Dissertations / Theses on the topic 'Basket of care'

This study explored the dynamics of local-level trade in plant-based mats and baskets in Khanyayo village, Eastern Cape. These dynamics include social aspects of harvesting, resource tenure and trade. It also includes institutional issues such as legislation that enhances or restricts the degree to which local people could benefit from the trade or direct use. The study also explored the contribution of the trading in mats and baskets to the livelihoods of the Khanyayo people.

La science du bien-être animal est une discipline bien établie qui permet de faire des mesures objectives. Les grands dauphins (Tursiops truncatus) sont une espèce de cétacés communément présente en captivité, et bien que des questions se posent sur la qualité de leur vie dans cet environnement, très peu d'études ont porté sur la mesure objective de leur bien-être. Cette thèse répond à ce manque de données en développant des indicateurs de bien-être basé sur l’animal, ici le grand dauphin. Une revue bibliographique initiale a identifié des mesures potentielles de bien-être, avant que des indicateurs comportementaux choisis aient été mesurés par rapport aux sessions d’entrainement. Un test de biais de jugement a alors été adapté aux dauphins, où des biais optimistes ont été significativement liés aux fréquences les plus hautes de nage synchronisée durant leur 'temps libre' et aux fréquences les plus basses de comportement anticipatoire avant les sessions d’entrainement. Une avant dernière étude a montré que le comportement anticipatoire prédisait la participation à l'événement à venir, et que des Interactions Humaines-Animales positives étaient anticipées plus que l’introduction de jouets. Une dernière expérience en cours a développé un protocole standardisé pour mesurer la motivation des dauphins pendant des sessions d’entrainement par rapport aux problèmes de bien-être sociaux et de santé. Bien que le bien-être global soit toujours difficile à mesurer, cette thèse propose des premières mesures d'émotions et d’états affectifs chez le dauphin. La nage synchronisée est un indicateur probable d'émotions positives, bien que plus de recherches doivent examiner la variabilité entre divers contextes. Le comportement anticipatoire semble témoigner de la motivation pour des événements à venir et nous suggérons qu'il reflète une sensibilité à la récompense comme chez d'autres animaux : des travaux ultérieurs portant sur des seuils de fréquence le transformerait en indicateur de bien-être pertinent. Un objectif majeur de la thèse est de stimuler plus de recherches sur des mesures de bien-être chez des grands dauphins et d'autres espèces de cétacés en captivité
Welfare science is now an established discipline which enables objective measurements of animal welfare to be made. Bottlenose dolphins (Tursiops truncatus) are a common cetacean species kept in captivity, and although questions are arising over their quality of life in this environment, very few studies have focussed on objectively measuring their welfare. This thesis aimed to address this lack of data by developing animal-based indicators of bottlenose dolphin welfare. An initial review identified potential dolphin welfare measures, before selected behavioural indicators were measured in relation to training sessions. A judgement bias test was then adapted to dolphins, where optimistic biases were significantly linked to higher frequencies of synchronous swimming in their ‘free-time’ and lower frequencies of anticipatory behaviour before training sessions, (concurring with there ward-sensitivity theory). A penultimate study showed that anticipatory behaviour predicted participation in the upcoming event, and positive Human-Animal Interactions were anticipated more than access to toys. A final, on-going experiment has developed and applied a standardised protocol for measuring dolphins’motivation during training sessions in relation to social and health-related welfare problems. Although overall welfare is still difficult to measure, this thesis has proposed some first measures of dolphin emotions and affective states. Synchronous swimming is a likely indicator of positive emotions and social support, although more research should investigate variability between contexts. Anticipatory behaviour seemed to indicate motivation for events, and we suggest it reflects reward sensitivity as in other animals : further work into frequency thresholds would render it a valuable welfare indicator. A major objective of the thesis is to stimulate more research on welfare measures for bottlenose dolphins and other cetacean species in captivity

Magister Curationis - MCur
The purpose of the study will be to explore the discharge referral pathway for patients that have been discharged from hospital to home in the Western Cape Province. A mix of quantitative and qualitative research, using a descriptive design will be undertaken. Quantitatively, following the patient paper trail from Tertiary Hospital to grassroots level. Qualitatively, to identify whether the referral pathway was user friendly. Records of discharged patients from the Tertiary Hospital will be used as the study population. Patient information will be accessed from patient files at the hospital. Interviews will be conducted with the relevant discharge liaison officers at the Tertiary Hospital, and Primary Health Care level. Relevant staff members within the non–governmental –organisations (NGOs), will also be interviewed in order to determine their perception of the discharge referral pathway. The findings of the study will be used to inform policy guidelines. Challenges encountered by staff members in referring patients for continuum of care, and the perception of consumers will also be described and documented.

Asthma is a chronic disease that affects 8.4 million children in the United States (American Lung Association [ALA], 2007). Adolescents with asthma need tailored management of their care with attention given to particular developmental concerns. Standards of care, such as the National Heart, Lung, Blood Institute [NHLBI] 2007 asthma guidelines (NHLBI, 2007), exist to guide patient care and in this case, also address specific adolescent needs. Advanced practice nurses should incorporate "national standards of care as a framework for managing patient care" (American Association of Nurse Practitioners [AANP], 2007, p. 2). There is a lack of research about nurse practitioner use of standards of care, especially in caring for adolescents with asthma.The purpose of this practice inquiry was to explore patterns of practice and perceptions of practice by the nurse practitioners who care for adolescents with asthma, and to evaluate the current patterns of practice in comparison with national standards for providing care to adolescents with asthma at the Larry Combest Community Health Wellness Center [LCCHWC]. The design for this practice inquiry was descriptive retrospective, using mixed methods for process evaluation of a program through description of nurse practitioner practice at an academic nurse-managed primary care clinic.The nurse practitioners addressed all components of the process of care recommended by the AANP (2007), which includes assessment, diagnosis, development and implementation of a treatment plan, and evaluation of the patient status. However, despite comments about the importance of using evidence based practice in the form of guidelines, results from health records review indicate that nurse practitioners have not fully integrated the NHLBI 2007 asthma guidelines into providing care to adolescents with asthma. This study establishes a baseline measure of adoption of the NHLBI 2007 asthma guidelines by nurse practitioners at this clinic site. The results of this study may ultimately contribute to nurse practitioners' awareness of use of standards of care and improved quality of care for adolescents with asthma.

L'accès aux soins de santé, notamment des plus pauvres, est une préoccupation au coeur des réflexions dans tous les systèmes politiques et juridiques nationaux. La question se pose davantage sur le continent africain où il existe peu de mécanismes de couverture santé. Les différents projets de Couverture maladie universelle initiés dans un certain nombre de pays africains tentent d'y apporter des solutions, mais peinent encore à se déployer. C'est le cas en Côte d'Ivoire depuis l'entrée en vigueur, le 1er octobre 2019, de la loi n°2014-131 du 24 mars 2014 instituant la Couverture maladie universelle. En dehors des travailleurs salariés et des fonctionnaires en activité ou à la retraite, les populations intègrent lentement et difficilement la CMU pourtant obligatoire pourtous. Il faut dire que le projet fait l'objet de critiques et de peu d'adhésion de la part de la population. Il pèche également par ses dispositions qui alimentent ces critiques, notamment sur la durée du délai de carence s’imposant à l’assuré, le caractère obligatoire de l'activité professionnelle pour les étrangers, le manque d'ouverture à d'autres formes de médecine telle que la médecine traditionnelle. Cela dit, l'exercice du droit fondamental à la santé dans un environnement marqué par un secteur informel important et une population à majorité pauvre passe par un système obligatoire et solidaire de mutualisation du risque comme la CMU. Reste à déterminer le modèle adéquat, notamment en termes de financement, afin de mettre en adéquation son objectifd’universalité et le contexte dans lequel il est mis en oeuvre
Access to health care, particularly for the poorest, is a central concern in all national political and legal systems. The issue is more acute on the African continent, where there are few health coverage mechanisms. The various Universal Health Coverage projects initiated in a number of African countries are attempting to provide solutions, but are still struggling to get off the ground. This has been the case in Côte d'Ivoire since law no. 2014-131 of 24 March 2014 instituting Universal Health Coverage came into force on 1 October 2019. Apart from salaried workers and civil servants, both active and retired, people are slowly and painstakingly integrating the CMU, despite the fact that it is compulsory for everyone. It has to be said that the project is the subject of criticism and little support from the population. It is also flawed by its provisions, which fuel these criticisms, in particular the length of the waiting period imposed on the insured, the compulsory nature of professional activity for foreigners, and the lack of openness to other forms of medicine such as traditionalmedicine. That said, if the fundamental right to health is to be exercised in an environment characterised by a large informal sector and a predominantly poor population, a compulsory, solidarity-based risk-pooling system such as the CMU is needed. What remains to be done is to determine the appropriate model, particularly in terms of funding, so as to match its universal objective with the context in which it is implemented

People with diabetes mellitus are more likely to die from cardiovascular causes than those without diabetes, and modifiable risk factors, such as hyperglycaemia, dyslipidaemia and hypertension can be targeted in intervention programs to decrease this risk. In addition to tertiary care for patients with diabetes, there is a need for simple programs to be implemented in the community that allow the benefits of improved metabolic and blood pressure control to be realised more widely. Pharmaceutical care comprises the detection, prevention and solution of drug-related problems in a quantifiable form, so that outcomes of care can be easily reviewed and monitored. Previous studies of pharmaceutical care programs in patients with diabetes do not provide conclusive evidence of the benefit of pharmaceutical care. The aim of this research was to evaluate the impact of the provision of pharmaceutical care to patients with diabetes mellitus in an Australian context. In order to develop a pharmaceutical care program, the characteristics of an Australian cohort of patients with diabetes were reviewed. The Fremantle Diabetes Study (FDS), was a community-based prospective observational study of diabetes care, control and complications in a postcode-defined region of 120 097 people surrounding the port city of Fremantle in Western Australia. It was intended that the FDS annual reviews would provide important local information in order to design and implement a prospective pharmaceutical care program. A pilot pharmaceutical care program was subsequently developed for use in a diabetes outpatient clinic. This program was then modified for use in a community-based sample of type 2 diabetes mellitus patients, drawn from the FDS cohort.Demographic parameters, including ethnicity and treatment details, were reviewed at study entry for the full FDS cohort and then over time for a subset of patients that returned for four subsequent annual assessments. Insulin use was more common in patients of Southern European origin compared with the Anglo-Celt group irrespective of the level of glycaemia, at baseline. This difference persisted during subsequent follow-up but was not associated with improved glycaemic control. These findings demonstrated that there are important ethnic differences in the management of patients with type 2 diabetes mellitus. The pilot pharmaceutical care program was carried out in high-risk diabetes mellitus patients attending a hospital outpatient clinic. The patients had poor glycaemic control, dyslipidaemia, hypertension and/or were on three or more prescription medications. In the pharmaceutical care arm, a clinical pharmacist reviewed and monitored all aspects of the patients' drug therapy in collaboration with other health care professionals at six weekly intervals for six months. The control patients received usual outpatient care. Seventy-three patients were recruited into the study, of whom 48 (66%) were randomised to receive pharmaceutical care. One in six patients was taking complementary medicines. The pharmaceutical care program provided patients with important medication information that resulted in changes to drug therapy. However, the six-month program did not lead to an improvement in glycaemic control. The next phase of the study adapted the pilot hospital-based pharmaceutical care program to a community-based setting.Two hundred and two type 2 diabetes mellitus FDS patients were recruited, of whom 101 (50%) were randomised to the pharmaceutical care program, and all were followed for 12-months. There were significant reductions in risk factors associated with coronary heart disease in the case but not the control group over time, specifically glycaemic control, lipid levels, and blood pressure. Glycosylated haemoglobin fell from 7.5% to 7.0% (P<0.0001), total cholesterol fell from 5 mmol/L to 4.6 mmol/L (P<0.0001), systolic blood pressure fell from 158 mmHg to 143 mmHg (P<0.0001) and diastolic blood pressure fell from 77mmHg to 71mmHg (P<0.0001). Multiple linear regression analysis confirmed that pharmaceutical care program involvement was an independent predictor of benefit after adjustment for key variables. The 10-year coronary heart disease risk for patients without a previous coronary event was reduced by 4.6% over the 12-month study period in the pharmaceutical care group (P<0.0001), while there was no change in the controls (P=0.23). This phase of the study showed that medium-term individualised pharmaceutical care reduced vascular risk factors in a community-based cohort of patients with diabetes and that provision of a multifactorial intervention can improve health outcomes in type 2 diabetes mellitus. As part of the pharmaceutical care program, a high level of complementary medicine use was found. As a result, a study of complementary medicine use was undertaken in 351 patients from the FDS. A convenience sample of FDS patients was interviewed regarding their use of complementary medicines. A literature search was conducted to assess the potential impact of these medicines on diabetes, concomitant medications or diabetes-related co-morbidities.Eighty-three of 351 (23.6%) patients with diabetes had consumed at least one complementary medicine in the previous year and 42% (77/183) of the products potentially necessitated additional patient monitoring or could be considered potentially inappropriate for a diabetic patient. The data indicated the need for patient disclosure of complementary medicine use and adequate monitoring for complementary medicine-related adverse events, as part of the pharmaceutical care process. The pharmaceutical care model was established to provide a framework by which drug use could be improved to enhance patients' clinical and health-related quality of life outcomes. For the present study, a straightforward pharmaceutical care program was adapted from a hospital setting to a community setting, where the principal requirement was a clinical pharmacist who had completed a self-directed diabetes-training program. In this context, clinically relevant parameters improved over the course of the study period. Pharmaceutical care programs such as this can begin the process of translating the findings of large and expensive clinical trials into standard clinical practice.

People with diabetes mellitus are more likely to die from cardiovascular causes than those without diabetes, and modifiable risk factors, such as hyperglycaemia, dyslipidaemia and hypertension can be targeted in intervention programs to decrease this risk. In addition to tertiary care for patients with diabetes, there is a need for simple programs to be implemented in the community that allow the benefits of improved metabolic and blood pressure control to be realised more widely. Pharmaceutical care comprises the detection, prevention and solution of drug-related problems in a quantifiable form, so that outcomes of care can be easily reviewed and monitored. Previous studies of pharmaceutical care programs in patients with diabetes do not provide conclusive evidence of the benefit of pharmaceutical care. The aim of this research was to evaluate the impact of the provision of pharmaceutical care to patients with diabetes mellitus in an Australian context. In order to develop a pharmaceutical care program, the characteristics of an Australian cohort of patients with diabetes were reviewed. The Fremantle Diabetes Study (FDS), was a community-based prospective observational study of diabetes care, control and complications in a postcode-defined region of 120 097 people surrounding the port city of Fremantle in Western Australia. It was intended that the FDS annual reviews would provide important local information in order to design and implement a prospective pharmaceutical care program. A pilot pharmaceutical care program was subsequently developed for use in a diabetes outpatient clinic. This program was then modified for use in a community-based sample of type 2 diabetes mellitus patients, drawn from the FDS cohort.
Demographic parameters, including ethnicity and treatment details, were reviewed at study entry for the full FDS cohort and then over time for a subset of patients that returned for four subsequent annual assessments. Insulin use was more common in patients of Southern European origin compared with the Anglo-Celt group irrespective of the level of glycaemia, at baseline. This difference persisted during subsequent follow-up but was not associated with improved glycaemic control. These findings demonstrated that there are important ethnic differences in the management of patients with type 2 diabetes mellitus. The pilot pharmaceutical care program was carried out in high-risk diabetes mellitus patients attending a hospital outpatient clinic. The patients had poor glycaemic control, dyslipidaemia, hypertension and/or were on three or more prescription medications. In the pharmaceutical care arm, a clinical pharmacist reviewed and monitored all aspects of the patients' drug therapy in collaboration with other health care professionals at six weekly intervals for six months. The control patients received usual outpatient care. Seventy-three patients were recruited into the study, of whom 48 (66%) were randomised to receive pharmaceutical care. One in six patients was taking complementary medicines. The pharmaceutical care program provided patients with important medication information that resulted in changes to drug therapy. However, the six-month program did not lead to an improvement in glycaemic control. The next phase of the study adapted the pilot hospital-based pharmaceutical care program to a community-based setting.
Two hundred and two type 2 diabetes mellitus FDS patients were recruited, of whom 101 (50%) were randomised to the pharmaceutical care program, and all were followed for 12-months. There were significant reductions in risk factors associated with coronary heart disease in the case but not the control group over time, specifically glycaemic control, lipid levels, and blood pressure. Glycosylated haemoglobin fell from 7.5% to 7.0% (P<0.0001), total cholesterol fell from 5 mmol/L to 4.6 mmol/L (P<0.0001), systolic blood pressure fell from 158 mmHg to 143 mmHg (P<0.0001) and diastolic blood pressure fell from 77mmHg to 71mmHg (P<0.0001). Multiple linear regression analysis confirmed that pharmaceutical care program involvement was an independent predictor of benefit after adjustment for key variables. The 10-year coronary heart disease risk for patients without a previous coronary event was reduced by 4.6% over the 12-month study period in the pharmaceutical care group (P<0.0001), while there was no change in the controls (P=0.23). This phase of the study showed that medium-term individualised pharmaceutical care reduced vascular risk factors in a community-based cohort of patients with diabetes and that provision of a multifactorial intervention can improve health outcomes in type 2 diabetes mellitus. As part of the pharmaceutical care program, a high level of complementary medicine use was found. As a result, a study of complementary medicine use was undertaken in 351 patients from the FDS. A convenience sample of FDS patients was interviewed regarding their use of complementary medicines. A literature search was conducted to assess the potential impact of these medicines on diabetes, concomitant medications or diabetes-related co-morbidities.
Eighty-three of 351 (23.6%) patients with diabetes had consumed at least one complementary medicine in the previous year and 42% (77/183) of the products potentially necessitated additional patient monitoring or could be considered potentially inappropriate for a diabetic patient. The data indicated the need for patient disclosure of complementary medicine use and adequate monitoring for complementary medicine-related adverse events, as part of the pharmaceutical care process. The pharmaceutical care model was established to provide a framework by which drug use could be improved to enhance patients' clinical and health-related quality of life outcomes. For the present study, a straightforward pharmaceutical care program was adapted from a hospital setting to a community setting, where the principal requirement was a clinical pharmacist who had completed a self-directed diabetes-training program. In this context, clinically relevant parameters improved over the course of the study period. Pharmaceutical care programs such as this can begin the process of translating the findings of large and expensive clinical trials into standard clinical practice.

Despite indications that colorectal cancer (CRC) screening strategies can decrease mortality and morbidity, screening rates among veterans remains to be low. In the Veterans Affairs (VA), the performance measure for CRC screening is lower than the national standard. This quality improvement (QI) project evaluated the effect of a team-based approach, effective electronic information structures, and the provision of education to nurses and patients in increasing CRC screening rate in primary care from 77% to 85%. CRC screening data were retrospectively collected prior to the start of the project and then compared to screening data 3 months after project implementation. The t test showed a statistically significant increase (p = .009) in CRC screening post intervention. Descriptive analysis was performed to evaluate the knowledge and proficiency of nurses with regard to CRC screening by using pre- and posttest questionnaires. The findings showed that emphasizing the importance of CRC screening among team members as well as appropriately dividing the work was effective in contributing to an increase in CRC screening in primary care. This project contributes to positive social change by increasing the nurses' confidence and proficiency in promoting health and disease prevention among the veterans; decreasing patient suffering; and improving collaboration between providers, nurses, and other departments in the VA primary care.

This project has been developed in the breakthrough framework of the Value Based Health Care (VBHC), which aims at improving health outcomes at lower cost in different medical conditions. The VBHC paradigm has been applied in cancer care to improve the management of the disease, considering epidemiological, medical, psychological and economic outcomes. Two studies have been designed and implemented to better investigate the psychological perspective of lung and prostate cancer patients, in the light of the VBHC paradigm. The project identifies the trend of clinical and psychological status over time and predict this change with sociodemographic or medical variables. Several categories of patients characterized by different trends were identified, elucidating the psychological dimension of cancer patients. A person-oriented approach was used to analyze patients’ recovery. One-year Quality of Life (QoL) trends in early stage of lung and prostate cancer patients undergoing surgery were identified. Patients’ recovery after surgery was characterized by both an overall decrease of symptoms and an increase of health and functioning over time. Prostate cancer patients showed different longitudinal trajectories of urinary incontinence and sexual dysfunction. In lung cancer patients, pre-surgery QoL, type of surgery, perioperative complications, and age, affected the post-surgery QoL as well as the linear and quadratic trends over time. Through the implementation of this holistic approach, the predictive model of patients’ recovery will be developed, thus improving medical decision-making, the choice of treatment, and patients’ awareness about their care process. Potential harms, QoL, and expected outcomes will be more predictable and better manageable. Participants will be more empowered, being more aware of their post-surgical care.

Improving access to care is not enough if it is not effectively delivered. Poor quality healthcare services have proven to slow progress to achieve better health outcomes and substantially increase the societal and economic burden of diseases. It is essential to provide healthcare services that constantly meet client-specific needs, which vary widely per individual, and to consider factors such as sociodemographic, psychological, health conditions. The emergence of digital technologies has played a critical role in the advancement of the healthcare sector. However, there remains critical knowledge-gaps demonstrating best practices to support digital health adoption and integration. The current research aimed to address this gap by making a case for providing a user-informed digital health model to improve Australians’ experience of melanoma post-treatment care. It captured information about the experience of care from a melanoma patient’s perspective and attitude toward digital health interventions. The data were collected through an online questionnaire developed based on clinical recommendations from melanoma guidelines and the literature. 95 patients were investigated, as well as their attitude toward digital health. Overall, 30% expressed difficulties accessing care due to geographical barriers, cost and time pressure. A majority presented signs of distress and desire for more educational and psychosocial support. The data also identified significant associations between access and psychological distress. Overall, participants reported positive attitudes toward the use of digital health, particularly if it can improve their quality of life. The findings showed that adapted uses of digital health could increase self-management and healthy behaviour; reduce psychological distress and social isolation; enable timely access to healthcare providers and communication, and support collaboration between clinicians. However, the study also reported a substantial lack of knowledge and awareness about technologies made available to melanoma patients. Recommendations on where to start and how we could encourage digital health uptake to provide high-quality, effective and adequate care are proposed. The thesis concludes on a call to action for healthcare stakeholders to ‘upgrade’ the existing melanoma healthcare system.

Introduction: Home-based care is an important part of the health care sector globally. But there is a lack of studies of the working conditions for health care workers within home-based care. Aim: The aim of the study is to illuminate the different experiences of working within home-based care for healthcare workers in economically poor communities.   Method: A qualitative research, data was collected through six semi-structured interviews and data was analysed by content analysis. Results: Three categories and eight sub-categories was identified in the data analysis: The Community; Working Conditions in the Community, Safety in the Community & Attitudes in the Community, The Family; The Family Affects the Patient & The Family Affects the Work Tasks and The Health Care Worker; Helping Beyond the Work Tasks, Emotional Involvement & Job Satisfaction. Conclusion: The study presents different challenges such as safety- and attitudes in the community but also the love for the work in the community.

This study describes primary care nurse practitioner (PCNP) beliefs in, knowledge, implementation and utilization of evidence based practice (EBP). Research questions answered are: 1. What are the levels of belief, implementation, knowledge and utilization of EBP among PCNPs? 2. Is there a relationship with PCNP demographics (personal, professional, and practice), belief, knowledge, implementation and utilization of EBP? 3. Do PCNP demographics (personal, professional, and practice) and scores on belief, knowledge and implementation influence EBP utilization? EBP is considered a standard of care and essential to nurse practitioner practice. The primary advantages of EBP include improved quality of care through the utilization of patient resources, provider resources and experiences, current research and scientific information. However, few studies describe nurse practitioner beliefs, knowledge in EBP and the extent to which this may affect primary care nurse practitioners' (PCNP) utilization of EBP in their practice. Four questionnaires incorporated into one survey were used to examine PCNP beliefs, knowledge, implementation and utilization of EBP. JNC7 guideline knowledge and self-reported use was used to measure EBP utilization. A convenience sample of 202 FNPs, ANPs and GNPs were obtained during the American Academy of Nurse Practitioners National Conference 2011 in Las Vegas, Nevada. PCNPs surveyed were found to have a high level of belief in EBP but did not report implementing EBP more than 3 times in the past 8 weeks. Belief was statistically higher in doctorally prepared PCNPs. Ninety-five percent of the participants were familiar with the JNC7 guideline but the group scored a mean of 69% on knowledge of JNC7 guideline specifics. Only 25% of respondents indicated they utilized guidelines in hypertension management. Future studies should include quantitative and qualitative evaluation of EBP implementation facilitators and obstacles. Findings in this study have provided initial information to better understand PCNPs and EBP.

Background: The global Stop TB Strategy introduced by the World Health Organization included empowering people with tuberculosis (TB) as a key element in TB care and prevention. The community can successfully contribute to achieving high levels of coverage of TB diagnosis and treatment. However, whether the community is a true partner or a mere beneficiary of the health interventions and whether locally led initiatives are sustainable in the long term remain the main challenges in involving the community in TB care. An asset-based approach emphasises positive capabilities, nurtures the strengths and resources of local people, and has potential to reinforce participation, local leadership and sustainable initiatives at the community level. While asset-based approaches have been found to be effective for other issues, no published studies were identified that utilised asset-based approaches in interventions to empower TB patients or to guide community-based TB care. This study implemented an asset-based intervention with leadership groups in small number of rural Indonesian villages where TB is prevalent. Goal: This project aimed to integrate an asset-based approach into an existing TB program and to assess whether this approach could reduce the communities’ dependency on the TB service provided by a non-government organisation. It also aimed to investigate whether this approach could improve the current TB program and the communities’ knowledge and behaviours related to TB prevention and case finding. Methods: The study applied the principle of community-based participatory research. An asset-based intervention was implemented with TB leadership groups in three villages, and another three similar villages provided a comparison group. Semi-structured interviews were conducted with 50 participants, including village TB volunteers, TB patients, ex-TB patients, village leaders and public health centre staff at the beginning of the study and repeated six months after the asset-based intervention in all six villages. A record audit to assess case finding was also conducted. Two- to 4-day asset-mapping workshops were carried out in the three intervention villages. Monthly visits, home visits, informal discussions, group discussions, and observations recorded in field notes were conducted following the intervention. Similar follow-up activities were performed in the comparison villages. Thematic analysis was performed on interview data to describe the experiences of the TB leadership groups and key stakeholders after the asset-based intervention, and simple descriptive analysis using frequencies was carried out on field notes and observational data collected to describe each theme of knowledge about TB. Results: The intervention successfully generated significant changes in relation to the TB leadership groups’ perceptions of themselves and their leadership capacity, built dialogue among stakeholders, strengthened local initiatives and encouraged community engagement. This in turn improved community-based TB activities and improved knowledge of TB and behaviours related to prevention of TB and early case finding. These changes did not occur in the comparison villages. Thematic analysis of the experiences of TB leadership group members and key stakeholders revealed that local leadership and the role of ‘catalyst’ were the most important factors in the success of the intervention and in ensuring the continuation of the TB program. Conclusion: Despite several barriers identified during the study, the approach and techniques demonstrated in this study may represent an effective method to engage communities, build local leadership and deliver outcomes that could be generalisable to similar settings and other health issues.

In this study, I explored Adult Foster Care (AFC) provider experiences. AFC is a small-setting option for community-based long-term care. This option varies considerably in accessibility and structure across states; due to the nature of the state's approach to AFC, this initial research effort focused on AFC provider experiences in North Carolina. As of 2013, there were 632 AFC facilities in North Carolina (NC DHHS, 2013). AFC homes in North Carolina are licensed by the state and allow service for 2-6 residents per home (Mollica et al., 2009). The approach to research was informed by literature on AFC, the disabilities context of AFC, and Child Foster Care (CFC). The theoretical framework guiding the study included theories of care and relational reciprocity; power, difference, and hierarchy; and intersectionality. I conducted semi-structured, guided interviews with 26 providers. As a context for grounded theory data analysis, I also relied on reflexive material stemming from my positionality as a care worker. Emergent codes related to issues of the providers' motivation for beginning work as an AFC provider; providers' personal and professional roles; perspectives on giving residents a choice; balancing "family" with business; reciprocity and how residents express their affection and care to providers; providers' values; and dialectics of power and care. Findings shed light on implications for state and organizational responsibility to the AFC system, and practice context for provider-resident relationships.
Ph. D.

Thesis (MPH) -- University of Limpopo, 2010.
Background Namibia is one of the country most affected by HIV/AIDS epidemic in the world and in Sub¬Sahara Africa with an adult prevalence of 19,7 %, and 210.000 people estimated to be living with HIV/AIDS at the end of 2003. The Caprivi region adult prevalence in adult pregnant wom~n is estimated at 43%. The health care services are overstrained with patients and home-based care (HBC) is seen a possible solution. The scale up of HBC and expansion of coverage to patients has lessened the burden of public hospitals to deal with all these chronically ill patients. The challenges that volunteers are facing impact in the quality of care people living with HIV I AIDS receive. Objectives This study assessed the utilization of home-based care service, knowledge and perception of People living with HIV and AIDS (PL WHA) toward home-based care services. The views of volunteers towards home-based care service are also reported. Methods This is a qualitative study that utilized Focus Group Discussions (FGDs) for the home-based care-givers and in-depth interview with the clients accessing antiretroviral treatment at Katima State Hospital. A total of four focus group discussions were organized with care-givers comprising 31 adult participants (15 males and 16 females) and 18 in-depth interviews were conducted with the people living with HIV and AIDS accessing antiretroviral treatment (ART) at Katima State Hospital. All FGDs were tape recorded and one-to-one interview was hand written. Result The study demonstrates that most of the participants have positive attitudes toward utilization of HBC service. However, few people are still afraid to disclose their health status. In general, the community participation has tremendously reduced stigmatization. The self-reported health status by the HBC givers in order to have access to nutrition support may have played a role in reducing the stigma associated with HIV and thus increased the number of people utilizing the HBC service. The HIV -positive participants valued the assistance received from the volunteers and volunteers appreciate the training received to enable them to undertake their duties with more confidence. The dress code of volunteers when visiting patients was perceived to disclose HIV status but did not influence patient attitude to access the service. Conclusion The improvement in community knowledge about HIV and HBC service has enhanced the positive attitude toward utilization of home-based care service which has consequently reduced the stigma associated with HIV. Advocacy is required to improve the working condition of volunteer care-givers home-based care by policy markers. The collaboration between different stakeholders will advance and sustain the HBC service in focusing on prevention of HIV infection.

Magister Scientiae (Physiotherapy) - MSc(Physio)
People with disabilities (PWD) often come from disadvantaged communities and struggle to access health and rehabilitation, education and employment. This leads to poorer health outcomes, lower education achievements, and higher rate of unemployment in comparison to people without disabilities. Therefore there is a need to empower PWD to remove all barriers which prevent them from participating in all aspects of their communities. In South Africa, 5% of the population is disabled and in a worldwide review conducted on access to rehabilitation services, it was reported that South Africa provided 21% to 40% of the disabled population with rehabilitation services. In 2012 the Department of Health (DOH) trained a new cadre of community health worker (CHW) in the field of rehabilitation in order to improve PWDs‘ access to health services. As a result, health professionals in the Western Cape became concerned about the role of this new cadre of rehabilitation care worker in PHC and CBS. The aim of this study was therefore to explore health professionals‘ perceptions of the newly trained rehabilitation care workers (RCWs). Q methodology was selected as an appropriate research design to meet the objectives of this study as it can be used to analyse opinions, perceptions and attitudes. The study population consisted of all the health professionals who engaged with the RCWs in the clinical workplace during their clinical practice module. A convenient sample of sixteen health professionals participated in this study. Ethics approval was obtained to conduct this study and all participants gave written consent to participate in this study. The researcher gathered all the viewpoints of the health professionals regarding the new rehabilitation care workers (RCWs) by conducting focus group discussions and document analysis. Statements were then drawn up based on the health professionals' viewpoints. The participants then ranked these statements from strongly agree to strongly disagree on a Q data score grid, in a process called Q sorting. The completed Q data score grids, called Q sorts, were then entered into PQMethod software programme for statistical and factor analysis. From the results of this Q analysis, two factors emerged which were analysed and interpreted. A factor is representative of participants with similar opinions. The participants loading onto Factor one and Factor two shared similar opinions of the RCWs. The results indicated that the participants were of the opinion that RCWs‘ role would be to strengthen primary health care (PHC) and community-based rehabilitation (CBR) and promote the participation of PWD in society. The results suggested that the RCWs were capable of improving the quality of life of PWD by empowering PWD to become actively involved in all aspects of community life. The participants felt that the RCWs would be included in the health system by working at intermediate care centres (facility-based) and in the community (home-based). However, the participants agreed that the RCWs must work under the direct supervision of qualified health professionals. Participants loading onto Factor one and Factor two further agreed that RCWs worked well in the structured environment of intermediate care health facilities. They felt that it would be beneficial for RCWs to be employed at these health facilities as the RCWs reduced the workload of the health professionals. From the results, it was also found that health professionals were of the opinion that the RCWs displayed positive attitudes and good professional behaviour in the clinical environment. Health professionals however identified gaps in the knowledge of the RCWs and a lack of skills to perform certain tasks. However, health professionals agreed that the RCWs' skills will develop and improve with time and exposure. This study showed that health professionals had positive perceptions of the RCWs and this could indicate that RCWs will be well accepted by health professionals as part of the PHC team. This could lead to the effective utilisation of RCWs in community-based rehabilitation. Recommendations can be made to the developers and implementers of the RCW training curriculum to make adjustments to the curriculum so as to address the lack of knowledge and skills in certain aspects of health and disability. It can further be recommended that South Africa's National DOH capitalise on these positive perceptions and train more RCWs to extend rehabilitation and health services to more underserved communities. This will assist the South African Government in ensuring that more PWD receive rehabilitation and become included in all aspects of their communities as is envisaged in the 2020/2030 health plan.

Thesis (PhD)--Stellenbosch University, 2015.
ENGLISH ABSTRACT: Background A need for primary care practitioners to utilise clinical research evidence in practice has been identified and is well described. However a chasm between evidence and practice still exists in primary health care (PHC). Although clinical practice guidelines have been shown to improve the quality of clinical practice and attempt to bridge the gap between evidence and practice, practitioners are often not aware of practice guidelines and fail to access, adopt or adhere to evidence-based recommendations contained in them. Central question How can the implementation of clinical research evidence, using the example of the national evidence-based guideline on asthma, be improved in the PHC sector in the MDHS of the Cape Town metropole? Aim This research aimed to improve the implementation of clinical research evidence in PHC, by learning from the specific example of the national evidence-based asthma guideline in PHC practice in the Metro District Health System (MDHS) of the Cape Town metropole, and to make recommendations to key stakeholders regarding the future implementation of evidence-based guidelines. Objectives  To gain insight into the current quality of asthma care in PHC in the MDHS of the Cape Town metropole.  To determine whether the process of implementation of the new asthma guideline contributed to an improvement in the quality of care in the MDHS.  To explore ways of improving the process of implementation of the national asthma guideline in PHC in the MDHS.  To gain insight into the perceptions, attitudes and knowledge of asthmatic patients regarding their asthma management.  To explore how EBP is understood and perceived by doctors in PHC. Stellenbosch University https://scholar.sun.ac.za  To understand how PHC doctors in the public and private health sectors gain access to and use guidelines.  To explore the experiences, perspectives and understanding of family physicians (FPs) (academic, private and public sector) with regard to EBP and the implementation of guidelines in PHC practice.  To gain insight into the understanding of FPs regarding the perceived problems and main barriers to EBP and their views of the process of guideline implementation in PHC.  To gain insight into the knowledge, perceptions and attitudes of clinical nurse practitioners in the public sector with regard to EBP and the process of guideline implementation. Methodology This study was conducted in the PHC setting of the Cape Town metropole. This research was conducted in three phases and used cross-sectional surveys, quality improvement (QI) cycles, qualitative research methods, such as interviews with FPs, and participatory action research (PAR). Phase 1 involved a cross-sectional survey, which looked at the knowledge, awareness and perspectives of doctors, regarding evidence-based practice (EBP) and guideline implementation using the national evidence-based asthma guideline published in 2007. It also involved QI cycles conducted over a period of five years to assess the baseline quality of asthma care in the PHC sector and to evaluate improvement in asthma care as a result of the QI cycles and associated educational workshops. Phase 2 involved interviews conducted with FPs in academia as well as in the private and public health care sectors who were responsible for clinical governance in PHC in the Cape Town metropole. During this phase of the research the experiences, perspectives and understanding of FPs (academic, private and public sector) with regard to EBP and the implementation of guidelines in PHC practice were explored. Phase 3 involved PAR with primary care practitioners at community health centres (CHCs) using a co-operative inquiry group (CIG) to improve asthma guideline implementation in PHC. The CIG investigated how to improve the implementation of the asthma guideline in their respective CHCs and completed four cycles of planning-action-observation-reflection. The four cycles focused on implementation of an asthma self-management plan (ASMP), exploring the capability of clinical nurse practitioners to implement the guidelines, exploring the views of patients on their asthma care and implementing better patient education. A final consensus of the CIG’s learning was then constructed. Results With regard to quality improvement of asthma care in PHC: The first objective of the study was largely addressed through the baseline audits conducted in 2007 and 2008. This showed that the baseline quality of asthma care, with specific reference to the assessment of the patient’s level of control, measuring the patient’s peak expiratory flow rate (PEFR), assessing the patient’s inhaler/ spacer technique, recording the smoking status, the adequate prescription of controller and reliever metered dose inhalers (MDI) refills during visits and particularly the issuing of an ASMP during visits, was poor. The second objective was addressed through the annual audits conducted in 2007, 2008, 2010 and 2011 during the period of implementation. This showed that although clear cause and effect reasoning cannot be inferred, overall statistically and clinically significant improvements in the quality of care occurred in conjunction with the process of asthma guideline implementation. Despite the improvement in structural and process criteria there was no corresponding improvement in the outcome criteria and in fact the utilisation of facilities for emergency visits significantly increased, while the hospitalisation of patients remained constant. The third objective was to explore ways of improving the process of implementation of the national asthma guideline in PHC in the MDHS. This was largely addressed through the action-research process at selected CHCs. This showed that implementation could be improved by ongoing educational support and formal interactive training workshops with the staff members who were directly involved with patients. The development and use of educational aids and ASMPs based on the guideline recommendations were useful and encouraged patient participation in decision making regarding their care. The fourth objective, specific to asthma care, addressed by means of a survey and showed that even though the majority of asthma patients participated in decisions regarding their asthma and felt satisfied with the quality of care they received, the prevalence of smoking among asthma patients was high and opportunities for smoking cessation counselling were missed. Even though documentation of peak flow recordings and patients’ knowledge of the difference between the reliever and controller MDIs were good, patients’ perceptions with regard to education on the inhaler technique, the assessment of the level of control, the issue of written information regarding asthma and the use of ASMPs remained poor and could be improved. With regard to EBP and asthma guideline implementation in PHC: The fifth objective of the study was addressed by means of a survey which showed that the doctors in PHC used evidence in clinical decision making and agreed on the usefulness and importance of EBP in improving the quality of patient care in South Africa. There was a difference in the engagement with activities related to EBP between the public and private sector PHC doctors and there is a need for formal training in the skills and processes of EBP. The sixth objective was addressed by means of a survey which showed that a good proportion of both public and private sector doctors in the Cape Town metropole were well aware of the asthma guideline, had used the guideline and had adopted, acted on and adhered to specific guideline recommendations. There was a high level of general awareness of the asthma guideline and recommendations were being adopted in practice, although the lack of formal disease registers, monitoring and evaluation of asthma care and the utilisation of an ASMP could be improved on. The seventh objective was addressed by qualitative research which showed how the views and perspectives of FPs regarding EBP and the process of guideline implementation contributed to the development of a conceptual framework for the process of guideline implementation. The eighth objective was addressed by qualitative research, which identified barriers present in each step of the implementation process. Time constraints, practitioner workload, lack of financial resources, lack of ownership, the lack of timeous organisational support and practitioner resistance to change were important barriers to guideline implementation in an already overburdened PHC setting. A conceptual model was developed which showed that the process of guideline implementation should be tailored to the barriers identified. The ninth objective was addressed by means of a survey which showed that the concept of EBP was fairly new to CNPs in PHC and identified a need to learn more about it. CNPs agreed that clinical research evidence is useful in the daily management of patients, that their decision making is based on evidence, that evidence-based nursing can improve the quality of patient care, that there is a place for evidence-based nursing in their practices at their respective CHCs, that EBP will make a difference in the quality of care of their patients and that evidence-based nursing practice has an important role to play in South Africa. Although the awareness of CNPs with regard to the asthma guideline was poor, the vast majority reported that they personally educated patients on the difference between reliever and controller MDIs, recorded the smoking status of patients in the records, demonstrated the inhaler technique to all their asthma patients, assessed the level of control and agreed that inhaled corticosteroids are the mainstay of treatment in patients with chronic persistent asthma. However only a small minority (mainly at the CHCs where action research occurred) started issuing patients with ASMPs. In answering the central question: “How can the process of implementation of clinical research evidence, using the example of the national evidence-based guideline on asthma, be improved in the PHC sector in the MDHS of the Cape Town metropole?”, this thesis concludes that the process of guideline implementation can be improved in the PHC sector by an in depth understanding and systematic approach to the whole process. A conceptual framework is provided as a model which attempts to guide and make sense of this process of guideline implementation. A stepwise approach is presented and provides a summary of the main research findings. The model shows that the initial process of evidence creation should not only deal with research evidence of high quality, but should incorporate research evidence that is relevant to the particular context of care. In addition the model shows that guideline development should be inclusive and involve a wider spectrum of stakeholders as well as patients; that guideline contextualisation, dissemination and implementation should be carefully planned. Special consideration should be given to local decision making about adoption or prioritisation of specific recommendations as part of ongoing quality improvement cycles and the conversion of published guidelines into practical tools for practitioners to use in consultation, prior to dissemination. Implementation should anticipate that members of the PHC staff will differ in their readiness to change and that strategies should consciously embrace principles of behaviour change and build up a sense of ownership, choice and control over local adoption of the guidelines. Academic centres, such as universities and professional bodies, have a role to play in identifying, appraising and synthesising the evidence, and giving input into guideline development. They can also assist by innovating and evaluating practical tools as part of the contextualisation stage and by providing continuing education during implementation as part of their social responsibility. The health care organisation (HCO) should prevent unnecessary delays in guideline implementation by ensuring that policy, resources and recommendations are aligned during the contextualisation stage; that barriers encountered should be dealt with throughout the entire process, and that ongoing monitoring and evaluation of the quality of care occurs. Conclusion This research used different methods and innovative PAR to bridge the gap between evidence and practice. A new conceptual model for guideline implementation is recommended for use to assist with implementation and knowledge translation in PHC locally, nationally and in similar Low Middle Income Countries (LMIC) in Africa.
AFRIKAANSE OPSOMMING: Agtergrond ‘n Behoefte om kliniese navorsingsbewyse in die praktyk te benut, is by primêre – sorg praktisyns geïdentifiseer en word goed beskryf. Daar bestaan egter steeds ‘n gaping tussen bewyse en die praktyk in primêre gesondheidsorg. Alhoewel getoon kon word dat kliniese praktykriglyne die kwaliteit van kliniese praktyk verbeter, en poog om die gaping tussen bewys en praktyk te oorbrug, is praktisyns dikwels nie bewus van praktykriglyne nie, en faal daarin om toegang te verkry tot bewysgebaseerde aanbevelings wat daarin vervat is, asook om dit aan te neem en na te kom. Sentrale vraag Hoe kan die implementering van kliniese navorsingbewyse, deur die voorbeeld van nasionale bewysgebaseerde riglyne oor asma te gebruik, verbeter word in die primêre gesondheidsorgsektor in die Metropooldistrik – gesondheidstelsel van die Kaapstad – metropool? Doel Die doel van hierdie navorsing was om die implementering van kliniese navorsingbewyse in die primêre gesondheidsorg te verbeter, deur te leer vanuit die spesifieke voorbeeld van die nasionale bewysgebaseerde asmariglyne in die primêre gesondheidsorgpraktyk in die Metropooldistrik – gesondheidstelsel van die Kaapstad - metropool, en om aanbevelings aan sleutel – rolspelers te maak aangaande die toekomstige implementering van bewysgebaseerde riglyne. Doelwitte  Om insig te verkry in die huidige kwaliteit van asmasorg in die primêre gesondheidsorg in die Metropooldistrik – gesondheidstelsel van die Kaapstad – metropool.  Om vas te stel of die implementeringsproses van die nuwe asmariglyne bygedra het tot ‘n verbetering in die kwaliteit van sorg in die Metropooldistrik – gesondheidstelsel.  Om maniere te verken om die implementeringsproses van die nasionale asmariglyne in die primêre gesondheidsorg in die Metropooldistrik – gesondheidstelsel te verbeter.  Om insig te verkry in die opvattings, houding en kennis van asmatiese pasiënte met betrekking tot hul asma – bestuur.  Om te verken hoe bewysgebaseerde praktyk verstaan en deur dokters in primêre gesondheidsorg toegepas word.  Om te verstaan hoe primêre gesondheidsorgdokters in die openbare - en privaatgesondheidsektore toegang tot, en die toepassing van riglyne verkry.  Om die ervaringe, perspektiewe en begrip van gesinspraktisyns (akademies, privaat en openbare sektor) met betrekking tot bewysgebaseerde praktyk, en die implementering van riglyne in primêre gesondheidsorg, te verken.  Om insig te verkry in die begrip van gesinspraktisyns met betrekking tot die probleme wat waargeneem is, hoofhindernisse tot bewysgebaseerde praktyk, asook hul persepsies van die proses van riglyn – implementering in primêre gesondheidsorg.  Om insig te verkry in die kennis, persepsies en houding van kliniese verpleegpraktisyns in die openbare sektor, met betrekking tot bewysgebaseerde praktyk en die proses van riglyn – implementering. Metodologie Hierdie studie is uitgevoer in die primêre gesondheidsorg - instellings van die Kaapstad – metropool. Hierdie navorsing is in drie fases uitgevoer, en het deursnee – ondersoeke, kwaliteitverbeteringsiklusse, kwalitatiewe navorsingsmetodes soos onderhoude met gesinspraktisyns, en deelnemende aksienavorsing gebruik. Fase 1 het ‘n deursnee – ondersoek behels oor die kennis, bewusmaking en perspektiewe van dokters met betrekking tot bewysgebaseerde praktyk en riglyn – implementering , deur die nasionale bewysgebaseerde asmariglyne te gebruik wat in 2007 gepubliseer is. Dit het ook kwaliteitverbeteringsiklusse behels wat oor ‘n tydperk van vyf jaar uitgevoer is, om die basislyn – kwaliteit van asmasorg in die primêre gesondheidsorg te assesseer, en om die verbetering in asmasorg te evalueer as ‘n uitvloesel van die kwaliteitverbeteringsiklusse en geassosieerde opvoedkundige werkswinkels. Fase 2 het onderhoude behels met gesinspraktisyns in akademia, sowel as in die privaat - en openbare gesondheidsorgsektore wat verantwoordelik was vir kliniese staatsbestuur in primêre gesondheidsorg in die Kaapstad – metropool. Gedurende hierdie fase van die navorsing was die ervaringe, perspektiewe en begrip van gesinspraktisyns (akademia, privaat – en openbare sektor) met betrekking tot bewysgebaseerde praktyk, en die implementering van riglyne in primêre gesondheidsorg, verken. Fase 3 het deelnemende aksienavorsing met primêre sorg – praktisyns by gemeenskaps – gesondheidsentrums behels, deur ‘n koöperatiewe ondersoekgroep te gebruik om die asmariglyn – implementering in primêre gesondheidsorg te verbeter. Die koöperatiewe ondersoekgroep het ondersoek ingestel hoe om die implementering van die asma – riglyne in hul onderskeie gemeenskaps – gesondheidsentrums te verbeter, en het vier siklusse van beplanning – aksie – observasie – refleksie voltooi. Die vier siklusse het gefokus op die implementering van ‘n asma – selfbestuurplan, die bekwaamheid van kliniese verpleegpraktisyns om die riglyne te implementeer te verken, die persepsies van pasiënte oor hul asmasorg te verken, en die implementering van beter pasiënt – opvoeding. ‘n Finale konsensus van die koöperatiewe ondersoekgroep se studie was toe opgestel. Resultate Met betrekking tot gehalteverbetering van asmasorg in primêre gesondheidsorg: Die eerste doelwit van die studie is hoofsaaklik aangespreek deur die basislyn – oudit wat in 2007 en 2008 uitgevoer is. Dit het getoon dat die basislynkwaliteit van asmasorg, met spesifieke verwysing na die assessering van pasiënte se vlak van beheer, meting van die pasiënt se piek ekspiratoriese vloeitempo, assessering van die pasiënt se inhaleringstegniek, optekening van die pasiënt se rookstatus, die voldoende voorskryf van reguleerder - en verligter gemeterde dosis inhaleerderhervullers tydens besoeke, en veral die verskaffing van ‘n asma – selfbestuurplan tydens besoeke, swak was. Die tweede doelwit is aangespreek deur die jaarlikse ouditte wat uitgevoer is in 2007, 2008, 2010 en 2011 gedurende die periode van implementering. Dit toon dat, hoewel duidelike oorsaak en effek – argumentering nie afgelei kan word nie, algehele statisties en klinies - beduidende verbeterings in die kwaliteit van sorg voorgekom het, in samewerking met die proses van asmariglyn – implementering. Ten spyte van die verbetering in strukturele – en proseskriteria, was daar geen ooreenstemmende verbetering in die uitkomskriteria nie. In werklikheid het die benutting van fasiliteite vir noodbesoeke aansienlik verhoog, terwyl die hospitalisasie van pasiënte konstant gebly het. Die derde objektief was om maniere te verken om die implementeringsproses van die nasionale asmariglyne in primêre gesondheidsorg in die Metropooldistrik – gesondheidstelsel te verbeter. Dit was hoofsaaklik aangespreek deur ‘n aksienavorsingproses by geselekteerde gemeenskaps – gesondheidsentrums. Dit het getoon dat implementering verbeter kon word deur deurlopende opvoedkundige ondersteuning en formele interaktiewe opleidingswerkswinkels met die personeellede wat direk betrokke was met die pasiënte. Die ontwikkeling en gebruik van opvoedkundige hulpmiddels, en asma - selfbestuurplanne gebaseer op die riglyn – aanbevelings was nuttig, en het pasiëntdeelname in besluitneming rakende hul sorg, aangemoedig. Die vierde doelwit, spesifiek met betrekking tot asmasorg, is aangespreek by wyse van ‘n opname. Dit het getoon dat, alhoewel die meerderheid van asma – pasiënte deelgeneem het aan besluite rakende hul asma, en tevrede was met die kwaliteit van sorg wat hulle ontvang het, die voorkoms van rook onder asma – pasiënte hoog was, en geleenthede vir rookstaking – berading was gemis. Alhoewel dokumentasie van piekvloei – opnames en pasiënte se kennis van die verskil tussen die verligter en kontroleerder - gemeterde dosis inhaleerders goed was, was pasiënte se persepsies met betrekking tot opvoeding in die inhaleringstegniek, die assessering van die vlak van beheer, die uitreiking van geskrewe inligting ten opsigte van asma, en die gebruik van asma – selfbestuurplanne steeds swak en kon dit verbeter word. Met betrekking tot bewysgebaseerde praktyk en asmariglyn – implementering in primêre gesondheidsorg: Die vyfde doelwit van die studie is aangespreek by wyse van ‘n opname wat getoon het dat die dokters in primêre gesondheidsorg bewyse in kliniese besluitneming gebruik het, en saamgestem het met die nuttigheid en belangrikheid van bewysgebaseerde praktyk in die verbetering van die kwaliteit van pasiëntsorg in Suid – Afrika. Daar was ‘n verskil in omgang met aktiwiteite wat verband hou met bewysgebaseerde praktyke tussen die openbare – en privaatsektordokters. Daar is dus ‘n behoefte aan formele opleiding in die vaardighede en prosesse van bewysgebaseerde praktyke. Die sesde doelwit is aangespreek by wyse van ‘n opname wat getoon het dat ‘n goeie proporsie van beide openbare en privaatsektordokters in die Kaapstad- metropool wel bewus was van die asmariglyn en het spesifieke riglyn – aanbevelings aangeneem, daarop gereageer en nagekom. Daar was ‘n hoë vlak van algemene bewustheid van die asmariglyn, en aanbevelings was aangeneem in die praktyk, alhoewel daar verbeter kon word op die gebrek aan formele siekteregisters, monitering en evaluering van asmasorg, en die benutting van ‘n asma – selfbestuurplan. Die sewende doelwit is aangespreek deur kwalitatiewe navorsing wat getoon het hoe die persepsies en perspektiewe van gesinspraktisyns ten opsigte van bewysgebaseerde praktyk en die proses van riglyn – implementering bygedra het tot die ontwikkeling van ‘n konseptuele raamwerk vir die proses van riglyn – implementering. Die agste doelwit is aangespreek deur kwalitatiewe navorsing, wat hindernisse in elke stap van die implementeringsproses identifiseer het. Tydbeperkings, praktisynswerklading, gebrek aan finansiële hulpbronne, gebrek aan eienaarskap, die gebrek aan tydige organisasie – ondersteuning en praktisynsweerstand ten opsigte van verandering, was belangrike hindernisse in riglyn – implementering in ‘n reeds oorlaaide primêre sorg – omgewing. ‘n Konseptuele model is ontwikkel wat getoon het dat die proses van riglyn – implementering aangepas moet word by die geïdentifiseerde hindernisse. Die negende doelwit is aangespreek by wyse van ‘n opname wat getoon het dat die konsep van bewysgebaseerde praktyk betreklik nuut was vir kliniese verpleegpraktisyns in primêre gesondheidsorg, en het ‘n behoefte geïdentifiseer om meer hieroor te leer. Kliniese verpleegpraktisyns het saamgestem dat kliniese navorsing nuttig is in die daaglikse bestuur van pasiënte, dat hul besluitneming gebaseer moet wees op bewyse, dat bewysgebaseerde verpleging die kwaliteit van pasiëntsorg kan verbeter, dat daar ‘n plek is vir bewysgebaseerde verpleging in hul praktyke by hul onderskeie gemeenskap-gesondheidsentrums, dat bewysgebaseerde praktyk ‘n verskil sal maak in die kwaliteit van sorg van hul pasiënte, en dat bewysgebaseerde verpleegpraktyk ‘n belangrike rol kan speel in Suid – Afrika. Alhoewel die bewustheid onder kliniese verpleegpraktisyns met betrekking tot die asmariglyne swak was, het die oorgrote meerderheid verslag gegee dat hulle die pasiënte persoonlik opgevoed het oor die verskil tussen verligting – en beheerder gemeterde dosis - inhaleerders, die rookstatus van pasiënte in die verslae opgeteken het, die inhaleringstegniek aan al hul pasiënte gedemonstreer het, die vlak van beheer geassesseer het, en saamgestem dat geïnhaleerde kortikosteroïede die staatmaker van behandeling is in pasiënte met chroniese, aanhoudende asma. Slegs ‘n klein minderheid (hoofsaaklik by die gemeenskap – gesondheidsentrums waar aksienavorsing geskied) het egter begin om pasiënte van asma – selfbestuurplanne te voorsien. In die beantwoording van die sentrale vraag: “Hoe kan die proses van implementering van kliniese navorsingsbewyse, deur die voorbeeld van die nasionale bewysgebaseerde riglyne oor asma, verbeter word in die primêre gesondheidsorgsektor in die Metropooldistrik - gesondheidstelsel van die Kaapstad – metropool?”, kom hierdie tesis tot die gevolgtrekking dat die proses van riglyn – implementering in die primêre gesondheidsorg verbeter kan word deur ‘n in – diepte begrip en sistematiese benadering tot die hele proses. ‘n Konseptuele raamwerk word voorsien as ‘n model wat poog om te lei en sin te maak van hierdie proses van riglyn – implementering. ‘n Stapsgewyse benadering word aangebied en verskaf ‘n opsomming van die hoof – navorsingbevindinge. Die model toon dat die aanvanklike proses van bewyse – skepping nie slegs navorsingbewyse van hoë kwaliteit moet oorweeg nie, maar navorsingbewyse moet inkorporeer wat relevant is tot die bepaalde konteks van sorg. Boonop toon die model dat riglyn – ontwikkeling inklusief behoort te wees, en behels dit ‘n wyer spektrum van rolspelers sowel as pasiënte; dat riglyn – kontekstualisering, verspreiding en implementering versigtig beplan behoort te word. Spesiale oorweging moet gegee word aan plaaslike besluitneming oor die aanneming of prioritisering van spesifieke aanbevelings as deel van volgehoue kwaliteitverbeteringsiklusse, en die omskakeling van gepubliseerde riglyne na praktiese hulpmiddels vir praktisyns om te gebruik in die konsultasiefase, alvorens verspreiding daarvan plaasvind. Implementering behoort te verwag dat lede van die primêre gesondheidsorg sal verskil in hul gereedheid om te verander, en dat strategieë doelbewus die beginsels van gedragsverandering sal insluit en ‘n gevoel kweek van eienaarskap, keuse en beheer oor plaaslike aanneming van die riglyne. Akademiese sentrums, soos universiteite en professionele liggame, het ‘n rol om te speel in die identifisering, gehalteversekering en sintetisering van die bewyse, en om insette te lewer in die riglyn - ontwikkeling. Hulle kan ook behulpsaam wees deur praktiese hulpmiddels te innoveer en te evalueer as deel van die kontekstualiseringfase, en om deurlopende opvoeding te verskaf gedurende implementering as deel van hul sosiale verantwoordelikheid. Die gesondheidsorg – organisasies moet onnodige vertragings in riglyn – implementering voorkom deur te verseker dat beleid, bronne en aanbevelings in lyn is gedurende die kontekstualiseringsfase; dat hindernisse wat teëgekom word, regdeur die hele proses hanteer word, en dat volgehoue monitering en evaluering van kwaliteitsorg plaasvind. Gevolgtrekking Hierdie navorsing het van verskillende metodes en innoverende deelnemende aksienavorsing gebruik gemaak om die gaping tussen bewyse en praktyk te sluit. ‘n Nuwe konseptuele model vir riglyn – implementering word aanbeveel vir gebruik om behulpsaam te wees met die implementering en kennis -translasie in primêre gesondheidsorg plaaslik, nasionaal en in soortgelyke lae - en middel - inkomstelande in Afrika.

Medical-surgical nurses at the project site demonstrated a knowledge deficit regarding the care of adult patients with a tracheostomy. Such knowledge deficits could expose patients to higher risks for infection, bedsores, prolonged hospital stays, increased costs, increased caregiver burden, and death. The purpose of this project was to develop an educational program to improve nurses'€™ knowledge and confidence in the provision of evidence-based tracheostomy care to answer the question if the content of an evidence-based educational program developed to improve nurses'€™ knowledge and confidence in managing adult patients with tracheostomy on a medical-surgical floor would meet the expectations of a panel of content experts. Bandura'€™s self-efficacy and social learning theories provided theoretical guidance for the project. Five local nurse practitioners served as content experts and made recommendations about how the program could be improved, as well as suggestions relating to the wording of and the time allowed for the simulation aspect of the program. Content experts used a 5-point Likert-scale survey to evaluate the education at the completion of the program. Results showed that all reviewers strongly agreed that the content of the program was relevant, was based on the best available evidence, and was well organized and easy to follow. This project may promote positive change on the medical-surgical floor by improving providers'€™ knowledge, skills, and confidence in the provision of care based on the best available evidence, which may lead to improvements in the quality of care provided to tracheostomized patients.

What are the design possibilities for the adaptive reuse of an outdated mall into a community centered case study model of pediatric palliative care?This thesis therefore explores the following questions. What solutions are possible in the adaptive reuse of Cloverleaf Mall? As designers what is our responsibility when reusing existing spaces? How and in what ways can design build community? How can design create a place which meets the personal needs of patients with a wide variety of illnesses in various stages of progression? What does the design of a centralized prototype for pediatric palliative care look like?

The current study consisted of two experiments to examine the impact of home-based therapy on mental illness in multiproblem families. Review of the literature focused on the interplay between poverty and mental illness in defining multiproblem families and the utilization of home-based therapy with this population and others. Experiment 1 focused on delineating the type and severity of psychological distress in families characterized as multiproblem. Subjects were 58 participants in the Community-Family Partnership, a Comprehensive Child Development Program located at Utah State University in Logan, Utah. In this sample, serious psychological distress was evident with depression in both women and men as a primary symptom. Female participants in Experiment 1 showed psychological distress across more subscales and higher standardized mean difference effect sizes on the global subscales of the Symptom Checklist-90-Revised than male participants. Significant distress was also evident on the Somatization and Obsessive-Compulsive subscales for female participants and on the Hostility subscale for male participants. In a corollary to Experiment 1, participants in this study also fit the description of multiproblem based on their demographic characteristics. Experiment 2 implemented a home-based therapy program based on Sherman's Action Counseling model and evaluated its effectiveness in terms of reduction of psychological distress. Six individuals drawn from the Experiment 1 sample participated in Experiment 2. At pretest, they were not demographically different from the Experiment 1 sample, and they exhibited severe psychological symptoms such that their score profiles on the Symptom Checklist 90-Revised met both definitions of caseness for that instrument. These subjects participated in nine weekly sessions of home-based therapy based on the Action Counseling model. Therapy was very successful for one subject, moderately successful for four subjects, and not successful for one subject using reduction of psychological distress as the measure of effectiveness. Additionally, Experiment 2 examined elements of the therapy that contributed to effectiveness. Mastery of and implementation of the 10 Action Counseling steps appeared to contribute to therapy success. Limitations were discussed with respect to internal and external validity in the current study. Recommendations for future work were provided.

Interprofessional team-based care has the potential to improve patient outcomes, improve access to care, decrease costs, and improve team satisfaction. In recent years, efforts to implement team-based care have grown with the adoption of the Patient-Centered Medical Home (PCMH) and an increasing focus on value-based payment models. To better prepare our learners for this future, we introduced a formal team-based care curriculum in our three family medicine residency programs and one pediatric program. In addition to curricula for residents, we developed a team-based care didactic for family medicine clerkship students, presented by an interprofessional team of faculty. This session will describe our curricular efforts, team-based didactic for students, and outcomes related to students’ experiences with and knowledge of team-based care.

ABSTRACT Clinical evidence technologies (CETs) are information sources derived from medical research literature that may assist health care providers in continued learning, decision-making, and patient care. Examples of CETs include: MEDLINE/PubMed and Cochrane Reviews, research journal literature, print and electronic medical texts, clinical topic summaries, guidelines, and interactive decision tools. Clinicians utilize CETs to find answers to questions that arise during patient care. However, it was unclear if CETs had a measurable impact on provider practice or patient outcomes. A literature review identified twenty-two articles evaluating CETs’ impact. Study designs included surveys, observational studies, randomized controlled trials and quasi-experimental methods. The review revealed mixed evidence of CET impact on provider-level outcomes such as improved diagnoses and treatments, and on patient level outcomes such as length of hospital stay and mortality. Additional research was needed to determine whether certain CETs or CET types have impact on patient care outcomes in clinically targeted areas. We conducted a cluster-randomized controlled trial (CRCT) to evaluate the effect of a dermatology-focused CET (VisualDx) when used by primary care providers. We found no difference in the patient skin disease outcomes of resolution of symptoms and return visits for the same problem in that trial. Thirty-two PCPs and 433 patients participated. In proportional hazards modelling adjusted for provider clusters, the time from index visit to skin problem resolution was similar in both groups (Hazard Ratio=0.92; 95% Confidence Interval (CI)=0.70, 1.21; P=0.54). Patient follow-up appointments did not differ significantly between groups (Odds Ratio=1.26; CI=0.94, 1.70; P=0.29). In a follow up mixed-methods study, we sought to understand why VisualDx did not make a difference. All CRCT provider participants were surveyed about their experience in the trial. VisualDx users (intervention arm) were interviewed about their experience using the CET. Ease of access and usefulness for patient communication facilitated successful use while irrelevant search results and use of other sources were barriers. Although PCPs reported benefits, they did not perceive the CET as useful often enough to motivate using it frequently or exclusively, thereby reducing the likelihood of it making a difference in the problem resolution and return appointment outcomes. There was no difference in skin problem resolution or number of follow-up visits when PCPs used VisualDx. PCPs did not perceive VisualDx as “useful” often enough for to use it frequently, or exclusively, thereby reducing the likelihood of this CET making a difference in patient-level outcomes.

The green trend has exploded on the skin care market, as it is the fastest growing sector in the world market compared to other green cosmetic products. However, previous literature has primarily focused on cosmetics rather than skin care, which is why this study uses an exploratory and qualitative approach to study the attitudes Swedish consumers have towards skin care brands. The study aims to test the applicability of Keller’s (2001) Customer-Based Brand Equity (CBBE) model pyramid in a growing brand segment, to understand which aspects of green skin care brands consumers find to be important. Furthermore, this study provides managerial implications to help brands develop marketing strategies on how to strengthen the consumer-brand relationship. The findings indicate that there are opportunities for green skin care brands to increase their brand equity with the help of Keller’s brand building blocks. However, the findings suggest that green skin care brands need to focus on strengthening how consumers perceive the price and performance of green skin care products in order to establish a strong brand. Ultimately, the study presents a revised CBBE model that highlights the established subdimensions of green skin care brands and those that are in need of improvement.

L'obiettivo della tesi è quello di sviluppare una piattaforma software a supporto della programmazione di applicazioni mobile per la rilevazione di parametri vitali. Questo caso di studio offre una ampia discussione su wearable computing, healthcare e prototipazione del wearable. La tesi va a descrivere tutte le fasi di analisi, modellazione e progettazione del sistema, evidenziando problematiche e soluzioni adottate.

Although advanced medical technology has been progressively developed, access to quality healthcare services is still a major problem, especially in developing countries. Advanced medical technology requires enormous and expensive resources; therefore, affordable, easy to use and accessible technology could bridge the gap, improving people’s lives, and attracting venture capital investment. Moreover, it is expected that the diagnostic device market would grow exponentially, particularly for paper-based technology. As a result, technology development could promote the local economy by creating jobs. Paper-based analytical devices have been introduced and developed over the last decades. This technology has been widely used as a tool for diagnosis in fields such as environment, food quality and healthcare. Point-of-care (POC) diagnosis has attracted a great deal of attention from the research community, eventually aiming for the development of a platform that can evaluate biological markers in body fluids such as saliva and urine. Paper-based diagnostic devices make an impact because of their low cost, environmentally friendliness and biodegradability. The significant advantage of paperbased devices is the capillarity driven fluid transport through the paper network without the need for additional equipment. This thesis starts with a detailed literature review on paper-based devices. The literature review includes material selection, fundamentals, applications and design criteria, and mainly discusses the technical challenges in engineering and biochemical aspects. Additionally, this section will discuss the current research trends and perspectives of advanced technologies for enhancing assay performance. The study of wicking in paper strips predicts the flow behaviour to control fluid flow and perform programmable fluid handling tasks. An accurate model to predict flow in paper is required for designing paper-based devices. In this thesis, a novel model explains wicking in paper strips altogether with liquid absorption capacity. Based on observation, paper can store liquid in a matrix because after removing the reservoir, the fluid continues flowing. We employ the electrical circuit analogy to formulate the model. The capacitance should be included in the model because the capability to store and release charges is analogous to liquid absorption capacity in the matrix which contain and discharge the fluid. The theoretical data from the model agrees well with the experimental data obtained for wicking in paper strips in a vertical configuration. Additionally, fitting the model with experimental data confirms the critical parameters of liquid absorption capacity and capillary pressure. Considering liquid absorption capacity as a capacitance in electrical circuit analogy could elucidate the relationship between materials and wicking mechanism. Next, the thesis focuses on developing of paper-based analytical device fabrication technology that allows the defined hydrophobic pattern on paper to guide fluid along a hydrophilic path in a controlled manner. There have been many fabrication processes reported in recent decades. However, some methods using harsh chemicals result in contamination of the subsequent reagents for analytical assays. Some other techniques have complicated processes requiring expensive equipment, impractical for mass production. The subsequent study focused on a parametric fabrication of parafilm hot pressing, which is inexpensive, rapid, and straightforward. The basic concept is providing heat and pressure to melt and squeeze parafilm into the paper matrix resulting in a hydrophobic pattern defined by a laminate mask. The smallest hydrophobic barrier made by this technique is 821 um, resulting from the resolution of the laminate mask. Likewise, this study also demonstrated the suitability of paper for both physical and biochemical functions. In terms of physical function, the wicking speed on fabricated paper is slower than on non-fabricated paper because the pore could be reduced due to pressure. Diffusive mixing in 2D and 3D paperfluidics are also reported. We employed a sandwich immunological assay for biochemical functions to evaluate protein binding capacity on the paper. Demonstrating the paper device from this fabrication process is potentially applicable to analytical instrument for wicking studies and biomolecule detection. Besides investigating wicking in paper strips and the fabrication process to handle engineering challenges, biomarker detection has been studied to demonstrate diagnostic applications for the developed devices. Biomarkers used in this study include SARSCoV-2 humanised antibody and cell-derived exosomes. The readout methods implemented in this study are colourimetric, fluorescent, and electrochemical. First, we employed a paper-based colorimetric assay using the horseradish peroxidase and 3,3’,5,5’-tetramethylbenzidine (TMB)/hydrogen peroxide system. The colourimetric readout was obtained from a self-made image acquisition system and is quantified using the MATLAB program. The detection limit of SARS-CoV-2 humanised antibody assay was 9.00 ng/uL, which is lower than commercially available kits (0.112 IU/mL vs 5 IU/mL). However, the result for exosome detection encountered many challenges. Firstly, the exosome concentration may be inadequate to reach a detectable range. Secondly, high background signal resulting from non-specific binding on the platform leads to a lack of sensitivity and specificity for exosome detection. A paper-based colourimetric assay has the potential to be further developed into a point-of-care diagnostic device. Further modification of the paper may be required to promote protein binding for specific targets and prevent non-specific binding to reduce the background signal. Next, the thesis reports a paper-based immunofluorescent assay for biomarker detection using fluorophore conjugation with detecting antibodies. The fluorescent-based assay requires a specific excitation wavelength and retrieves a wavelength of emission. Fluorescent microscopy was used to observe the readout. Before, the images were processed and quantified using a MATLAB program. The assay selectively detects SARS-CoV-2 humanised antibodies spiked in PBS and healthy human serum samples. The limit of detection of the assay was 2 ng/uL (0.025 IU/mL) and 10 ng/uL (0.125 IU/mL) in PBS and human serums, respectively. This assay can detect 1010 exosome/mL obtained from cell culture media, but also faced many obstacles. First, exosome concentration prepared from cell culture media may be insufficient to reach the detectable range. Second, minimising chemical contamination could enhance assay specificity and sensitivity to prevent non-specific absorption. Therefore, a paper-based fluorescent assay could be further developed into a portable device. The light source to excite the fluorophore and to emit the signal, including an optical system, could be scaled down from fluorescent microscopy into a handheld-size device. Lastly, this thesis presents a proof-of-concept electrochemical paper-based device for biomarker detection. The paper-based device is fabricated using parafilm hot pressing, as reported previously. The electrochemical chacracterisation on paper-based carbon electrodes was thoroughly investigated using cyclic voltammetry. The detection employed a sandwich immunological assay using carbon electrodes on paper. Differential pulse voltammetry was used to observe the current response in the subsequent steps. The stepwise addition of biomolecules on paper-based carbon electrodes results in the attenuation of the current response caused by stepwise biomolecules binding on the electrode surface. The current reaction after target binding corresponds to the target concentrations. In addition, electrochemical impedance spectroscopy is utilised to affirm the validity of the assay by observing the electron transfer resistance coming from the interfacial electron transfer at the electrode surface. The assay for SARS-CoV-2 antibody detection in PBS samples detected the target concentration in the range of 10 to 100 ng/uL. The detection limit is estimated to be 9.37 ng/uL. For exosome detection prepared from cell culture media, this assay quantified the total exosome and ovarian cell-derived exosome concentration with a limit of detection of 9.3 X 10 exosomes/mL and 7.1 x 10 exosomes/mL with < 10% relative standard deviation for samples of n =3. However, the limit of detection can be enhanced by strengthening antibody immobilisation on the paper-based device and stabilising the carbon electrodes on paper to be conductive enough to sense the change of the subsequent loading of biomolecules. Our electrochemical paper-based assay could be an alternative tool for detecting diseasespecific exosomes in biological samples for point-of-care diagnosis. In conclusion, this study aims to overcome engineering and biochemical challenges posed by paper-based analytical devices. To tackle the engineering issues, a novel wicking model with consideration of liquid absorption capacity offers an alternative way to predict flow behaviour in capillary rise experiments and explain the material characteristics. Additionally, the thesis studies the fabrication parameters to control the paper-based device fabrication better using parafilm hot pressing, demonstrating the functionality of paper for both physical and biochemical applications. Regarding biochemical challenges, the thesis reports colourimetric, fluorescent, and electrochemical techniques implemented on paper-based platforms, employing a sandwich immunological assay to detect biomarkers, which include SARS-CoV-2 humanised antibody and cell-derived exosome samples. These established protocols have the potential to be further improved for automation and portability, which could be compatible with other advanced technologies such as wearable sensing devices, artificial intelligence and machine learning.
Thesis (PhD Doctorate)
Doctor of Philosophy (PhD)
School of Eng & Built Env
Science, Environment, Engineering and Technology
Full Text

The outcomes of a child protection/family support programme, the Cottage Community Care Pilot Project, were evaluated in this study. The evaluation employed a non-equivalent comparison group design of 'at risk' consenting first-time mothers in the perinatal period with babies up to 6 weeks of age. Ninety-three families were recruited and 58 of these were matched with a trained volunteer home visitor. Analysis of assessment items and questionnaires, reviews of hospital records and the Department of Community Services Child abuse and neglect notification register and focus groups with mothers and volunteers provided the information used in this study. The CCCP had an impact on particular aspects of family function, certain infant and maternal health indices and the families' use of community services, but its contribution to reducing the incidence of child abuse and neglect is less clear. Client and volunteer feedback indicated support for the programme. While home visitation by trained volunteers is not proposed as the total answer for effective child protection or family support, the findings of this evaluation suggest that there is a place for similar programmes.
Master of Science (Hons)

Thesis advisor: Dorothy Jones
A family's unique way of being, formulated through social, economic, environmental and political factors, becomes fractured during a loved one's critical illness. Family members experience burdensome physical and emotional symptoms as they transition through the marked uncertainty endemic to high acuity illness. For some, this burden results in long term psychiatric disturbances. Assessment tools and interventions have been proposed for family members experiencing a loved one's critical illness. However, ongoing suffering suggests inherent limitations within these reductionist approaches. The need for a more encompassing disciplinary perspective is suggested. Margaret Newman's (1986, 1994, 2008) theory of Health as Expanding Consciousness (HEC) and its praxis research method was employed to explore relationship based care among intensive care unit (ICU) family members and registered nurses. HEC retains person/environmental integrity through unfolding of unitary knowledge via exploration of meaning. Additionally, its holistic perspective aligns philosophically with the belief in nursing science as the study of caring in the human health experience, endorsing both the mutuality of the nurse/client relationship and pattern recognition's capacity to inspire transformational growth. The study was performed in an eighteen bed medical ICU in the northeast region of the United States. This unit's design includes an integrated critical/palliative care model. Exploration of the study's two research questions was accomplished using the practice and research components of HEC within a sample of eight family members and six registered nurses. Results demonstrated family members' capacity to achieve consciousness expansion within the context of a loved one's critical illness. Registered nurses revealed their ability to steadfastly partner with both patients and families. Repetitive elements distinguished as thematic commonalities were recognized among both family member and registered nurse participants. Additionally, thematic integration between family members and registered nurses was appreciated. HEC was found to offer unique insights into caring relationships between ICU family members and registered nurses
Thesis (PhD) — Boston College, 2014
Submitted to: Boston College. Connell School of Nursing
Discipline: Nursing

This research is about evidence based practice, which is an area of increasing interest and emphasis in social work today. Initially apparent in medical and health care settings, evidence based practice now has widened applicability to a broad range of contexts and professional disciplines. The ways in which research evidence is translated into policy and practice is itself a topic area for social work research. The study investigates evidence based practice in child welfare, specifically the out-of-home care system. Out-of-home care provides alternative placements for children and young people who cannot live with their families because of abuse and neglect, and generally consists of placement with foster carers or in a residential/group care setting. This research is an exploratory study which investigates through individual interview how nineteen out-of-home care Senior Managers and Team Leaders in the states of New South Wales, Western Australia and the Australian Capital Territory interpret and understand evidence based practice, and the degree and depth of knowledge they transfer from research awareness into out-of-home care practice and policy development. The research has three main objectives. Firstly to investigate the understanding of out-of-home care managers of evidence based practice, secondly to determine the influence of relevant research on practice and policy in out-ofhome care, and thirdly to explore potential barriers to evidence based practice. Looking After Children, a social work case management system for children and young people in out-of-home care, provides the context for this research, in which evidence based practice is critically examined. A thematic analysis of the interview data identified five major themes. These included: the benefit of broadening definitions of evidence based practice to include a wide range of influences on practice; the value and importance of 2 considering a broad range of research approaches in connecting research with policy and practice AND the potential for influencing outcomes of social work intervention via research based and influenced guided practice systems and techniques; factors which constitute barriers and also those that enhance the implementation of evidence based practice; the potential for instigating and supporting new research via the use of evidence based practice for purposes such as data aggregation, in addition to practice development and enhancement of client outcomes. Implications and conclusions are drawn from this study in relation to out-ofhome care policy and practice, with particular reference to use of the Looking After Children case management system in the Australian context. These include the potential of a consistent system such as LAC to provide common language and assessment tools and procedures in a welfare sector that is fragmented by lack of national legislation, and the potential for development of national out-of-home care research projects as a result of cross agency LAC implementation resulting in data aggregation opportunities.

The rising population of older people in the UK (Office for National Statistics 2010) and pressure on healthcare services to reduce costs indicate the necessity of developing strategies that enable coping and independence. Loss through death of close family members, partners and friends is a key factor that inhibits physical, emotional and social well being of older people. The research carried out for this thesis explored bereavement in healthcare settings where contacts with bereaved older people commonly occur, and used data collected to develop guidelines for practice. The guidelines provide research informed enhancement to bereavement care and develop opportunities for meaningful interactions. They complement current policy development work on bereavement in healthcare settings (The Scottish Government 2011). A qualitative design drawing on phenomenological methodology was used to explore healthcare staffs’ experiences of caring for bereaved older people, and older people’s experiences of being bereaved and bereavement care. Theoretical sampling took place to recruit staff from a range of roles in general practice and community nursing, hospital wards and care homes, as well as a small sample of bereaved older people. Thirty nine participants took part in in-depth interviews that yielded four key themes: bereavement care depends on a relationship between healthcare staff and relatives; preparation for a relative’s death may not equate to preparedness for bereavement; the ‘Open Door’ to bereavement care is only slightly ajar, and bereavement care supports progression of the ‘Rolling Ball’ of life. The themes informed development of the guidelines in terms of structure and content. Recommendation statements consider bereavement care before the death; at the time of the death; and follow up in the weeks and months afterwards. Criteria in the recommendations provide suggestions for enhancements to practice that facilitate appropriate response to bereavement in older people. Consultation on the guidelines provided positive feedback that identified the potential to promote consistent interactions with bereaved older people, respond to needs and support coping.

Le travail expose dans ce manuscrit concerne l'etude de la diffusion elastique d'une onde plane electromagnetique par des objets dielectriques isotropes de forme quelconque pour les cas limites hautes et basses frequences. Un premier travail conduit a la generalisation de l'approximation eikonale de glauber (methode hautes frequences) a des objets ne possedant pas d'axe de symetrie parallele au vecteur d'onde incident. La deuxieme etape de cette etude est la mise au point d'un modele vectoriel de la diffusion par des objets absorbants symetriques par rapport a la direction du vecteur d'onde incident. Il est base sur la representation en terme de parametre d'impact du champ diffuse. Une extension de ce modele au cas d'objets rugueux est obtenue dans le cadre du modele eikonal. La derniere etape de ce travail concerne l'etude d'un cas limite basses frequences basee sur l'approximation dipolaire du potentiel diffuseur: la particule diffusante est remplacee par un ensemble de dipoles situes sur les nuds d'un reseau cubique. Les interactions entre elements dipolaires sont prises en compte pour le calcul des champs. Une amelioration de ce modele consiste a affiner le maillage du reseau pres de la surface de la particule

Master of Public Health - MPH
Community health workers (CHWs) are integral to improve Primary health care (PHC) coverage, utilising their unique skills within the community to make services accessible and equitable. PHC is the cornerstone of the National Health Insurance (NHI) Bill for the provision of Universal Health Care (UHC). The Department of Health (DOH) in the Western Cape, South Africa, has set priorities and requirements for the provision of funding to Non-profit organisations (NPOs) for forming coalitions with the Health Department to deliver various aspects of health care. The post-2015 agenda of the Sustainable Development Goals (SDGs) are underscored by a strong sense of intersectoral collaboration to work together to attain sufficient and sustainable progress. Collaboration between CHWs and PHC facilities is important in aligning goals and activities to ensure a comprehensive and sustainable approach to ensuring UHC

Trauma-informed Care (TIC) is a paradigm that has gained much traction in medical and human services settings over the past decade, motivated by the recent research findings that many poor physical, mental, and behavioral outcomes are more likely in individuals who experienced trauma in childhood (Adverse Childhood Experiences [ACEs]) such as abuse and neglect. The TIC paradigm, offered as novel, seems to be a secular repackaging of the biblical mandate to love our neighbors (Mark 12:31; Gal 5:14). The central tenets of TIC include feeling empathy with and demonstrating empathy toward others in their suffering; understanding that having experienced past traumatic events changes a person physically, mentally, and emotionally; that efforts should be made to prevent retraumatization; and that every person is valuable and has strengths that can be cultivated. Empathy, or feeling what other feel, is taught in Rom 12:15, “Be happy with those who are happy, and weep with those who weep,” and Gal 6:2, “Share each other’s burdens, and in this way obey the law of Christ.” Having an understanding of the pain experienced by those who have experienced trauma and caring for that suffering part of the body is clearly a biblical concept. Paul states, in 1 Cor 12:25-26, “This makes for harmony among the members, so that all the members care for each other. If one part suffers, all the parts suffer with it, and if one part is honored, all the parts are glad.” This supports the emphasis on empathy as well. The ACE Study which sparked the development of the TIC paradigm, highlights the likely impacts of adversity on children who have been treated unjustly. Throughout the Bible, those who follow God’s principles are instructed to care for the child, the weak, and those experiencing injustice (Isa 1:17, “Learn to do good; seek justice, correct oppression; bring justice to the fatherless, plead the widow’s cause.”). Finally, in teaching the tenets of TIC, we foster a belief that everyone has value and we should help each other to capitalize on strengths. Hebrews 10:24 echoes this by saying, “And let us consider one another to provoke unto love and to good works.” How do we know people have strengths to be capitalized upon? Rom 12:6 says, “In his grace, God has given us different gifts for doing certain things well,” and 1 Pet 4:10 says, “Each of you has received a gift to use to serve others. Be good servants of God’s various gifts of grace.” ​ I and a colleague have been teaching TIC principles to health care professionals and human service workers over the past two years. We have trained almost 2,000 people in these concepts. It has been embraced like nothing I have seen in my three decades in the psychological and counseling profession. Is it that our secularized society is hungry for biblical wisdom? Is it that He who created us knows best what we need? I can’t say, but our current research seeks to verify effects as organizations implement TIC.

Healthy romantic relationships are associated with a multitude of positive physical and mental health outcomes. Conversely, low relationship quality and relationship dissolution are associated with risk for poor health outcomes. Accordingly, numerous studies investigate ways to preserve healthy relationships through the use of preventative relationship education interventions, many of which improve relationship outcomes. However, evidence for the efficacy and effectiveness of these interventions is somewhat mixed, and promising interventions often fail to reach at-risk populations due to high participant burden. There is a movement within clinical psychology to create easily accessible, targeted therapy protocols in order to increase the broad availability of these evidence-based interventions. The current study aimed to replicate and extend the Marriage Hack (MH), a brief, evidence-based preventative relationship intervention designed to stabilize the natural decline in relationship quality over time. This study addressed four specific aims designed to: 1) examine the efficacy of the MH intervention using an abbreviated protocol; 2) extend the original MH intervention by investigating theory-based mechanisms of change and assessing individual health outcomes; 3) explore how theory-based mechanisms change over time; and, 4) evaluate the relationship between within-person and between-person variance in process variables and outcome measures. Seventy-eight (N = 78) couples were randomized to the 4-week MH protocol (n = 41) or control condition (n = 37). Results demonstrated men in the intervention group exhibited 1) greater improvements in relationship satisfaction and 2) decreases in both anxiety and depression compared to men in the control group. This study did not replicate the findings of the original MH for additional outcome variables and process variables for men or women. No support was found for mediating effects of additional theory-based mechanisms of change on outcome measures. However, exploratory intensive longitudinal analyses revealed noteworthy relationships between within-person and between-person variance in process variables and treatment outcomes. Research recommendations to further improve preventative relationship interventions and clinical implications of the current findings are discussed.

Thesis advisor: Dorothy A. Jones
Purpose: The purpose of this study was to define, develop, and psychometrically evaluate a scale designed to measure Nurse’s Perception of the Relationship Based Care Environment. Background: Relationship is a complex multidimensional concept. It is a critical component of professional practice and core to the interaction between nurse and patient. While there are a number of scales available to measure different dimensions of relationships between nurses and other groups there is no one scale that captures multiple dimensions. Methods: Based on a review of the literature and an earlier qualitative study, a theoretical representation was developed. This representation became the framework for development of elements and items for the NPRBCE scale. The content validity of the NPRBCE scale was determined by an expert panel of Registered Nurses. Four hundred and seventy three Registered Nurse participants completed the survey. Analysis: Data were subjected to Principal Components Analysis and Cronbach’s alpha was computed to determine reliability of the scale as a whole and each of the components of the scale. Results: The final solution was a five component 56-item scale. The five components include: nurse/ other discipline; nurse/organization; nurse/ nurse; nurse/ patient- knowing the patient; and nurse/patient-respecting the patient. The scale as a whole and each of the resulting components were found to be reliable. The components were parsimonious and interpretable. Keywords: relationship based care, relationship centered care, nurse practice environment
Thesis (PhD) — Boston College, 2016
Submitted to: Boston College. Connell School of Nursing
Discipline: Nursing

BACKGROUND:The Affordable Care Act of 2010 proposed maximum penalty equal to 1% of regular Medicare reimbursements which prompted change in how hospitals regard 30-day readmissions. While several hospital to home transitional care models demonstrated a reduction in readmissions and cost savings, programs adapted to population needs and existing resources was essential.METHODS:Focusing on process and outcomes evaluation, a retrospective analysis of a modified community based care transitions program was conducted.RESULTS:In addition to high levels of patient satisfaction with the care transitions program, participants' confidence with self care was significantly improved. Further, the program evaluation demonstrated a 73% reduction in readmissions and an actual Medicare cost savings during the 9-month study period of $214,192, excluding the cost to administer the program.CONCLUSIONS:While there are several transitional care programs in existence, a customized approach is desirable and often required as the most cost effective way to manage care transitions and employ evidence based policy making. This study established some of the pitfalls when implementing a community-based transitional care program and demonstrated encouraging outcomes.

Master of Public Health - MPH
In 2018 within the Kingdom of Eswatini, there were an estimated 1 074 new cancer cases and 660 cancer-related deaths. For some time, there has been a growing trend away from the provision of palliative care within an institutional setting to providing palliative care to the patient within the context of their own home. As a result, the majority of dying patients spend their final days at home with much of the care being provided by family caregivers. In Eswatini, little is known about the impact that managing a terminally ill patient has on the family caregiver and whether they experience receiving sufficient support from the local health services. This study aimed to explore the needs and challenges of family caregivers in providing palliative care for their relatives living with cancer in Hhohho Region, Kingdom of Eswatini.