is a lack of research about FPG in the Commonwealth of Virginia. This M.S. thesis describes a study design to investigate how the structure, issue framing, activities and priorities of diverse FPG in Virginia can develop a healthy, resilient and sustainable food system. Results found that 58% of FPG (n=32/55) are located cities around universities (i.e., Richmond, Blacksburg and Charlottesville), and fewer located in rural counties with higher health outcomes. A majority (75%, n=12/16) operated on annual budget less than $50,000. A third (37.5%, n=6/16) reported food system resilience work and 50% (n=8/16) reported sustainability work. Stakeholders (n=11) reported collaboration as a mutual interest and necessary to address systemic challenge and all interviewed FPG (n=11) reported sustainable funding as a major challenge. The results of this study may inform future policies for Virginia’s FPG to support a healthy, resilient and sustainable food system at local, state and national levels.

Os sistemas de medição de desempenho em segurança e saúde no trabalho (SMDSST) contribuem para identificar e caracterizar os riscos de acidentes, sendo um elemento fundamental da gestão da SST em qualquer setor industrial e também uma base para a melhoria contínua. O presente trabalho propõe um conjunto de critérios para avaliar SMDSST no setor da construção civil. Os critérios desenvolvidos foram estabelecidos a partir de três tipos de requisitos: (a) consistência do SMDSST com uma filosofia de gestão da SST, denominada engenharia de resiliência; (b) conformidade dos SMDSST com requisitos gerais de sistemas de medição de desempenho, tais como o grau de definição dos indicadores, a sua incorporação na rotina organizacional e o alinhamento das medidas com as estratégias; e (c) contribuição para a identificação e monitoramento dos principais fatores causais de acidentes, classificando-os em falhas relacionadas aos subsistemas pessoal, tecnológico, organizacional e do ambiente externo. A aplicação dos critérios é ilustrada por meio de dois estudos de caso, realizados em duas construtoras. Os resultados indicaram que tais critérios contribuem para a identificação de oportunidades de melhoria nos SMDSST tradicionais no setor da construção civil, tais como o desenvolvimento de novos indicadores e adaptações naqueles já existentes.<br>Performance measurement systems in occupational health and safety (SMDSST) help to identify risks of accidents, and play a key role in the management of occupational health and safety in any industry, establishing a basis for continuous improvement. This research work proposes a set of criteria for assessing SMDSST in the construction industry. This set of criteria was devised by taking into account three groups of requirements: (a) consistency of the SMDSST with an occupational health and safety management philosophy, known as resilience engineering; (b) compliance of the SMDSST with general performance measurement system, such as the definition of indicators, their incorporation into the organizational routine, and alignment of measures with strategies; and (c) contribution for the identification and control the main accident causal factors, classifying them in failures related to personnel, technological, organizational and external environment subsystems. The application of criteria is illustrated in two case studies carried out in different construction companies. Results indicated that the proposed criteria help to identify opportunities for improvement in SMDSST, such as development of new indicators and improvement in the existing ones.

With more than 75% of its population experiencing poverty, Zimbabwe was in 2012 considered one of the world's poorest countries. The country sits at the centre of the global HIV/AIDS epidemic and remains one of the hardest hit countries accounting for 5% of all new infections in sub-Saharan Africa. Zimbabwe's 15% HIV prevalence rate was 19 times the global average by 2012, and the total years of life lost due to premature mortality increased by over 150% between 1990 and 2010 because of HIV/AIDS. This study draws on notions of 'governmentality' to ask how the 'framing' of the value of PLWHA has influenced their treatment by the Zimbabwean government and society. Four questions are posed: first the study asks, in what ways do health policy decision-makers in Zimbabwe frame the value of people living with HIV/AIDS (PLWHA)? Secondly, the study questions the ways in which people not infected by HIV (Non-PLWHA) frame the value of PLWHA. Thirdly, the study turns to PLWHA and asks how they frame their own value. Finally, the study investigates the implications of valuing PLWHA, for their lives, or conversely, their deaths. The study draws upon primary research undertaken through interviews, focus group discussions, observations and document review. While there are some contradictions within and between groups of study participants in the ways they frame the value of PLWHA; the study finds consensus within and between these groups in the manner in which they tend to value PLWHA. Analysing these findings, there are five ways people in Zimbabwe frame the value of PLWHA. Firstly, from a 'citizen' perspective, PLWHA are both legal and political citizens who can identify as equal members of society like other citizens. They have social rights; participate, belong and can access HIV treatment that can reduce risks of death. Secondly, from a 'client' standpoint; PLWHA are customers, gaining access to health services through individual monetary payments or social payments such as Government budget allocations. This introduces a degree of 'rationing', forcing the clients (PLWHA) to behave in ways that increase their chances of receiving services. Those with lower purchasing power struggle to access expensive life-saving anti-retrovirals, thus individual wealth confers value on the lives of the wealthy. Thirdly, framing from a Statistical Representation perspective - through statistics, PLWHA can be used as a means of bargaining for government to gain access to international funding, to increase the chances of survival for PLWHA by bringing services such as antiretroviral therapy (ART). Fourthly, the 'Expendable populations' perspective views subgroups of PLWHA who fail to adhere to norms of behaviour prescribed by the government, including those unable to purchase services, such as the poor and homosexuals, sex workers and prisoners, as populations that may be allowed to die. Finally, the study shows that PLWHA lament the discursive space of technocrats with a counter-narrative of their value in which they emerge not as expendable victims but as victors reframed as an indefatigable population - 'Resiliencers'. PLWHA create a narrative of disobedient materiality, challenging totalising notions of governmentality. This study concludes by considering the relevance in the Zimbabwean context of the concept of 'Allowable Death' as a premature, avoidable death despite consciously crafted narratives that the death happened because nothing could have been done under the prevailing conditions to prevent it.

Marine and coastal ecosystems are subject to diverse and increasingly intensive anthropogenic activities, making understanding cumulative effects critically important. However, accurately accounting for the cumulative effects of human impacts can be difficult, with the possibility of multiple stressors interacting and having greater impacts than expected, compounding direct and indirect effects on individuals, populations, communities and ecosystems. Assessment of multiple stressors therefore requires extensive scientific research that directly tests how single or multiple ecological components are affected by stressors, both singly and when combined, and as a consequence, cumulative effects assessments are now increasingly included in environmental assessments. Currently, there is a need to assess these at larger spatial scales, with additional research also urgently needed on the responses of ecological components, processes and functions to single and cumulative stressors. As cumulative environmental impacts could be better addressed by regional stressor effects assessments that combine methods for predicting multiple pressures on ecosystem recovery alongside degradation, this study used several separate approaches that can be used in parallel to give support for local management measures. I tested four completely different methods - a range of multi-metric indices, a food web model (Ecopath), a predictive model (Ecosim) and a Bayesian Belief Network model. Each approach was tested and compared in two shallow water estuarine systems, in Scotland and England, initially concerning the impact of nutrient enrichment and subsequent recovery and was followed by an investigation of how the addition of multiple stressors (nutrient levels, temperature and river-flow rates) would impact the future state of each system. The response to stressors was highly context dependent, varying between and within geographic locations. Overall, each of the four different approaches complemented each other and gave strong support for the need to make big reductions in the pressures and to consider trade-offs between impacting pressures. The models and tools also indicate that in order to reach an improved overall environmental state of each ecosystem, a focus on nutrient reductions are likely to be the most effective of the controls on stressors explored and that cumulative effects of the management of nutrient inputs and increased water temperatures and river-flow are likely to exist.

La structuration territoriale des soins primaires peut être définie comme un processus de transformation évolutif et stratégique visant à réorganiser et renforcer l'organisation des soins et services de santé de première ligne. Ce processus consiste à passer d'un modèle traditionnel d'activité isolée à un modèle d'organisation territoriale plus intégré et coopératif entre professionnels, conduisant le secteur des soins primaires à se saisir d'enjeux de santé publique territoriaux. La gestion des situations sanitaires exceptionnelles constitue l'un de ces enjeux. Ce travail de thèse a pour objectif d'étudier le lien entre la structuration territoriale des soins primaires et la capacité de ce secteur à répondre aux situations sanitaires exceptionnelles, en s'appuyant sur l'exemple de l'épidémie de COVID-19.Le premier volet de la thèse présente une étude mixte visant à mieux comprendre le concept de structuration territoriale des soins primaires et à en proposer une typologie en France métropolitaine sur les territoires de vie-santé. La partie qualitative, réalisée au sein de 7 territoires, a permis d'identifier des facteurs clefs de cette structuration. A partir de ces facteurs, la partie quantitative a conduit, au moyen d'une classification hiérarchique sur composantes principales, à définir 4 types de territoires de vie-santé : des territoires peu ou pas structurés, des territoires à potentiel de structuration, des territoires en voie de structuration et des territoires déjà structurés abritant une communauté professionnelle territoriale de santé (CPTS).Le deuxième travail de la thèse a consisté à utiliser cette typologie dans une étude épidémiologique transversale portant sur l'évolution de l'activité des médecins généralistes lors de la première vague du COVID-19 en 2020. Cette étude a montré que les territoires bien structurés ont permis aux médecins de mieux s'adapter à la pandémie par un recours accru à la téléconsultation. Les résultats ont ainsi mis en évidence un lien significatif entre le niveau de structuration territoriale des soins primaires et la capacité d'adaptation des médecins généralistes.Le troisième volet s'est intéressé aux établissements d'hébergement pour personnes âgées dépendantes (EHPAD) et à leur adaptation à la crise en fonction de la structuration territoriale des soins primaires. En évaluant plusieurs catégories d'EHPAD, l'étude a montré que ceux situés dans des zones où les soins primaires étaient bien structurés présentaient une meilleure capacité de réponse face à la crise, avec moins de recours à l'hospitalisation et une mortalité plus faible. Cela souligne l'importance de la coopération entre les soins primaires et le secteur médico-social pour renforcer la résilience territoriale.La structuration territoriale des soins primaires apparaît comme un levier important pour améliorer la réponse aux crises sanitaires. Ce travail a montré que les territoires dotés d'une organisation des soins primaires structurée étaient mieux à même de maintenir la continuité des soins et de collaborer avec les autres secteurs de santé. Les perspectives pour l'avenir incluent le renforcement de cette structuration, catalyseur de la responsabilité populationnelle des acteurs, afin de mieux préparer le système de santé français aux futures crises<br>The territorial structuring of primary care can be defined as an evolving and strategic transformation process aimed at reorganising and strengthening the organisation of first-line healthcare services. This process involves moving from a traditional model of isolated practice to a more integrated and cooperative territorial organisation among professionals, leading the primary care sector to address territorial public health challenges. The management of exceptional health situations is one of these challenges. The main objective of this thesis is to study the relationship between the territorial structuring of primary care and the sector's capacity to respond to exceptional health situations, using the COVID-19 epidemic as an example.The first part of the thesis presents a mixed-methods study designed to better understand the concept of territorial structuring of primary care and to propose a typology for mainland France at the level of life-health territories. The qualitative component, conducted in seven territories, helped identify key factors of this structuring. Based on these factors, the quantitative component used a hierarchical clustering on principal components approach to define four types of life-health territories: territories that are poorly or not structured, territories with potential for structuring, territories in the process of structuring, and fully structured territories hosting a health territorial and professional community (HTPC).The second part of the thesis used this typology in a cross-sectional epidemiological study focused on changes in the activity of general practitioners during the first wave of COVID-19 in 2020. This study showed that well-structured territories allowed physicians to better adapt to the pandemic, notably through increased use of teleconsultation. The results highlighted a significant link between the level of territorial structuring of primary care and the adaptability of general practitioners.The third part focused on nursing homes and their adaptation to the crisis based on the territorial structuring of primary care. By evaluating several categories of nursing homes, the study demonstrated that those located in areas with well-structured primary care exhibited a better capacity to respond to the crisis, with fewer hospital admissions and lower mortality. This underscores the importance of cooperation between primary care and the medico-social sector to enhance territorial resilience.The territorial structuring of primary care appears to be an important lever for improving responses to health crises. This work has shown that territories with structured primary care organisations were better able to maintain continuity of care and collaborate with other health sectors. Future perspectives include strengthening this structuring, which serves as a catalyst for population-level responsibility among stakeholders, to better prepare the French healthcare system for future crises

I. BACKGROUND: Following a review of donor funding priorities and concepts of health system strengthening (HSS) and resilience, this dissertation documents health system resilience factors existing in the Liberian health system in late 2014/early 2015 as the Ebola epidemic flared. The effectiveness of the WHO health system building blocks framework in addressing resilience was assessed, and specific factors that can promote health system resilience for Liberia going forward were identified. II. METHODS: Methods applied as part of this intrinsic case study include document and literature review, analysis of health facility and population-level statistics, and key informant and group interviews at the county and national levels. The methodology allowed for an in-depth assessment of how HSS (using the WHO health system building blocks) and resilience factors (using the WHO-defined key aspects of emergency preparedness) exist (or could exist) within the Liberian institutional and cultural context, and for tentative conclusions to be drawn about the importance of system factors to building specific health system capacities and overall health system resilience. III. FINDINGS: While dealing with myriad other public health priorities, public health preparedness went largely unaddressed in pre-Ebola Liberia where effectively none of the 16 key components or their 51 essential attributes listed in the WHO table of emergency preparedness were in place. The lack of integration of public health preparedness into HSS interventions left the country vulnerable to public health emergencies. There are two limitations to the government’s Ebola recovery and investment plan: (1) lack of a holistic approach to addressing emergency preparedness; and (2) not integrating emergency preparedness needs and corresponding activities into the existing national HSS framework. IV. CONCLUSION: By integrating emergency preparedness and response initiatives into HSS activities, health systems in Liberia and elsewhere can be strengthened to be more resilient, and thus better able to anticipate and adapt to challenges, and ultimately improve the system to be able to anticipate new future challenges. However, strengthening health systems so that they are resilient takes resources, including sector-wide, HSS resources that can be used to build functioning, integrated systems and skilled, networked individuals and groups across sectors.

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.<br>text

The focus of this thesis is on the impact that a hospital admission can have on the continuing ability of Home and Community Care¹ (HACC) clients (older people and people with disability) to remain living in their home. Of concern to HACC service providers were their clients' readmissions to hospital and/or unnecessary institutionalisation after hospitalisation. Both events were considered poor outcomes by HACC service providers. The desire to improve these poor outcomes and to alleviate discontinuous care led the HACC program to fund a project in Adelaide, which I undertook as action research. In this thesis I investigated how poor outcomes could be avoided and continuity of care improved in the South Australian hospital and HACC systems. A literature review revealed that population ageing, the demand and resource pressures on acute hospitals and community services and the paucity of discharge planning were factors leading to discontinuity of care of older people and people with disability, as well as impacting on their carers. Theoretical perspectives first look at the divisions between the biomedical and social models of health, as well as the critiques of medical care and the role of bureaucracy put forward by iatrogenesis and medicalisation. Next, the theoretical lens turns to the lives of people, where the centrality of 'care' and interdependence are considered, along with the need to improve our understanding of the nature of vulnerability and the importance of resilience to moving beyond the dominant 'problem-based' discourse of ageing and disability. Processes in the action research included two cyclical phases of making plans, embarking on actions and observing the results of the actions. Methods for collecting data included surveys (n=16 older patients and 10 carers), an evaluation (n=28), face-to-face interviews (n=52), one focus group (n=8), three Reference Groups (n=46), a workshop (n=14) and a nominal group (n=14). The interviews and surveys provided the opportunity to analyse the admission, hospitalisation and discharge issues for HACC clients and their carers from the perspectives of hospital nurses (n=19) and 33 community care providers. The latter participants were clinicians and case managers from domiciliary care² (n=23) and community nurses³ (n=10). These interviews were analysed thematically. Results from the action research project yielded valuable research insights and successful actions which were reflexively planned, implemented and evaluated. The actions increased local linkages between the hospital and community service providers, collaboration, communication and access to information about the HACC program. Despite this, the action research project appeared to have little or no direct effect on avoiding poor outcomes or improving discontinuity of care. Such effects were more complex and beyond the scope of a project of this size. Achieving the necessary systems and structural changes to address these problems would have required more time, resources, capacity and leadership to be committed by government departments and the agencies. The descriptive statistics of surveys with patients and carers and the key issues identified by the Reference Group supported triangulation of the interviews with domiciliary, community nursing and hospital participants. Findings from the interviews with domiciliary, community nursing and hospital participants point to uncertainty and complexity before, during and after hospitalisation of older people, people with disability, their carer/family, and also for service providers. Before admission to hospital there are four 'dimensions of uncertainty', and during hospitalisation, there were four categories which contributed to 'complexity in discharge planning'. When leaving hospital, 'adjustment and adaptation' highlights individual patients' and carer/families' adjustments. In addition, it points to the need/potential for service adaptation to support people's ability to return home. Putting these dimensions together, the main themes to emerge in this context are ‘systemic uncertainty and complexity'. In building upon these themes, I have developed a model of systemic uncertainty and complexity before, during and after hospital. Given this new knowledge about the context of uncertainty and complexity on the one hand, and adjustment and adaptation on the other, I conclude by considering the implications of these understandings for theory, policy and practice. ¹ The HACC program, funded jointly by the Australian, State and Territory governments, targets community-dwelling frail aged people, people with disability, and their carers, who in the absence of basic maintenance and support services are at risk of premature or inappropriate long-term residential care. ² Domiciliary care services are provided to older people (aged 65 years and over) and younger people with disability whose ability to care for themselves is reduced. Domiciliary care assists them to stay living in their own homes, by providing physical assistance, rehabilitation and personal care, as well as respite and support for carers. By promoting independence and improving quality of life for clients, domiciliary care services aim to prevent unnecessary admission into hospital or residential care. ³ Community nursing services provide community based health and care services, including rehabilitation, therapy and nursing care.<br>Thesis (Ph.D.) -- University of Adelaide, School of Population Health and Clinical Practice, 2010

Yes<br>Poor medicines management places patients at risk, particularly during care transitions. For patients with heart failure (HF), optimal medicines management is crucial to control symptoms and prevent hospital readmission. This study explored the concept of resilience using HF as an example condition to understand how the system compensates for known and unknown weaknesses. We explored resilience using a mixed-methods approach in four healthcare economies in the north of England. Data from hospital site observations, healthcare staff and patient interviews, and documentary analysis were collected between June 2016 and March 2017. Data were synthesised and analysed using framework analysis. Interviews were conducted with 45 healthcare professionals, with 20 patients at three timepoints and 189 hours of observation were undertaken. We identified four primary inter-related themes concerning organisational resilience. These were named as gaps, traps, bridges and props. Gaps were discontinuities in processes that had the potential to result in poorly optimised medicines. Traps were features of the system that could produce errors or unintended adverse medication events. ‘Bridges’ were features of the medicines management system that promoted safety and continuity which ensured that, despite varying conditions, care could be delivered successfully. ‘Props’ were informal, temporary or impromptu actions taken by patients or healthcare staff to avoid potential adverse events. The numerous opportunities for HF patient safety to be compromised and sub-optimal medicines management during this common care transition are mitigated by system resilience. Cross-organisational bridges and temporary fixes or ‘props’ put in place by patients and carers, healthcare teams and organisations are critical for safe and optimal care to be delivered in the face of continued system pressures.

Research Doctorate - Doctor of Philosopy (PhD)<br>An environmental history approach is used in this thesis as a foundation for the analysis of the social and environmental changes that have occurred from the ancient past to the present within the Paterson Valley in New South Wales, Australia. The study examines the biophysical basis of the valley’s ecological processes and then describes the influence of the activities of Aboriginal peoples and subsequent European colonisation on the landscape. The study makes use of the various methodologies within social and ecological systems to assist with the analysis. It demonstrates the value of concepts such as complex adaptive systems, the adaptive cycle, panarchy and ecosystem health as ways of conceptualising complex transdisciplinary issues to reach conclusions based on temporal and spatial evidence. The complex relationships that the Aboriginal peoples had with the environment are compared with the various and rapid phases of colonial influences and processes. The social dimension of the changes over time is examined particularly with respect to the Indigenous and European institutions and infrastructure that influence the landscape. A significant issue identified in the study was the changing influence of Western institutions on the ecosystem health of the Valley; from local to global. The implications of this on ecosystem health are discussed. The Valley’s landscapes are divided into alluvial and non-alluvial, with the latter receiving the most attention in the study primarily due to its more extant nature whereas the alluvial rainforest has been virtually eliminated through extensive land clearing. The analysis of the non-alluvial landscape shows how important the Indigenous land management practices were in the maintenance of a complex mosaic of vegetation types specifically influenced by fire. The impact of the removal of the Indigenous influences on the landscape and the imposition of European practices and processes have seen a major reduction in the Valley’s ecological complexity. The study identified processes and factors external to the Valley which are increasingly influencing it. Not all of these are detrimental but they result in the Valley’s ecosystem health being more dependent on global events and processes. The study demonstrates the value of the ecosystem health framework for conceptualising the Valley’s ecosystems and the adaptive cycle for analysing and understanding their changes over time. These approaches provide an opportunity to identify pathways for future management of the Valley’s resources.

Research Doctorate - Doctor of Philosopy (PhD)<br>An environmental history approach is used in this thesis as a foundation for the analysis of the social and environmental changes that have occurred from the ancient past to the present within the Paterson Valley in New South Wales, Australia. The study examines the biophysical basis of the valley’s ecological processes and then describes the influence of the activities of Aboriginal peoples and subsequent European colonisation on the landscape. The study makes use of the various methodologies within social and ecological systems to assist with the analysis. It demonstrates the value of concepts such as complex adaptive systems, the adaptive cycle, panarchy and ecosystem health as ways of conceptualising complex transdisciplinary issues to reach conclusions based on temporal and spatial evidence. The complex relationships that the Aboriginal peoples had with the environment are compared with the various and rapid phases of colonial influences and processes. The social dimension of the changes over time is examined particularly with respect to the Indigenous and European institutions and infrastructure that influence the landscape. A significant issue identified in the study was the changing influence of Western institutions on the ecosystem health of the Valley; from local to global. The implications of this on ecosystem health are discussed. The Valley’s landscapes are divided into alluvial and non-alluvial, with the latter receiving the most attention in the study primarily due to its more extant nature whereas the alluvial rainforest has been virtually eliminated through extensive land clearing. The analysis of the non-alluvial landscape shows how important the Indigenous land management practices were in the maintenance of a complex mosaic of vegetation types specifically influenced by fire. The impact of the removal of the Indigenous influences on the landscape and the imposition of European practices and processes have seen a major reduction in the Valley’s ecological complexity. The study identified processes and factors external to the Valley which are increasingly influencing it. Not all of these are detrimental but they result in the Valley’s ecosystem health being more dependent on global events and processes. The study demonstrates the value of the ecosystem health framework for conceptualising the Valley’s ecosystems and the adaptive cycle for analysing and understanding their changes over time. These approaches provide an opportunity to identify pathways for future management of the Valley’s resources.

There is a notable overlap and co-occurrence of mental health and learning challenges among school-aged youth. Existing research highlights associations between learning disabilities (LD) and mental health problems; however, there has been little exploration of additional variables, such as familial influences, that represent multiple levels of influence (Cen & Aytac, 2016). From a developmental relational systems framework (Overton, 2015), advancing the understanding of familial influences on youth development is crucial. Using a mixed methods design, the present study examined the influences of parent depression, parenting behaviours, family functioning, and youth social and emotional competencies on symptoms of anxiety and depression among youth with LD. Addressing two hypotheses, the quantitative Study 1 aimed to identify factors associated with mediating effects on internalized distress in 14- and 15-year-old youth with LD using secondary analysis of a cross-sectional national sample of youth and their parents. Youth social and emotional competencies and parental monitoring were found to be the most significant buffering influences in reducing symptoms of anxiety and depression. The qualitative Study 2 built on the results from Study 1, to expand the quantitative findings. In Study 2, youth at the end of middle school and their parents were interviewed to gain deeper understanding about the experiences of co-occurring LD and mental health problems from a family perspective. Data analysis identified youth fatigue, youth self-efficacy, and family relationships as central themes related to the challenges youth and their families experienced. Integrating the findings of the two studies illustrated the complex psychological, social, and educational implications for youth with LD in a family context. The interplay of factors embedded in the relation between the LD and mental health problems underscores this complexity, suggesting the relation cannot be completely understood without considering the multiple levels of influences. Implications for theory, research, and practice are described with an emphasis on ecological approaches and building school-family relationships.<br>Graduate

Indiana University-Purdue University Indianapolis (IUPUI)<br>The city of Austin is a small community in Southern Indiana that experienced a large HIV/AIDS outbreak which infected over 180 people. Due to rapid spread of the disease from shared needles during intravenous drug use, a public health emergency was declared in March 2015. This epidemic was a symptom of the overall communal health issues within the area related to drugs, crime, prostitution and poverty. These problems affect residents’ physical and mental health, however, often go unaddressed due to limited resources, healthcare and education. Organizations within the area were affected by the epidemic, and many provided a response to help combat the issue. The purpose of this study is to examine how organizations respond to a health crisis from a communication perspective. Research question one is, what was the level of coordination between the seven organizations during the HIV/AIDS epidemic? Research question two is, what was the public’s response to the effort made by the seven organizations? This study interviewed seven participants and a thematic analysis was conducted that discovered four themes: coordinated response, uncoordinated activities, response time, and inadequate response. In response to research question one, the levels of coordination were infrequent with the seven agencies. Research question two found multiple areas that indicated the agencies approach ineffective in adequately informing the public. The agencies’ efforts displayed a lack of coordination and poor timely response to the crisis. These issues show it is imperative that we develop a resilient health system to operate systemically. By implementing communication for whole health, it would provide a resilient system for agencies to understand and develop coordination and collaboration between each other. With a sense of coordination, they would then be able to execute ways of promoting and living out better physical and mental health (Parrish-Sprowl and Parrish-Sprowl, 2016).