Dissertations / Theses on the topic 'Unmet needs'

Philosophiae Doctor - PhD
The first objective of this study is to show if diffusion of contraception in areas of traditional high fertility has gone through profound changes. Indeed, we would like to know if contraceptive behaviours have evolved because of new fertility perceptions and also because partners now have greater freedom to make choices in a relationship. The second objective of this study is not only to highlight the levels and trends of contraception and the factors influencing their use (government policies, role of family planning, etc.) in developing countries, but also to consider the population of unmet-needs of contraception. Indeed, the level of contraceptive use depends obviously on users, but also on non-users with no needs and non-users with unsatisfied needs. The understanding of this last category of females is essential to a more accurate estimation of contraception levels, and, therefore for the estimation of fertility levels. This study analyses the contraceptive use in several developing countries in Africa and highlights the unsatisfied needs of contraception, to understand why such needs exist. To do so, we shall analyse available demographic data for thirty-five African countries by using the available Demographic and Health Surveys (DHS), from the 1980's to 2000's considering the DHS I, DHS II, DHS III and DHS IV. This great variety of surveys, seventy-nine in total, permits one to compare levels of contraception and 'unmet-needs' from country to country. The surveys also, make it possible to compare the evolution over time of specific countries or specific regions, and to subsequently comprehend the determining factors of contraceptive use or non-use.
South Africa

Caregivers while, the biggest providers of palliative care for terminally sick patients, are often neglected in the process of providing care, which inadvertently affects their overall health and well-being. This study aims to explore the experiences of the unmet needs of the caregivers in palliative care. The literature review is based on seven quantitative, four qualitative and one mixed methodology approach studies. Results show a shortage of information given to caregivers regarding disease progression, symptomatology, support services and financial services. Furthermore the themes of unmet needs that emerged are physical, psychological, emotional, social and spiritual needs. Caregivers also reported the shortage of standard services provided by healthcare sector.  A healthy relationship scenario, where caregivers are supported to look after themselves as well as their loved ones, would boost the support they render to the patients.  The provision of needed services to caregivers, nurses, and healthcare personnel is required to fulfill a healthy relationship and further develop it by learning from the caregivers’ experiences. In conclusion, effective communication between caregivers and care providers is found to be a prerequisite for building trust and could contribute to satisfy the informational, medical, social and spiritual needs while helping to decrease health strains of caregivers.

Due to projected growth of the 65-and-older population and concerns of an impending care gap, reliance on informal caregivers is expected to increase. Improving support for informal caregivers is viewed as a national priority, yet research related to the unmet support needs of informal caregivers is limited. The purpose of this cross-sectional correlational study was to examine predictive relationships between contextual factors (caregiving relationship and type of illness) and environmental factors (rurality) and the unmet support needs (classes, service access, support groups, counseling, and respite) of informal caregivers of older adults. The theoretical framework was Bronfenbrenner's ecological systems theory. Archival data were drawn from the 2015 Behavioral Risk Factor Surveillance System optional caregiver module dataset provided by the Centers for Disease Control and Prevention. Findings from multiple logistic regression analysis revealed that spousal caregivers had 42.7% lower odds than adult child caregivers of reporting unmet support needs related to service access. Dementia caregivers had 2.05 times higher odds of reporting unmet support needs of counseling, 1.31 times higher odds of reporting unmet support needs related to service access, and 1.91 times higher odds of reporting unmet support needs for respite care, relative to other caregivers. Caregivers residing in a suburban county had 28.7% lower odds and caregivers not residing in a metropolitan statistical area (MSA) had 30.5% lower odds of reporting unmet support needs related to service access, relative to caregivers residing in the center city of an MSA. Health care leaders and policymakers may use the findings to distribute resources and tailor interventions to better meet the needs of informal caregivers of older adults.

The importance of psychological needs for optimal mental and physical well-being has been well documented within the literature. However, there remains little consensus on the definition of basic psychological needs, on which needs are most important or fundamental, and on how to best assess basic needs in individuals. The purpose of this dissertation was to develop and validate a comprehensive measure of fundamental psychological needs and to examine its predictive utility for both mental and physical health. To fulfil these objectives, measure construction and validation studies were conducted in 2 separate undergraduate student samples (N = 226; N = 283). Participants completed online self-report measures of emotional and psychological symptoms, negative life events, personality characteristics, and psychological needs. Factor Analyses of the Psychological Needs Questionnaire (PNQ) revealed that needs can be classified in a three-level multi-factorial confirmatory model and that self-worth and relationship types of psychological needs can be further divided into several, second-level factors. Results also indicated that the PNQ is reliable and possesses good construct validity as well as predictive utility for numerous psychological and physical problems. In addition, psychological needs moderated the relationship between depressive personality characteristics and mood. Future studies should examine the proposed needs-based model in a longitudinal fashion, both in community and clinical samples. In addition to functioning as a global introduction and providing an overview of the relevant literature, Chapter 1 proposes a new model of psychological needs. Chapter 2 describes in further detail the importance of each need identified by the new model, with a particular emphasis on the consequences associated with having each need unfulfilled. Chapter 3, 4, and 5 represent three academic journal articles resulting from the data collected in the current project. Finally, chapter 6 provides a global discussion of the entire dissertation.

As people age, they are increasingly likely to develop health problems that can lead to an impaired ability to perform essential activities of daily living (ADL). This decrease in functional ability may then result in an increased need for physical assistance which, in turn, may not be met. There has been little research on unmet need in the elderly and its association with psychological distress. This research used data from the Montreal Unmet Needs Study, a prospective cohort study of 576 women and 263 men designed to investigate self-reported unmet need for community-based services among the Montreal elderly aged 75 and older. Information on psychological distress and unmet need was obtained by self-report during in-depth face-to-face interviews at baseline, and again twelve months later. Interview information was supplemented with data provided by RAMQ and MEDECHO government databases. Multivariable linear and logistic regression models were used to investigate the associations between unmet need and psychological distress, and to determine the conjoint effect of both these factors on emergency department (ED) visits within the six months following the baseline interview. All analyses were stratified by sex. For elderly women, unmet need at baseline predicated increased psychological distress one year later. Conversely, psychological distress was not found to predict the development of any unmet need one year later. Both unmet need in IADL and increased psychological distress at baseline were found to be independent predictors of an increased likelihood of elderly women visiting an ED. For elderly men, unmet need was not found to be associated with psychological di
À mesure qu'ils vieillissent, les gens ont de plus en plus tendance à développer des problèmes de santé susceptibles de causer une dégradation de leurs capacités à effectuer des activités essentielles de la vie quotidienne (Activities of Daily Living). Cette diminution des capacités fonctionnelles peut entraîner une augmentation des besoins d'aide physique, qui à leur tour, ne peuvent toujours être comblés pour autant. Peu de recherches ont été menées sur les besoins non comblés des personnes âgées et leur relation avec la détresse psychologique. La recherche s'est appuyée sur les données de l'étude prospective de cohorte Montreal Unmet Needs Study à laquelle ont participé 576 femmes et 263 hommes et dont l'objectif consistait à étudier les besoins non comblés auto-déclarés en matière de services communautaires chez les personnes âgées de 75 ans et plus à Montréal. Les renseignements relatifs à la détresse psychologique et aux besoins non comblés ont été obtenus par auto-évaluation pendant les entrevues personnelles initiales au temps zéro et celles qui ont eu lieu douze mois plus tard. Les renseignements obtenus pendant les entrevues ont été complétés par de l'information provenant des bases de données gouvernementales de la RAMQ et MEDECHO. Les chercheurs ont utilisé les modèles de régression linéaire multivariable et de régression logistique pour étudier les corrélations entre les besoins non comblés et la détresse psychologique et pour déterminer l'effet conjoint de ces deux facteurs sur les visites au service des urgences pendant les six mois suivant les entrevues au temps zéro. Toutes les analyses ont ét

Thesis (M.Eng. and S.B.)--Massachusetts Institute of Technology, Dept. of Electrical Engineering and Computer Science, 2001.
Includes bibliographical references (leaf 73).
by Hoi Wai Thomas Cheng.
M.Eng.and S.B.

There is little work done in the area of indigenous disability identity issues and how they are recognised in domestic and international human rights laws. The discourse of disability has always been based on social constructionism and without it, there is no identity. I discuss its relevance to indigenous (Māori) with disabilities and how the multiplicitous nature of the identity of other has a particular impact when indigenous, gender and disability are all identified from marginalised groups. I also explore the impact of westernised thinking around impairment, in particular the models of disabilities on indigenous well-being. The issues of family (whānau), whakawhanaungatanga (family relationships), interdependence (community) and collectivity identities central to indigenous thinking are largely ignored by law and policy, yet central to indigenous identity. This ignorance in policy has led to the disparities that continue to remain for indigenous persons with disabilities, particularly those from within thematic identity groups.

This thesis collates a research programme of published papers completed by the candidate during the registration period of study, that are relevant to various aspects of feeding, eating and drinking difficulties (referred to as dysphagia) within a paediatric population from a speech and language therapy (SLT) perspective. Very few studies examine current SLT practice with this population. In the absence of research specific to the needs of children with congenital disorders, there are approaches being used by SLTs without a full rationale for their use and there is persistence in using therapy approaches that might not be beneficial for a child (Harding & Cockerill, 2014). Key themes present throughout this work include understanding the neurological and physiological underpinnings to an approach; being clear about a therapy rationale; creating therapy methods that consider the capacity of children who are neurologically and learning disabled and their caregivers and integrating communication more clearly into the management of dysphagia. The studies presented include: i) small case studies describing observations and analysis of communication during typical mealtimes; collaborative therapy programmes specifying strategies and sessions for use of Alternative and Augmentative communication (AAC); evaluation of a therapy programme to reduce aversion to tube feeding; ii) data on use of a straw to evaluate and record changes over age and gender; iii)evaluation of an SLT intervention to train staff within a special school ; iv)a pilot study and RCT investigating the use of non-nutritive sucking (NNS) to wean premature infants off tube feeding onto full oral feeding, and iv) case reports on use of NNS with infants with congenital disorders and the relationship between feeding difficulties and speech development. The studies presented contribute to the evidence base for SLT in a number of ways including describing and evaluating current practice and techniques through case studies and measuring the effectiveness of a SLT protocol through an RCT. The case studies highlight: the importance of checking the knowledge, skills and training of significant others in delivering therapy interventions, the importance of working collaboratively, specifying components of therapy programmes and time needed to implement them, and the importance of communication in its broadest sense within a meal time context. The non – nutritive sucking (NNS) RCT found that children in the intervention groups were able to leave hospital significantly sooner than in the control groups. However, unlike many other studies there was no difference in the time taken to be able to feed orally. There are a number of methodological issues to consider in evaluating the studies. The issues arising from conducting research within a complex clinical environment are discussed in Chapter 5. These complexities include using significant others to deliver therapy programmes, accurate understanding and descriptions of the premature population, the inclusion and exclusion criteria for studies, and consideration of infants with congenital and neurodevelopmental needs. The needs of and difference between parents are also considered. Evaluation of results also needs to take into account the paucity of tools to measure infants’ skills both by SLTs and parents and other professionals. Recommendations are made for future research. These include more studies to investigate accurate interpretation of infant states, improved descriptions and subsequent stratifications of infant participants; repetition of the RCT with larger sample and in range of settings, inclusion of follow up to 24 months with added measurements of feeding and language skills. The thesis papers also suggest more focus in future studies on the role of communication as a tool to manage risk within mealtimes.

PURPOSE The purpose of this study was to explore how primary care registered nurses address unmet social needs in patients. SPECIFIC AIMS Explore how RNs in a safety-net, primary care setting develop an awareness of and address patient's unmet social needs. Describe how information about unmet social needs are integrated into nursing assessment and intervention activities, and are shared with other members of the health care team. Describe the challenges primary care RNs face when addressing unmet social needs. FRAMEWORK Critical caring theory provided the framework for this study. DESIGN This study used a descriptive, qualitative design. Semi-structured interviews were conducted with seventeen nurses working in 11 different safety-net primary care clinics within a hospital-based system. RESULTS Three major themes emerged. Key findings included the importance of the nurse-patient relationship, the establishment of trust, and a caring, nonjudgmental approach to patients with unmet social needs. Nurses used knowledge of unmet needs to coordinate patient care, provide social support, and work collaboratively with care team members to refer patients to resources within the health care system and in the community. CONCLUSION Unmet social needs contribute to adverse health outcomes, and addressing social and medical needs is critical to eliminating health inequities and reducing health care costs. In this study, primary care nurses described relationships with patients that allowed for the sharing of sensitive information, leading the nurse to identify and address unmet social needs that could impact patient health.

The diagnosis and treatment of cancer can have a major impact on many aspects of health and well-being, with patients experiencing a variety of supportive care needs. In recognition of these needs, cancer policy internationally now acknowledges the importance of supportive care alongside clinical care. In order to reduce unmet supportive care needs among people with cancer, these unmet needs must first be quantified and then potential interventions to reduce unmet needs must be developed and tested. This thesis presents a series of studies which addresses the following aims: 1) To quantify and measure the unmet supportive care needs of people with colorectal cancer; 2) Ascertain the utility of a particular approach of supportive care service delivery, specifically nurse-delivered telephone supportive care; 3) To evaluate in a pilot study the novel nurse-delivered telephone supportive care intervention - CONNECT. Chapter One first provides an epidemiological perspective of colorectal cancer. Within Australia and NSW it is the second most common cancer, and cases in both jurisdictions have doubled in the last two decades. Within NSW, future modelling predicts that the number of new colorectal cancer cases in 2016 will represent a 19.5% increase from what was reported in 2007, and by 2036 will represent a 60.3% increase. Therefore the burden of this disease within the community will remain high. Chapter One next summarises the main treatment options for colorectal cancer, that is surgery, radiotherapy and chemotherapy. Clinical overviews of these treatment modalities are provided with the rationale for their use described. Advances in clinical management have improved post-operative mortality and survival outcomes of people treated for colorectal cancer. Therefore these survival improvements, coupled with increases in cases of colorectal cancer, will result in more people living with the outcomes of treatment. It is expected that in the future, disability due to colorectal cancer and its treatment will become a more important contributor to the burden of disease than mortality. The remainder of Chapter One then describes the range of adverse outcomes of colorectal cancer treatment. These include reductions in quality of life and specific morbidities such as pain, issues with wound healing, bowel, urinary and sexual dysfunction. The negative psychological consequences of treatment are also explored. Chapter One concludes by acknowledging that cancer treatment and treatment outcomes will result in a unique set of health care needs. Chapter Two introduces that health care need as a foundation to guide cancer service development and delivery. Despite the growing interest in health care need, there is little discourse of what is actually meant by the term ‘need’ and the underlying theoretical or conceptual basis of its measurement. Therefore a critical overview is presented in Chapter Two of the range of definitions and theories that seek to conceptualise what is meant by the term ‘need’. Need interpretations are described from psychological, humanitarian, social policy, academic and health care perspectives. The concept of unmet need is also introduced whereby unmet need is viewed as resource deficit. The findings of this review confirm that ‘need’ and ‘unmet need’ are conceptually different and distinct. Measurement of need is argued to be limited in scope as it only identifies potential problems. Need identification does not provide information about whether need has been met or whether current service interventions are successful at addressing and satisfying need. In contrast, ‘unmet need’ is considered a more patient relevant concept. It is indicative of where patient care is compromised and therefore is more relevant to health service development, as the focus of attention is on areas were service provision is inadequate, inaccessible or not in existence. Following this, Chapter Two concludes with a definition of the types of potential unmet needs that people with cancer could experience, in particular unmet supportive care needs. Supportive care is defined as an umbrella term that embraces the full range of needs, physical and psychosocial, that emerge for a patient due to the impact of cancer. Following this discussion of need and unmet need, Chapter Three describes the specific aims of this thesis. Chapter Four presents the results of a systematic review of the international literature in which the prevalence of unmet supportive care needs of people is described. The initial search identified 22,781 potentially relevant articles. However only 94 were found to be relevant to the research question and only 57 studies quantified unmet supportive care need. These studies were classified by specific time of the cancer illness, for example diagnosis, treatment and post-treatment. Prevalence of need was highly variable in all domains (ranging from 1% to 93%), across all time points and varied within and between studies. The most frequently reported unmet needs were those in the activities of daily living domain (1–73%), followed by psychological (12–85%), information (6–93%), psychosocial (1–89%) and physical (7–89%). Needs within the spiritual (14–51%), communication (2–57%) and sexuality (33–63%) domains were least frequently investigated. Compared to any other time points of the cancer illness, the treatment phase exhibited the largest variation in the prevalence of unmet need for each domain. However, unmet needs were more likely to be found in a larger proportion of people post-treatment. Trends and predictors were also highly variable across all time points. Tumour specific unmet needs were difficult to distinguish and notably, there is a significant lack of evidence pertaining to any specific unmet needs of people with colorectal cancer. The review also highlights the difficulties in gauging levels of unmet need given the varied study questionnaires used and differences in the classification of unmet need reporting methods. Further, a lack of standardised approach to reporting of the instruments precludes comparison of data from different sources. Accurate measurement of unmet need is essential to be able to monitor patients as they progress through their cancer illness and identify where additional support is required. It is also imperative that within supportive care trials unmet need is reliably assessed to determine the true efficacy of an intervention. Therefore, given the issues with unmet need measurement identified in Chapter Four, Chapter Five sought to provide a systematic overview of instruments that measure this concept. Eighteen instruments were identified and were classified as generic, need, cancer type or stage of illness specific. Based on the descriptions and psychometric properties of each instrument, the following recommendations are made for the most optimal instruments to measure unmet need in people with cancer from each category of instrument; the Supportive Care Needs Survey was considered to be the best generic instrument to measure unmet need, whereas the Prostate Cancer Needs Questionnaire and Needs Evaluation Questionnaire were the best available tumour and stage of disease specific assessments respectively. Chapter Six reports the findings from an empirical study to quantify colorectal cancer patients’ supportive care needs following their discharge after cancer surgery. As post-discharge needs are managed by a senior colorectal cancer nurse co-ordinator, a review of these occasions of service provides a measure of the level of unmet need. Nursing records for consecutive patients discharged from a quaternary referral colorectal cancer surgical unit in Sydney were reviewed. All non-admitted patient occasions of service (NAPOOS) were identified. Of 521 eligible patients, 219 (42%) received 988 postoperative NAPOOS. These were largely delivered over the telephone (72%) or during face-to-face contact at outpatient appointments (26%). Most NAPOOS were recorded within the first two weeks following discharge but some occurred beyond 6 months. Overall, 1369 specific unmet needs were identified during these NAPOOS. Ongoing support, reassurance and monitoring were required for 186 patients (85%). Physical needs relating to wound care and bowel function were prevalent for 15-20%, information needs for 20% and assistance organising follow-up appointments for 36% of the sample. Predictors of unmet need in this patient group were varied. Older patients (>65 years) were significantly less likely to record a NAPOOS (OR 0.97, 95%CI: 0.96-0.99) whilst people with rectal cancer were significantly more likely to report multiple NAPOOS (OR 2.80, 95%CI: 1.60-5.01) and physical needs (3.56, 95%CI: 2.03-.27). Rehabilitation needs were more likely to be expressed by emergency department admitted patients (AOR 2.23, 95%CI: 1.07-4.65). After adjusting for admission status, patients residing in capital cities were significantly less likely to experiences need in this domain (AOR 0.37, 95%CI: 0.20-0.70). Given that ad-hoc nurse-delivered supportive care by telephone is currently provided as described in Chapter Six, systematisation of this type of intervention holds promise to reduce unmet needs in this patient group. Chapter Seven presents a systematic review of studies which have evaluated nurse-delivered supportive care interventions. Critical appraisal of studies was conducted using standardised instruments namely the CONSORT statement for randomised trials and STROBE statement for non-randomised studies. Of 2,451 potentially relevant articles, only 13 studies were found to be relevant to the research question, comprising five randomised controlled trials and eight nonrandomised studies. All studies demonstrated that it is feasible to deliver supportive care over the telephone for people in follow-up for cancer. Furthermore, using a nurse to deliver such interventions was found to be acceptable to patients resulting in a positive experience. Some studies have highlighted that potentially, significant improvements can be made to patients’ quality of life, satisfaction with care and unmet information needs, but definitive conclusions could be recorded due to the variable methodological quality and reporting characteristics. Chapter Eight describes a nurse-led telephone intervention, the ‘CONNECT’ intervention and presents a randomised pilot study. CONNECT is delivered by a cancer nurse over the telephone in the six months following patients’ discharge from hospital after surgery. This intervention was designed to supplement exist follow-up strategies. The content of each CONNECT call is standardised to address supportive care domains of unmet need. To evaluate this intervention, patients with colorectal cancer at Royal Prince Alfred Hospital, Sydney were randomised to receive the telephone intervention (n=39) or usual follow-up care (n=36). Feasibility and acceptability of this service delivery approach were assessed as a primary outcome. Patient reported primary outcomes assessed included unmet supportive care needs, quality of life, psychological distress and health service utilisation. Outcomes assessments were assessed at baseline then at one, three and six months post-discharge using a series of postal or telephone questionnaires. The consent rate to this trial was 86%. The CONNECT intervention was shown to be feasible and successful in identifying patient unmet needs. Between 84% and 95% of intervention group patients completed each CONNECT call with the nurse, where a range of unmet needs were identified. Feedback from participants about the intervention was extremely positive. The reassurance, support and sense that someone was monitoring individual needs during each call were seen as benefits of this service. Statistically significant differences between study groups in terms of all patient reported outcomes eluded this evaluation. Scores and changes scores for unmet need, quality of life, psychological distress and health service utilisation were comparable between groups. However scores favoured the intervention group. For example, at three months total SCNS-SF34 scores for intervention group was 98.1 and 110.0 for the control group. At six month total CaSUN scores were 10.0 (intervention) and 14.0 (control). Trends over time for these outcomes were also not statistically significantly different between groups. However some clinically relevant findings from this evaluation were demonstrated. Total FACT-C scores at six months showed that intervention group participants reported higher quality of life compared to control group participants (106.0 versus 98.6). Whilst not statistically different, the findings were in the expected direction and the difference (7.4) between the groups is clinically relevant. The most promising development from utilisation data was the difference, favouring the intervention group, resulting in a ≥10% reduction in presentations to emergency departments and readmission rates to hospital. Given this trial was a pilot study, post-hoc power was ascertained. This found that despite an a priori sample size calculation, the trial was underpowered. This may have resulted in a false negative result. Chapter Nine provides an overview of the key findings from the series of studies undertaken in this thesis. The implications of study results are explored in relation to policy, clinical practice and research.

Background: Gynaecological cancers (GC) have unique effects on women’s sexuality, fertility, body image, and identity. Unmet needs in this group are likely to be high but GC research is hampered by a lack of valid and reliable measures that cover GC specific issues relevant to all age groups. Aims: Develop and validate the Gynaecological Cancer Needs Questionnaire (GCNQ), and examine the prevalence and correlates of unmet needs of younger and older GC patients. Method: ‘Younger’ women were premenopausal or had primary school age children at diagnosis, all others were categorised as ‘older’. Study 1 Telephone interviews were conducted to explore needs in 19 younger and 10 older women. Study 2 & 3 76 younger and 101 older women completed the 61-item GCNQ, comprising four domains: 1) Information, 2) Emotions/Sexuality, 3) Wellbeing/Coordinated Care, and 4) Fertility. Depression, anxiety, and quality of life (QoL) were also assessed. Results: Study 1 Most needs were shared, however younger (fertility and the need to meet other GC patients of similar age) and older (delayed diagnosis) women also reported unique needs. Study 2 Psychometric evaluation supported the validity and reliability of the GCNQ. Study 3 65% of younger and 48% of older women reported at least one unmet need. Younger women reported more unmet needs than older women in all but the Information domain. Parental and employment status, education level, cancer type, anxiety and depression, and QoL were significantly correlated with reporting at least one unmet need. Age (younger) was an explanatory variable for Fertility needs only. QoL correlated with reporting unmet needs in all domains. Conclusion: Many women report a need for additional help with post-treatment difficulties. Age-related variances in reported needs may reflect the level of disruption to pre-diagnosis activities and valued goals. The GCNQ can assist clinicians to routinely identify women’s needs, and make appropriate and timely referrals.

Background and Purpose: According to the Canadian Community Health Survey conducted in 2000-1, 12% of Canadians reported experiencing an unmet health need compared to four percent in 1994-5. There is growing reason to investigate the increasing number of Canadians reporting unmet health needs, particularly among young adults (between 18 and 30 years of age) who access health services less frequently than any other age group. In particular, the growing population of Chinese living in Canada present unanswered questions regarding the health needs of Chinese young adults. The purpose of this study was to examine: 1) if Chinese young adults who primarily speak Chinese experience more unmet health needs when compared to English-speaking Chinese young adults and, if there are, 2) the reasons why Chinese young adults have unmet health needs. Methods: A mixed methods approach was taken; in-depth interviews (n=8) with Chinese young adults were used to complement and explain findings from a secondary analysis of a larger cross-sectional survey of the primary health care seeking behaviours of Chinese-, English-, and Punjabi-speaking Canadians. Findings: Fifty-eight Chinese young adults participated in the primary health care survey; ten percent (n=6) reported having an unmet health need related to the availability and accessibility of health care. Language preference was not found to be associated with unmet health needs. Close to two out of three young adults reported seeing a physician in the past year. Twenty-four percent reported accessing health care outside of Canada. In-depth interviews revealed that Chinese young adults had unmet needs due to the lack of a primary care provider and not accessing preventive care. Acculturation and health behaviour was found to be more predictive of unmet health care needs than language.

Seniors 75 years of age and older, the majority of whom live in the community, constitute a segment of the population that is vulnerable to loss of autonomy. Indeed many community dwelling seniors have difficulty performing daily living activities, such as bathing, toileting, walking, preparing meals and housekeeping.
In the setting of a population based cohort study of community-dwelling seniors 75 years of age or older, we examined the effect of unmet needs for community services for activities of daily living (ADL) and instrumental activities of daily living (IADL) on health services utilization. Self-perceived unmet need status was determined using a baseline in-home interview. A total of 839 subjects were recruited from the Greater Montreal Region, Quebec, Canada, using random telephone number dialling.
Health services utilization data were obtained from administrative databases from the Quebec Health Insurance Board (Regie de l'Assurance-Maladie du Quebec - RAMQ). Multivariable negative binomial regression models were used to examine the association between unmet need status and health services utilization during the six month period following the baseline interview.
The results of this study indicate that unmet needs are associated with higher rates of emergency department visits, hospitalization and prescription drug use. No statistically significant association was found between unmet needs and physician utilization among single seniors, although married seniors with unmet needs in activities of daily living had 2.8 times the rate of medical specialist visits as compared to those who reported no unmet ADL needs.
Unmet need for community services among the elderly has implications for the use of more expensive acute and long-term health care services. The results of this research suggest that developing programs to address unmet needs in the elderly population can potentially reduce health services utilization by the elderly.

The work described in this thesis concerns the use and quality of primary care service use by people living beyond a diagnosis of breast, colorectal and prostate cancer and long-term risks associated with cancer. Firstly, the thesis provides a background for this work, with a definition of long-term survivors as those living at least five years past cancer, and the role of primary care in the care of this population. The second section describes use of the General Practice Research Database amongst a cohort of cancer survivors compared to a control population. Breast and colorectal cancer survivors consult more frequently than controls up to 10 years post-diagnosis, while prostate survivors continue to see their GP up to 3 times more for at least 15 years. Most survivors receive adequate preventative care and chronic disease monitoring, excepting mammography for long-term breast cancer survivors. Cancer survivors receive more prescriptions for pain relief, anti-depressants and erectile dysfunction, suggesting higher rates of pain, depression and sexual dysfunction. Breast cancer survivors have an elevated risk of incident heart failure, coronary artery disease and hypothyroidism, while colorectal survivors experience increased risk of dementia and diabetes. All three groups of cancer survivors had higher risks of osteoporosis and second cancers, all-cause, non-cancer and cancer mortality compared to controls. The third section describes a qualitative study of the primary care usage and unmet needs of 40 long-term survivors of breast, colorectal and prostate cancer. Most respondents did not need active GP involvement. Others had ongoing information and psychological service needs. Some felt that their GPs did not have the right expertise for cancer related issues or were too busy, while others had concerns about continuity of GP care. Overall, this thesis provides a background on how the increasing numbers of cancer survivors use and experience primary care in the UK, areas of good practice, and areas where care can be improved in the future.

The goal of this investigation was to assess service use, self-management strategies, and health status of older adults (60+ years) with perceived need who sought assistance from the Virginia Medicaid Elderly and Disabled Consumer-Direction (EDCD) waiver services. A sequential explanatory mixed method design was used to address the overall research question: How do older adults manage unmet needs? Using health services data from two independent State agencies, regression techniques were used to examine predictors of service use, hospitalization, and mortality among 1,008 individuals. A purposive subsample of eight rural-dwelling waiver-ineligible individuals was identified for follow-up semi-structured telephone interviews to explore self-management strategies for confronting functional care needs. Waiver-ineligible individuals were at risk for hospitalization and mortality; rural-dwelling individuals were more likely to be waiver-ineligible and had increased risk of mortality. Analysis of interviews revealed individuals had ongoing unmet needs and relied on family and community services and used internal and external strategies to manage them; plans were not in place should their health continued to decline. For this group of near-risk older adults who are waiver-ineligible and do not have financial means to pay for more help, accessible preventive services are necessary to reduce risk of adverse health outcomes. Policymakers are encouraged to advocate for preventive services that assist individuals before care needs become unmanageable. Agencies responsible for service delivery need to target efforts toward this group, particularly those residing in rural areas. Researchers must continue forging partnerships that permit use of health services data to identify when and how older adults use services, and explore how self-management strategies influence health and functioning over time.
Ph. D.

The problem of this study was to determine if employee child care difficulties were related to absenteeism. A case study was conducted among sixty-three employees at a north Dallas bank using a survey questionnaire. Descriptive statistics were used to analyze child care difficulties. A majority of employees experienced difficulty when co-workers had child care problems. A majority of the parent employees had difficulty finding sick or emergency/temporary child care, affording child care, and working overtime due to child care. The majority of parents had child care related absences and work interruptions and thirty-nine percent of them considered quitting their jobs due to child care problems. This study implied the need for employer-supported child care options for the bank employees.

Medically complex children have at least one chronic condition resulting in high service needs, including medication, equipment and multiple subspecialist involvement. Evidence has shown that increased care coordination reduces the number and length of hospital stays, and decreases healthcare costs. The Rainbow Medical Home Initiative (RMHI) at Children’s Hospital Primary Care Center targets the medical and social care coordination needs of this population. In 2011, 91.3% of caretakers reported unmet needs in at least one of the following areas: medical equipment, medical supplies, educational and therapy services, mental health support, recreational/social opportunities and home caregiver support. 47.1% reported unmet needs in 3 or more areas. The objectives of this project are: 1) develop a screener for unmet needs amongst RMHI families; and 2) assess the acceptability and feasibility of incorporating this screener into routine care. If successful, this screener will allow providers to more proactively address patients’ unmet needs. Two focus groups and 4 individual cognitive interviews of families were performed to evaluate the completeness, format and literacy level of a draft of the screener. The screener was piloted during the summer of 2012 at patient visits. Feedback on the acceptability and feasibility of screener implementation was solicited through surveys from stakeholders (patient families, providers, social work and administrative staff). Qualitative feedback was solicited in group format from stakeholders to elicit process issues not accounted for by our surveys. Feedback was incorporated into a more refined screener that was distributed during the second half of summer. A similar feedback cycle was performed to develop the final screener. Major unmet needs identified by the 70 completed screeners are: securing educational services (12/25, 48%), finding people or programs parents can trust to help care for their child (22/68, 32%) and finding recreational/social opportunities (21/69, 30%). The 74 stakeholders queried generally agree that the screener helps identify needs and improves communication between providers and families. Most stakeholders believe that the screener is feasible to incorporate into routine practice. This project will improve the effectiveness and efficiency of our medical home by enhancing our understanding of our patients’ non-medical issues. Future directions include screener incorporation into routine practice; screener translation into Spanish; ongoing data collection of unmet needs; development of resources to respond to these needs; dissemination of results to clinical care teams and training on resources designed to address them.

This thesis is comprised of three chapters that empirically examine two important areas in health economics: access to health care and health outcomes. The first chapter explores the impact of health care utilization on unmet health care needs (UHC) using four biennial confidential master files (2001-2010) of the Canadian Community Health Survey and applying an instrumental variables (IV) approach to deal with the endogeneity of health care utilization. The presence of drug insurance and the number of physicians in each health region are used to identify the causal effect. I find a clear and robustly negative relationship between health care use and unmet health care needs; individuals who are more likely to report unmet health care needs are those who use the health care system less frequently. One more visit to a family doctor, specialist or a medical doctor on average, decreases the probability of having unmet health care needs by 7.1, 4.6 and 2.8 percentage points, respectively. Further analysis by sub groups reveals that the impact of health care utilization on UHC is larger for females in comparison to males, rural residents in comparison to urban dwellers and those with low household income rather than high. The second chapter of this thesis examines whether the presence of the unmet health-care (UHC) needs has an adverse effect on health outcomes using the National Population Health Survey, a nationally representative longitudinal data set spanning 18 years. I pay close attention to the potential endogeneity of this problem. Five direct and indirect measures of health-related outcomes are examined. I find clear and robust evidence that the presence of UHC either two-years previously or anytime in the past, affects negatively the current health of the individual – controlling for a host of other influences. For instance, reporting UHC in the previous cycle reduces the probability of being in excellent or very good health and in good mental health, respectively by 8.1 and 1.2 percentage points; it reduces the HUI3 score by 2.9 percentage points and increases the expected number of medications used by 11%. Further analysis by looking at the effect of UHC when it was due to accessibility reasons, reveal that the effect of UHC because of accessibility reasons on health outcomes is larger than the one of the overall UHC, but the difference is small in general. Finally, the third chapter of this thesis examines the link between social networks and access to health care utilization, focusing particularly on the probability of having a regular family doctor. Unlike previous work that uses cross sectional data, I use panel data from the National Population Health survey to control for unobserved heterogeneity. Access to a regular family doctor is modeled using the dynamic random effects probit model, which makes it possible to explore the dynamics of access to a regular family doctor– for instance, the role played by past access status to a family doctor in predicting current access. In particular, I use the dynamic random effects probit model that controls for both unobserved heterogeneity and for initial conditions effects. I find robust evidence of a highly statistically significant relationship between social capital and the probability of having a regular family doctor. Although the marginal effects are modest, the results from all model specifications show that there is clear evidence that individuals with high levels of tangible, affection, emotional, social interaction, who live with spouse only or with spouse and children are more likely to have a regular family doctor, whereas those living alone are less likely to have a regular family doctor. The results also reveal that past access to a family doctor is an important determinant for both current and future access. The predicted probability of having a regular family doctor is about 18 percentage points (or 20%) higher for individuals who had a family doctor in the previous period, relative to those who did not. In addition, I find that unobserved heterogeneity accounts for about 25% of the variation in accessing a regular family doctor and is significantly correlated with the access to a family doctor over my long panel.

Thesis (S.M.)--Massachusetts Institute of Technology, System Design & Management Program, 2000.
Includes bibliographical references (p. 77).
As the diffusion of the Internet reaches the early majority phase, customers, both retail consumers and businesses, are utilizing the Internet in ever increasing numbers for the information search and decision making portions of the sales process. Consumers are online actively searching, researching, selecting, and purchasing products. The most direct output of this process is the end product selection, but many opportunities present themselves for the improvement of market research and corporate product development through the utilization and analysis of the online purchase process. This opportunity is especially applicable to a purchase process in which the customer is not just searching for products by selecting hard constraints around product attributes, but is instead engaged in an online dialogue with a trusted virtual advisor. During this dialogue, the customer reveals their product needs and preferences and the trusted advisor recommends products based upon a maximization of customer utility. If a "perfect" product is available for each customer, then the maximum utility value across all available products will be constantly rising during the online dialogue and all customer needs will be met. Given the reality of product development limitations, ever-changing customer needs, and the introduction of new products and features, consumers are routinely left with unmet needs. This thesis focuses on the development and implementation of a virtual engineer who, after the customer has explicitly given permission, listens to the dialogue between the customer and the trusted virtual advisor. When an unmet customer need is identified through a drop in the maximum calculated utility, the virtual engineer joins the online dialogue. Through the automated generation of contextual questions around the unmet need, the engineer gathers detailed information about the exact nature of the customer's need and translates that need into useful engineering terms. After a large number of customer needs have been collected, the Listening In! process estimates the market share opportunity currently available through the introduction of products that meet the identified needs. The Listening In! process represents a new opportunity in the utilization of the Internet for the improvement of both market research and the traditional product development process.
by Christopher Cyril Mann.
S.M.

Unmet psychosocial needs indicate a desire for additional support in cancer patients, having a direct clinical utility in directing the provision of supportive care. There is evidence in wider cancer groups that unmet needs relate to psychological wellbeing but this relationship has yet to be fully explored and factors that may explain or moderate this relationship yet to be examined. There has been little investigation of type or prevalence of unmet need in haematological cancer patients, however, haematological cancers are noteworthy for their high levels of associated distress. Understanding causality of distress is key to the effective implementation of supportive care services. This thesis aimed to highlight the unmet needs most relevant to haematological cancer patients and to explore their impact upon psychological wellbeing. This thesis comprises four interconnected research studies: a systematic review exploring existing knowledge of unmet needs; a qualitative exploration of patient experiences of unmet needs and their impact; a quantitative questionnaire study of unmet need and psychological wellbeing in newly diagnosed haematological cancer patients, placing a special emphasis on the difference between active treatment and watch and wait regimes; and, a second quantitative questionnaire study that explores unmet need, psychological wellbeing, and psychological flexibility as a potential moderator in their relationship in a sample of haematological cancer survivors. This thesis demonstrates a relationship between unmet need and psychological wellbeing in haematological cancer patients. Fear of recurrence, concerns about loved ones, being able to do the things you used to, and a need for information were all found to be of relevance. The qualitative study highlighted that patients feel that, as haematology patients, they are distinct from other cancer patients which impacts upon the perceived acceptability of support services and specific barriers to the accessing of support services are presented. Significant correlations between unmet need and key psychological outcomes such as anxiety, depression and quality of life were observed in both quantitative studies. In addition, the concept of psychological flexibility was found to moderate the relationship between unmet need and psychological wellbeing in haematological cancer survivors. This work has clear implications for both future research and clinical practice. Unmet needs assessment has the potential to be used as a screening tool for overall psychological wellbeing, a way to stratify and understand the specific causes of distress and poor quality of life for this patient group. In the UK, on-going support for cancer patients diminishes at the end of treatment, these findings suggest that further support is needed in order to meet the psychological needs of cancer survivors. Further research is needed to further explore the role of psychological flexibility in cancer-related distress: interventions that target psychological flexibility have the potential to improve both unmet need and distress.

Objectives and methods: DETECT is a cross-sectional study of 55,518 unselected consecutive patients in 3188 representative primary care offices in Germany. In a random subset of 7519 patients, an extensive standardized laboratory program was undertaken. The study investigated the prevalence of cardiovascular disease, known risk factors (such as diabetes, hypertension and dyslipidemia and their co-morbid manifestation), as well as treatment patterns. The present analysis of the DETECT laboratory dataset focused on the prevalence and treatment of dyslipidemia in primary medical care in Germany. Coronary artery disease (CAD), risk categories and LDL-C target achievement rates were determined in the subset of 6815 patients according to the National Cholesterol Education Program (NCEP) ATP III Guidelines. Results: Of all patients, 54.3% had dyslipidemia. Only 54.4% of the NCEP-classified dyslipidemic patients were diagnosed as ‘dyslipidemic’ by their physicians. Only 27% of all dyslipidemic patients (and 40.7% of the recognized dyslipidemic patients) were treated with lipid-lowering medications, and 11.1% of all dyslipidemic patients (41.4% of the patients treated with lipid-lowering drugs) achieved their LDL-C treatment goals. In conclusion, 80.3% of patients in the sample with dyslipidemia went undiagnosed, un-treated or under-treated.

Lung cancer has developed from a rare condition into the leading cause of cancerrelated death in the United Kingdom. Lung cancer patients face a disease with a high symptom burden, increased psychosocial needs and a high mortality. Supportive care needs are often relevant from diagnosis. Despite this there are no clear follow-up structures for lung cancer patients that address both cancer management and supportive care. The aims of this study were to evaluate supportive care needs, assess predictors of such needs and identify factors which could aid service provision within Stobhill lung cancer services. Methods Supportive care needs were measured using an adapted Palliative Outcome Scale (POS), incorporated within a larger questionnaire. All lung cancer patients attending the clinic could complete this questionnaire. Respiratory symptoms, performance status, service usage, preferences and satisfaction were also assessed. Data were stratified to allow evaluation of three clinical groupings: all patients, newly diagnosed patients and patients in the last three months of life. Analyses were phased: descriptive analyses, univariate tests of association and multivariate regression. Results Three hundred and fifty three lung cancer patients completed questionnaires. The high symptom burden in lung cancer was confirmed. Anxiety, pain and dyspnoea were identified as the key issues. Poor performance status was identified to be an independent predictor of increased POS score, increased anxiety, increased pain and increased dyspnoea. There was no independent relationship between POS and survival. Although the majority of patients were satisfied with the care received, there was uncertainty regarding who was in charge of care and some disparity in preferred structure for follow-up. Conclusions Despite recent advances in lung cancer management, improvements are still required to address unmet supportive care needs of patients. Particular attention should be given to those with poorer performance status to effectively identify and meet such needs.

Objectives and methods: DETECT is a cross-sectional study of 55,518 unselected consecutive patients in 3188 representative primary care offices in Germany. In a random subset of 7519 patients, an extensive standardized laboratory program was undertaken. The study investigated the prevalence of cardiovascular disease, known risk factors (such as diabetes, hypertension and dyslipidemia and their co-morbid manifestation), as well as treatment patterns. The present analysis of the DETECT laboratory dataset focused on the prevalence and treatment of dyslipidemia in primary medical care in Germany. Coronary artery disease (CAD), risk categories and LDL-C target achievement rates were determined in the subset of 6815 patients according to the National Cholesterol Education Program (NCEP) ATP III Guidelines. Results: Of all patients, 54.3% had dyslipidemia. Only 54.4% of the NCEP-classified dyslipidemic patients were diagnosed as ‘dyslipidemic’ by their physicians. Only 27% of all dyslipidemic patients (and 40.7% of the recognized dyslipidemic patients) were treated with lipid-lowering medications, and 11.1% of all dyslipidemic patients (41.4% of the patients treated with lipid-lowering drugs) achieved their LDL-C treatment goals. In conclusion, 80.3% of patients in the sample with dyslipidemia went undiagnosed, un-treated or under-treated.

The aim of this study was to investigate met and unmet palliative care needs for people living with HIV/AIDS in selected areas in Rwanda. The achieve this aim, the study, firstly, identified the palliative care needs of people living with HIV/AIDS, secondly, it identified the health care services available to meet these needs, and thirdly, it determined the extent to which palliative care needs were met.

Background: Im/migrant women often face barriers to conventional labour markets in destination countries, and are disproportionately represented in precarious employment arrangements, including sex work. Apart from sexual health, research examining broader health concerns of im/migrant sex workers (SWs) remains scarce. This thesis sought to investigate the relationship between im/migration experiences and (1) inconsistent condom use with clients, (2) unmet health needs, and (3) dimensions of work stress among SWs. Methods: This thesis utilized data from “An Evaluation of Sex Workers Health Access” (AESHA), a community-based prospective cohort of SWs in Metro Vancouver. Bivariate and multivariable logistic regression using generalized estimating equations (GEE) were used to model correlates of inconsistent condom use among im/migrant SWs only (Objective 1) and unmet health needs among all SWs (Objective 2). Multivariable confounder models using linear regression with GEE were developed to examine independent relationships between im/migration experience and dimensions of work stress (Objective 3). Results: In Objective 1, multivariable GEE analysis conducted among 182 im/migrant SWs enrolled in AESHA from January 2010 and February 2013 revealed that difficulty accessing condoms was the strongest predictor of inconsistent condom use (Objective 1). In Objective 2, among 742 im/migrant and Canadian-born SWs enrolled from January 2010 to February 2014, multivariable GEE analysis found that recent and long-term im/migration, police harassment and arrest, and lifetime abuse/trauma were associated with greater unmet health needs. In Objective 3, among 545 SWs enrolled from January 2010 to September 2014, multivariable confounder GEE modeling revealed that recent and long-term im/migrant SWs faced decreased work stress related to job demands compared to their Canadian-born counterparts, after adjustment for key confounders. Conclusions: Findings suggest that im/migration experience is a key driver of HIV/STI prevention, healthcare access, and work stress among SWs. Importantly, im/migration experiences intersect with other structural factors – working conditions, violence, policing, sex work criminalization– to shape the health and safety of im/migrant SWs. Culturally appropriate, low-barrier health and support services should be made accessible to im/migrant SWs. Sex work decriminalization along with supporting collectivization efforts within the workplace are also recommended to improve working conditions, health, and human rights for im/migrant SWs.
Medicine, Faculty of
Population and Public Health (SPPH), School of
Graduate

Thesis: S.M. in Management Research, Massachusetts Institute of Technology, Sloan School of Management, 2015.
Cataloged from PDF version of thesis.
Includes bibliographical references (page 56).
The Small and Medium Enterprises in India face a major problem with Travel & Expense management due to higher prices, low return-on-investment, higher transition costs and steeper learning curve. In order to address this unmet need and huge opportunity, we are building 'T-Desque' a cloud-based travel solution for the Indian market. Our vision is to make the entire travel related processes seamless, efficient and cost effective. Our product will focus on the following modules: - Travel Requisitions, Approvals & Reimbursement to streamline existing manual/ semi-manual process - Rewards to incentive for employees to be prudent on official travel - Spend Visualization for better visibility and control on travel spend Our key differentiator will be the rewards module, which will be a one of its kind offering which incentivizes employees to be prudent during business travel. This module will also help employers contain travel costs and be our source of monetization.
by Shreyas Gupta [and] Mahesh Chayel Mohinder-Singh.
S.M. in Management Research

Due to the demanding structure of caring for a child with a life-threatening disease (LTD), parents experience psychosocial distress. Studies have shown that stress in parents of children with LTDs can be increased by unmet needs or fragmented care and may be mitigated by coordinated and comprehensive care. Limited literature exists about unmet needs of parents of children with LTDs and the barriers they encounter to accessing mental health resources within pediatric palliative care (PPC) programs. This research study applied quantifiable descriptive methods including a purposive sample of ninety-eight (98) PPC and other pediatric practitioners through the distribution of anonymous online surveys in order to examine unmet needs for mental health resources as they relate to parents of children with LTDs who experience psychological distress exacerbated from psychosocial stressors of care giving. Influenced by Andersen’s predisposing, enabling, and need factors, this study found that PPC practitioners perceived parents encountering waitlists and/or denials when referred to community mental health resources as demonstrating resistance against seeking help.

Thesis (M.A. (Clinical psychology) --University of Limpopo, 2009.
The study aimed at assessing and understanding the unmet needs and well-being among people living with HIV/AIDS. People living with HIVAIDS experience many challenges. Challenges may be characterized by medical, social and psychological challenges. Method: A cross sectional design was used. A total of (N = 200) young and adult age ranged from 20-71 years ( = 43.70, SD = 12.420) women (62%) and 75 men (37, 5%) living with HIV/AIDS who attend HIV/AIDS clinic/unit in Polokwane/Mankweng hospital complex was selected with purposive sample. Results: Four hypotheses were tested with one-way ANOVA. The findings indicated that social support (p < .001) and age (p < .04) plays a significant role in the psychological well-being of people living with HIV/AIDS. Medical challenges and gender revealed no significant results. Conclusion: It is concluded that PLWHA attend some form of support groups which will aid in alleviating the psychological distress associated with HIV/AIDS.

Abstract INFORMATION NEEDS AND INFORMATION SOURCES OF PATIENTS DIAGNOSED WITH RARE CANCERS By Dana L. Ladd, Ph.D., MS, SLIS BACKGROUND: Approximately 25% of all cancers diagnosed are considered rare. Patients may face many significant challenges including difficulty obtaining information about their rare conditions. Patients often have high information needs and may seek desired information from a variety of informational sources including healthcare providers, media, print, government and non-profit organizations in order to meet their needs. Accessing reliable consumer-level information can be challenging and often information needs are unmet. Dissatisfaction with health information provision can result in negative health-related outcomes and factors including decreased health-related quality of life. METHOD: This cross-sectional design study used validated measures to assess the information needs, information sources, information satisfaction, and health-related quality of life of patients diagnosed with rare cancers (n=113). Adult patients at the VCU Health Massey Cancer Center who had been diagnosed with a rare cancer in the past 12 months were contacted via mail survey. Descriptive statistics were used to summarize patients’ information need and information received levels. Unmet needs were analyzed using a two-sample T-test. Chi-square tests were used to analyze information needs and received by demographics for gender and race and logistic regression analysis was used for age. Descriptive statistics summarized information sources used and preferred. Finally, descriptive statistics were used to summarize information satisfaction. The relationship between information satisfaction and health-related quality of life was assessed using a two-sample T-test. RESULTS: Study participants had high information needs, particularly for information about disease, medical tests, and treatment. Though patients also reported receiving information at high levels, 21 participants (18.9%) reported being unsatisfied with information provision. Unmet needs were found for information about disease and on the item level for information about causes of cancer, whether their cancer was under control, expected benefits of treatment, and financial, insurance, and work-related information. Although participants reported preferring information from their healthcare providers, they most commonly sought information from the Internet more than any other source. CONCLUSION: By identifying patients’ information needs and sources, this study fills an important gap in the information needs and sources literature of patients diagnosed with rare cancers. Identification of these needs allows healthcare providers to tailor information provision to more effectively meet patients’ information needs.

Aims: Unmet needs have mainly been investigated with formal and informal adult caregivers and ill individuals within psycho-oncology; findings indicate unmet needs are associated with negative affective state and caregiver burden. Research relating to adolescent children’s experiences of unmet needs during parental illness has, in the main, been based upon parental reports or professional opinion, yet research suggests that parental reports can downplay the effects and it is important to ask the adolescent child for their opinion. Adolescence is a transitional time in development; this may make the illness experience and subsequent needs vary from those of formal and informal adult caregivers. This thesis pragmatically investigates adolescent children’s firsthand accounts of unmet psychosocial and supportive care needs when they have a parent with a non-communicable disease. Methods: Systematic Review: To inform the direction of the thesis and capture all relevant published literature, a comparative systematic review was carried on adolescent’s experiences of unmet needs when they have a parent with a NCD, cancer or psychological problem. The review was conducted using standardized procedures and guidance from the Cochrane collaboration. Interpretative Phenomenological Analysis: Qualitative methodology was used to investigate seven adolescent’s experiences of unmet psychosocial and supportive care needs in relation to having a parent with a NCD. Participants were recruited through institutions of further and higher education. Quantitative Research: Pearson’s correlation and multiple regressions were used to test associations between unmet needs, depression, stress, anxiety and quality of life, and to determine the applicability of the revised version of the Offspring Cancer Needs Inventory (OCNI) for individuals who have a parent with a NCD. One hundred and seven adolescent children completed the revised version of the OCNI, the DASS-21 (depression, anxiety, and stress) and AC-QoL (Adult carers’ quality of life) scales. Findings: Systematic Review: In the review 1479 papers were considered. Seven met the inclusion criteria, of these five papers related to cancer, one to chronic illness and one to psychological problems. Results suggest that adolescents had informational, supportive and recreational needs, and did not want to worry parents by asking them questions. The lack of hits and the disparity between illness groups is problematic in making comparisons and drawing definitive conclusions. Interpretative Phenomenological Analysis: Four interdependent themes emerged from the data, two relating to interpersonal needs (Information Needs and Support Needs), and two relating to intrapersonal needs (Need for 4 Acknowledgement and Need to be Them-Self), each had their own number of sub-themes. Adolescent’s had a variety of needs that could be partially met through honest and accurate information, interpersonal support and acknowledgment of their caring role within the family. The interdependence of the needs indicated that the fulfilment of one need has the potential of meeting other needs. Unmet needs were comparable to those of adolescent children who have a parent with cancer; as such it was deemed that the new version of the OCNI would be suitable for use with individuals who had a parent with a NCD. Quantitative Research: Ninety-Three percent of adolescents reported at least one unmet need. Analysis suggests that the unmet needs variables were co-dependent and correlated with depression, stress, anxiety, and quality of life. Certain unmet need variables predicted stress, anxiety, depression, and quality of life. Conclusion: The findings of this thesis indicate that adolescent children who have a parent with a NCD have a variety of unmet needs, and that these are associated with affective state and well-being. It is suggested that counselling psychologists are well placed to provide psychological and needs based interventions based upon the findings within this thesis. More research is required in this area to determine cause and effect; owing to counselling psychologists working with the lifespan they would be well placed to further the knowledge in this area.

Background: Advanced breast cancer (ABC) is affecting substantial number of Chinese women in Hong Kong. Understanding their unmet supportive care needs (SCNs) is important for health care system to precisely allocate resources to areas demanded for help the most and for patients to achieve better quality of life. Objectives: (1) To validate Chinese version of Supportive Care Needs Survey Questionnaire (SCNS-SF34), (2) to address the prevalence of unmet SCNs at baseline (newly diagnosis of ABC) and explore relevant factors associating with baseline unmet SCNs, (3) to identify the trajectories of unmet SCNs from baseline, 6-week, 12-week, 18-week to one-year post-diagnosis of ABC among Hong Kong Chinese women and identify the predictors related to individual resources. Methods: The study consisted of two phases. In Phase I, breast cancer (BC) patients were recruited from six public hospitals and the SCNS-SF34 (which covers five domains of needs) was administered concurrently with measures of psychological distress CHQ-12 (Chinese Health Questionnaire-12), HADS (Hospital Anxiety and Depression Scale), symptom distress (MSAS-SF), and patient satisfaction (ChPSQ-9) to explore factor structure by using Exploratory Factor Analysis (EFA) and to examine internal consistency, and convergent, divergent and discriminant validities of the identified factor structure. In phase II, women newly diagnosed with ABC were recruited and followed up to assess their unmet SCN trajectories one year after diagnosis. Prevalence of initial baseline SCNs and associated demographic, medical and psychological factors were identified. Linear Mixed Modeling (LMM) was performed to assess trajectories for each SCNs domain. Hypothesized variables reflecting personal and social resources (optimism, trait hope, social support, psychological distress and patient satisfaction) were examined for association with the changes of unmet SCNs after adjusting for demographic and medical characteristics. Results: Instead of five-factor structure identified in the original SCNS-SF34, a four-factor structure with 33 items was identified, comprising: 1) Health system, information and patient support needs (HSIPS), 2) Psychological needs (PSYC), 3) Physical and daily living needs (PDL) and 4) Sexuality needs (SEX). The SCNS-SF33-C demonstrated moderate-to-good internal consistency (Cronbach’s alphas=0.75-0.92) across all domains. Acceptable convergent and divergent validity were demonstrated. Discriminant validity was demonstrated in the SCNS-SF33-C’s ability to differentiate between clinically distinct patient groups (ABC vs. localized BC and active treatment vs. no active treatment). Of the top 15 unmet SCNs, all belonged to the HSIPS domain. There were significant linear declines in unmet HSIPS and PSYC needs over the year after diagnosis, but not in PDL and SEX. After adjusting for demographic and medical factors, LMM identified symptom distress, patient satisfaction and patient satisfaction x time are predictors of HSIP. Total symptom distress, optimism, anxiety and anxiety x time predicted PSYC. Total symptom distress was predictor of PDL. Anxiety was predictor of SEX. Conclusions: The SCNS-SF33-C has a suitable factor structure and psychometric properties for the use in assessing unmet psychosocial SCN among Chinese women with BC. Generally, unmet HSIP and PSYC tended to decline, while levels of unmet PDL and SEX tended to persist over time. Specific individual resources predicted the future change of unmet SCNs.
published_or_final_version
Community Medicine
Master
Master of Philosophy

Bronchiectasis is a chronic lung disease that can create significant symptom and treatment burdens for those affected, and significant costs to the National Health Service. Treatment concordance can be problematic and improvements in interventions are urgently required. There is little patient information available, yet information and education could support patients to self-manage, improve understanding and optimise engagement with treatment. This in turn could facilitate reductions in unscheduled presentations to healthcare services and improvements in longer-term health-related outcomes. A mixed methods approach was taken to this work. Qualitative interviews were conducted with patients and carers to explore and understand their unmet information needs. Using thematic analysis, a core mediating issue emerged: what it means to learn to live your life with bronchiectasis. Embedded within this journey were issues around developing support and coping mechanisms, learning to connect with information, taking back control and developing active partnerships with the medical team. Using the interview findings, a novel information resource was co-developed during a series of workshops with patients and carers. Potential designs, formats and content were discussed and prototypes developed, reviewed and refined. A booklet and a website featuring video content (www.bronchiectasis.me) were produced. A feasibility study (The BRIEF Study, ISRCTN84229105) was subsequently conducted comparing use of this novel information resource to usual care. Feasibility outcomes included recruitment and retention rates and questionnaire completion rates. 62 participants were randomised; 60 completed the study. Recruitment and questionnaire completion rates were excellent. Resource evaluation conducted within the trial was positive and demands for access worldwide were high. By understanding what it means to live with bronchiectasis, a resource that meets users’ needs has been co-developed. The feasibility study indicates that a definitive trial establishing effect on understanding, self-management and health-related outcomes would be feasible and that the resource is credible and of high quality.

Health inequality has become a research imperative worldwide. Cancer is a global burden, but little is known about the experiences of immigrant patients. This mix-method research aimed to fill the knowledge gaps. The qualitative phase involved a descriptive, focus-group study to explore immigrants’ cancer experiences in Australia. Participants were 91 cancer patients/carers from Arabic, Chinese and Greek communities. The data were subjected to thematic analysis. Participants raised main challenges including: 1) high level of cancer-related distress; 2) communication barriers; 3) lacking understanding of the health system; 4) cultural alienation. Culturally-driven coping styles and coping resources were also explored. The quantitative phase involved a large scale survey via 16 recruiting clinics nationwide, yielding a dataset of 571 immigrant patients (145 Arabic, 248 Chinese, and 178 Greek-speaking patients) and 274 Anglo-Australian-born patients. Three separate analyses were conducted of the data: 1) to document the extent of disparities in psychosocial outcomes in immigrants; 2) to elicit cancer patients’ unmet Cancer Information and Support, Physical and Daily Living, and Sexuality needs during the active treatment phase; 3) to compare illness perceptions of cancer among immigrants and Anglo-Australians, applying the Self-Regulatory model. The quantitative results showed that immigrants are disadvantaged compared to Australian-born English-speaking patients, with worse psychosocial outcomes. Contributing factors include poor understanding of English and of the health system, as well as maladaptive culturally-driven perceptions of cancer. Immigrants reported many unmet needs for help with daily living activities, information, and language assistance. This research has provided insights into the factors influencing the psychosocial outcomes of immigrants with cancer, and provides some guidance regarding appropriate interventions to reduce health disparities.

Mental illness is far higher among prisoners than in general populations, especially for female prisoners. Previous research has discovered that traumatic experience plays a crucial role in the development of psychiatric disorder and other mental health issues in female prisoners. The present paper reviews eight articles, investigating into the negative outcomes associated with trauma-related mental health issues for female prisoners, and how their trauma-related mental health needs are addressed in prison. Systematic text condensation was used to discover similar themes and meanings throughout the articles. The results found a high prevalence of unrecognized and misdiagnosed trauma-related mental health issues across the articles, in particular post-traumatic stress disorder, with treatment having too much focus on substance abuse rather than addressing trauma directly. The review concludes that current prison screening measures and interventions do not identify trauma-related mental health issues adequately or address trauma directly. As a result, prison services do not meet the complex trauma needs of women. Further research needs to be conducted in this area for this population, as trauma-specific treatment is in its infancy.

This dissertation investigates the process of forced eviction (i.e., gentrification) and its influence on Harlem culture. The study quantifies four (4) significant factors involved in the influencing of a paradigm shift. The study explicitly examines the historical and traditional cultures of Harlemites' when framed in the theoretical context of unmet human needs. In this study, unmet human needs in association with theoretical constructs have demonstrated strong correlations in relation to altering attitudes that affect complex thought and human behavior. This study reports the empirical results and the investigated associations of theoretical constructs as they pertain to the various hypotheses outlined in this dissertation. Analytical measurements used in this study include both descriptive and inferential statistics. The sample population was 300 and six (6) statistical tools are used to examine and analyze the data. This study will show that correlations and regression results suggest unmet human needs shape the observation on the preconceptions of culture and the findings are conclusive. Psychological characteristics moderately influence culture and congruent with Maslow's and Burton's human needs theories. The researcher postulates that the theoretical models used in the study and working hypotheses in this exposition can be used in guiding impending research.

One of the frequently observed issues related to fiscal decentralisation in developing and transition countries is that subnational governments may not have adequate resources to finance the expenditure responsibilities decentralised to them. This often results in expenditure needs not being met in poorer areas. In China, fiscal decentralisation has taken place in an extreme form, where the social security responsibility, a conventional central government function, has been devolved to subnational governments during the fiscal reforms. While existing studies have anatomised the problem of unmet fiscal needs in poorer areas of China using economic and political economy theories of fiscal federalism, they tend to under-estimate or neglect the fiscal needs induced by market transition—the increasing demand for social security by workers from state and non-state sectors since the mid-late 1990s. This research illustrates that excess fiscal decentralisation, as in the case of China, could also create serious fiscal burdens for relatively affluent local areas and generate unmet social security needs in these localities. It is discovered that in response to the emerging social security burdens, even the relatively affluent local governments are forced to adopt measures that may counter the intent of social benefit programs or produce other detrimental consequences. In addition, this dissertation applies statistical analysis to ascertain a few inconclusive issues raised by the China-specific literature. It is perceived that the negative correlation between the share of consolidated provincial budgetary spending on social security and health sector has become stronger and more significant in more recent time. This suggests that the expansion of social security expenses at subnational levels might have bid away budgetary resources for health. The result from the multiple regression analysis indicates that the degree of market transition has explanatory power on the size of provincial government, even when a number of other independent variables are controlled for. However, the explanatory power of market transition on the size of central-provincial fiscal transfer is not robust.

There are many factors that influence health and health care seeking. Although many of these factors are similar across populations, exactly how they interact and influence the actions of people is often unique to a population in the context of the environment they live in. The current study, a population-based cross sectional survey, identifies three specific geographically diverse populations in rural areas of Kenya, to gain information regarding overall influences on health care seeking, and also information specific to each geographical area to directly target the health needs of the individual population living there. Participants of the survey were interviewed for personal information and details regarding their activities in response to their health and ill-health. The subsequent data was then analysed to determine which factors affected the use of health and medical services within the study areas and whether the study participants believed their health needs were being met.

Health care evaluation serves the purpose of monitoring the quality of health care provided by Health Care Providers (HCP), so that health care services can be provided most effectively and efficiently. Patient satisfaction studies are widely used to assess the quality of outpatient care. A client satisfaction study was conducted at an HIV health care facility in Sydney, Australia during 2007-2008. There were three objectives: 1.) To validate a questionnaire for future determination of client satisfaction in HIV health care facilities. 2.) To identify the levels of satisfaction of clients, and investigate any dissatisfaction and unmet needs towards HIV health care. 3.) To provide recommendations for improving client satisfaction levels in HIV health care. This research used a mixed method approach and consisted of two phases. The first phase was a quantitative survey conducted with 166 clients (both HIV positive and negative) at Albion Street Centre (ASC) using a newly-devised questionnaire. Clients were asked to answer demographic questions, rate their levels of satisfaction with each aspect and each HCP category, and provide suggestions for improvement. Quantitative statistical analysis was conducted to obtain a general view of client satisfaction levels. Dissatisfaction and unmet needs of clients were then investigated in-depth in the second phase of the research through qualitative face-to-face semi-structured interviews. Twenty-two clients (both HIV positive and negative) at ASC were interviewed individually and asked about their attitudes, perceptions, and experiences towards their HCP and the HIV health care services received. Thematic analysis was used to categorise and interpret the qualitative data. More than 90% of the clients were satisfied with most of the aspects covered in the survey, with a mean overall satisfaction score of 84 out of 100. Clients were most iii satisfied with the “technical quality” and “interpersonal manner” of the HCP, and were least satisfied with “waiting time” and “availability of HCP”. The HCP category with which the clients has the highest level of satisfaction was “nurses” (86%), followed by “psychologists” (84%), then “doctors” (83%). Clients who were HIV negative, had a full time job, visited ASC less frequently, or did not possess any type of Health Care Card were more satisfied with the services overall. No common dissatisfaction or unmet needs towards HIV health care service were identified. “Technical quality of HCP” and “the relationship with HCP” were the two most important determinants of client satisfaction, which outweighed the inconvenience contributed by the poor availability of HCP and the location of ASC. The maintenance of “confidentiality/privacy” was shown to be fundamental in HIV health care facilities. The multi-disciplinary nature of ASC increased the degree of convenience and satisfaction level among clients. Suggestions for improvement in client satisfaction levels include increasing the attractiveness of the physical environment and the variety of educational reading materials in the waiting area; introducing beverages, and encouraging clients to be involved in their treatment decisions. Health care administrative staff in particular are reminded not to neglect the importance of the availability of HCP, accessibility, and physical environment when establishing a new HIV health care facility. The mixed method approach (quantitative survey and qualitative interviews) proved beneficial. It increased the validity of the findings by assessing client satisfaction levels using more than one method. This enabled clarification of ambiguities noted in the initial survey through probes used in the interviews, and also allowed investigation of the determinants of client satisfaction through understanding their experiences in HIV health care. Future client satisfaction studies would benefit from using this approach.

Master of Philosophy (Medicine)
Health care evaluation serves the purpose of monitoring the quality of health care provided by Health Care Providers (HCP), so that health care services can be provided most effectively and efficiently. Patient satisfaction studies are widely used to assess the quality of outpatient care. A client satisfaction study was conducted at an HIV health care facility in Sydney, Australia during 2007-2008. There were three objectives: 1.) To validate a questionnaire for future determination of client satisfaction in HIV health care facilities. 2.) To identify the levels of satisfaction of clients, and investigate any dissatisfaction and unmet needs towards HIV health care. 3.) To provide recommendations for improving client satisfaction levels in HIV health care. This research used a mixed method approach and consisted of two phases. The first phase was a quantitative survey conducted with 166 clients (both HIV positive and negative) at Albion Street Centre (ASC) using a newly-devised questionnaire. Clients were asked to answer demographic questions, rate their levels of satisfaction with each aspect and each HCP category, and provide suggestions for improvement. Quantitative statistical analysis was conducted to obtain a general view of client satisfaction levels. Dissatisfaction and unmet needs of clients were then investigated in-depth in the second phase of the research through qualitative face-to-face semi-structured interviews. Twenty-two clients (both HIV positive and negative) at ASC were interviewed individually and asked about their attitudes, perceptions, and experiences towards their HCP and the HIV health care services received. Thematic analysis was used to categorise and interpret the qualitative data. More than 90% of the clients were satisfied with most of the aspects covered in the survey, with a mean overall satisfaction score of 84 out of 100. Clients were most iii satisfied with the “technical quality” and “interpersonal manner” of the HCP, and were least satisfied with “waiting time” and “availability of HCP”. The HCP category with which the clients has the highest level of satisfaction was “nurses” (86%), followed by “psychologists” (84%), then “doctors” (83%). Clients who were HIV negative, had a full time job, visited ASC less frequently, or did not possess any type of Health Care Card were more satisfied with the services overall. No common dissatisfaction or unmet needs towards HIV health care service were identified. “Technical quality of HCP” and “the relationship with HCP” were the two most important determinants of client satisfaction, which outweighed the inconvenience contributed by the poor availability of HCP and the location of ASC. The maintenance of “confidentiality/privacy” was shown to be fundamental in HIV health care facilities. The multi-disciplinary nature of ASC increased the degree of convenience and satisfaction level among clients. Suggestions for improvement in client satisfaction levels include increasing the attractiveness of the physical environment and the variety of educational reading materials in the waiting area; introducing beverages, and encouraging clients to be involved in their treatment decisions. Health care administrative staff in particular are reminded not to neglect the importance of the availability of HCP, accessibility, and physical environment when establishing a new HIV health care facility. The mixed method approach (quantitative survey and qualitative interviews) proved beneficial. It increased the validity of the findings by assessing client satisfaction levels using more than one method. This enabled clarification of ambiguities noted in the initial survey through probes used in the interviews, and also allowed investigation of the determinants of client satisfaction through understanding their experiences in HIV health care. Future client satisfaction studies would benefit from using this approach.