Thesis (Ph. D.)--University of Washington, 1999. / Vita. Includes bibliographical references (leaves 211-222).

This research report is submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfillment of the requirements for the degree of Master of Medicine in the branch of Psychiatry. / AIM: To describe the demographic and clinical characteristics of a group of patients of Xhosa ethnicity diagnosed with schizophrenia. To also determine the prevalence of their consultations with a traditional healer as well as the factors associated with an increased likelihood of such consultations. METHOD: The study was a review of a database originally compiled as part of an ongoing genetic study. Patients on the database were all of Xhosa ethnicity, with a diagnosis of schizophrenia and had all been recruited from community clinics and psychiatric hospitals in the Cape Town Metropole region. RESULTS: Data was extracted and analysed for 92 patients, who met the criteria for inclusion in this study. The majority of the patients were male (77.2%), single (88%) and unemployed (96%). The mean duration of illness was 20.5 years and the mean number of hospital admissions for their mental illness was 2.4. Close to half (43.5%) of the patients reported being non-compliant on their medication. Ten percent admitted to making one or more suicide attempts in their lifetime. Nicotine was the most commonly used substance (69.6%) followed by alcohol (55.4%), cannabis (37%) and methamphetamines (9.8%). Thirty eight percent of the patients reported having a traditional healer in their family. Twenty two percent had consulted with a traditional healer. In the bivariate analysis the following factors were significantly associated with consulting a traditional healer: having two or less psychiatric admissions (p=0.014); compliance on medication (p=0,012); and having a traditional healer in the family iii (p=0.005). When controlling for age, sex and marital status only having a traditional healer in the family was significantly associated with consulting traditional healer (p=0.011). CONCLUSIONS: This study found that a high proportion of the participants had consulted a traditional healer. This was significantly associated with having a traditional healer as a family member. It is recommended that programmes, to improve the mutual understanding and co-operation between Western practitioners and traditional healers and consequently mental health outcomes, need to be developed and implemented.

Thesis (doctoral)--Universität Hamburg, 1980.

Introduction Older adults’ sexuality has been linked with a number of factors associated with wellbeing. Despite sexual practices changing across the lifespan, sexuality remains an important part of the identity of older adults. The ageing population of the United Kingdom is placing increasing demands on care homes, yet despite the recognised benefits of older adults’ sexuality best practice guidelines for care homes either fail to comment on residents’ sexuality or provide recommendations which are too minimal or vague to operationalise. Most research exploring older adults’ sexuality in care homes has focussed on the views of health and social care practitioners who report on their lack of willingness to engage with residents about their sexuality needs. Research which attempts to explore older adults’ sexuality in care homes from the perspective of residents favours quantitative research methods, an approach which arguably fails to acknowledge the changes in sexual expression which occur with age. Furthermore, the lack of consensus regarding the conceptualisation of the term ‘sexuality’ across the literature limits the extent to which research findings can be synthesised. This research sought to contribute to understandings of older adults’ sexuality experiences in care homes from a first-person perspective by adopting a prospective planning approach to explore prognostications about how transitioning to a care home might impact upon experiences of sexuality and participants’ hopes and fears regarding care provision. To increase the interpretability of findings and contextualise responses, the definition of sexuality from the perspective of older adults was also considered. Methods Semi-structured interviews were conducted with ten participants to explore three broad questions: (1) How do older adults define ‘sexuality’? (2) What impact might a care home have on sexuality experience? (3) How would individuals like sexuality to be acknowledged by care services? Face-to-face and telephone interviews were audio recorded, transcribed, and analysed using a hybrid inductive/deductive thematic analysis approach at a mixed manifest/latent level. Results Participants defined sexuality as a multifaceted component of self-identity which held individual meaning and changed across the lifespan. Participants’ definitions of sexuality were compared with the World Health Organisation’s (WHO) working definition of sexuality, and areas of difference and similarity were identified. Participants anticipated that becoming a resident of a care home would prompt significant (and often negative) changes with regards to how they could experience sexuality. Participants wanted services to demonstrate attempts to minimise the environmental impact on sexuality and promote positive experiences in a manner that was responsive to individual need. Discussion While used as an ageless term, ‘sexuality’ has different understandings and applications across the lifespan and remains an important part of the identity of older adults. Findings from this study indicated that participants expected to embody the role of the non-sexual resident when transitioning into a care home, changes in identity which were predicated on living in an environment which was predicted to neither acknowledge nor facilitate positive sexuality experiences.

Background: Thai culture venerates caring for elders, thus care homes are stigmatised as the domain of poor older adults with no family. This impacts negatively on the psychological wellbeing of older residents and the high prevalence of depression reported among them. However, little is understood about the key factors influencing the depressive symptoms and how such stigma is experienced among care home residents. This study explored factors associated with depressive symptoms, internalised stigma, self-esteem, social support and coping strategies among residents from the perspectives of residents and staff. Methods: Mixed methods research (convergent parallel design) was conducted in two care homes in northeast Thailand using a cross-sectional questionnaire, in-depth interview and non-participant observation. A cross-sectional questionnaire study was conducted with 128 older care home residents (with a response rate of 98.46%) using the 15-Item Thai Geriatric Depression Scale, Internalised Stigma of Living in a Care Home Scale, Thai Version of Rosenberg Self-Esteem Scale, Thai Version of Multidimensional Scale of Perceived Social Support and a Coping Strategies Inventory Short Form. Qualitative interviews were conducted with 30 older residents and 20 care home staff purposively sampled from both care homes. Non-participant observation was conducted in various public spaces of the care homes in both care homes for one month. Quantitative data was analysed using the Statistical Package for Social Science (SPSS) IBM PASW Version 22.0 for Windows. Thematic analysis was used to analyse the qualitative data. Results: Depressive symptoms were significantly correlated with internalised stigma, self-esteem and social support (r= 0.563, -0.574, -0.333; p< 0.001), respectively. Perceived internalised stigma of living in a care home was the strongest predictor of care home residents reporting depressive symptoms (odds ratio=9.165). In addition, the qualitative research explained the dynamics of the process of stigma related to three elements: the causes of stigma, the manifestation of stigma and the mitigating factors. Negative beliefs about care homes and people who live in them, coupled with negative attitudes and stereotypes toward older people, are the causes of stigma which are dominated by negative societal attitudes towards care homes. In addition, care home features contributing to stigma and staff issues are negative perceptions and experiences among residents whilst living in care homes. These factors trigger residents exhibiting negative emotions and behaviours (including depressive symptoms). However, the mitigating factors help to diminish or control the manifestation of stigma. These include coping strategies, social support and activities provided in care homes. Conclusion: Older adults who perceived high internalised stigma of LiCH were over nine times as likely to report experiencing depressive symptoms. This was related to the dynamics of the process of stigma with three elements (the causes, the manifestation and the mitigating factors of stigma). The causes of stigma are the factors creating the negative emotions and behaviours among residents living in Thai care homes. In addition, the mitigating factors help to diminish the manifestations of stigma. The most compelling need to improve the physical and mental wellbeing of elderly residents of care homes in Thailand is to combat the societal and cultural stigma associated with this population. This may be achieved through media collaboration, educational interventions in the care home setting and organising social activities for residents and their families.

Dissertation submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in fulfilment of the requirements for the degree of Master of Science in Occupational Therapy Johannesburg, 2015 / Numerous factors influence the employment of people with chronic illness. At some point, these people withdraw from the labour market. This has both a direct and indirect cost to the person, their family and society as a whole. Aim: To explore the factors affecting sustained employment of people with chronic illness. A second component explored participants’ opinions regarding return to work in the future. Research Methods: The study was done in two phases: 1) The identification and validation of the research instrument; and 2) The administration of the research instrument. Descriptive statistics were utilised to analyse data obtained from the research instrument. Two sets of correlations were run to identify significant differences between the participants expecting to return to work and those who did not expect to return to work. Results: Descriptive statistics revealed no meaningful trend on self-reported factors. The Mann-Whitney U identified a number of significant differences between participants expecting to return to work and those who did not expect to return to work, in both personal and contextual factors. Conclusion: A broad range of factors were elicited regarding the barriers and accommodations required for sustained employment within both the personal and environmental constructs. Self-report questionnaires provided some useful information, but a broader understanding of the factors influencing work was obtained from a comprehensive interview. Significant differences were present between people expecting to return to work and those who did not expect to return to work regarding environmental and personal factors as well as factors supporting work.

Somalis represent the largest consecutively displaced and resettled group in the United States yet, little is known about their experiences with and perceptions of illness in diaspora. In this research project I examine how Somalis’ understandings of the body and embodiment shape perceptions of diabetes and mental health. In addition, I ask how are the effects of migration and diaspora embodied among Somalis in Boston? To answer these research questions, I developed a qualitative study among Somali Muslims in Boston. I utilized information from semi-structured interviews (n=6), informal interviews (n=4), and participant observation at a local mosque from March 2015 to March 2016. I argue that for Somalis, diaspora is embodied through: bodily practices based on fluid and complex body ideals and values, food ritual and practices of consumption, and chronic physical health and mental health issues resulting in culturally relevant somatic explanatory models.

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.

There are concerns about cognitively impaired older patients’ experiences of general hospital care. Nottingham University Hospital developed a medical and mental health unit (MMHU) as a demonstration model of best practice dementia care. This thesis describes a controlled clinical trial comparing patients’ experiences of care on the MMHU to standard care wards. Patient experience was measured using the structured non-participant observational tool Dementia Care Mapping. Observations lasted 6 hours during which a score was recorded every five minutes for the patient’s mood and engagement and activity, together with incidents of enhancing and detracting staff behaviours. Noise (alarms, background noise and co-patients calling out) was recorded. 90 (46 MMHU, 44 Standard care) patients were observed between March and December 2011. At admission, most characteristics of patients on MMHU and standard care were similar. However, patients observed on MMHU had more behaviour disturbance, more often were care home residents and were less disabled than those observed on standard care. Patients on MMHU experienced a median 11% (95% Confidence Interval (CI) 2%, 20%) improvement in the proportion of time in positive mood and engagement (79% versus 68%); a median 3 (95%CI 1, 5) more enhancers (4 versus 1); a median 13% (95%CI -17%, -7%) less time noise could be heard (79% versus 92%) but a median 15% (95%CI 1, 23%) increase in proportion of time co-patients called out (21% versus 6%). Patients on MMHU had a better experience of care than those on standard care wards in terms of their mood and engagement, number of enhancers and improved noise levels, but experienced more co-patients calling out. This is the first study measuring an intervention to improve cognitively impaired older patients’ experiences in the general hospital and the first study to use the Dementia Care Mapping tool to evaluate an intervention in this setting.

Falls are a major cause of injury fear of falling and death affecting 24% of older people annually. Falls have a major impact on hospital services, are an important cause of carer strain and admission to long term care. Multifactorial interventions delivered to fallers are effective in reducing falls rates by 25%. However, no UK studies have evaluated the role of screening older people living in the community and offering those at high risk a falls prevention programme. This work describes two studies – the evaluation of a postal falls risk screening tool, and a randomised controlled trial assessing the benefits of offering a falls prevention programme to those identified as being at high risk. 335 older people were recruited into the screening study, using a modified version of the Falls Risk Assessment Tool. The sensitivity was 79%, specificity 58%, positive predictive value 50% and the negative predictive value 83%. In the RCT, 364 community-dwelling older people at high risk of falls were randomised into a pragmatic, multicentre trial evaluating falls prevention programmes. 181 were allocated to the control group and 183 to the intervention. The primary outcome was the rate of falls; the adjusted IRR was 0.73 (0.51-1.03), p=0.071. There were no significant differences between the groups in terms of the proportion of fallers, recurrent fallers, medically verified falls, injurious falls, time to first fall or time to second fall. Nor were there significant differences in terms of institutionalisation, mortality, basic or extended activities of daily living, or fear of falling. Further work on testing falls prevention interventions for acceptability is required, followed by a further adequately powered RCT to determine the clinical effectiveness of a systematic screening programme and intervention. At present, there is insufficient evidence for health care commissioners to recommend screening and intervention for falls.