“Fiction makes a better job of the truth”: dialogism, oppositional consciousness and re-membering in the novels of Helena María Viramontes

This thesis comprises close textual analyses of Chicana author Helena María Viramontes' two published novels, Under the Feet of Jesus (1995) and Their Dogs Came With Them (2007). These analyses fall under three broad frameworks: space, time and body. Chapter One engages with the first of these frameworks, space, and explores concepts of cognitive mapping and heteroptopias. Chapter Two, which looks at time, employs theories of intertextuality and the palimpsest, while Chapter Three looks at the interrrelationship between mythology and images of the body in the texts. This study emerges five years after the publication of Viramontes' last novel, Their Dogs Came With Them, but offers fresh insight into the contribution of the author to both the Chicano literary tradition and also the U.S. canon through her critique of hegemonic power structures that suppress not only the voices of lower class ethnic citizens but also of ethnic writers. In particular, her work chastises the paucity of attention given to ethnic women writers in the U.S. This thesis reaffirms Viramontes' position as one of the most important writers living and writing in the U.S. today. It corroborates her work as a contestation against ethnic and gender suppression, and applauds the craftsmanship of her narrative style that delicately but decisively exposes the socio-political wrongs that occur in ocntemporary U.S. society.

An Irish apostle: articulating and actualising apostolicity in the early Irish church

This thesis examines the earliest extant Latin Lives of Brigit and Patrick; Cogitosus’s Vita Brigidae and Muirchú’s Vita Patricii as evidence for a seventh-century debate on Irish apostolicity. While often dismissed as mere propaganda, this thesis shows they are highly sophisticated demonstrations of the continuing connection that Kildare and Armagh had to their patron saints and their authority. It examines the importance of this connection for concepts of ecclesiastical organisation, teaching authority and episcopal succession against the backdrop of the seventh-century Easter question in the Insular Church. This will show that apostolicity was considered to be intrinsically linked with orthodoxy and universality. A textual focus brings forth general patristic themes and ideas that Irish hagiographers evoked through specific words and phrases. The thesis contextualises hagiographical material using evidence from Hiberno-Latin and early Insular exegetical commentaries, referring to major patristic exegetes such as Origen, Jerome, Augustine, and Gregory the Great as support. The introduction discusses the importance of apostolic ideology for the seventh-century Irish Church, and outlines a methodology for examining such abstract themes. The first chapter looks at how developments in apostolic ideology led to ideas of apostolic primacy seen in the Insular material. Chapters two, three, and four examine metaphors of food and feeding, the fountain and the stream, and the head and the body, as significant articulations of apostolicity. Chapter five examines how corporeal relics were understood as the visible proof of this continuity and preserved a saint’s authority for their episcopal heirs. Chapter six looks at how Muirchú engaged with Patrick’s connection to the universal Church and his self-professed lack of disciplina to reconcile his apostolicity with seventh-century norms. Chapter seven places the issues considered thus far in a thoroughly Insular context by examining how the earliest English sources present the Irish legacy in Northumbria after the synod of Whitby. Chapter eight looks at how the text of Patrick’s Confessio in the Book of Armagh relates to a wider seventh-century campaign by Armagh to rehabilitate Patrick’s apostolicity. The conclusion briefly summarizes the thesis, and suggests further avenues for researching this topic in the Insular material

The effects of copayment policies on adherence to prescription medicines in publicly insured populations

Introduction: Copayments for prescriptions are associated with decreased adherence to medicines resulting in increased health service utilisation, morbidity and mortality. In October 2010 a 50c copayment per prescription item was introduced on the General Medical Services (GMS) scheme in Ireland, the national public health insurance programme for low-income and older people. The copayment was increased to €1.50 per prescription item in January 2013. To date, the impact of these copayments on adherence to prescription medicines on the GMS scheme has not been assessed. Given that the GMS population comprises more than 40% of the Irish population, this presents an important public health problem. The aim of this thesis was to assess the impact of two prescription copayments, 50c and €1.50, on adherence to medicines.Methods: In Chapter 2 the published literature was systematically reviewed with meta-analysis to a) develop evidence on cost-sharing for prescriptions and adherence to medicines and b) develop evidence for an alternative policy option; removal of copayments. The core research question of this thesis was addressed by a large before and after longitudinal study, with comparator group, using the national pharmacy claims database. New users of essential and less-essential medicines were included in the study with sample sizes ranging from 7,007 to 136,111 individuals in different medication groups. Segmented regression was used with generalised estimating equations to allow for correlations between repeated monthly measurements of adherence. A qualitative study involving 24 individuals was conducted to assess patient attitudes towards the 50c copayment policy. The qualitative and quantitative findings were integrated in the discussion chapter of the thesis. The vast majority of the literature on this topic area is generated in North America, therefore a test of generalisability was carried out in Chapter 5 by comparing the impact of two similar copayment interventions on adherence, one in the U.S. and one in Ireland. The method used to measure adherence in Chapters 3 and 5 was validated in Chapter 6. Results: The systematic review with meta-analysis demonstrated an 11% (95% CI 1.09 to 1.14) increased odds of non-adherence when publicly insured populations were exposed to copayments. The second systematic review found moderate but variable improvements in adherence after removal/reduction of copayments in a general population. The core paper of this thesis found that both the 50c and €1.50 copayments on the GMS scheme were associated with larger reductions in adherence to less-essential medicines than essential medicines directly after the implementation of policies. An important exception to this pattern was observed; adherence to anti-depressant medications declined by a larger extent than adherence to other essential medicines after both copayments. The cross country comparison indicated that North American evidence on cost-sharing for prescriptions is not automatically generalisable to the Irish setting. Irish patients had greater immediate decreases of -5.3% (95% CI -6.9 to -3.7) and -2.8% (95% CI -4.9 to -0.7) in adherence to anti-hypertensives and anti-hyperlipidaemic medicines, respectively, directly after the policy changes, relative to their U.S. counterparts. In the long term, however, the U.S. and Irish populations had similar behaviours. The concordance study highlighted the possibility of a measurement bias occurring for the measurement of adherence to non-steroidal anti-inflammatory drugs in Chapter 3. Conclusions: This thesis has presented two reviews of international cost-sharing policies, an assessment of the generalisability of international evidence and both qualitative and quantitative examinations of cost-sharing policies for prescription medicines on the GMS scheme in Ireland. It was found that the introduction of a 50c copayment and its subsequent increase to €1.50 on the GMS scheme had a larger impact on adherence to less-essential medicines relative to essential medicines, with the exception of anti-depressant medications. This is in line with policy objectives to reduce moral hazard and is therefore demonstrative of the value of such policies. There are however some caveats. The copayment now stands at €2.50 per prescription item. The impact of this increase in copayment has yet to be assessed which is an obvious point for future research. Careful monitoring for adverse effects in socio-economically disadvantaged groups within the GMS population is also warranted. International evidence can be applied to the Irish setting to aid in future decision making in this area, but not without placing it in the local context first. Patients accepted the introduction of the 50c charge, however did voice concerns over a rising price. The challenge for policymakers is to find the ‘optimal copayment’ – whereby moral hazard is decreased, but access to essential chronic disease medicines that provide advantages at the population level is not deterred. This evidence presented in this thesis will be utilisable for future policy-making in Ireland.