This qualitative interview study explored the responses of child participants and their primary caregivers to the experience of completing a multi-stage screening process designed to identify depressed youth. Participants were sixteen girls ages 9 to 11 and caregivers of twelve of the girls. The child participants selected for this study were those who reported symptoms of a depressive disorder at the initial stages of screening without receiving diagnosis of a depressive disorder at the final stage of screening. Qualitative interviews were completed separately with child participants and their caregivers using a semi-structured interview format. A grounded theory approach was used to analyze interview transcripts and generate an integrated explanation of child and caregiver responses to depression screening and assessment (Strauss & Corbin, 1998). Results of this study indicate that depression screening and assessment serves the function of creating a forum for the child perspective by raising the child‘s emotional state and concerns to the attention of both the child and the parent. The child participants in this study reported experiencing emotional distress or a sense of burden prior to the first stage of screening. A process of reflecting on their emotions, beliefs, and stressors began as child participants completed screening questionnaires, followed by a sense of relief or improved mood in response to talking with interviewers during a brief interview. The forum for the child perspective expanded as parents received interviewer feedback about child emotions and concerns and began to assess the information in light of their own observations and situational factors. The extent to which parent and child maintained the forum for the child perspective through sustained communication about the child‘s emotions and concerns influenced the type and intensity of interventions subsequently introduced by parents. The chief means through which depression screening affected the child participants was through enhancing their understanding of themselves, promoting positive coping processes, facilitating parent/child communication, and influencing parent perceptions and the parenting agenda. / text

The Baby-boom generation, a major contributor to an unprecedented increase in older-aged people, is known for its zest for life and autonomy. Boomers are predicted to enter nursing homes in record numbers with multiple chronic illnesses and person-centered health care expectations. The purpose of this work was to describe current chronic illness management practices in nursing homes focused on person-centered (resident-directed) care and involvement of residents in health-related decision-making and self-care activities. Four projects were undertaken to accomplish this objective: (1) a systematic review of the quantitative literature regarding the management of type 2 diabetes, an exemplar chronic illness; (2) a synthesis of the qualitative literature describing chronically ill, older-aged adults' perceptions of chronic illness care decision-making; (3) an ethnographic pilot study describing the meaning of having type 2 diabetes to nursing home residents; and (4) a qualitative descriptive study of secondary data describing nursing home stakeholder perceptions of opportunities for resident involvement in chronic illness decision-making and self-care activities. Wagner's Chronic Care Model, modified for the nursing home, was the sensitizing framework for this research. Twenty studies met criteria for the systematic review, which described a lack of adherence to clinical practice guidelines and rare inclusion of the resident and family in management practices. The synthesis of 7 qualitative studies revealed 4 themes: (1) Being recognized because I matter; (2) Awareness of importance; (3) Empower through connections and opportunities; and (4) Time is precious. Cognitively capable older-aged adults described benefits from involvement in health care decisions and harm from non-involvement. They perceived inadequate time spent with health care providers as a major determinant of involvement. The pilot ethnography included 3 residents. Findings revealed a perception of few diabetes management choices but many unspoken resident preferences. The qualitative descriptive secondary analysis study included 5 residents, 7 family members, 8 advanced practice registered nurses, 5 physicians, and 6 administrators. Stakeholders perceived many opportunities for resident involvement in decision-making and self-care, but described as many limitations. Findings indicated a shortage of health care providers and differing stakeholder ideas of purpose and goals restricted resident involvement. Clinical, research, and policy implications were discussed. / text

Background Postnatal depression (PND) has become a world-wide public health problem. Maternal Child Health Centers (MCHCs) provide maternal and child healthcare with community-based Comprehensive Child Development Services (CCDS) aimed for early identification for provision of appropriate referral for intervention. There were 13.8% suspected PND cases in 2011(Department of Health PND Report, 2011). Antenatal Interpersonal Psychotherapy (IPT) has found efficacious for high depression risk (HDR) pregnant women. Evidence-based practice (EBP) antenatal IPT guideline best suited for MCHCs implementation. Purpose This dissertation intends to develop an effective EBP antenatal IPT guideline for HDR pregnant women, and to offer plans for implementation and evaluation. Methods Six electronic databases searched for updated relevant studies. Randomized controlled trails (RCTs) with antenatal IPT intervention for HDR pregnant women targeted. Evidence data related to EBP guideline development were extracted for critical appraisal. Program implementation potentials assessed for transferability, feasibility and cost-benefit ratio. Guideline with level of evidence and recommendation grading developed. Communication plan for different stakeholders and potential users were developed. Pilot test planned for process evaluation. Impact evaluation, outcome evaluation and economic evaluation planned to verify empirical evidences to initial changes in MCHCs. Results Eight RCTs studies, which compare group receiving antenatal IPT intervention with routine antenatal education group, were reviewed. Target population was HDR pregnant women. Antenatal IPT intervention found effective for HDR pregnant women with PND. The studies suggest antenatal IPT intervention give0.89 reductions in EPDS, improved psychological well-being, 0.77 reductions in GHQ and improved role competence2.43 increases in PSOC-E. After critical appraisal of reviewed studies, antenatal IPT guideline developed. Pregnant women should be screened between 20 to 32 gestation weeks. Those with EPDS≥13 scores should enrolled into two 2-hour antenatal IPT program educated by trained nurse educators in class size ≤10. Those refusing to join the program receive routine education. Three-point measurements of EPDS, GHQ and PSOC-E at baseline, postnatal 6 to 8 weeks and 3 to 6 months of both groups are conducted. Postnatal EPDS ≥13 participants referred for psychiatric services upon their consent. Program will propose implementation in MCHCs. Steering Committee is established and communicates with various stakeholders. Pilot test implement in one MCHC and reviewed for clinical applicability, feasibility and to obtain process evaluation for quality improvement. Program should have quasi-experimental non- equivalent pretest-posttest control group and analyze data with ‘two-sample t-test’, ‘paired t-tests’ and ‘chi-square test’. Target achievement should be: i. Primary outcomes: EPDS score reduced to0.89, GHQ reduced to0.77 and PSOC-E score increased to2.43; ii. Secondary outcomes: Reduction of PND incidence and PND management caseloads by 20%. Participants’ gestation ages, program attendance and satisfactory rates recorded. Economic evaluation indicates for every $1invested, the return is $8.45, program is a sound investment suggested. Conclusions Eight RCT studies provide evidence that antenatal IPT program is effective for HDR pregnant women in reducing PND, and in promoting higher maternal role efficacy level and psychological well-being. Implementation of this EBP program guideline can potentially help PND prevention and ease antenatal depression management of HDR pregnant women in MCHCs. / published_or_final_version / Nursing Studies / Master / Master of Nursing

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Chronic illness is endemic in the United States. Though people with chronic illnesses will not be cured, interventions can improve their well-being. Creating art as an intervention has been shown to assist people with chronic illnesses to improve well-being. Though creating art as a health promotion intervention is widespread it has not been well studied and the structure, process and outcomes of the intervention are not well understood. The purpose of this study was to identify and describe various key components of creating visual art as a healing intervention in the context of chronic illness. This study developed knowledge that will assist practitioners who use this complex intervention and researchers seeking to test its effectiveness in health promotion and healing in a chronically ill population. A qualitative descriptive design was used to explore art as a healing intervention. Photographs of art created by participants were observed, and participants were interviewed to collect data on the structure, process and outcomes of art as a healing intervention. The content and descriptive analysis of the data are used to describe the components of art as an intervention as well as the modifiers of the intervention process and the relationship of the components to each other to allow further research to be appropriately focused. Creating art is an intervention that works with a whole person to provide an opportunity for emergent change through disrupting old patterns, creating movement, and providing the opportunity for the participant to adopt new healthier patterns for living with chronic illness. Creating art does not have a predictable outcome, but rather has patient specific outcomes dependent on the patient's particular needs and individual self-organization. This study contributed to knowledge about creating art as a healing intervention by exploring various intervention components that must be explicated prior to development of program initiatives in practice and conducting systematic studies about the effectiveness of this intervention. The results of this study provide a foundation for a research career that both furthers the use of art as a healing intervention and further develops intervention theory to include complex evaluation methods.

Background: Studies showed differences in attitudes towards patients with mental illness in nurses who worked in somatic care compared to nurses who worked in psychiatric care. The nurses in somatic care stated more negative attitudes to mental illness in relation to the nurses in psychiatric care. Studies also showed that work experience affected attitudes towards mental illness. Nurses who often came in contact with people with mental illness had less negative attitudes and prejudices against mental illness. Aim: The aim was to examine the experiences from nurses in somatic care, caring for patients who also have a psychiatric diagnosis. Method: The study was conducted as a semi-structured interview. The study was conducted through interviews with six nurses from the departments with a focus on somatic care. Qualitative content analysis was used for the analysis, which resulted in 48 pieces of sub-categories and six categories. Results: The analysis resulted in six categories: “often psychiatric patients in the somatic care”, “difficult patients”, “sees the whole patient as a person, not a diagnose”, “if it is not written, it does not exist”, “I know how to do, but” and “psychiatric disorder, not for real”. Conclusion: Nurses experienced that caring for patients with psychiatric comorbidity was caring for patients who required a lot of time and attention. The nurses felt they lacked some knowledge how they should respond to, and how to provide the best care, for these patients. Nurse’s experience was that they did not get the support from the psychiatric clinic that they wanted.

Background Stigma and discrimination because of medical conditions is a global phenomenon. Epilepsy and mental illness belong to the most stigmatizing disorders world-wide. Culture, religion, education, life-style influences the perception of stigma. There are two aspects of stigma of special interest for this thesis; internalized stigma, which is the perception of a person suffering from a condition and the public perception of this disorder. This study investigates both aspects of stigma because of mental illness and epilepsy. Internalized stigma of mental illness and epilepsy are also studied in Umea, Sweden, with the same instrument as in Iran in order to look at the cultural influence. Methods Paper 1 and 2 on internalized stigma because of mental disorders and epilepsy in Tehran: These studies are cross-sectional with 138 persons with mental illness recruited from three different hospitals in Tehran and 130 persons with epilepsy from one neurologic clinic in Tehran and the Iran epilepsy association. Internalized stigma because of mental illness was measured using ISMI (Internalized Stigma of Mental Illness) questionnaire and because of epilepsy with the same instrument adapted for epilepsy (ISEP). ISMI/ISEP contains 29 items measured by a 4-point Likert scale. An open-ended question about the experiences of discrimination was added. Paper 3 and 4 on public attitudes towards mental disorders and epilepsy in Tehran: These two studies were performed with 800 individuals randomly chosen from households in four districts of Iran (north, south, east and west). In Paper 3 on attitudes and knowledge of mental illness a modified version of a questionnaire developed for the World Association program to reduce discrimination and stigma because of schizophrenia was used. In Paper 4 on awareness of and attitudes towards epilepsy a questionnaire originally developed by Caveness and Gallup in United States as early as 1949 was used and since used in many studies all over the world. Paper 5 and 6 comparing internalized stigma because of mental disorders and epilepsy in Tehran and Umea: These two studies included patients suffering from mental disorders (N=163) and epilepsy (N=93) recruited from the university hospital in Umea, Sweden. The same questions as used in Paper 1 and 2 were applied. Results The experience of stigma because of mental disorders was high in the Iranian sample. The Swedish sample generally reported lower levels of experienced stigma than the Iranian except for items covering self-blame and feelings of alienation. As regards epilepsy the Iranian sample reported quite a high level of experienced stigma compared to the Swedish sample. Generally the patients with epilepsy reported lower levels of experienced stigma compared to patients with mental illness in the two settings. Attitudes towards mentally ill persons in Tehran were at the same levels as in western high income countries. The knowledge about and attitudes towards persons with epilepsy was also generally at the same level as found in other European studies expect for a much lower acceptance as regards accepting a person with epilepsy to marry someone in the family. Conclusion Stigma because of mental illness and epilepsy is a reality even in Iran, which is an Islamic setting in spite of the teachings of the Koran to show mercy with people who suffer from different ailments and rather well developed health services. The levels of experienced stigma is higher in Iran compared to Sweden, but still there is quite a lot of stigma because of mental illness even in Sweden in spite of several national efforts to reduce stigma. The lower levels of stigma because of epilepsy in both settings and especially in Sweden, is suggested to be the consequence of effective treatments available for epilepsy compared to the less successful treatments available for mental illness. The differences in internalized stigma reported and the public perceptions of stigma because of both mental illness and epilepsy between Iran and Sweden is suggested partly a consequence of the different cultural settings, Sweden being an extremely individualistic society compared to the more collectivistic Iranian society.

In Canada, 3,300 children under the age of 20 are living with Crohn’s Disease (CD) (Crohn’s and Colitis Foundation of Canada, 2008). When an illness such as CD occurs in adolescence, the challenges associated with it are further compounded by the developmental tasks associated with this life stage. The purpose of this study was to understand how adolescents experience living with CD; to explore the impact of disease activity on their quality of life (QOL) and the strategies utilized to maintain and improve their QOL. Using a resiliency framework and narrative inquiry as a research methodology, seven adolescents were interviewed. The results include seven individual stories exemplifying their experiences, and from the stories shared, four patterns emerged: (1) Unconditional Support, (2) Embracing and Accepting Differences, (3) Attitudes and Personal Beliefs and (4) Daily Coping Strategies. These findings may have relevance for health professionals and families and adolescents with CD.

Cost-of-illness (COI) analysis was the first economic evaluation methodology used in the health field, and it aims to identify and quantify all of the costs incurred due to a particular illness. While cost-of-illness studies attract much interest from healthcare policy makers and public health advocates, inconsistencies in study methodologies and cost inventories have made cost-of-illness estimates difficult to interpret and compare, limiting their usefulness. The purpose of this thesis was to use a scoping review approach to systematically explore cost inventories in the cost of foodborne illness literature, and to investigate the association between study methodologies, component costs, and foodborne illness-related factors to the estimated cost of non-typhoidal Salmonella spp. illness, using studies identified in the scoping review. The results indicated high variability in terms of the depth and breadth of individual and societal level component costs, along with a wide range of data sources being used in the cost of foodborne illness literature. Additionally, the number of direct component cost categories included in an estimate, particularly long-term care costs, and the inclusion of chronic sequelae costs were significantly associated with the cost of non-typhoidal Salmonella spp. illness. Therefore, these may be important factors to consider when initiating a cost of foodborne illness study and when interpreting or comparing existing cost of foodborne illness estimates. The results of this thesis can be used to address issues that are believed to be limiting cost-of-illness studies as decision making tools, and to better understand factors which may impact a cost of foodborne illness estimate. / Scoping review and linear regression analyses in the area of cost of foodborne illness / Canadian Institutes of Health Research/Public Health Agency of Canada (CIHR/PHAC) Applied Public Health Research Chair (awarded to Dr. Jan M. Sargeant)