Management of chronic disease requires a different service delivery model from that of acute illness. The uninsured population experience poorer health status and increased incidence of chronic disease than do the insured population. The purpose of this study was to identify the supports and barriers present in providing chronic disease management to patients at Ohio free clinics. Wagner's theory of chronic disease management served as the theoretical lens. The sequential, exploratory mixed methods study collected data from 13 free clinics belonging to the Ohio Association of Free Clinics (OAFC). Quantitative questions focused on processes in clinics with high and low fidelity to the chronic care model (CCM) determined by the Assessment of Chronic Illness Care (ACIC) survey. A backwards stepwise logistic regression was used. The quantitative analysis determined the 3 highest and lowest scoring clinics on the ACIC survey who then participated in a 2 tiered multi-case study series. Qualitative questions examined supports present in high fidelity clinics and barriers present in clinics with low fidelity. Qualitative findings identified 5 support areas that centered on progressive vision and patient-centered care themes that existed in high fidelity clinics. Four barriers were identified in low fidelity clinics that focused on the theme of capacity building. These findings provide evidence to guide the OAFC's work in improving adherence to the CCM constructs, thereby elevating the quality of care to the uninsured with chronic disease to the level of those providers governed by accrediting organizations. Changes in quality of care may result in an improvement to the health status of the individual and the communities in which they live.

Local public health units in the province of Ontario, Canada, are often the primary source of health promotion and health education resources, but many do not provide programming specific to the Indigenous population. As of January 2018, modernization of the Ontario Public Health Standards requires public health units to work with the Indigenous population in providing culturally appropriate programs and services. The practice question guiding the capstone project was to determine what chronic disease and injury prevention programs exist that are culturally appropriate for the Indigenous population. The purpose of this project was to do an environmental scan and compile an inventory of existing health promotion programming that is culturally appropriate to the Indigenous population. In total, 72 Indigenous-specific programs were identified from the 26 organizations that were included in the environmental scan. Of the 26 organizations, 3 were public health units, 7 were Aboriginal health access centers, 7 were Indigenous friendship centers, 5 were Indigenous health organizations, and 4 were non-Indigenous organizations with an Indigenous component. Results from the capstone project will inform public health units of available, culturally appropriate programs that can be adapted to their local context, thereby addressing a significant gap in the current public health system. This doctoral project aligns with the design of a new model of care in the Ontario public health system and has the potential to address a gap in practice at both the local and provincial level by providing culturally appropriate guidance in the effective delivery of CDIP programming specific to the Indigenous population. This positive social change would impact the health status of this underserved population.

Abstract The prevalence of diabetes in the United States in 2015 was 30.3 million people; which is the equivalent of 9.4% of the population. It is a major contributor to morbidity and mortality. Depression is often underdiagnosed in these patients, which contributes to poor self-management and poor health outcomes. In a large primary-care practice on the East Coast, there is no guideline for depression screening in the diabetic population. Focusing on this specific primary care setting, the research question addressed the underdiagnoses of depression in diabetic patients. The project evaluated the prevalence of depression among patients diagnosed with diabetes by using the U.S. Preventative Services Task Force (USPSTF) depression screening tool called the Patient Depression Questionnaire. The Grove Model for Implementing Evidence-Based Guidelines in Practice Framework was used in systematically integrating the new practice guideline of screening all diabetes patients for depression. The framework involves identifying the practice problem, locating, and collecting the most well-founded evidence, and evaluating the quality of the evidence-based guideline of screening all diabetes patients for depression. To answer the project question, 135 diabetic patients in a primary care outpatient setting completed the Patient Depression Questionnaire. Descriptive statistics was used to describe the sample and determine the frequency of scores throughout the sample of patients. Ranges of scores and percentages were computed using frequency distribution. Of these 135 diabetic patients, 63.7% showed some level of depression ranging from mild to severe, which was undiagnosed prior to the administration of the screening tool. As a result of the project, recommendations were made to the site to implement the use of the depression screening tool as policy.

Background and aims: Despite living with a gluten-free diet (GFD) Swedish women with coeliac disease (CD) report a lower level of well-being than women without the disease and than men with the disease. The aims of this thesis were to describe the life experience of being a woman living with CD (I) and to assess the effects of patient education (PE) with problem based learning (PBL) on psychological well-being (II) and gastrointestinal symptoms (III). Subjects and methods: In total 106 women, > 20 years, with confirmed CD, who had been treated with a GFD for a minimum of five years were randomized (II&III) to one of two groups: either to the intervention group (n=54) that underwent a ten-session educational program, called ‘Coeliac School’, with PBL, or to a control group (n=52) that received information regarding CD, which was sent to their home on a regular basis. Assessments: Well-being (II & III) (the Psychological General Well-Being index and the Gastrointestinal Symptom Rating Scale) was assessed at baseline and after 10 weeks in all patients and after 6 months in the intervention group. Individual interviews (I) were carried out with purposefully selected women (n=15) before the start of the‘Coeliac School’. Result: The qualitative study showed that CD can influence women’s lives in different ways. A desire for a normalised life-world was described. Three conditions necessary to achieve a normalised life-world were described as: being secure, being in control and being seen and included. After ten weeks of education, participants in the “Coeliac school” reported a significant improvement in psychological well-being (p=0.001) and gastrointestinal symptoms (p=0.013). The controls did not improve significantly. However, at baseline the controls, for reasons which were not apparent, and despite randomization, expressed significantly better psychological well-being and fewer gastrointestinal symptoms than women in the intervention group. Six months after completion of the PE program some of its positive effect had decreased. Conclusions: A PE with PBL can help women with CD to benefit from a greater degree of well-being. It is important to offer PE to those women who fail to achieve a normalised lifeworld. However, intervention methods need to be refined in order to provide a more pronounced long-term effect.

This study explores the phenomenon of the relationships between practitioners and families who have a child with a chronic illness. Using a heremeneutic phenomenological method informed by the writings of Martin Heidegger [1889-1976] and Hans-Georg Gadamer [1900-2002], this study provides an understanding of the meaning of 'being in relationship' from the perspective of both families and practitioners.Study participants include ten family groups who have a child with a chronic illness and twelve practitioners from the disciplines of nursing, medicine, dietetics, physiotherapy and speech therapy who work with children with chronic illness. Narrative audiotaped interviewing was the means by which the participants told their stories about times that relationships worked well and when they did not. These stories uncover the every day realities of 'being in relationship' and provide another understanding of the relationship between family and practitioner.The findings of this thesis suggest that chronic childhood illness 'throws' families and practitioners together into a web of relationships that must work for the sake of the child. The relationship is primarily conducted between adults. Children are usually excluded. In order to understand and manage the child's illness, practitioners and families 'go around' and act 'in-between' relationships. While the quality of the relationship from the family perspective is not essential to the chronic illness journey, relationships are more successful when practitioners recognise the uniqueness of each family web. The nature of the relationship is often simple, yet it co-exists with complexity. This thesis proposes that a 'companion relationship' between practitioners and family may offer a more effective and satisfying way of working. It also challenges practitioners to consider the voice of children within health care relationships.

Previous researchers have identified that participation in a pulmonary rehabilitation program improves health outcomes yet, continuation in a weekly maintenance program yielded mixed results. Self-management programs have had reported use in chronic obstructive pulmonary disease (COPD). A meta analysis has identified that no self-management program had evaluated the effect of this type of intervention on the functional status of the participant with COPD. Reduced functional status is well reported as an indicator of disease progression in COPD. Adjuvant therapies for people with COPD need to demonstrate an effect in this domain. The Stanford model chronic disease self-management program (CDSMP) had been reported as a program that may optimise the health of people with chronic health conditions. However, its utility has not been formally evaluated for people with COPD. There have not been any reports of a comparison of the Stanford model CDSMP with pulmonary rehabilitation via a randomised controlled study in COPD. Aim: To compare and evaluate the health outcomes from participation in nurse ledwellness-promoting interventions conducted in the ambulatory care setting of a metropolitan hospital. Participants were randomised to either a six-week behavioural intervention: the Stanford model CDSMP or, a six-week pulmonary rehabilitation program and results compared to usual care (a historical control group). The efficacy of the interventions was measured at week seven and repeated at week 26 and 52. Following the week seven evaluation, the pulmonary rehabilitation program participants were rerandomised to usual care or, weekly maintenance pulmonary rehabilitation for 18 weeks and, followed up until the study completion at week 52.Little is reported about the costs of care for people with COPD in Australia. This study prospectively evaluated the costs of the interventions and health resource for the 52 weeks and undertook a cost utility analysis. Methods: Walking tests (The Incremental Shuttle Walking Test) and questionnaires asking participants about their health related quality of life, mood status, dyspnoea and self efficacy were assessed prior to randomisation to either six week intervention and repeated at weeks 7, 26 and 52. The implementation of these adjuvant therapies enabled all costs associated with the interventions to be prospectively examined and compared. Results: During the two years of recruitment 252 people (54% males) with a mean age 71 years (SD 11, range 39-93 years) were referred to the study. Student’s ttests identified that there were no statistically significant differences (P=0.16) between all those referred by age and gender as compared to all those admitted to Hospital A with an exacerbation of COPD. Ninety-seven people (51% male) with a mean age of 68 years (SD 9, range 39-87 years) agreed to participate in the study. Follow up in the study continued for 12 months following enrolment with only a modest level of attrition by week seven (3%) and week 52 (25%). Following the six-week interventions, both the pulmonary rehabilitation and CDSMP groups recorded statistically significant increases in functional capacity, self-efficacy and health related quality of life.Functional performance was additionally evaluated in the intervention arms with participants wearing pedometers for the six-week period of the interventions. There were no statistically significant differences between steps per week (P=0.15) and kilometres per week (P=0.17) walked between these two groups in functional performance. The Spearman rho statistic identified no statistically significant relationship between functional performance and the severity of COPD (rs (33) = 0.19, P = 0.26). No significant correlation between functional capacity and functional performance was identified (rs (32) = 0.19, P = 0.29). This suggests that other factors contribute to daily functional performance. The largest cost of care for people with COPD has been reported to be unplanned admissions due to an exacerbation of COPD.In this study there were no statistically significant differences between the three intervention groups in the prospective measurement of ambulatory care visits, Emergency Department presentations and admissions to hospital. The calculation of costs illuminated the costs of care in COPD are greater than the population norm. In addition, maintenance pulmonary rehabilitation generated a greater quality adjusted life year (QALY) than a six-week program. Despite the strength of the participants preferences (as measured by the QALY) for maintenance PRP, there were no significant differences in use of hospital resources throughout the study period by the three intervention groups, which suggests some degree of equivalence.

<p>Psykisk ohälsa är ett samhällsproblem som kräver mer uppmärksamhet från sjukvårdens sida. En kronisk sjukdom drabbar både patienter och deras livskamrater och präglas av olika förluster som förändrar livet. Förlusterna skapar en klyfta mellan det liv patienter och livskamrater lever och de liv de egentligen vill leva. Det är i denna klyfta som den kroniska sorgen skapas. Kronisk sorg skiljer sig från vanlig sorg då den återkommer i perioder och växlar i intensitet. Syftet med studien var att beskriva upplevelsen av kronisk sorg hos patienter och livskamrater i samband med en kronisk sjukdom. Studien är genomförd som en litteraturstudie där 15 vetenskapliga artiklar samlades in och granskades. Resultatet visar att patienter och livskamrater upplever olika typer förluster, både fysiska, sociala och psykiska. Dessa förluster ligger till grund för upplevelsen av kronisk sorg. Genom att få kunskap om patienter och livskamraters upplevelse av kronisk sorg i samband med kronisk sjukdom kan sjuksköterskan få förståelse för dessa patienter och utifrån det hjälpa dem att hantera sorgen. Kronisk sorg är ett relativt nytt begrepp inom sjukvården och det krävs därför mer forskning för att öka kunskapen om begreppet.</p> / <p>Mental health is a problem in society and it requires more attention from the healthcare side. A chronic disease means that both patients and spouses undergo different periods of losses that change their lives in different ways. These losses create a gap between the patients and spouse’s ongoing lives and the life they really want to live. It is in this gap that the chronic sorrow is created. Chronic sorrow differs from normal grief when it recurs in periods and switches in intensity. The aim of this study was to describe the experience of chronic sorrow in patients and spouses related to a chronic disease. The study was conducted as a literature review where 15 research articles were collected and examined. The results show that patients and spouses experience different types of losses, physical, social and psychological. These losses create their chronic sorrow. By gaining knowledge of patients and spouses experiences of chronic sorrow the nurse can obtain an understanding of their situations and based on that help they cope with grief. Chronic sorrow is a relatively new concept in healthcare and therefore more research is required to increase understanding of the concept. <strong></strong></p>

<p>Most patients are non-adherent with their medication sometimes, i.e. that they do not always use their medicines as prescribed. This might result in both under- and overuse and can lead to therapy failure, resulting in both unnecessary suffering and high costs. Therefore, medication adherence should be as high as possible. </p><p>The aims of this thesis were to investigate the refill adherence to long-term drug treatment, especially for patients with asthma and chronic obstructive pulmonary disease (COPD), and to study treatment gaps for patients with undersupply and drug costs for patients with oversupply. Further aims were to compare different methods for assessing refill adherence and analyse whether the same patient has the same refill adherence pattern to two different chronic drug treatments, i.e. diabetes and asthma/COPD. </p><p>The thesis shows that satisfactory refill adherence (80-120% of the prescribed dose) was 57% for repeat prescriptions with long-term drug treatment; undersupply was 21% and oversupply 22%. Patients with undersupply were without drugs more than half of the prescribed treatment time and the median oversupply for 90-100 days dispensation interval was 28 days. Patients who were exempt from charges had significantly higher oversupply than non-exempt patients and that leads to unnecessary cost for society. The level of satisfactory refill adherence for repeat prescriptions dispensed for asthma/COPD was on average 30%. The same low level was displayed for the elderly, where undersupply was more common than oversupply. </p><p>Assessments of refill adherence during a one-year period gave the same results irrespective of whether the repeat prescriptions were from an individual pharmacy record database or were manually collected at a pharmacy.</p><p>Patients with concomitant use of diabetes and asthma/COPD drugs do not have the same dispensation pattern for both drug types. </p><p>The introduction of patient profiles as a new approach to complement the calculated refill adherence needs to be further studied in larger and more divergent populations. In the future, the new national pharmacy record database in Sweden has opened up for larger studies and will be valuable when studying patterns of drug utilization.</p>

Most patients are non-adherent with their medication sometimes, i.e. that they do not always use their medicines as prescribed. This might result in both under- and overuse and can lead to therapy failure, resulting in both unnecessary suffering and high costs. Therefore, medication adherence should be as high as possible. The aims of this thesis were to investigate the refill adherence to long-term drug treatment, especially for patients with asthma and chronic obstructive pulmonary disease (COPD), and to study treatment gaps for patients with undersupply and drug costs for patients with oversupply. Further aims were to compare different methods for assessing refill adherence and analyse whether the same patient has the same refill adherence pattern to two different chronic drug treatments, i.e. diabetes and asthma/COPD. The thesis shows that satisfactory refill adherence (80-120% of the prescribed dose) was 57% for repeat prescriptions with long-term drug treatment; undersupply was 21% and oversupply 22%. Patients with undersupply were without drugs more than half of the prescribed treatment time and the median oversupply for 90-100 days dispensation interval was 28 days. Patients who were exempt from charges had significantly higher oversupply than non-exempt patients and that leads to unnecessary cost for society. The level of satisfactory refill adherence for repeat prescriptions dispensed for asthma/COPD was on average 30%. The same low level was displayed for the elderly, where undersupply was more common than oversupply. Assessments of refill adherence during a one-year period gave the same results irrespective of whether the repeat prescriptions were from an individual pharmacy record database or were manually collected at a pharmacy. Patients with concomitant use of diabetes and asthma/COPD drugs do not have the same dispensation pattern for both drug types. The introduction of patient profiles as a new approach to complement the calculated refill adherence needs to be further studied in larger and more divergent populations. In the future, the new national pharmacy record database in Sweden has opened up for larger studies and will be valuable when studying patterns of drug utilization.

Psykisk ohälsa är ett samhällsproblem som kräver mer uppmärksamhet från sjukvårdens sida. En kronisk sjukdom drabbar både patienter och deras livskamrater och präglas av olika förluster som förändrar livet. Förlusterna skapar en klyfta mellan det liv patienter och livskamrater lever och de liv de egentligen vill leva. Det är i denna klyfta som den kroniska sorgen skapas. Kronisk sorg skiljer sig från vanlig sorg då den återkommer i perioder och växlar i intensitet. Syftet med studien var att beskriva upplevelsen av kronisk sorg hos patienter och livskamrater i samband med en kronisk sjukdom. Studien är genomförd som en litteraturstudie där 15 vetenskapliga artiklar samlades in och granskades. Resultatet visar att patienter och livskamrater upplever olika typer förluster, både fysiska, sociala och psykiska. Dessa förluster ligger till grund för upplevelsen av kronisk sorg. Genom att få kunskap om patienter och livskamraters upplevelse av kronisk sorg i samband med kronisk sjukdom kan sjuksköterskan få förståelse för dessa patienter och utifrån det hjälpa dem att hantera sorgen. Kronisk sorg är ett relativt nytt begrepp inom sjukvården och det krävs därför mer forskning för att öka kunskapen om begreppet. / Mental health is a problem in society and it requires more attention from the healthcare side. A chronic disease means that both patients and spouses undergo different periods of losses that change their lives in different ways. These losses create a gap between the patients and spouse’s ongoing lives and the life they really want to live. It is in this gap that the chronic sorrow is created. Chronic sorrow differs from normal grief when it recurs in periods and switches in intensity. The aim of this study was to describe the experience of chronic sorrow in patients and spouses related to a chronic disease. The study was conducted as a literature review where 15 research articles were collected and examined. The results show that patients and spouses experience different types of losses, physical, social and psychological. These losses create their chronic sorrow. By gaining knowledge of patients and spouses experiences of chronic sorrow the nurse can obtain an understanding of their situations and based on that help they cope with grief. Chronic sorrow is a relatively new concept in healthcare and therefore more research is required to increase understanding of the concept.