The sustainability of publicly funded Canadian health care services is an ongoing debate. Timely access to services and the availability of qualified health care professionals are vital to the survival of emergency health care services in rural and small towns. One of many factors threatening sustainability is the lack of qualified professionals. The current nursing shortage and the aging nursing workforce present rural hospitals with recruitment and retention challenges that threaten the sustainability of emergency services and thus have the potential to compromise the health of Canadians living in rural communities. Health care decisions are primarily based upon economics without consideration of the diversity of rural communities. Challenges in health care delivery including access to emergency services affect Canadians living in rural communities. These challenges need to be highlighted in the context of rural health as a unique entity in order to build awareness in policy makers to ensure appropriate health care service delivery to rural communities. It is important for researchers and policy makers to recognize that rural hospitals are not mini-urban centres and thus have differing needs. This two phase study focused on the sustainability of emergency health care services in rural and small town Ontario. Using a mixed methods approach, this study explored a descriptive analysis of emergency departments in rural Ontario and concluded with in-depth case studies of three rural emergency departments with varying travel distances to tertiary care facilities. These findings have validated pre-existing frameworks and can be used to assist policy makers at all levels to develop recommendations for sustaining emergency health care services in rural Ontario including ways to recruit, train, retain, and maintain resources that are vital to the survival of rural emergency services. / Thesis (Ph.D, Nursing) -- Queen's University, 2013-09-24 16:23:27.162

L’objectif d’accès universel aux traitements antirétroviraux (ARV), adopté officiellement en 2006 par les Etats membres des Nations Unies, implique la décentralisation de la prise en charge de l’infection à VIH au niveau des districts de santé et l’accessibilité économique des services de santé et traitements pour les ménages touchés par la maladie. Les enjeux posés par les politiques de passage à l’échelle de l’accès aux ARV dans les pays à faibles ressources ont ainsi conduit récemment à un regain d’intérêt pour la recherche opérationnelle, et redonné une actualité particulière à l’évaluation en profondeur des processus de décentralisation, en fournissant un angle d’analyse de cette politique jusqu’à présent inexploré par l’économie appliquée. Intégrée au sein d’un programme concerté de recherche conduit au Cameroun, cette thèse cherche à évaluer la performance de cette politique, notamment du point de vue de l’efficacité des services VIH et de leur accessibilité économique pour les ménages. La première partie de la thèse est consacrée à l’analyse des relations entre décentralisation de l’offre de soins pour l’infection à VIH et efficacité des services délivrés. Les analyses, réalisées à partir de modèles de régression multi-niveaux, montrent que les services VIH décentralisés obtiennent d’aussi bons résultats que les services centralisés, voire même de meilleurs résultats pour certains critères, tels que l’observance et la qualité de vie mentale. Elles mettent également en évidence que les caractéristiques de l’offre de soins, dont notamment la disponibilité en ressources humaines qualifiées et la charge de travail des personnels soignants, jouent un rôle non négligeable dans l’explication des différences observées dans la performance des services.La seconde partie s’intéresse à l’analyse de l’accessibilité économique des soins et traitements de l’infection à VIH. L’analyse des déterminants de l’accès au traitement antirétroviral révèle l’existence d’inégalités d’accès liées à la fois à des facteurs socio-économiques et à des facteurs structurels. Les résultats montrent également que les coûts directs de la maladie sont considérables au regard des ressources des ménages, que leur distribution est régressive par rapport aux revenus et que de multiples facteurs socio-économiques limitent l’efficacité de la prise en charge.L’expérience du Cameroun montre la faisabilité et la pertinence, au regard des objectifs de la lutte contre le VIH, d’une stratégie de diffusion du traitement par antirétroviraux s’appuyant sur une décentralisation de l’offre de soins, sous réserve toutefois que les systèmes de santé soient renforcés, notamment en termes de ressources humaines, et que des réformes innovantes du financement de la santé soient entreprises, réduisant, de façon substantielle, les paiements directs à la charge des populations. / In order to reach the largest population throughout the whole territory of a country, scaling-up access to ART requires both the decentralization of HIV care from central to more local services at the district level, together with care and antiretroviral treatment being economically accessible for households affected by HIV/AIDS. The recent issues raised by ART scaling-up policies in low income countries have led to a revival of interest in operational research and provide the opportunity for an in-depth assessment of decentralization policies from a point of view hitherto unexplored in applied economics.The present thesis work, which forms part of a large programme of operational research conducted in Cameroon, aimed to assess the performance of the decentralization policy in the field of HIV, particularly in terms of services’ effectiveness and economic accessibility for households.The first part of the thesis was dedicated to the assessment of the relationships between decentralization of the healthcare delivery for HIV care and the effectiveness of the services provided. Using multilevel regression models, the analysis showed that decentralized services at the district level not only achieved outcomes as good as those in centralized services, but performed even better for certain outcomes such as adherence to ART and mental health related quality of life. The results also highlighted that healthcare supply characteristics, including in particular the availability of qualified human resources and the workload of health professionals, played a significant role in explaining the differences observed inservices performance.The second part of the thesis dealt with the economic accessibility of care and treatment for HIV infection. The analysis of the determinants of access to ART highlighted inequalities in access related both to socio-economic and structural factors. Results also showed that the direct costs of the illness are considerable compared to households’ resources, that their distribution in terms of income is regressive and that numerous socio-economic factors limited HIV care effectiveness.With respect to the objectives of the global fight against HIV/AIDS, the Cameroonian experience shows the feasibility and pertinence of implementing an ART scaling-up strategy based on the decentralization of the health care supply. However this can only be fully effective if the health system as a whole is strengthened, especially in terms of human resources, and if strong financing reforms are implemented in order to substantially reduce out-of-pocket payments for affected households.

This thesis develops our understanding of the roles and processes underlying the co-production of public services. The co-production concept encapsulates the joint contribution made by service users and service providers to the delivery of services, acknowledging the expertise, inputs and role of service users. There has been an expanding stream of literature within the public management field focusing on co-production, recently enhanced through combinatory insights drawn from the service management literature. The thesis builds on this perspective, and addresses a current gap in understanding regarding the processes and roles that underpin the concept of co-production. In particular the research questions consider: the factors that facilitate co-production; the features of co-production that are evident within everyday service interactions; how service users and employees interact within the processes of co-production; and how these impact upon the delivery of public services at an individual level. The research for the thesis is undertaken within the context of community health and social care services for older people, at two locations in Scotland. An interpretivist, constructionist approach is taken to the inductive study which adopts a qualitative case study methodology. The research findings are drawn from semi-structured interviews with managers, older people and employees delivering services, together with observations of meetings and service interactions. Extant research has often conflated the roles of employees and public service organisations, and equal attention is rarely paid to the co-productive roles of service users and employees. The study makes a theoretical contribution by: developing the concept of active co-production; highlighting the complexities of the roles and processes underpinning co-production; revealing the different types of learning occurring within co-production; and developing a model to explicate the processes that combine the expertise of older people and employees, during the delivery of public services. On a practical level the study also highlights how more advanced and ‘active’ forms of co-production have developed, and the impact this has on the delivery of health and social care services for older people in Scotland.

<p>The majority of Cameroonians depend on traditional medicines for their health care needs and about seven per cent of the average household health budget is spent on traditional medicines irrespective of their incomes. The aim of this study was (i) to assess the role of traditional healers (THs) in providing oral care services in Cameroon / (ii) to determine their cost of treatment and to investigate reasons why people visit THs. The present study was cross sectional and consisted of a sample of 21 THs and 52 clients with a history of dental problems. It utilized semi structured questionnaires and photographs to collect data. The mean age of THs was 46.0 years (range 20-77 years). Thirty per cent of THs were above 40 years and the majority males. Nearly a quarter of the THs practiced as herbalists and the remainder practiced both divination and herbalism. More than two thirds of Cameroonians, who patronize THs for their oral health needs, fall within the 20-40 year age group. THs in this region are experienced and enjoy good relationships with hospitals and other THs. However, collaboration between the oral health work force and THs is very poor as only 6% of all patients seen by THs are referred to the dentist. Socio-cultural and economic factors affect the oral health care seeking behavior of patients in this area and only 6.5% of patients visit dental clinics. Reasons for not attending dental clinics included cost, poor accessibility, superstition and fear.</p>

The establishment of medical institutions in Kaohsiung municipal is mainly to cooperate with the Kaohsiung City government in promoting health policy, equally allocating medical resources, enhancing the health of the citizens, looking after mid- or low-income citizens, and taking charge of the medical care services of special patients. However, many institutions encounter various internal constraints and environmental challenges, such as bureaucratic personnel management, inflexible accounting system, faulty implementation of national healthy insurance and competition between hospitals, the Taiwanese medical system has become ¡§high competition, low profitability¡¨. More institutions follow the trend to modify their medical care operation. Outsourcing is one of the methods to strength their medical services. The medical industry currently is highly competitive. By increasing awareness of health concern, patients are more cautious in searching for appropriate and reliable medical care. Therefore, the hospital management regards patient satisfaction, confidence, and loyalty as the core values to improve its medical care services. In this research paper, we discuss the relationship between the quality of medical care services in Kaoshiung municipal hospitals and their operating performance. We also compare the operating differences between public hospitals and outsourcing hospitals to provide authoritative reference. In our research, we selected samples of patients from the Kaoshiung Municipal Minsheng Hospital, United Hospital (Kaohsiung Museum of Fine Art Branch), Hsiaokang Hospital, and Cijin Hospital. We sent out 310 surveys and collected 287 responses by Apr 15 2010. Data analysis and hypothesis testing was based on SPSS for Windows12.0. Based on this research, we concluded that: 1.There is a significant correlation between quality of medical care services and hospital operating performance. Also, process of medical care services was highly correlated with operating performance. In addition, hospital operating performance could be effectively evaluated by quality of medical care services. 2.With regards to the evaluation of medical care services and operating performance for the four municipal hospitals, United Hospital received the highest scores, followed by Minsheng Hospital, Hsiaokang Hospital, and Cijin Hospital. However, the performance of these hospitals is average, indicating that their medical care services need improvement. 3.Finally, outsourcing hospitals have a competitive advantage, which could help the improvement of medical care services. Due to the different operating systems for each hospital, the regulatory authority should be cautious in supervising the performance of the hospital.

Thesis (PhD ) - Open University. BLDSC no.DXN054620.

published_or_final_version / Public Health / Master / Master of Public Health

Not available / text

The aim of this phenomenological study was to explore women’s experiences of an Elective Caesarean Section (ECS) following a previous Traumatic Birth (TB). Thirteen women who had undergone an ECS following a TB were either interviewed or provided written accounts of their experiences. Data from these sources were analysed using Interpretative Phenomenological Analysis (IPA) (Smith, Flowers and Larkin, 2009). Five main themes were identified: ‘cautiously moving forward into the unknown: the drive to reproduce’, ‘attempting to make the unknown known’, ‘the longed for, positive birthing experience’ , ‘a different post-natal experience’ and ‘the interaction of the two experiences’. These findings were considered in relation to previous research; relevant theoretical perspectives were considered including those attached to Post-Traumatic Stress Disorder (PTSD). Post-traumatic stress reactions may increase during subsequent pregnancy impeding on women’s ability to consider facing another ‘unknown’ natural birth and domineering their decision to elect for a CS. An ECS following a TB may provide women with the controlled experience and high levels of care they long for. Such experiences could be redemptive and have positive outcomes for women’s relationships and wellbeing. These results highlight the importance of providing women in this position with information and choice regarding a subsequent birth. They also stress that prevention of women carrying Post Traumatic Stress (PTS) reactions into their subsequent pregnancies is imperative. Future research would benefit from focussing on the development and trialling of effective screening tools for PTS reactions following birth.

Aim of the study was to investigate the present demand for in-patient nursing care service in Kaunas city. Methods: Analysis of the medical documents (patient’s file) and waiting lists at 4 Kaunas city nursing and supportive care hospitals was done: patients were studied according to their age, location, social and medical indications for hospitalization and their repeated registration on the waiting list. Microsoft Excel program and SPSS statistical package was used to analyze the results. The results: 95 per of patients in nursing and supportive care institution and 94,7 per those on the waiting lists are Kaunas citizenry. Examination of medical diagnoses of hospitalized patients revealed the neurological disease as a common: encephalophathy - 34,4 per and stroke – 18,4 per. 23,6 per of patients with post-stroke diagnosis and 19,5 per of oncology patients are on the waiting list. 36,1 per of patients at hospital were at the age of 81 - 90 y. Children take care of 57,5 per of the hospital patients, the strangers – of 12,7 per. The long waiting list for entering nursing and supportive care institution revealed the great demand for in-patient nursing care service in Kaunas city: 1845 names were put on it at the period of 1st of June, 2003 to 31st of May, 2004. However, double, treble or even fourfold registration of the same patient makes this statistic doubtful. After the additional selection of names the more realistic waiting lists consisted of 1441. 154 patients from... [to full text]