Thesis (M Med (Family Medicine)) -- University of Limpopo, 2010. / Background: Many patients move from one healthcare provider to another, disturbing the continuity of holistic patient care. Objectives: The aim of this study is; to investigate the reasons why patients leave their nearest clinic, and to determine if these patients are able to use the provided care when they need to. Methods: A cross-sectional, quantitative study was conducted during the winter of 2010. Questionnaires were given to 350 patients attending Karen Park Clinic. Patients completed the questionnaires in the presence of the researcher, who was able to assist where needed. Variables addressed in the questionnaire included: place where they stay; if they visited their nearest clinic; what services there are at their nearest clinic; would they go back to their nearest clinic and if not, what would be the reasons. Results: The majority of respondents stayed in Soshanguve, 153 (43.7%), Mabopane 92(26.3%)Garankuwa, 29(8.3%)and Hebron 20(5.7%), Most ofthe respondents were females 271(77.4%), with 177 (50.6%)aged between 26 and45years. Eighty percent of patients indicated that they visited their nearest clinic and 191(54.6%) said that they will not return to that clinic. The reasons for not returning to the nearest clinic were: - no medication, 39(11.1%); long queues, 59(16.9%); rude staff, 59(16.9%); long waiting time to be helped, 88(25.1%) and other, 63(18.0%). Conclusion: The researcher found that many patients, who first attended their nearest clinic, opted not to return. Reducing long waiting times and long queues at a primary health care centre can be achieved. Satisfied health care providers would provide quality service to patients. Training courses for management committee members could lead to improving the health center's management and patients could be redirected to their nearest clinic by giving them referrals or transfer letters. Purchasing enough medicine will reduce the problem of no medication and increase the capability of the health center. Staff should receive training about health care practices, to reduce the rude behaviors that drive patients away.

The study investigated the accessibility and use of health information within the lower echelons of Primary Health Care service delivery. Hence, it focused on women and health workers' experiences with information in rural Uganda. Face-to-face interviews were conducted using an interview schedule that consisted of open questions and one relating to health information critical incidents. The qualitative interviews added depth, detail and meaning at a very personal level of experience. A holistic inductive paradigm was used in the study with a grounded theory analysis. This approach was adopted because of its ability to generate findings inductively from empirical data. An 'Interaction-value model' emerged from the study. The model was driven by the value and impact of information unlike previous information models which have been driven by information needs. This study has demonstrated that although an information need could trigger off an information activity, the subsequent information process could only be sustained by the value of information. Hence, access and use of information depends on the value and impact of information to overcome or reduce constraints. The value of information is therefore the core category, while the moderation of constraints and interaction with sources for latent or apparent needs are the two main categories that make up the model. The study has also shown that not all information users are active seekers. The main difference between the two groups of interviewees was that health workers' needs were generally apparent and led to active information seeking, whereas the women's needs were generally latent. Women mainly accessed information passively. Passivity, however, was generally limited to the act of accessing information. After passive information access, the subsequent user behaviour was active. Hence, women passively accessed information, but actively used it. Women's information behaviour was therefore dynamic. This was confirmed throughout the study when, for example, their information needs changed from latent to active and vice versa. The difference in the findings appears to stem from the fact that for women, the process of information access and use was dependant on the relationship and interaction between their social and information environment in everyday life; while for the health workers, professional matters added a further dimension to their information activities. The ways in which women and health workers accessed and used information as elaborated in this study have a number of implications for improving information provision, policies, training of health workers, and further research.

Yes

O tempo é importante para o homem nas diversas áreas do conhecimento porque tem uma finalidade em cada área, por isso, é estudado, medido, analisado, avaliado de maneira tanto qualitativa como quantitativa. A questão do tempo de serviço, neste caso, o serviço de saúde, em algumas situações em que ocorre a demora no atendimento leva a formação de fila que faz a espera inevitável. A qualidade é reconhecida como um constructo multidimensional, com vários atributos e visões. Vários pesquisadores desenvolveram ou adaptaram um instrumento para medir qualidade de serviços de saúde e muitos estudos realizados revelaram que ainda ocorre a formação de longas filas para atendimento do paciente. O objetivo deste trabalho é a avaliação da perspectiva do paciente da qualidade de serviços de saúde na rede pública e privada de saúde, focada na análise do tempo de consulta médica. Visa fornecer informações para melhorar e auxiliar a tomada de decisão dos gestores de instituições de saúde sobre a qualidade de serviços de saúde prestados. A análise quantitativa de dados usou o teste de significância não-paramétrico, com o teste com sinais Wilcoxon, usado para pares conjugados e a análise qualitativa usou a técnica descritiva. O instrumento de coleta de dados baseou-se na SERVQUAL, utilizada para avaliação de qualidade de serviços de saúde. O desenvolvimento da pesquisa empírica ocorreu nas instituições de saúde da cidade de Ribeirão Preto devido sua importância no campo da saúde. Concluiu-se que as instituições de saúde que apresentaram o menor tempo de consulta médica também receberam um grau menor sobre a avaliação de qualidade em relação às outras instituições. / Time is important for the man in various areas of knowledge because it has a specific purpose in each area; therefore, time is studied, measured, analyzed and evaluated in a qualitative and quantitative way. The duration of the service provided by an organization, in this case a health care organization, sometimes leads to situations in which the delay in the appointments may result in queue lines, obliging the patients to wait, in order to receive health care assistance. The quality of the service provided by these organizations is mostly recognized as a multidimensional construct, with many attributes and points of view. Several researchers have developed or modified instruments to measure health care service quality and, most of the surveys conducted, have revealed that there is still formation of long queues for attendance of the patient. The objective of this study is the evaluation of the patient?s opinion about the quality of the health care service provided by public and private organizations, with emphasis on the analysis of the duration of medical consultation. This study also aims to gather data that could improve the decisions which have to be made by managers from health care institutions, regarding mainly the health care service quality rendered to patients. The quantitative data analysis, on one hand, was done using the significance test nonparametric, in addition with the Wilcoxon signed ranks test, which was used for conjugated pairs. The qualitative analysis, on the other hand, was done with the descriptive technique. The tool used to collect data was based on SERVQUAL, which evaluated the quality of health care services. The site chosen for the development of the empirical research was the city of Ribeirão Preto, state of São Paulo, Brazil, due to its importance in the area of health care assistance. The conclusion revealed that the health care facilities, which presented the shortest length during appointments with the patients, also received a smaller grade regarding the quality evaluation, in comparison to the other facilities.

Diabetes is emerging as a major threat to health, with global economic and social implications. Recent research has shown that the morbidity and mortality associated with diabetes can be reduced by timely and effective treatment. However, unless people with diabetes have access to this treatment, the impact of diabetes will continue to rise. This thesis therefore explores the current standards of care which people with diabetes receive. It also looks at factors likely to impact on delivery of diabetes care. Studies were conducted at two levels. In the studies described in Chapters 2 and 3, general data applicable to all or nearly all patients with diabetes were collected. This approach substantially eliminates selection bias but precludes the ability to examine clinical outcomes. In the other studies, detailed in Chapters 4, 5 and 6, specific aspects of diabetes care pertaining to more select groups of diabetic subjects were examined. This approach allows clinical parameters to be examined in more detail but is more subject to selection bias. It is hoped that the combination of these two approaches provides a more balanced view of the topic under examination. In Australia, the Medicare Program, a single government controlled universal health insurance fund, provides access to medical services for all residents. Medicare occasions of service data therefore represent the most comprehensive source of information regarding health service utilisation in Australia. The data does not account for people receiving diabetes care through public hospital based services. However, a survey of public hospitals within NSW (n=198), described in Chapter 2, showed that the number of individuals in this category is relatively small and represents only 5.2% of the diabetic population. Using Medicare item codes, and with the permission and assistance of the Commonwealth Department of Health and Aged Care, data were extracted on attendance to medical practitioners and utilisation of diabetes related procedures for people living in New South Wales (NSW) for the individual years between 1993 to 1997. All data were stratified by the presence of diabetes, gender and age group. Individuals were deemed to have diabetes if an HbA1c, which can only be ordered for a person with known diabetes, had been performed over the 5-year period and the sample size adjusted for the incidence of diabetes. Once adjusted, the number of people with diabetes in NSW for the individual years 1993 to 1997 were 143,920, 156,234, 168,216, 177,280 and 185,780. Comparison with 1996 census data confirmed a 91.7% capture of the total NSW population (5,495,900/5,995,545 individuals). The data were retrieved for NSW as a whole and for individual postcodes. Postcodes were then classified by population density as either major urban, urban or rural. On average over the study period, persons with diabetes accounted for 3.1% of the population but they used 5.5% of general practitioner services. As seen in Chapter 2, a large proportion of people with diabetes were also under the care of specialists and consultant physicians, up to 51.2% and 41.8% respectively, a 3 to 4 fold increase when compared with their non-diabetic counterparts. In regard to geographical location, once adjusted for age and gender, the odds ratio of attending a specialist was only slightly higher for people with diabetes living in areas of high population density when compared to people with diabetes living in rural areas. This ratio reached as high as 1.85 in regard to attendance to consultant physicians (Chapter 3). The odds ratio for the non-diabetic population was similar indicating that the difference in access to consultant physicians was not disease specific. Analysis of results showed that despite the increase in service utilisation, large proportions of people with diabetes were not routinely monitored in regard to diabetes and its complications across the State. By 1997, HbA1c was still not performed in over 40% of people with diabetes each year and only 11.6% of the diabetic population had undergone microalbuminuria estimation. Interestingly, the differences in levels of monitoring between rural and urban areas were surprisingly small. Monitoring of diabetes and its complications did improve in all parts of the State over the study period. However, the greatest improvement was seen in rural areas, despite rural patients having fewer attendances to general practitioners and fewer patients attending specialist care. In the face of finite resources and the rising prevalence of diabetes, an increasing number of patients will need to rely on general practitioners to provide diabetes care regardless of where they live. A 'shared care' approach which encourages and supports general practitioners to manage patients with diabetes, while giving them access to specialist services for those patients that require them, is increasingly being advocated as a way of maximising efficacy while minimising costs. Yet if health care professionals leave undone what they think is done by others, shared care can become neglected care. Chapter 4 reports a detailed audit of 200 randomly selected shared care patients who were assessed on two or more occasions. This study showed that the majority of specialist treatment recommendations are implemented by general practitioners. Doctors formally registered with the Diabetes Shared Care Programme and those who write longer referral letters were more likely to implement recommendations than their counterparts. Moreover, the average HbA1c and the complication profile of these patients were similar to those found in various studies around the world. This suggests that diabetes can be well managed by a shared care approach that is adequately integrated. To overcome the problem that data is lacking on those patients that did not return for specialist review, a further 200 shared care patients who were lost to follow up from the shared care system were traced. Information regarding whether treatment recommendations had been implemented was sought from both the referring doctor and the patient. Overall, information on 182 of the 200 patients could be obtained. As discussed in Chapter 5, comparison of the returned and non returned patients' demographic and clinical profiles at time of their initial specialist review showed that general practitioners differentiated between the 'more complicated' patients, choosing to re-refer those with macrovascular disease, while maintaining the care of 'less complicated' patients. Re-referral for specialist review was also dependent on the patient remaining under the care of their original doctor. Encouragingly, general practitioners seemed to take a more active role in the non-returned group. They included more details regarding type and duration of diabetes in the referral letters of patients who were not re-referred for specialist review. They also implemented more treatment recommendations in the non-returned group, with the difference in implementation rate for metabolic recommendations reaching statistical significance. This study also showed that movement of patients between doctors raises concern regarding continuity of care. The multi-factorial nature of diabetes means that best practice is not easily accommodated within a single appointment. Thus continuity of care becomes an important issue. To assess the current status, 479 consecutive patients referred to the Royal Prince Alfred Hospital Diabetes Centre in a 6-month period were recruited and underwent a detailed clinical assessment. They were also questioned regarding the number of general practitioners they attended and the length of time they had been under the care of the referring doctor. The results outlined in Chapter 6 showed that the majority of people with diabetes (87.7%) attended only one general practitioner and had been under the care of that doctor medium to long term. Younger patients, who were relatively healthy apart from the presence of diabetes, were more likely to attend several general practitioners or have changed their general practitioner within the last year. This lack of continuity had little difference on acute outcomes such as glycaemic and blood pressure control. Appropriately, continuity of care increased with increasing age and the increasing prevalence of diabetes complications, mainly macrovascular disease. These studies indicate that further efforts are required to improve the overall standard of diabetes care within Australia. At present there is a heavy dependency on specialist services. As the population ages and the number of people with diabetes increases, much of this burden will fall on general practitioners, as is already evident in rural areas. When provided with appropriate support and infrastructure, general practitioners are able to maintain standards of care through referral of patients with more complex medical problems and by maintaining the degree of continuity appropriate to the patient's needs. However, the collection of relevant information to monitor future trends in diabetes services provision is important. As shown in this thesis, Medicare data represents an easy and cost effective method with which to do so.

none

Diabetes is emerging as a major threat to health, with global economic and social implications. Recent research has shown that the morbidity and mortality associated with diabetes can be reduced by timely and effective treatment. However, unless people with diabetes have access to this treatment, the impact of diabetes will continue to rise. This thesis therefore explores the current standards of care which people with diabetes receive. It also looks at factors likely to impact on delivery of diabetes care. Studies were conducted at two levels. In the studies described in Chapters 2 and 3, general data applicable to all or nearly all patients with diabetes were collected. This approach substantially eliminates selection bias but precludes the ability to examine clinical outcomes. In the other studies, detailed in Chapters 4, 5 and 6, specific aspects of diabetes care pertaining to more select groups of diabetic subjects were examined. This approach allows clinical parameters to be examined in more detail but is more subject to selection bias. It is hoped that the combination of these two approaches provides a more balanced view of the topic under examination. In Australia, the Medicare Program, a single government controlled universal health insurance fund, provides access to medical services for all residents. Medicare occasions of service data therefore represent the most comprehensive source of information regarding health service utilisation in Australia. The data does not account for people receiving diabetes care through public hospital based services. However, a survey of public hospitals within NSW (n=198), described in Chapter 2, showed that the number of individuals in this category is relatively small and represents only 5.2% of the diabetic population. Using Medicare item codes, and with the permission and assistance of the Commonwealth Department of Health and Aged Care, data were extracted on attendance to medical practitioners and utilisation of diabetes related procedures for people living in New South Wales (NSW) for the individual years between 1993 to 1997. All data were stratified by the presence of diabetes, gender and age group. Individuals were deemed to have diabetes if an HbA1c, which can only be ordered for a person with known diabetes, had been performed over the 5-year period and the sample size adjusted for the incidence of diabetes. Once adjusted, the number of people with diabetes in NSW for the individual years 1993 to 1997 were 143,920, 156,234, 168,216, 177,280 and 185,780. Comparison with 1996 census data confirmed a 91.7% capture of the total NSW population (5,495,900/5,995,545 individuals). The data were retrieved for NSW as a whole and for individual postcodes. Postcodes were then classified by population density as either major urban, urban or rural. On average over the study period, persons with diabetes accounted for 3.1% of the population but they used 5.5% of general practitioner services. As seen in Chapter 2, a large proportion of people with diabetes were also under the care of specialists and consultant physicians, up to 51.2% and 41.8% respectively, a 3 to 4 fold increase when compared with their non-diabetic counterparts. In regard to geographical location, once adjusted for age and gender, the odds ratio of attending a specialist was only slightly higher for people with diabetes living in areas of high population density when compared to people with diabetes living in rural areas. This ratio reached as high as 1.85 in regard to attendance to consultant physicians (Chapter 3). The odds ratio for the non-diabetic population was similar indicating that the difference in access to consultant physicians was not disease specific. Analysis of results showed that despite the increase in service utilisation, large proportions of people with diabetes were not routinely monitored in regard to diabetes and its complications across the State. By 1997, HbA1c was still not performed in over 40% of people with diabetes each year and only 11.6% of the diabetic population had undergone microalbuminuria estimation. Interestingly, the differences in levels of monitoring between rural and urban areas were surprisingly small. Monitoring of diabetes and its complications did improve in all parts of the State over the study period. However, the greatest improvement was seen in rural areas, despite rural patients having fewer attendances to general practitioners and fewer patients attending specialist care. In the face of finite resources and the rising prevalence of diabetes, an increasing number of patients will need to rely on general practitioners to provide diabetes care regardless of where they live. A 'shared care' approach which encourages and supports general practitioners to manage patients with diabetes, while giving them access to specialist services for those patients that require them, is increasingly being advocated as a way of maximising efficacy while minimising costs. Yet if health care professionals leave undone what they think is done by others, shared care can become neglected care. Chapter 4 reports a detailed audit of 200 randomly selected shared care patients who were assessed on two or more occasions. This study showed that the majority of specialist treatment recommendations are implemented by general practitioners. Doctors formally registered with the Diabetes Shared Care Programme and those who write longer referral letters were more likely to implement recommendations than their counterparts. Moreover, the average HbA1c and the complication profile of these patients were similar to those found in various studies around the world. This suggests that diabetes can be well managed by a shared care approach that is adequately integrated. To overcome the problem that data is lacking on those patients that did not return for specialist review, a further 200 shared care patients who were lost to follow up from the shared care system were traced. Information regarding whether treatment recommendations had been implemented was sought from both the referring doctor and the patient. Overall, information on 182 of the 200 patients could be obtained. As discussed in Chapter 5, comparison of the returned and non returned patients' demographic and clinical profiles at time of their initial specialist review showed that general practitioners differentiated between the 'more complicated' patients, choosing to re-refer those with macrovascular disease, while maintaining the care of 'less complicated' patients. Re-referral for specialist review was also dependent on the patient remaining under the care of their original doctor. Encouragingly, general practitioners seemed to take a more active role in the non-returned group. They included more details regarding type and duration of diabetes in the referral letters of patients who were not re-referred for specialist review. They also implemented more treatment recommendations in the non-returned group, with the difference in implementation rate for metabolic recommendations reaching statistical significance. This study also showed that movement of patients between doctors raises concern regarding continuity of care. The multi-factorial nature of diabetes means that best practice is not easily accommodated within a single appointment. Thus continuity of care becomes an important issue. To assess the current status, 479 consecutive patients referred to the Royal Prince Alfred Hospital Diabetes Centre in a 6-month period were recruited and underwent a detailed clinical assessment. They were also questioned regarding the number of general practitioners they attended and the length of time they had been under the care of the referring doctor. The results outlined in Chapter 6 showed that the majority of people with diabetes (87.7%) attended only one general practitioner and had been under the care of that doctor medium to long term. Younger patients, who were relatively healthy apart from the presence of diabetes, were more likely to attend several general practitioners or have changed their general practitioner within the last year. This lack of continuity had little difference on acute outcomes such as glycaemic and blood pressure control. Appropriately, continuity of care increased with increasing age and the increasing prevalence of diabetes complications, mainly macrovascular disease. These studies indicate that further efforts are required to improve the overall standard of diabetes care within Australia. At present there is a heavy dependency on specialist services. As the population ages and the number of people with diabetes increases, much of this burden will fall on general practitioners, as is already evident in rural areas. When provided with appropriate support and infrastructure, general practitioners are able to maintain standards of care through referral of patients with more complex medical problems and by maintaining the degree of continuity appropriate to the patient's needs. However, the collection of relevant information to monitor future trends in diabetes services provision is important. As shown in this thesis, Medicare data represents an easy and cost effective method with which to do so.

This research reports on an observation study conducted in Adelaide, South Australia of how 12 educators working in six long day care centres spent their day when working in their care. Specifically the study sought to answer the following research questions: 1. How do educators spend their day in a long day care setting?-- 2. What is the quality of the interactions that occur between educators and children?-- 3. In what ways, if any, does an educator's qualifications and experience impact on the quality and frequency of interactions?

O tempo é importante para o homem nas diversas áreas do conhecimento porque tem uma finalidade em cada área, por isso, é estudado, medido, analisado, avaliado de maneira tanto qualitativa como quantitativa. A questão do tempo de serviço, neste caso, o serviço de saúde, em algumas situações em que ocorre a demora no atendimento leva a formação de fila que faz a espera inevitável. A qualidade é reconhecida como um constructo multidimensional, com vários atributos e visões. Vários pesquisadores desenvolveram ou adaptaram um instrumento para medir qualidade de serviços de saúde e muitos estudos realizados revelaram que ainda ocorre a formação de longas filas para atendimento do paciente. O objetivo deste trabalho é a avaliação da perspectiva do paciente da qualidade de serviços de saúde na rede pública e privada de saúde, focada na análise do tempo de consulta médica. Visa fornecer informações para melhorar e auxiliar a tomada de decisão dos gestores de instituições de saúde sobre a qualidade de serviços de saúde prestados. A análise quantitativa de dados usou o teste de significância não-paramétrico, com o teste com sinais Wilcoxon, usado para pares conjugados e a análise qualitativa usou a técnica descritiva. O instrumento de coleta de dados baseou-se na SERVQUAL, utilizada para avaliação de qualidade de serviços de saúde. O desenvolvimento da pesquisa empírica ocorreu nas instituições de saúde da cidade de Ribeirão Preto devido sua importância no campo da saúde. Concluiu-se que as instituições de saúde que apresentaram o menor tempo de consulta médica também receberam um grau menor sobre a avaliação de qualidade em relação às outras instituições. / Time is important for the man in various areas of knowledge because it has a specific purpose in each area; therefore, time is studied, measured, analyzed and evaluated in a qualitative and quantitative way. The duration of the service provided by an organization, in this case a health care organization, sometimes leads to situations in which the delay in the appointments may result in queue lines, obliging the patients to wait, in order to receive health care assistance. The quality of the service provided by these organizations is mostly recognized as a multidimensional construct, with many attributes and points of view. Several researchers have developed or modified instruments to measure health care service quality and, most of the surveys conducted, have revealed that there is still formation of long queues for attendance of the patient. The objective of this study is the evaluation of the patient?s opinion about the quality of the health care service provided by public and private organizations, with emphasis on the analysis of the duration of medical consultation. This study also aims to gather data that could improve the decisions which have to be made by managers from health care institutions, regarding mainly the health care service quality rendered to patients. The quantitative data analysis, on one hand, was done using the significance test nonparametric, in addition with the Wilcoxon signed ranks test, which was used for conjugated pairs. The qualitative analysis, on the other hand, was done with the descriptive technique. The tool used to collect data was based on SERVQUAL, which evaluated the quality of health care services. The site chosen for the development of the empirical research was the city of Ribeirão Preto, state of São Paulo, Brazil, due to its importance in the area of health care assistance. The conclusion revealed that the health care facilities, which presented the shortest length during appointments with the patients, also received a smaller grade regarding the quality evaluation, in comparison to the other facilities.

This thesis researches the need for increased social engagement among isolated elderly population receiving home care service in Sweden. The notion of ‘social engagement’ and how to stimulate it is a central point throughout the work. The author finds that the isolation issue is related to political factors, sustainability and Swedish culture and how they interact with the individual. The theoretical framework is comprised of the field of care science and theories regarding isolation and sense of community. Using such empirical research and more in-depth own research such as interviews, the author concludes that social isolation is, in fact, a problem. The answer or suggested solution to this problem takes the shape of a design proposal: Play, Share, Connect, Repeat. Play, Share, Connect, Repeat is a game introduced by home care service that aims to create bonds and stimulate social engagement between care receivers.