Rozprawy doktorskie na temat „Indian patient”

Purposes/Aims: This study described the unique relationships that develop while providing cancer care to American Indian (AI) populations and the underlying meaning that nurses ascribed to these experiences. Rationale/Conceptual Basis/Background: The establishment of caring relationships in order to provide high quality cancer care is particularly challenging for nurses who engage with ethnic minority populations as they contend with cultural and contextual influences different from those found in the majority population. AIs represent an Indigenous minority group in the U.S. facing a considerable cancer care inequity. Nurses who care for AI patients frequently encounter population-specific issues that impact the caring dynamic, yet their experiences and the meaning they ascribe to them are largely unknown. Methods: This was an interpretive phenomenological study with iterative data collection and analysis. Nine cancer care nurses with a minimum of three years of experience working with AI patients participated by engaging in 2-3 exploratory, open-ended, reflective interviews over a period of 9 months. Thematic reduction was completed to explicate the fundamental structures of nurse-patient relationships during cancer care. Phenomenological and hermeneutical reflective writing resulted in linguistic transformation illuminating the essential meaning for nurses within this patient-nurse phenomenon. Results: Findings include individually-situated wholistic descriptions capturing the existential experiences of each of the participants. Reduction of individually-situated themes into seven shared meta-themes included From Task to Connection; Unnerving Messaging; We Are One; the Freedom of Unconditional Acceptance; Attuning and Opening; Atoning for the Past, One Moment at a Time; and Humanizing the Inhumane. Themes were explicated in a comprehensive general structural description followed by the reconstitution of the data and self-reflection into a deeply introspective essential description, suggesting that the meaning of the AI patient-cancer care nurse relationship was expressed in contradictory yet simultaneous patterns of joy and sorrow; ease and difficulty; obligation and vocation. From one moment to the next, nurses sought synchronicity with their patient as they danced to a life rhythm that revealed and concealed; enabled and limited; connected and separated. Being in relationship provided nurses great purpose within the universal human context of caring. Implications: Results contribute to the development of interventions designed to improve both the AI cancer care experience and the support and training of the nurses who serve this population. Refinement of our praxis will result in improved outcomes for both nurses and AI patients, reflecting the inseparability of the two entities within the cancer care relationship. The complimentary and mutually dependent nature of the patient-nurse relationship implies that strengthening and improving support for one entity may in turn positively impact the other. Further research into the AI patient’s perspective of their relationships with cancer care nurses is called for.

Type 2 diabetes is epidemic in the American Indian population. One problem health care providers face when working with the American Indian population is communicating about secondary complications, such as periodontal disease. From a public health standpoint, periodontal disease prevention is important not only to prevent unnecessary oral pain and tooth loss, but also to prevent other more serious systemic problems from occurring such as cardiovascular disease, strokes, and bacterial pneumonia. The purpose of this qualitative study was to examine the communication efforts of health care providers and understand if and how they discuss periodontal disease with their American Indian patients with type 2 diabetes. Structured interviews were conducted with health care providers at an American Indian community clinic using questions based on the model of communication competence. Data analysis consisted of an analysis of the interview transcripts looking for concepts, themes, and events to see if discussion of periodontal disease is occurring at diabetic visits. Results of the study showed that although all the providers knew about the link between diabetes and periodontal disease risk, not all the providers were discussing the risk with their patients, and time, perceived health literacy, and other priorities all played a role in the lack of communication. This finding has the potential to influence positive social change by being an impetus for change in current diabetic patient care policies in the areas of communication and education regarding American Indian patients with diabetes about periodontal disease risk.

This PhD thesis has two core objectives: 1) To critically analyse and compare the legal provisions relating to capacity assessment in England and Wales, Scotland and India; (2) To critically analyse and compare the legal provisions relating to decision-making on behalf of the incapable patient in England and Wales, Scotland and India. The methodology utilised to achieve these objectives is essentially a classic literature based comparative approach. This thesis provides an original contribution to knowledge by virtue of the fact that an in-depth tripartite comparative study of capacity law provisions in England and Wales, Scotland and India has yet to be undertaken within existing literature. The research undertaken in this thesis is timely given the implementation of capacity legislation in England and Wales and the relevant provisions of the Mental Capacity Act 2005 of England and Wales and the Adults with Incapacity (Scotland) Act 2000 are compared and critiqued as part of a discussion of the key ethical, legal and procedural concepts which underpin the law of capacity. In addition, the capacity law of England and Scotland is compared with the equivalent system in Indian law, which is at a nascent stage of development in comparison to the United Kingdom. The fact that India, despite being an Eastern country, also retains the influence of U.K law through its status as a Commonwealth country, means that the differences between the English, Scottish and Indian approaches to capacity can be attributed to issues of culture or development. The research undertaken for this thesis has shown that developmental issues are of greater impact, and while cultural issues are of some relevance, there are enough underlying commonalities between the three jurisdictions to suggest that India's capacity law is at a different point developmentally speaking.

In Australia, type 2 diabetes mellitus (T2DM) is a leading cause of morbidity and mortality with approximately 1.2 million people affected. Australia has a large number of migrants: as of June 2019, 7.5 million (29.7%) Australians were born overseas, and the Indian migrant population is 660,000 (2.6% of the total population). Evidence suggests that there is a very high prevalence of diabetes among Indian migrants (14.8%) compared to the Australian-born population (7.1%) along with a high rate of diabetes-related hospitalisation and complications. Indians are traditionally known for high use of ayurvedic medicines (AM), a component of complementary and alternative medicines (CAMs). Diabetes management's primary goal is to reduce symptoms, avoid the associated harms and improve quality of life. The patient can achieve these goals by adhering to treatment and lifestyle modifications. However, maintaining a normal blood sugar level can be challenging for Indian migrants because of several factors, such as an unhealthy diet, inadequate physical activity, poor adherence to medicines, religious factors, poor understanding of the health system, treatment costs, migration-related stress, seeking a job and other family-related issues. Ethno-racial and socio-cultural characteristics affect not only the susceptibility of individuals to diabetes, but also the day-to-day management of diabetes. While it is understood that Indian migrants are generally more at risk of developing diabetes than local Australians, the impact of Indian ethno-cultural traditions and religious and social norms on diabetes management is not well understood. The socio-cultural structure, traditions and ideologies of Indian migrants are complex and unique, and their impact on diabetes needs to be explored for a comprehensive understanding of, and interventions to improve, diabetes management for Indian migrants. Overall, this research aimed to gain an understanding of the factors that influence decision-making about medications and medication adherence in Indian migrants with type 2 diabetes (T2D), living in Australia. The research consisted of two stages: in-depth qualitative interviews and on-line survey using discreet choice experiments. The specific qualitative study objectives were: • To investigate Indian migrants’ awareness and understanding of, and access to, the healthcare system; how they feel it compares with their experience in India; and how they perceive this access influences their diabetes care. • To investigate Indian migrants’ medication-taking behaviour (with conventional medicines for diabetes) and factors that influence adherence at its three phases. • To explore the beliefs, decision-making process and experiences of patients with type 2 diabetes mellitus (T2DM) using AM, with a specific focus on the AM use pattern and disclosure to doctors, sources of information about AM and where AM is purchased. • To explore how Indian migrants cope with T2DM through religion and spirituality, and the impact of religion and fasting on insulin use. The specific discrete choice experiment (DCE) study objectives were: • To determine the preferences for conventional vs AM in Indian migrants with T2DM. • To identify the factors that may influence the preferences. Methods Qualitative study A qualitative study was designed consisting of face-to-face interviews. The study included Indian-born migrants (Australian citizen/permanent resident) aged 18 years or over; with T2DM; using at least one anti-diabetic medication; living in Greater Sydney or its surrounding suburbs, responsible for their own medications and fluent in English and/or Hindi. Twenty-three participants were interviewed; data saturation was reached after the 18th interview. The interview protocol was prepared after an extensive literature review, and comprised open-ended questions to enable participants to speak freely. The 40–45-minute interviews were audio recorded, transcribed verbatim and thematically analysed using a framework and an inductive approach to thematic analysis. Data analysis was performed manually using Microsoft Word. The consolidated criteria for reporting qualitative research (COREQ) was used to provide transparency in data reporting to improve the rigor, comprehensiveness and trustworthiness of the study. DCE research methods Participants completed an online survey with eight choice tasks and answered demographics questions. In the choice tasks, they chose their preferred medicine (conventional vs AM) or a 'no medicine' option. Paid and unpaid strategies were employed to recruit the participants, using Facebook and email. A D-efficient design was used to balance the attribute levels and to select a subset of the medication profiles. A total of 32 choice tasks were generated; however, to improve feasibility, the survey was blocked in 4 iterations, with each respondent completing 8 chosen tasks. Attributes and attribute-levels for the DCE were chosen systematically following a literature review and the qualitative research findings. Eight attributes (glycated haemoglobin, side effects, number of times medicine is taken (frequency), formulation, instructions to take with food, hypoglycemic events, weight change and cost of the medications) were selected. The levels chosen were widely spaced to encourage participants to maximise trade-off and increase the reliability of parameter estimates. Descriptive statistics (standard deviation, mean and frequency) for the socio-demographic characteristics of the sample and other parameters were reported. The DCE responses were analysed; a mixed multinomial logit (MMNL) model was used as it relaxes the assumption of identical distribution and accounts for heterogeneity in preferences between individuals. In DCE, parameter (β) estimates refer to the importance given by patients to an individual attribute-level, where a higher value indicates higher utility. The computer programme NLogit 6 was used for data analysis. Results Qualitative study Twenty-three participants were interviewed. The majority of participants were male (n=18) and followed Hinduism (n=17). Twelve participants had used AM at least once since they had been diagnosed with diabetes, and the remaining 11 had never used AM for diabetes (5 used AM for other conditions). Once diagnosed with T2DM, Indian migrants reported mixed emotions. Participants contemplated the need to restrict their diet, change their lifestyle and use lifelong medicines, and raised several issues related to their physical and mental health, which they felt were deteriorating. Consequently, they felt that they had to take further action to manage their diabetes: to maintain a normal blood sugar level, and to maintain well-being and inner or spiritual comfort. Controlling diabetes and associated health problems, such as co-morbid conditions and diabetes-related health issues, through the use of medications (either conventional or ayurvedic) was regarded as an important strategy. The findings show a limited knowledge of the healthcare system, and the use of informal sources (e.g., family, friends, social media) to learn about the healthcare system and the available services. Several barriers to decision-making in accessing health services were identified, such as socio-cultural beliefs, social impacts, preference for Indian healthcare professionals and the high cost of medications; these ultimately influenced diabetes management, which could lead to poor diabetes control. The study also identified some enablers encouraging people to improve their diabetes care, such as Health Cards (Medicare and NDDS card), which enable access to free GP consultations and laboratory tests and other diabetes products at a subsidised price. The findings suggest that religious beliefs influence diabetes management in this group. Participants believed that prayers gave them inner strength to manage their diabetes, and that prayers/blessings from religious leaders could help them manage their health conditions, including diabetes. Participants who held stronger religious beliefs were not in favour of using insulin or other medication derived from animal sources, and believed that fasting was an important religious obligation which could not be skipped due to diabetes. In contrast, some participants believed that animal-based medicines were permissible to consume and fasting could be skipped as it was detrimental to the health and well-being of people with diabetes. For the 12 participants that used AM, the decision-making process included evaluating AM benefits vs harms, and the positive opinions of others who used AM. Most participants expressed positive beliefs about AM (no side effects, can cure the condition and are effective), which influenced their decision to initiate AM. The decision to initiate AM was also influenced by other factors such as personals beliefs, social influence, and others’ experiences of using AM. They sought information from various sources such as family members, friends, multimedia, and from healthcare professionals in India. Participants believed that AM does not have side effects because it is obtained from a natural source (herbals), is effective and can cure diabetes. The use of AM was discontinued within months of initiation if there were no benefits. Participants used both ayurvedic and conventional medicines together as they believed that the combination of both medicines could better control blood sugar with no harmful effects. Most participants discontinued taking AM if they felt it was ineffective. Negative beliefs about AM centered on lack of scientific evidence to show effectiveness, and formulations. The majority of participants were initially prescribed oral antidiabetic medication and only two were started on insulin. From the time of diagnosis, patients made daily decisions about their diabetes disease control. The medication-taking behaviour among the participants changed at the three different phases of medication-taking (initiation, implementation, and discontinuation). Several factors influenced adherence at these three phases of adherence. At the initiation phase, most of the patients started conventional medication as soon as prescribed by GPs, while some postponed treatment initiation. The decision to initiate and continue the use of medications (adherence) was based on a balance between patient concerns and needs. The key motive was the desire to improve the diabetes outcome (control blood glucose level), and some participants were motivated to initiate treatment by advice/recommendations from GPs and the information they received about the medication. Fear of side effects delayed treatment initiation with conventional medications. Most participants reported taking their medication as prescribed. However, some reported forgetting their medication, especially when they were in a hurry for work or were out for family dinners or a party. In the implementation phase, patient benefits in (blood glucose levels) influenced people to adhere to conventional medications. Negative factors such as stigma and fear of side effects and drug dependence were identified barriers to adherence during the implementation phase. A few participants discontinued taking conventional medications once they started getting benefits and moved to AM; however, they restarted conventional medications if the desired results were not achieved with the ayurvedic medication. A few participants discontinued taking their medication due to fear of side effects. Overall, findings showed that negative beliefs and concerns about medications, such as fear of side effects, the stigma of diabetes and medications and fear of drug dependence, are common factors that influenced the initiation of medication. Decision to initiate the process was influenced by the balance between the desire to improve blood sugar levels and Hba1c outcomes (necessity beliefs) and negative medication beliefs (concerns). If the benefits were greater than the concerns, participants were more likely to initiate medications (either conventional or ayurvedic). DCE research The survey was completed by 141 participants. The average age was 49.7 years; most were male (n=92, 65.2%). The majority followed Hinduism (n=75, 53.2%). Many (n=80, 56.7%) respondents had co-morbid conditions, mainly cardiovascular disease. The majority (n=114, 80%) of participants used prescribed oral conventional medicine and 31.2% (n=44) used AM alone or with conventional medicines for their diabetes. Overall, the preference of respondents to initiate a medicine was negative for both medicines (conventional (β=−2.33164, p<0.001) and AM (β=−3.12181, p<0.001)); however, significant heterogenicity was noted in participants’ preferences (SD: 2.33122, p<0.001). Six attributes were identified to be a significant influence on medicine preferences: occurrence of hypoglycaemic events (relative importance, RI= 24.33%) was the most important, followed by weight change (RI=20.00%), effectiveness of the medicine (RI= 17.91%), instructions to take with food (RI= 17.05%), medicine side effects (RI=13.20%) and medicine formulation (RI= 7.49%). Another important finding was that participants expressed a desire to initiate a medicine despite the medicine having side effects, with the preference for initiation being higher with mild side effects compared with moderate to severe side effects. Conclusions This is the first qualitative study of Indian migrants with T2DM to explore their understanding of the Australian healthcare system; their medication-taking behaviour; and the impact of religious, cultural and other factors on diabetes management. The qualitative study revealed that Indian migrants had limited knowledge about the Australian healthcare system and relied on informal sources for information. Sociocultural beliefs, social influences, preferences for healthcare professionals, and high cost of medicine were barriers to accessing healthcare, while healthcare cards (Medicare and NDSS) were the main enablers. Religious beliefs play an important role in the self-management of diabetes among Indian migrants living in Australia. However, both positive and negative beliefs were identified regarding praying, using animal-based medicines, and the impact of fasting on the management of diabetes. Participants had a limited understanding of the rulings and teachings of their religion within the context of diabetes. Overall, Indian migrants usually use AM alone or with conventional medicine for diabetes self-management. Most took conventional medicines, though there were delays in initiation of the prescribed medicines. Side effects was a significant factor influencing medication adherence at all phases, whilst motivation to manage diabetes effectively was the key facilitator of medication taking. The quantitative findings demonstrated negative preferences for both conventional and ayurvedic medications; that is, Indian migrants were more likely to not start either conventional or ayurvedic medication to manage diabetes. Overall, if choosing between medications, they were more likely not to take ayurvedic medication compared to conventional medication. Preferences for conventional and ayurvedic medication were heterogenous and influenced by several factors. Experiencing hypoglycemic events was the most influential factor, followed by weight change, glycated haemoglobin, instructions for taking with food, side effects and formulation of medications. However, Indian migrants with T2DM indicated willingness to initiate medication to gain benefits despite mild and moderate side effects. This research has highlighted the importance of AM as a treatment option for T2D in Indian migrants living in Australia, and the range of factors influencing medication taking. The study findings point to the importance of healthcare professionals, particularly prescribers, to consider the range of factors that can impact medication taking when monitoring adherence, from initiation to persistence and discontinuation of therapy

The United States (US) is plagued by a high-cost health care system producing lower than desired patient quality outcomes. In 2012, the Patient Protection and Affordable Care Act was enacted to financially incentivize cost-effective models of care that improve the health of US citizens. One emerging solution is engaging patients with chronic conditions in self-management practices.

Guided by Krieger's Eco-Social Theory, this study used semi-structured interviews, scales and a questionnaire to detect factors that facilitate patient activation of self-management in patients with type 2 diabetes. Managed and unmanaged participants were equally represented in the study sample. White participants and participants from two American Indian tribes located in Northeast Wisconsin were included in this study. Findings indicated the establishment of routine behavior and the ability to identify healthy alternatives when routines were disrupted support patient activation of self-management. Experiencing success such as weight loss was also identified as a factor in facilitating patient activation. Social roles and responsibilities challenged unmanaged patients.

The study concluded that community, culture and environment have both a negative and positive influence on patient activation of self-management of type 2 diabetes. The current epidemics of obesity and diabetes create an apathetic response to the type 2-diabetes diagnosis that affects subsequent treatment and self-management in the communities studied. Aspects of local cultures such as unhealthy regional and tribal foods, lack of options for menu items low in carbohydrates and sugar in restaurants, high consumption of soda and alcohol and holidays/tribal events provide significant challenges for unmanaged patients. Workplace policies surrounding health insurance premiums had an impact on attendance at educational events but not on sustaining self-management behaviors. Positive aspects of the workplace include the imposition of structure and routine and the emotional support of colleagues. Warm seasons were also found to activate self-management by providing an opportunity for outdoor exercise and healthier modes of food preparation.

Consistent with a previous study, high rates of childhood trauma were found among the study groups. However, findings did not support the hypothesis that levels of childhood trauma were linked to self-management. While some evidence of historical grief and loss along with associated symptoms was found among the American Indian populations, there was no correlation between managed condition and level of grief and loss. Further examination of the connection between childhood and historical trauma to the current obesity and diabetic epidemics in these communities is recommended. Recommendations for changes to public health and health care policy are included.

Introduction - India is beginning to resemble the western worlds’ way of living and that leads to an increased risk of chronic diseases such as diabetes. Due to its very large population India has the world second largest number of people with diabetes; 61, 3 million people. Studies have shown that the awareness of diabetes is poor, especially in rural areas. Aim - To investigate nurses’ experience of applying professional competence in patient education with focus on diabetes type II in an Indian rural hospital. Method – Data was gathered through twelve qualitative interviews. The interviews were tape recorded, transcribed verbatim and then analyzed through content analysis. Result – Three main categories were identified; Acquired competence to meet the patients, Helping the patients manage their disease and Nurses’ ideas for quality improvements regarding diabetes care. Conclusion - This study identified different obstacles that could have a negative effect on the care and treatment of patients with diabetes type II. The nurses had many ideas for quality improvements which could raise the awareness of the disease among patients, improve clinical outcomes and the work environment for the nurses. The nurses are willing to get more education about the disease and implement quality improvements if the resources and equipment are provided by the hospital.

Britain's Asians are a young population and their socio-economic status is low, with racial disadvantage in housing, employment, education and health. Research on their health has usually not been conducted in its socio-economic and demographic context and there is little on their use of primary care. Three studies were conducted to investigate their relationship with primary care in Bradford. A study of general practice attenders of white/British, Pakistani and Indian origin confirmed the demographic and socio-economic differences between the groups. The former had higher rates of alcohol and cigarette consumption. For Pakistanis and Indians, fluency and literacy in English was poor. Ethnic and linguistic match between doctor and patient was more important in patients' choice of doctor than the doctor's sex. Differential employment status of Asian and white/British accounted for some of the differences in health. A study of general practice attendance showed similar rates of surgery consultations between Asians and Non-Asians; the latter made greater use of domiciliary services. Both these studies were conducted in an inner Bradford health centre with an Asian male, a white male and a white female doctor. Bradford GPs were found to perceive that Asian patients made greater use of surgery and domiciliary consultations; attended more often for trivial complaints; and had lower compliance rates than Non-Asians. These perceptions were not supported by objective data. Better qualified GPs had a smaller, and Asian doctors had a greater proportion of Asian patients on their lists. Research, and action on Asians' health, needs to take account of their poorer socio-economic status.
Yorkshire Regional and Bradford District Health Authority.

The American Indians population in Minneapolis, Minnesota has experienced limited health care access and threefold diabetes health disparity. The purpose of this study was to measure the extent to which collaborating marketplace clinics and community-based support groups expanded diabetes care and provided self-management education for this largely urban Indian neighborhood. The marketplace clinics located in nearby CVS, Walmart, Target, and Supervalu stores committed financial support, certified educators, and pharmacy staff for the community-based support group. The study was conducted within the patient activation measure (PAM) analytical framework to assess the participants' acquired knowledge, skills, and confidence for diabetes self-management. A case-control study and 3 years retrospective analysis of secondary data were used to test whether the Minneapolis marketplace clinics and the Phillips community diabetes support group participants (n = 48) had improved diabetes health outcomes relative to the control group (n = 87). The intervention group employed motivational interviewing and PAM in coaching diabetes self-care and behavioral modification. The control group received only basic self-management education. T test and Cohen's d effect size measurements were used to quantify the size of the health outcome variables' difference between the study intervention and comparison groups. The positive effects of marketplace clinics and community-based complementation were shown through improved blood sugar control (A1C), weight loss (BMI), and healthful lifestyle changes. Social change progress could be realized by incorporating PAM with diabetes prevention programs for 33 Urban Indian Health Organizations that are located in large cities throughout the United States.

Hand hygiene compliance is one of the most important factors to prevent healtcare associated infections (HAI), which can cause unnessesary suffering, prelonged insitutional care, invalidity and higher mortality rate. It has been shown that despite regulations for hygiene compliances in healthcare, these are used unadequately. HAI affects 5-10 % of all patients in industrailized countries, in development countries the number is estimated to be up to 20 times higher. The aim of this study was to illustrate healthcareworkers hygiene compliances in patient care at a rural healthcarecentre in western India. Participant observation was used as a method, fieldnotes was taken for qualitative analysis. As a result of the analysis five fields emerged; use of handdesinfection and handwashing, complaince of gloves, the healthcareworkers clothing, use of jewlery and other hygienic aspects, which made the result. This study reveals that handhygiene complaince was poorly used by all informants, gloves was used only by one of the informants, and then only when bandaging wounds. The techniques used for both handwashing, handdesinfection and puttning on gloves was unadequate and therefor did not fullfil their purpose. Even though, the healthcare workers showed that they were aware of and thougt about hygiene in many ways.

Handhygien är en av de viktigaste faktorerna för att förhindra vårdrelaterade infektioner (VRI), vilket kan orsaka onödigt lidande, förlängd vårdtid, invaliditet och en högre mortalitet. Det har påvisats att trots att det finns riktlinjer för vårdhygien, används inte alltid dessa på rätt sätt. I industrialiserade länder beräknas 5-10 % av alla patienter att drabbas av VRI. I utvecklingsländer rapporteras siffran vara upp till 20 gånger högre. Syftet med studien var att belysa hur vårdarbetet bedrevs med avseende på vårdhygien på en vårdcentral på landsbygden i Indien. Deltagande observationer användes som metod, fältanteckningar fördes och analyserades sedan kvalitativt. Analysen utmynnade i fem områden; brukande av handdesinfektion och handtvätt, användandet av handskar, sjukvårdspersonalens klädsel, smyckeanvändning samt övriga hygienaspekter, vilka utgör resultatet. Studien visar att handhygien brukades sparsamt av samtliga informanter, handskar användes endast utav en av informanterna och då endast vid såromläggningar. Teknikerna som användes både för handtvätt, handdesinfektion samt att sätta på handskar var bristfälliga och uppfyllde därför inte sitt syfte. Trots detta visade vårdpersonalen att de var medvetna om och att de tänkte på hygien på många olika sätt.

This thesis explores and explains the development of day care for people with dementia in Kerala, India. The development process is framed within the context of social globalisation. The central aim of the thesis is to further build theory on how and why social policy from one context is transferred and utilised in the development of social policy in another. The theoretical constructs of policy transfer and policy translation are used to explore the development process. Policy transfer is an existing concept within policy and politics literature. Theory on the concept of policy translation is built up within the thesis using theories of literary translation. Exploration of these processes provides an explanation of the development of day care. Policy transfer and policy translation are found to take place between the UK and Kerala. Policy ideas and information from the UK are transferred and then used within the implementation of day care in Kerala. A two-part research design explores firstly policy transfer and then policy translation. Policy transfer is examined within an analytical framework developed from existing models of policy transfer. Policy translation is investigated through a comparative analysis of day care for people with dementia between the UK and Kerala. The differences between day care in the two contexts represent the changes caused by the processes of policy transfer and policy translation. The main findings of the thesis are that policy transfer and policy translation have taken place within the development of day care in Kerala. The two concepts are found to complement each other. The theoretical construct of policy translation provides additional detail and clarity on the process of policy development to that provided by policy transfer. Policy transfer and policy translation can be described as mechanisms by which social globalisation is taking place and in turn globalisation promotes these processes. The thesis concludes that the theoretical constructs of policy transfer and policy translation as developed here could be used within other research to explore the processes of globalisation.

The purpose of this descriptive study was to document and analyze the perceptions of family caregivers of non-institutionalized Alzheimer's patients about the benefits and limitations of Alzheimer's support groups. Survey methodology was used to survey caregivers and support group leaders from eight Alzheimer's support groups in the central Indiana area. Several of the major findings challenge the literature. These findings are as follows: The majority of caregivers attended the support group to receive information. None of the caregivers attended the support group due to frustration, and only one caregiver responded that relieving frustration was a benefit of participating in the support group. A majority of caregivers and support group leaders were positive about mixed (spouses and adult children) support groups. A majority of caregivers responded that they did not have guilt, anger, fears about caregiving in the future, or stress concerning their caregiving responsibilities. The study generated several implications that can be used by planners to improve support groups.
Department of Educational Leadership

Background: Type 2 diabetes is among the fastest growing diseases in the world, especially in India where the prevalence is 9 percent and expected to rise significantly. Managing diabetes involves a substantial portion of self-care and lifestyle changes for the patient. Hence, the nursing care to patients needs to be focused on promoting self-care and empowerment. Objective: To describe the nursing care, focusing on self-care and empowerment, provided to patients with type 2 diabetes at a private diabetes clinic in India. Method: Eleven diabetes educators with specialist training were interviewed individually. Data was analysed using qualitative contents analysis. Results: One core category called Comprehensive approach was found. Additionally, the data was sorted into four main categories: Nursing care interventions, Counselling, Health education and Health protection. Conclusion: The participants had a comprehensive view of the patients, the disease and the role of health personnel involved in the care. This holistic approach permeated the nursing care performed by the participants, facilitated empowerment and the promotion of self-care to the patients. Clinical relevance: The study provides a widened perspective and understanding of the concepts of self-care and empowerment to patients with type 2 diabetes in different cultural contexts. The results can serve as an inspiration to new ways of promoting self-care and empowerment to patients with other health problems.
Bakgrund: Diabetes typ 2 är en av de snabbast ökande sjukdomarna i världen, särskilt i Indien. Där är prevalensen 9 procent och den befaras stiga betydligt. För att hantera sjukdomen behöver patienten genomföra livsstilsförändringar och behärska egenvård. Därför bör omvårdnaden inriktas på empowerment och att främja patientens förmåga till egenvård. Syfte: Att beskriva den omvårdnad, med fokus på egenvård och empowerment, som ges till patienter med diabetes typ 2 på en specialistklinik i Indien. Metod: Elva diabetesutbildare med specialistutbildning intervjuades individuellt. Materialet analyserades med hjälp av kvalitativ innehållsanalys. Resultat: En kärnkategori, kallad Helhetsperspektiv, hittades. Därutöver sorterades materialet in i fyra huvudkategorier: Omvårdnadsåtgärder, Rådgivning, Hälsoutbildning och Hälsoskyddande åtgärder. Slutsats: Respondenterna hade en helhetssyn på patienterna och sjukdomen, samt på den roll all hälsopersonal som var inblandad i vården hade. Denna helhetssyn genomsyrade omvårdnaden, hur respondenterna arbetade med empowerment till patienterna samt hur de stärkte patienternas kapacitet att utföra egenvård. Klinisk betydelse: Studien bidrar till en vidgad syn på och ökad förståelse för begreppen egenvård och empowerment när det gäller patienter med diabetes typ 2 i olika kulturella kontexter. Resultatet kan även inspirera till nya sätt att arbeta med empowerment och att främja egenvård bland andra patientgrupper.

The problem of the study was to determine the status of bloodborne pathogen education for injection drug users in Indiana hospital emergency departments. The study was designed to answer the following research questions: (a) Do Indiana hospital emergency departments have written policies on bloodborne pathogen education for injection drug users? (b) To what extent do Indiana hospital emergency departments provide bloodborne pathogen education for injection drug users? and (c) What are the major barriers for Indiana hospital emergency departments in providing bloodborne pathogen education for injection drug users?A valid instrument was developed and sent to 110 Indiana hospital emergency department nurse managers. Forty-six instruments were returned for a response rate of 43.8%.The results indicated only three (7.1 %) responding hospital emergency departments had written bloodborne pathogen educational policies. Ten (20.8%) emergency departments provided some form of bloodborne pathogen education for injection drug users. Major barriers indicated for not providing patient education consisted of insufficient monetary resources, injection drug users denying a drug history, and emergency department nurses being unable to identify injection drug usage.
Department of Physiology and Health Science

A growing body of research suggests that certain environmental conditions may positively contribute to the healing process. Consequently, the medical and design professions are now exploring how the medical environment - both indoors and out - can better support the health and well being of its patients and their caregivers. Landscape architects and environmental psychologists are contributing to the growing interest in healing environments by exploring the relationship between nature, therapeutic gardens, and patient healing.One result of this interest has been the formulation of design recommendations for therapeutic gardens serving specific populations such as those with Alzheimer's Disease, AIDS or psychiatric illnesses. However, little attention has been given to therapeutic gardens designed to meet the needs of cancer patients even though a number of such gardens already exist. The purpose of this project is to identify design guidelines for therapeutic gardens that support the health and well being of cancer patients and to use these guidelines to design a model garden.The research for this project focused on two areas. First, literature review and interviews with employees of Ball Memorial Hospital were used to establish a base knowledge of cancer, including the emotional, physical and psychological characteristics associated with it. Next, characteristics of healing environments for cancer patients were determined through literature review, review of case studies and interviews with Ball Memorial Hospital employees. Based upon this research, design guidelines were established for therapeutic gardens serving cancer patients and applied in a design for Ball Memorial Hospital's soon to be completed CancerCenter.
Department of Landscape Architecture

This study was designed to answer the following research questions: "Are those at risk for coronary heart disease being screened for high blood cholesterol?" and "Are those with high blood cholesterol being treated according to the national guidelines?" The importance of early detection and treatment of high blood cholesterol is vital for preventive health care. A chart review of patient records was conducted to determine the behavior of the family practice residents. From the analysis of data it was determined that the residents screened their patients 83.0% of the time and when compared with national guidelines, treated those patients identified with high blood cholesterol 52.8% of the time. Third year residents screened their patients more (88.7%) for blood cholesterol than first (82.1%) or second (74.7%) year residents. Male residents screened a higher percent of their patients (84.8%) than female residents (75.0%).
Department of Physiology and Health Science

Doctor of Philosophy
Department of Geography
Bimal K. Paul
Medical tourism comprises a phenomenon where over five million patients a year are traveling across international borders to obtain various forms of health care. Most of these patients travel from developed countries to developing countries, seeking highly invasive medical treatments to less invasive and recreational medical procedures. By the year 2012, the medical tourism industry generated over $100 billion with over 50 countries making it a priority in trade for their country. With active government promotions, India has become one of the leading destinations for medical tourism. The objective of this research was to answer the questions: 1) how do the attitudes and behaviors of patients towards the concept of medical tourism influence their decision to become a medical tourist; 2) why do medical tourists seek treatment in India; and 3) what are the issues and challenges they face before coming to India as well as while in India. Interviews of thirty-four foreign patients were conducted in six sites spread across the South-Indian cities of Bangalore, Hyderabad, and Chennai which revealed useful information in addressing the research objectives. The three most important reasons that these medical tourists chose India for their treatments were: 1) the high quality of the doctors and medical facilities in India, 2) the affordable cost of treatments, and 3) the availability of specific treatments that might not have been available in their home countries. Patients also researched the topic thoroughly before they came to India. Knowledge was gained primarily from the Internet, print media, television shows and friends. Overall, the patients had very positive attitudes towards medical tourism. Most of them felt that they could get treatment because of their positive opinion on medical tourism, their ability to get treatment if they desired, and support from their families and loved ones.

Non-disclosure of a cancer diagnosis is a common practice in Asian cultures. However, little is known about the reasons for (non)disclosure among caregivers and the psychological experience of (non)disclosure on patients. This thesis reports four studies on cancer diagnosis (non)disclosure in India using the Common Sense Model of illness representations as a theoretical framework. Study 1 explored the experiences of, and reasons for, (non)disclosure among family caregivers of cancer patients using a qualitative methodology. Informing caregivers cited a range of reasons for informing including patient's suspicion, preparation, patient's personality, lack of control, patient's emotional well-being and self-belief. In contrast, non-informing caregivers cited patient's emotional well-being, patient's personality, jeopardizing patient's lifespan and family concerns as reasons for not informing. Study 2 examined differences between informing and non-informing caregivers on various demographic, medical and psychological variables. Reasons for, and for not, informing were the most important discriminating variables; informing caregivers more likely to agree with preparing the patient and patient's personality as reasons for informing, whereas noninforming caregivers more likely to agree with longevity and patient's personality as reasons for not informing. Study 3 explored the experiences of (non)disclosure in cancer patients using a qualitative methodology. Non-informed patients had an intense negative experience of the illness and used only passive coping strategies, whereas informed patients used a range of coping strategies. Study 4 investigated differences between informed and non-informed patients on various demographic, medical and psychological variables. Non-informed patients were less educated, were less likely to be involved in medical decision-making, were less likely to be having a combination of treatments, had weaker illness coherence, and were less likely to engage in a range of coping strategies. The thesis findings have important implications for both patient care and our understanding of the role of illness perceptions in caregivers and patients.

BACKGROUND:India has the second largest diabetic population (61 million) and tobacco users (275 million) in the world. Data on smoking cessation among diabetic patients are limited in low and middle income countries. The objective of the study was to document the effectiveness of diabetic specific smoking cessation counseling by a non-doctor health professional in addition to a cessation advice to quit, delivered by doctors.METHODS:In our parallel-group randomized controlled trial, we selected 224 adult diabetes patients aged 18 years or older who smoked in the last month, from two diabetes clinics in South India. Using a computer generated random sequence with block size four
the patients were randomized equally into intervention-1 and intervention-2 groups. Patients in both groups were asked and advised to quit smoking by a doctor and distributed diabetes specific education materials. The intervention-2 group received an additional diabetes specific 30 minutes counseling session using the 5As (Ask, Advise, Assess, Assist and Arrange), and 5 Rs (Relevance, Risks, Rewards, Roadblocks and Repetition) from a non-doctor health professional. Follow up data were available for 87.5% of patients at six months. The Quit Tobacco International Project is supported by a grant from the Fogarty International Centre of the US National Institutes of Health (RO1TW005969-01).The primary outcomes were quit rate (seven day smoking abstinence) and harm reduction (reduction of the number of cigarettes / bidis smoked per day > 50% of baseline use) at six months.RESULTS:In the intention to treat analysis, the odds for quitting was 8.4 95% confidence interval (CI): 4.1-17.1] for intervention-2 group compared to intervention-1 group. Even among high level smokers the odds of quitting was similar. The odds of harm reduction was 1.9 (CI: 0.8-4.1) for intervention-2 group compared to intervention-1 group.CONCLUSIONS:The value addition of culturally sensitive diabetic specific cessation counseling sessions delivered by non-doctor health professional was an impressive and efficacious way of preventing smoking related diabetic complications.TRIAL REGISTRATION:Clinical Trial Registry of India (CTRI/2012/01/002327)

The American Indian/Alaska Natives people are plagued by Type II Diabetes. The poor management of this disease process has dire effects on the morbidity and mortality of this population. It is imperative to identify the challenges that this group of people face with the self-management of Type II Diabetes. The conceptual framework for this study was based on Dorothea Orem's health deviation of self-care requisites. These health deviations result from the disease state and are used for diagnosis and treatment (Orem, 1985). The literature review and the discussion of results with the relevant literature were organized according to Orem's six themes of health deviations in the self-management. A qualitative research method, involving open-ended interviews with five Native American participants, was used. The participants were asked questions regarding their diagnosis, challenges in self-management, knowledge of long term effects, and additional needed resources. The data were analyzed using Luborsky's (1994), method of thematic analysis to identify the challenges Native American adults encounter in the self-management of Type II Diabetes, resulting in 8 topics. These included: a) feelings about Type II Diabetes diagnosis and the implications for lifestyle changes, b) prior experiences with family who have Type II Diabetes, c) challenges and lifestyle changes in managing Type II Diabetes, d) personal contributing factors to poor management, e) support systems for managing Type II Diabetes, f) identification of good management of Type II Diabetes, g) knowledge of long term effects of Type II Diabetes, h) additional support and resources needed to manage Type II Diabetes. Diabetes is a complex disease process that requires ongoing education and consistent medical care. It is essential that health care providers evaluate and tailor their care to the challenges of their patient population to improve the health status of those with Type II Diabetes.

Lung cancer is the leading cause of cancer death in the United States and survival rates of American Indian and Alaska Native (AIAN) patients are worse than those of non-Hispanic White (NHW) patients. A contributing factor to the worse outcomes may be lower healthcare utilization of AIAN patients. But improving healthcare utilization of AIAN to levels used comparable to those of NHW might increase costs of their care to amounts comparable to those of NHW. Objectives: 1) To examine differences in total healthcare costs and healthcare utilization 12 months following lung cancer diagnosis between AIAN patients and NHW patients, 2) To examine differences in total healthcare costs and healthcare utilization during the end-of-life period (last 6 months of life) between AIAN patients and NHW patients who died from lung cancer or any cause, and 3) To compare the incidence of depression disorder 60 months after cancer diagnosis and determine depression treatment utilization among those with a depression disorder. Methods: The Surveillance, Epidemiology, and End Results (SEER)-Medicare dataset was used. Patients included in the study were those age 65 years and older, diagnosed with lung cancer between 2000 and 2011, Part A coverage, Part B coverage and no managed care plan before. Diagnosis and procedure codes were used to identify costs, utilization, and depression diagnoses. The propensity score matching method was used to balance groups. A generalized linear model (GLM) was used for costs analysis and the negative binomial regression model was used to analyze healthcare utilization. A Cox proportional hazards regression model was used to identify risk factors for new diagnosis of depression. Results: Being AIAN was associated with lower total healthcare costs 12 months following lung cancer diagnosis. In contrast, being AIAN was not associated with total healthcare costs six months before date of death among patients diagnosed with lung cancer and ≤ 6 month survival time. The incidence of diagnosis of depression disorder 60 months after lung cancer diagnosis was 3.67% for AIAN patients and 6.16% for NHW patients. The mean number of depression treatment visits suggests higher utilization among AIAN patients compared with NHW patients. AIAN patients were not at increased risk for depression after cancer diagnosis. Conclusions: The healthcare utilization of AIAN patients with lung cancer could be improved while keeping costs of care no higher than those of NHW patients. But any improvements of health care use would need to take account of the variability among AIAN patients receiving health care 12 months following cancer diagnosis, in the last six months of life, and after depression disorder diagnosis.

This study investigates HIV/AIDS-related knowledge, attitudes, behaviours and practices among people living with HIV/AIDS (PLWHA). A hospital-based survey of (n=292) PLWHA in Tamil Nadu, using both quantitative and qualitative techniques, was the first of its kind to be conducted in India in 1999. The study represents a contribution to knowledge, being one of very few studies of PLWHA in India. The main sources of reported HIV knowledge among PLWHA were discussions with peers, community members, other hospital patients, and friends, for both men and women (80% and 79%, respectively). Latent class analysis of correct knowledge showed that 76% of respondents had high knowledge of sex-related transmission and 86% had high knowledge of blood-related transmission. Education was an important predictor of knowledge for women. Contrary to socio-cultural norms, ever-married male respondents reported relatively high levels of premarital sex (80%) and extra marital sex (49%). This study examined reported behaviour changes post-diagnosis with a positive prevention focus, including condom use. A large majority of PLWHA had heard about condoms (94% men, 81% women) and their use as a prophylaxis for HIV/AIDS. However, only 35% of men (excluding high-risk occupation groups) reported ever-use of condoms. Qualitative evidence revealed that reported consistent condom use did not, in fact, mean every single time they had sex. Culture was intricately interwoven with attitudes and behaviours reported by PLWHA and experiential knowledge influenced attitudes towards possible behaviour change. This research suggests the need to shift HIV/AIDS prevention models from biomedical to models more closely situated in their socio-economic and cultural context. In particular, behaviour change communication (BCC) models for positive prevention in India.

Background: Successful return to work after stroke may improve economic circumstances, quality of life, and overall life satisfaction but not everyone is able to return to work. Aims: To determine what proportion of previously employed patients return to work after an acute stroke with mild to moderate disability and examine factors associated with successful return to work. Methods: Patient interviews and chart review collected information and assessed anxiety, depression and social support using previously validated instruments with previously employed patients with a first-ever stroke 3 months to 2 years prior, aged 18-60. Multivariate logistic regression assessed factors associated with successful return to work. Results: 52.5% of 141 patients (mean age 48 ± 8.8), returned to work after stroke. Analysis demonstrated a lower modified Rankin scale at 3 months (OR 2.68, 95% CI 1.08-6.02), younger age (OR 2.26, 95% CI 1.04–4.89), and professional or business jobs (OR 2.61, 95% CI 1.6 - 5.97) were significantly associated with successful return to work. Anxiety, depression and social support score did not affect patients’ decision to return to work (p=0.30, 0.37, 0.27 respectively) Conclusions: Among patients with mild to moderate disability after stroke, almost half do not return to work. Functional disability and type of job rather than psychosocial factors such as anxiety and depression were most important.

Background: Type 2 diabetes mellitus (T2DM) is a major health concern among Navajo Indians. Native Americans and Alaskan Natives (NA/AN) currently have the highest rates of T2DM in the United States (Indian Health Service, 2016). The rate of diabetes on the Navajo Indian reservation is 22% (Partnersinhealth.org, 2009). Major health concerns for patients with T2DM include cardiovascular complications. Treatment is essential to prevent high-risk complications such as, cardiovascular disease (CVD). Purpose: The purpose of this quality improvement project was to implement a clinical decision support tool (CDST) to increase primary care provider awareness of current American Diabetes Association (ADA) statin therapy guidelines. The first objective was to increase the prescription rates of statin medications by 10%. The second objective of this project was to increase the performance target rate by 10%. Setting: This project was implemented at the Gallup Indian Medical Center (GIMC) Family Medicine Clinic. GIMC is located in Gallup, New Mexico. Participants: Participants included primary care providers, six Medical Doctors, two Nurse Practitioners, and one Physician Assistant. Methods: An evidence based clinical support decision tool (CDST) was generated the ADA statin therapy guidelines. Participants were educated on these practice guidelines and the CDST. The CDST was implemented into the electronic health record (EHR) over a four-week period. The provider used the CDST as a point-of-care guide when prescribing statin therapy to those with T2DM. Results: There was a 0.5% increase in the GPRA performance rating at GIMC as well as a 10% increase in prescribed statin therapy medications. There were 253 newly prescribed statin medications during data collection. Conclusion: While this project did not result in significant improvement of statin therapy GPRA performance ratings, a new EHR tool that providers can use to improve patient care was implemented. One outcome was met, there was a 10% increase in statin medication prescriptions. Further studies and future PDSA cycles will be required for testing the effectiveness of CDSTs.

Les ostéoclastes sont les cellules responsables de la résorption osseuse et par conséquent ils jouent un rôle primordial dans de nombreuses pathologies osseuses et articulaires, dont la polyarthrite rhumatoïde (PR). L'étude présentée dans ce mémoire a comme objectif de déterminer si l'ostéoclastogenèse, la capacité de résorption osseuse et la susceptibilité à l'apoptose des ostéoclastes matures peuvent être reliées à la présence et/ou à l'activité de la PR. Pour ce faire, des PBMCs, isolées par gradient de Ficoll du sang périphérique de patients atteints de PR ou de volontaires sains, sont différenciées en ostéoclastes matures in-vitro (ostéoclastogenèse) et leurs caractéristiques sont étudiées. Nous démontrons tout d'abord que l'ostéoclastogenèse est significativement plus élevée chez les patients atteints de PR en rémission comparativement aux patients en phase active et aux volontaires sains (contrôles). La caractérisation des ostéoclastes matures in-vitro a démontré que chez les patients atteints de PR, les ostéoclastes présentent une capacité de résorption accrue et une moins grande susceptibilité à l'apoptose comparativement à ceux des volontaires sains. Les résultats présentés dans ce mémoire suggèrent une modification phénotypique des ostéoclastes chez les patients atteints de PR. De plus, ces changements pourraient apparaître en amont de l'ostéoclaste, au niveau de cellules précurseures CD14[indice supérieur +] . Nos résultats soulignent l'importance des ostéoclastes dans la pathophysiologie de la PR et la pertinence d'approfondir nos recherches sur l'ostéoclastogenèse dans les pathologies osseuses afin de cerner de nouvelles cibles thérapeutiques.

Introduction: There is growing evidence that a combination of aerobic and resistance training is more effective than aerobic training only in cardiac rehabilitation (CR), but the approach used to assess strength and deliver resistance training varies greatly. There is a wealth of literature on how to assess strength in the general population, yet caution about the use of some approaches (e.g. one repetition maximum or 1 RM) in patients with cardiovascular disease is advised. The primary aims of this thesis were (1) to develop a scientific yet clinically easy to use strength assessment protocol in a CR setting for a diverse population of different ethnic and cultural backgrounds and (2) to investigate the effects of resistance training when added to a traditional cardiac rehabilitation programme offered in the UK. There is growing evidence that biomarkers influence strength, so the secondary aim of this study was to investigate the association between strength and inflammatory biomarkers in CVD patients. Methodology: Three studies were conducted. Study one (n=20) was an observational study conducted with community-based CR participants in the UK, in order to develop a 1 RM protocol for cardiac patients. The second study (n=30) was a randomised controlled trial conducted on outpatient-based CR patients, to investigate the effects of high to moderate intensity (recommended) resistance training when added to the usual six-week phase III cardiac rehabilitation programme offered in the UK. The third study (n=40) was conducted on outpatient-based CR patients in India, to evaluate the 1 RM protocol and investigate the association between the inflammatory biomarker TNF alpha and strength in patients of Asian ethnicity. Results: The 1 RM protocol developed for strength assessment was feasible in CVD patients but had to be modified for use in the Indian CVD patient population. There was a significant (p