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Gillian Mulvale, Jeremiah Hurley. Publisher's website: http://www.chepa.org. Archived by Library and Archives Canada. Title from title screen (viewed on Nov. 29, 2007). Includes bibliographical references. Mode of access: World Wide Web.

Gillian Mulvale, Julia Abelson, Paula Goering. Title from title page of source document (viewed July 24, 2007). Includes bibliographical references. Mode of access: World Wide Web. Mental health policy-making in Ontario has a long history of frustrated attempts to move from a hospital and physician-based tradition to a coordinated system with greater emphasis on community-based mental health care. This study examines policy legacies associated with the introduction of psychiatric hospitals in the 1850s and the introduction of public health insurance (Medicare) in the 1960s in Ontario; and their effect on subsequent mental health reform initiatives using a qualitative case study approach. Following Pierson (1993) we capture the resource/incentive and interpretive effects of prior policies on three groups of actors: government elites, interests and mass publics. Data is drawn from academic and policy literature, and key informant interviews. The findings suggest that psychiatric hospital policy resulted in important policy legacies which were reinforced by Medicare. These legacies explain the traditional difficulty in achieving mental health reform, but are less helpful in explaining recent promising developments that support community-based care. Current reform of the Ontario health system features the introduction of regionalized service delivery and new models of interdisciplinary team-based primary care delivery and presents an opportunity to overcome several of these legacies. The analysis suggests a pressing need to link these two initiatives to overcome system fragmentation.

Mental health policy-making in Ontario has a long history of frustrated attempts to move from a hospital and physician-based tradition to a coordinated system with greater emphasis on community-based mental health care. This study examines policy legacies associated with the introduction of psychiatric hospitals in the 1850s and the introduction of public health insurance (Medicare) in the 1960s in Ontario; and their effect on subsequent mental health reform initiatives using a qualitative case study approach. Following Pierson (1993) we capture the resource/incentive and interpretive effects of prior policies on three groups of actors: government elites, interests and mass publics. Data is drawn from academic and policy literature, and key informant interviews. The findings suggest that psychiatric hospital policy resulted in important policy legacies which were reinforced by Medicare. These legacies explain the traditional difficulty in achieving mental health reform, but are less helpful in explaining recent promising developments that support community-based care. Current reform of the Ontario health system features the introduction of regionalized service delivery and new models of interdisciplinary team-based primary care delivery and presents an opportunity to overcome several of these legacies. The analysis suggests a pressing need to link these two initiatives to overcome system fragmentation.

Understanding how proximal, intermediate, and distal determinants of Indigenous peoples’ health in Canada, relate to the physical and mental health of First Nations, Métis, and Inuit, can shed light on how to allocate health-related resources to address well documented health disparities in these groups. This dissertation contributes to the literature by addressing two population-level quantitative research questions pertaining to Indigenous peoples’ physical and mental health, and a qualitative case study examining what factors maintain and improve Indigenous community health workers’ mental wellness and access to mental health supports. First, this thesis establishes a link between being Indigenous and health-related quality of life using multivariate regressions, as well as decomposition techniques. Second, the relationship between having an ancestor who survived the Residential School System, and five physical and mental health outcomes, controlling for determinants of health are estimated using multivariate ordered logistic and logistic regressions. Third, given that Indigenous self-government is an important determinant of health and wellbeing, an explanatory single-case study design is used to explore what factors maintain and improve, or create barriers to mental wellness and access to mental health supports for Indigenous community health workers in an Indigenous-governed health system. These chapters build on each other, and use a variety of methodological approaches, to identify if and to what degree observable determinants of health account for the physical and mental health of Indigenous peoples living in Canada. Substantively, this thesis evaluates empirically, the relationship between determinants of health and health outcomes for Indigenous peoples. Findings could be used to advocate for adequate and sustained investment in programs and services responsive to the contexts and needs of Indigenous men and women living in Canada. Methodologically, novel applications of statistical/econometric methodologies, furthers understanding of quantitative relationships examined with respect to Indigenous peoples’ physical and mental health at the population-level. In terms of a theoretical contribution, this dissertation contributes by lending further insight into the empirical relationships between determinants of Indigenous peoples’ health and health outcomes, and by introducing a framework for conceptualizing factors that strengthen mental wellness of Indigenous community health workers in remote Northern contexts in Canada. Thesis Doctor of Philosophy (PhD) First Nations, Métis, and Inuit make up 4.3% of the Canadian population and together represent the three distinct identities of Indigenous peoples living in Canada. Indigenous peoples’ experiences of colonization have had impacts on their physical and mental health. Additionally, experiences of colonization have also affected many determinants of Indigenous peoples’ health ranging from access to food and clean drinking water, to the availability of appropriate education, social, and healthcare services. The following chapters explore how certain experiences of being Indigenous in Canada are associated with physical and mental health outcomes, taking into consideration determinants of health. Even after controlling for all of the things known to be related to Indigenous peoples’ physical and mental health, and that are typically used to explain any differences in health between groups, there is still a difference in health outcomes between Indigenous and non-Indigenous peoples in Canada. There is also still a difference in physical and mental health outcomes between Indigenous adults with and without an ancestor who attended the Residential School System. The effects of colonization also influence Indigenous community health workers’ mental wellness, and access to mental health supports while living and working in a remote, Northern community.

The overall purpose of this study was to examine the relevance of policy factors identified by Mulvale and Bourgeault (2007) on interprofessional collaboration in PHC, by soliciting stakeholders’ perspectives. ABSTRACT Background: Interprofessional team-based approaches to primary health care (PHC) delivery have gained support in the literature. Interprofessional primary health care (IPC) models of service delivery allow for different professionals to work together to address patients’ needs. Family Health Teams (FHTs) are a newly introduced model of IPC delivery in Ontario. A variety of factors can influence collaboration between professionals in IPC teams. Purpose/Research Objectives: The purpose of this study was to examine stakeholders’ perspectives about policy factors that influence IPC team collaboration, using the example of FHTs in Ontario. Methods: This descriptive study employs semi-structured interviews with key informants from select Ontario FHTs. Directed content analysis was used to examine the Mulvale and Bourgeault (2007) framework. Interviews were conducted with FHT professionals to describe their perspectives on the influence of policy factors in shaping collaboration within their teams and whether identified policy factors acted to enhance or hinder collaboration. Findings: Key informants cited, with highest agreement, economic and regulatory factors as influencing collaboration. Factors agreed upon unanimously by all key informants included funding, provider payment/remuneration, and practice scope. Key informants identified a range of policy factors that hinder collaboration. These included provider payment/remuneration, legal accountability, and the existence of multiple governing bodies. Implications/Conclusion: A number of policy factors were reported to influence collaboration in FHTs in Ontario. Although the findings suggest that incremental reform is possible, widespread policy reform of physician incentives, a key barrier to collaboration, is unlikely. Prospects for reform of this factor may be more promising at an organizational level. Thesis Master of Science (MSc)

Background: Organ donation in India is a complex issue due to the country’s large population, diverse religious beliefs and myths surrounding organ donation, varying literacy rates, nation-wide focus on disease control, and the commercialization of organs. India has only made marginal steps to address the significant obstacles in order to ensure adequate supplies of organs are available to meet the demand. Purpose: The purpose of this study is to analyze the feasibility of implementing an organ donor registry in Mumbai, India. This is achieved by reviewing current organ donation policies and processes in Mumbai, exploring perceptions of key informants about Indian government health priorities, and identifying possible reasons why the Indian government has not made efforts to increase the deceased donor rate. Methods: This qualitative policy analysis employs semi-structured interviews with physicians, transplant coordinators, and representatives of organ donation advocacy groups in Mumbai to explore key informants’ perceptions about the feasibility of developing and implementing an organ donor registry. The 3-I framework (ideas, interests, and institutions) is used to analyze the results and frame the discussion and their implications. Results: Key informants cite various barriers to the implementation of an organ donor registry in Mumbai, including public misconceptions about organ donation, competing health priorities on the government agenda, and limited hospital infrastructure. Conclusion: In the absence of a focusing event or a policy entrepreneur who is able to push the issue of organ donation onto the health policy agenda, both central and state governments may have little incentive to aggressively pursue the implementation of a donor registry in more than a superficial way. Moreover, even if the issue reached the government’s policy agenda, current barriers may be too overwhelming to overcome. This suggests that implementing an organ donor registry in Mumbai as a means of enhancing organ availability is not feasible in the current environment. Instead, efforts to enhance the transplant system should focus on alternate strategies, such as public education, until the policy environment becomes more amenable to change. Master of Science (MSc)