Meeting the health care needs of people with chronic conditions presents one of the greatest challenges for 21st century health care system renewal. Appropriate redesign of health care delivery with this complex patient population in mind requires information from many sources. Although much is known about the patient experience of chronic illness much less is understood about how patients navigate their health care delivery context. The purpose of this qualitative study was to examine the point of view of patients dealing with multi-morbidity. These people have a unique understanding of how health care delivery links across time, place, and settings because of the care they require for their multiple chronic conditions. An interpretive descriptive design was used to examine patient navigation from the perspective of 20 adult patients with chronic kidney disease, and co-existing diagnoses of diabetes mellitus and/or cardiovascular disease. The findings generated from iterative, constant comparative analysis add important patient perspectives about health care system navigation. From the consumer perspective health care navigation is challenging, requiring (a) ongoing discovery about the complex social structures that make up the health care system, and (b) learning how to strategically use this knowledge to manage the health care system. The findings highlight the disjunctures and misalignments in the health care delivery system, the cumulative health care-related burden of multiple chronic conditions for consumers, and consumer concerns about subtle inequities in the health care system. As health care renewal efforts gain momentum new knowledge from the perspective of consumers, such as that captured in this research, is important. The consumer perspective provides a valuable opportunity for stakeholders in health care policy- and decision-making to contextualize and make greater sense of the information used in making decisions about health care service delivery for vulnerable populations, like patients with multiple chronic conditions. / Applied Science, Faculty of / Nursing, School of / Graduate

The purpose of the current study was to investigate the effects of a multidisciplinary pain management program on five measures of subjective psychosocial factors. Ninety-five participants in the comprehensive multidisciplinary treatment group and the standard medical intervention control group were surveyed about various psychosocial factors using Axis II of the West Haven - Yale Multidimensional Pain Inventory (MPI), pre- to post-treatment. It was hypothesized that post-treatment levels would be significantly lower than pre-treatment levels for all five psychosocial variables. Additionally, gender and ethnicity variables were examined. Based on preliminary analyses indicating pre-treatment differences between the experimental and control group, five 2 x 2 x 3 analyses of covariances (ANCOVAs) were used to examine the above hypotheses. Results indicated significant differences between the treatment conditions on measures of control, with the comprehensive group feeling more in control than the standard group at post-treatment. No other significant main effects for treatment condition were found on the measures of pain severity, interference with daily activities, negative mood, or social support. However, a significant gender main effect was found for social support at post-treatment, with females reporting more social support than males. A significant gender x ethnicity interaction was also found for post-treatment control, with African-American females exhibiting higher levels of control than the other groups. Finally, a significant gender x treatment condition was found for negative mood, with males in the comprehensive group reporting more affective distress than those in the standard group. In this study, control appeared to be an integral factor in the chronic pain sample and greatly improved with comprehensive multidisciplinary treatment; while other areas of relative efficacy were not confirmed in this population.

Thesis(Ph.D.(Medical Science)) -- University of Limpopo, 2016 / Background: Chronic disease management (CDM) is an approach to health care that keeps people as healthy as possible through the prevention, early detection and management of chronic diseases. This approach offers holistic and comprehensive care, with a focus on rehabilitation, to achieve the highest level of independence possible for individuals.The aim of this study was to develop an integrated, evidence-based model for the management of chronic non-communicable diseases in a rural community of the Limpopo Province, South Africa. Methods: The study was conducted at Dikgale Health and Demographic Surveillance System (HDSS) site is situated in Capricorn District of Limpopo Province in South Africa. This study followed mixed methods methodology with an aim on integrating quantitative and qualitative data collection and analysis in a single study to develop an intervention program in a form of model to improve management of chronic diseases in a rural area. Therefore, this included literature review and WHO STEPwise approach to surveillance of NCD risk factors for quantitative techniques and focus group discussions, semi-structures interviews and quality circles for qualitative techniques. In the surveillance of NCD risk factors standardised international protocols were used to assess behavioural risk factors (smoking, alcohol consumption, fruit and vegetable consumption, physical activity) and physical characteristics (weight, height, waist and hip circumferences, and blood pressure). A purposive sampling method was used for qualitative research to determine knowledge, experience and barriers to chronic disease management in respect of patients, nurses, community health workers (CHWs), traditional health practitioners (THPs) and managers of chronic disease programmes. Data were analysed using STATA 12 for Windows, INVIVO and Excel Spreadsheets. Results: The study revealed that epidemiological transition is occurring in Dikgale HDSS. This rural area already demonstrates a high burden of risk factors for non-communicable diseases, especially smoking, alcohol consumption, low fruit and vegetable intake, physical inactivity, overweight and obesity, hypertension and dyslipidaemia, which can lead to cardiovascular diseases. The barriers mostly mentioned by the nurses, patients with chronic disease, CHWs and THPs include lack of knowledge of NCDs, shortages of medication and shortages of nurses in the clinics which cause patients to stay for long periods of time in a clinic. Lack of training on the management of chronic diseases, supervision by the district and provincial health managers, together with poor dissemination of guidelines, were contributing factors to lack of knowledge of NCDs management among nurses and CHWs. THPs revealed that cultural insensitivity on the part of nurses (disrespect) makes them unwilling to collaborate with the nurses in health service delivery. x The model developed in this study which was the main aim of the study describes four interacting system components which are health care providers, health care system, community partners and patients with their families. The main feature of this model is the integration of services from nurses, CHWs and THPs including a well-established clinical information system for health care providers to have better informed patient care. The developed model also has an intervention such as establishment of community ambassadors. Conclusion: Substantially high levels of the various risk factors for NCDs among adults in the Dikgale HDSS suggest an urgent need for adopting healthy life style modifications and the development of an integrated chronic care model. This highlights the need for health interventions that are aimed at controling risk factors at the population level in order to slow the progress of the coming non-communicable disease epidemic. Our study highlights the need for health interventions that aim to control risk factors at the population level, the need for availability of NCD-trained nurses, functional equipment and medication and a need to improve the link with traditional healers and integrate their services in order to facilitate early detection and management of chronic diseases in the community. The developed model will serve as a contribution to the improvement of NCD management in rural areas. Lastly, concerted action is needed to strengthen the delivery of essential health services in a health care system based on this model which will be tasked to organize health care in the rural area to improve management and prevention of chronic illnesses. Support systems in a form of supervisory visits to clinics, provision of medical equipments and training of health care providers should be provided. Contribution from community partners in a form of better leadership to mobilise and coordinate resources for chronic care is emphasized in the model. This productive interaction will be supported by the district and provincial Health Departments through re-organization of health services to give traditional leaders a role to take part in leadership to improve community participation. / Medical Science Department, University of Limpopo in South Africa,International Health Unit, and Antwerp University

Doctor Educationis / Background: Since 2005 the Chronic Dispensing Unit (CDU) has been part of the Western Cape Government’s strategy to address increasing demand for chronic medication for patients with non-communicable diseases. However, some patients are unable to collect their pre-packed chronic medication parcels from health care facilities on the due date. Recent research reported that some patients utilise collectors or medicine agents to collect their prepacked chronic medication parcels. Currently little is known about this phenomenon of collectors. Aim and Objectives: This study explored the acceptability of collectors of CDU chronic medication parcels to improve access to medicines for patients with non-communicable diseases at Lotus River Community Day Centre (LRCDC). Methodology: An exploratory descriptive qualitative study using semi-structured interviews in English and Afrikaans was conducted with six purposively selected collectors, three patients who use collectors and three key informants who have intimate knowledge of the collectors and system at the health facility. Interviews were recorded, transcribed, translated into English (where applicable) and thematically coded to derive themes from the data. Ethical approval was provided by the University of the Western Cape Bio-Medical Research Ethics Committee and informed consent was obtained from all study participants. Results: Patients reported that their collectors exhibited positive characteristics such as trust, patience and reliability, as well as, a passion for helping the community and organisational skills. All patients acknowledged the benefits of utilising a collector and found them to be highly acceptable. Key informants, however, had some reservations about the characteristics of collectors and their role in medication distribution and were sceptical as to whether collectors were suitably equipped to perform this function. Patients were grateful when their collector had some knowledge about their condition and were able to converse with them regarding their medication. Key informants suggested that with sufficient training and skills development, collectors could potentially improve access to chronic medication parcels and impart basic knowledge about chronic medication adherence to patients. iv Conclusion: The collector system that has emerged at LRCDC is highly acceptable to patients, but health facility staff were more measured in their assessments. Health facility staff, however, acknowledged the potential of collectors to improve access to chronic medication parcels for patients with chronic conditions and the benefit of upskilling collectors to perform this function. Recommendations: As a short-term measure, collectors should be formally accepted at facilities as medicine agents. They should receive basic education about safe medication distribution practices. Patients should screen collectors to ensure that they have the desired positive attributes. Furthermore, future research is necessary to comprehensively understand the current scope of practice of collectors within communities

First year death rates remain unacceptable high for the end-stage renal disease (ESRD) population. New effective methods are vital to improve first year morbidity and mortality outcomes for the population transitioning from Stage 4 chronic kidney disease (CKD) to ESRD)/Stage 5 CKD. Based on current methods, evidence-based recommendations made by nephrology providers are frequently not heeded by patients in Stage 4 CKD. Low levels of patient knowledge, self-efficacy, and a poor ability to self-manage CKD negatively influence a patient’s ability to follow provider recommendations. The group visit (GV) intervention has demonstrated improvements in disease-related outcomes through increased levels of patient knowledge, self-efficacy, and disease self-management for other chronic diseasses such as diabetes and congestive heart failure (CHF). No data are available for the use of GVs in CKD The purpose of the study was to develop and test a nurse practitioner-facilitated chronic CKD GV model versus usual nephrology care for Stage 4 CKD patients (knowledge, selfefficacy/self-management, physiological data, and satisfaction). As classified by the National Kidney Foundation’s (NKF) staging system, Stage 4 CKD is considered severe kidney disease, with a decrease in the functional capacity of the kidney as determined by a glomerular filtration rate (GFR) of 15-30 ml/min. It is common for patients with Stage 4 CKD to progress to Stage 5 CKD/end-stage renal disease (ESRD), requiring dialysis or transplantation to survive. Preliminary instrumentation and feasibility studies were conducted prior to a pilot study of a CKD GV model. The development and validation of the Stage 4 CKD Knowledge Instrument was completed with 59 Stage 4 patients. Findings supported reliability (KuderRichardson-20 [KR] = .89) and content validity (I-CVI = .97, S-CVI= 1.0) Feasibility of the CKD GV model was assessed with a single group, pretest-posttest design using a convenience iv sample of eight Stage 4 patients. Results demonstrated an improvement in knowledge of CKD from a median of 69% to 86% (p =.012). No improvements were noted in self-efficacy scores (p = .230). GV satisfaction ranged from very good to excellent. Feasibility was supported by a high retention rate (100%). No barriers to participant recruitment or GV implementation were encountered. The pilot study used a two-group, repeated measures experimental design, with a sample of 30 Stage 4 CKD patients from two office locations of an outpatient nephrology practice. Patients were randomized to the GV intervention or to usual nephrology care. CKD-knowledge, self-efficacy, and self-management scores were collected at baseline, six months, and nine months. Physiological data were measured at baseline, six months, and nine months. GV satisfaction was obtained after the completion of GVs (six months). Nephrology practice satisfaction was obtained from by both groups at nine months. MANOVA for repeated measures was calculated for data collected at the three time points. Twenty-six of 30 patients completed the study, with four patients ineligible to complete the study due to progression to ESRD and dialysis initiation. GV attendance was 92%. CKD knowledge was statistically improved for both groups (F(1.498, 34.446) = 6.363, P = .008). While not statistically significant, a favorable upward trend in the mean scores for the subscales of self-management (communication, partnership in care, and self-care) was demonstrated in the GV patients, with a lack of improvement found in the usual care group for these subscales. Selfefficacy scores revealed a non-significant improvement in mean scores for the GV patients during the GVs, not seen with usual care patients. GV satisfaction was again high with the vast majority of patients requesting use of GVs in their future nephrology care. v Current methods of intervention in the Stage 4 CKD population have made little impact on reducing first-year ESRD mortality and morbidity rates. Opportunities to intervene in the poor outcomes begin in the predialysis care of Stage 4 patients. Based on the documented success of multidisciplinary approaches in predialysis care, of GVs in other chronic diseases, and of chronic illness care based on the CCM, a high probability for success exists with the application of GVs in CKD. Although limited by a small sample size, promising improvements in the subscales of disease self-management, self-efficacy, CKD knowledge, and high satisfaction with the GV model for GV participants were revealed in this study. Further research is warranted for the CKD GV model on a larger randomized sample in other locations. Much needed data would be provided on which to base decisions for use of the CKD GV intervention in the predialysis care of Stage 4 patients.

Chronic low back pain (CLBP) is one of the most prevalent and disabling health conditions in the US and worldwide. Biomedical explanations of acute injury fail to account for why some individuals experience remission of pain and restoration of physical function while others do not. Pain-related fear, accompanied by elevated appraisals of physical exertion and avoidance of physical activity, has emerged as a central psychosocial risk factor for transition from acute injury to chronic pain and disability. Research has indicated that these pain-related factors may be maintained through observational learning mechanisms. To date, no studies have experimentally examined the role of observational learning and pain-related fear in the context of actual musculoskeletal injury. Accordingly, the present study examined the impact of observational learning and pain-related fear on activity appraisals and exertion following experimentally- induced acute low back injury. Healthy participants' appraisal of standardized movement tasks along with measures of physical exertion were collected prior to and following a procedure designed to induce delayed onset muscle soreness (DOMS) to the lower back. Following induction of DOMS, participants observed a video prime depicting CLBP patients exhibiting either high or low pain behavior during similar standardized movements. In line with hypothesized effects, participants assigned to the high pain behavior prime demonstrated greater elevation in pain and harm appraisals as well as greater decrement in physical exertion. Further in line with hypotheses, significant changes in appraisal and physical performance following the high pain behavior prime were only observed among participants endorsing high pain-related fear during baseline assessment. Discussion of findings addresses potential mechanisms of action as well as study limitations and direction for future research.

Recent advances in neuroimaging and electromagnetic measurement technology have permitted the exploration of structural and functional brain alterations associated with chronic pain. A number of cortical and subcortical brain regions have been found to be involved in the experience of chronic pain (Baliki et al., 2008; Jensen et al., 2010). Evidence suggests that living with chronic pain shapes the brain from both an architectural and a functional perspective, and that individuals living with chronic pain display altered brainwave activity even at rest. Quantitative EEG (qEEG) is a method of spectral analysis that utilizes a fast Fourier transform algorithm to convert analog EEG signals into digital signals, allowing for precise quantification and analysis of signals both at single electrode locations and across the scalp as a whole. An important advance that has been permitted by qEEG analysis is the development of lifespan normative databases against which individual qEEGs can be compared (Kaiser, 2006; Thatcher et al, 2000). Pilot data utilizing qEEG to examine brainwave patterns of individuals with chronic pain have revealed altered EEG activity at rest compared to age- and gender-matched healthy individuals (Burroughs, 2011). The current investigation extended the findings of the pilot study by utilizing qEEG to examine a larger sample of individuals with chronic pain. Individuals with chronic pain displayed significantly reduced slow wave activity in frontal, central, and temporal regions. Findings will be presented in terms of specific patterns of altered EEG activity seen in individuals with chronic pain.

To understand pain processing requires the assessment of an individual’s perception of pain with temporal stimulation over different periods. Offset analgesia (OA), a phenomenon widely studied, refers to a disproportionate decrease in pain experience following a small reduction in temperature during noxious thermal stimulation. OA leads to skin desensitization, causing brief pain inhibition at the stimulation site and leading to adaptation and a decrease in pain scores. To avoid sensitization and habituation during thermal pain procedures, previous studies have utilized protocols in which the thermal stimulation is applied to different areas of the skin (e.g., upper forearm versus lower forearm). The reliability of this thermal pain calibration procedure in producing a nonadaptive effect has been previously tested using pain rating scales. The utilization of neuroimaging to further elucidate these relationships has not been widely studied, but it is likely an important tool to investigate these constructs. Functional near-infrared spectroscopy (fNIRS) is a noninvasive optical imaging technique that measures changes in hemoglobin (Hb) concentrations within the brain using the characteristic absorption spectra of Hb in the near-infrared range. This thesis investigated whether adaptation exists across four conditions of the OA paradigm using fNIRS. Introducing fNIRS to define significant differences in brain metrics (e.g., activated regions of interest) in participants who have undergone surgery and are experiencing chronic pain as well as healthy, pain-free controls could have implications for more accurate measures of OA and more reliable pain treatment options. In this study, noxious thermal stimulation was given to 19 participants on the forearm of the nondominant hand through a commonly used three-temperature OA paradigm with offset, constant, and control trials. Each OA paradigm consisted of four conditions (A, B, C, and D) with a pseudorandom sequence design of three trials. OA was implemented with the participant while real-time fNIRS data were obtained on the subject’s prefrontal and somatosensory cortices, regions known to be involved in pain processing. Hemoglobin responses during the four OA trials were evaluated and compared within experimental conditions. Repeated measures ANOVA was used to analyze the significant differences among conditions. Results showed no significant differences among the four OA trials. The findings of this thesis study indicated that brain response from the prefrontal and somatosensory cortices is not affected within the four OA trials. The consistent brain activation across multiple trials of stimulation suggests an absence of adaptive responses. In line with previous findings, these results imply the reliability of such thermal pain calibration procedures by fNIRS brain imaging. Further investigation with a larger sample size is likely for the verification of the findings from this study. / 2026-02-14T00:00:00Z

Published Article / According to Wills reflexology entails the division of the body into ten zones, concentrating on the pressure points on the feet, with each foot representing five zones (2006: Online). Colour therapy uses the vibrational frequencies of colour to restore the client's health. Colour zone therapy on the other hand, is a combination of reflexology and colour therapy. Zone refers to the working of key points on the feet, where colour refers to the assessment of the condition and treating it with the correct colour's frequency (Gimbel, 1993: 2-3). Reflexology uses a physical stimulus and colour therapy, emotional stimulus, thus colour zone therapy addresses both. In this study the researcher's objective was to investigate treatments with reflexology compared with treatments of colour zone therapy, by treating chronic sinusitis to explore the influence of colour on the outcome of reflexology treatments. Ten chronic sinusitis-suffering clients were treated with reflexology in a white cubicle. Another ten clients were treated with colour zone therapy (thus colour therapy as well as reflexology). They had indigo coloured paper in their hands. Results were obtained as case studies, with clients reporting how they felt before and after each treatment. Each client received five treatments. The results indicated that the reflexology clients did experience an improvement after the fourth treatment. By the fifth treatment three of the ten clients had discharged some mucus. However, clients treated with colour zone therapy showed results after the second treatment. At the fourth treatment, already seven of the ten colour zone therapy clients had discharged a large amount of mucus. This concludes that treating a condition with colour, in combination with another treatment provides better and quicker results.

Purpose: To explore how older people with complex problems experience and make sense of frailty in their daily lives. Relevance: Frail older people have complex care and support needs that are currently challenging the health and social care system. There is a need for more appropriate models of service provision that can deliver personalised care for frail older people. Although there is an increasing body of literature that has explored the concept of frailty from a biomedical and functional perspective, there is a lack of research-based evidence exploring the personal experience of frailty from an older person’s perspective. Study design: A prospective, longitudinal, ethnographic case study design was adopted. Ten cases were studied over a period of two and a half years. Each case comprised an older person, a community matron and a significant other, such as a daughter. Cases were followed up monthly for a minimum of six months or until death. In total, 56 care visits between an older participant and their community matron were observed and 54 interviews were conducted with older people. Medical and nursing documents were reviewed for each case. A narrative approach to data analysis was undertaken, with identification of common themes within and across cases. Findings: Three themes illuminated the experience of living with frailty. ‘Transitions in health and illness’ details how the older people in this study experienced transitions in health and illness in later life. ‘Dimensions of frailty’ reports perceptions of frailty in later life and accounts of how feeling frail relate to episodes of uncertainty. ‘The provision of health and social care – rhetoric and reality’ explores the inter-relationship between the older person’s world of declining health and the episodic interactions with health professionals. Conclusions: This study offers a number of original contributions to the body of knowledge pertaining to the personal experience of frailty. First, new insights into the interrelationship between frailty and transitions in health and illness have been revealed, particularly how transitions in health and illness contribute to and shape the experience of frailty. Second, frail older people experience temporary moments of ‘liminality’ which are expressed as uncertainty and/or feeling frail. It is in these situations where there is real therapeutic potential in exploring the emotional experiences linked to a frail older person’s interpretation of events. Third, there are challenges to engaging in partnership working with frail older people. In some circumstances frail older people can exercise autonomy and make decisions that are relevant to their own situation. However, often community matrons’ work is framed by a policy of clinical assessment and therefore at times assumptions underpinning the label of frailty can challenge partnership working. These competing demands need to be considered by policy makers, commissioners and providers of community services and practitioners alike. Only then can effective supportive care services be delivered to frail older people.