The last decade has been defined by the forced displacement of an unprecedented number of people, on a scale not seen since World War II. As of 2018, more than 71 million people across the globe have been forced to migrate as a result of conflict, natural disasters, drought and famine. More than 19 million crossed international borders seeking safety, and were formally registered as refugees. Forced migration has placed stress and pressure on surrounding low-and middle-income countries. This has been most notable in the Middle East and North Africa as a result of the crisis in Syria. Host countries in the Middle East and North Africa are overwhelmed by this rapid influx, particularly by the healthcare needs of this population. Stakeholders face difficulties providing health services to refugees, owing to the increased number of refugees in urban settings, the large demands on host country health systems and the epidemiologic transition towards non-communicable diseases (NCDs). Health challenges have been exacerbated by weaknesses in the global humanitarian architecture, that result in a fragmented and competitive sector that is unprepared for the current context. Few comparative analyses have examined the diversity of policies and practices aimed at improving services for urban-based refugees with NCDs in the MENA region. Furthermore, a variety of quantitative studies examined NCD incidence, prevalence and service utilization. However, these studies have quickly become outdated and do not explore, in adequate depth, the refugee experience and perspective on accessing NCD services in urban settings. Lastly, numerous NCD interventions have been recommended for LMICs. However, very little guidance exists to support actors addressing these health concerns in crisis-affected contexts. As a result, this dissertation is presented in three papers and responds to these gaps in the literature. Each paper focuses on a specific aim and research question and together they identify and provide recommendations for improvement to service delivery and policy formulation. Paper 1 identifies policies and practices, implemented by host countries and humanitarian actors, aimed at improving access to NCD services for urban refugees in the Middle East and North Africa. Paper 2 examines, using qualitative methods, the healthcare access experience of urban-based Syrian refugees who have been diagnosed with NCDs in Jordan. The third portion of this dissertation (Paper 3) is a policy series that provides recommendations for the government of Jordan and humanitarian actors to improve healthcare access for urban-based refugees with NCDs. It is anticipated that this series of publications will be relevant to traditional and non-traditional actors that respond to the health needs of refugees in urban settings in the MENA region.

The type 2 diabetes (T2DM) epidemic is a global health issue that is especially severe among Pacific Islanders in the United States (U.S.) and U.S. Associated Pacific Islands (USAPI) including Chuukese living in their homeland of Chuuk and the state of Hawaii. Although there are diabetes prevention and management programs in Hawai'i and the Pacific, success is limited due in part to the lack of tailoring for the Pacific audience. In spite of numerous recommendations to incorporate Pacific cultural constructs into health interventions, there are no studies in Chuuk or the Pacific that examine the integration of cultural constructs into diabetes prevention and management. To address this research need, the four studies in this dissertation used Grounded Theory and Community Based Participatory Research (CBPR) processes to explore the relationships between constructs such as culture, religion, family, and diabetes prevention and control. The aims were to obtain perspectives on diabetes prevention, screening and management (Study1) and identify socio-cultural influences that hinder or facilitate adherence to diabetes prevention and management behaviors specifically adherence to nutrition therapy (Study 2), physical activity (Study 3) and prescription medication (Study 4). Data where gathered through key informant interviews (faith leaders and health care providers) and focus group discussions (individual with diabetes and care takers). Results from Study 1 showed that participants perceived T2DM as a major problem and the discussion followed four significant narratives: (1) the need for specific information on "how to" operationalize diabetes treatment recommendations; (2) the practice of seeking medical help only when in pain; (3) the role spirituality plays in etiology disease beliefs and its influence on help-seeking behaviors; and (4) the role emotions play in treatment compliance. Study 2 revealed barriers to nutrition therapy adherence that were similar to other minority populations in the U.S. such as cost of healthy foods, taste preference, low availability of healthy food choices, lack of ideas for healthy meals/cooking, and lack of culturally appropriate nutrition modification options. It also elucidated: (1) food consumption and preparation practices; (2) the need for culturally tailored interventions; and (3) contextually appropriate approaches to address nutrition issues, including a plan for future research and interventions. Study 3 revealed a variety of behaviors, personal factors and environmental influences related to adherence to physical activity recommendations. Although the study was focused on physical activity, participants spent the majority of their time discussing sedentary behaviors and contextually appropriate interventions. Study 4 exposed vital factors that inclined patients' to comply with prescribed medication. Factors associated with the healer (messenger), medicine/remedy, and focus of healing. Furthermore, this study revealed that many patients not only seek multiple healing types (western, traditional, local and new), they also rotate among the types. These findings were communicated through two narratives: healer characteristics and medication-specific features. Overall, the most salient topics in all the focus group and interview discussions were on diabetes as a major problem and the pervasiveness of hopelessness. Woven into these conversations were narratives on how to address these two issues with stewardships of the spirit, mind and body. This became the foundation of a framework to address the diabetes epidemic in Pacific.

Herpes simplex viruses (HSVs), are among the most virulent and widespread pathogens; they affect 60-90% of the population worldwide. Substantial evidence indicates a possible association between pathogens and chronic disease. HSVs, among other viruses, have been associated with increased risk for inflammatory diseases. However, prior findings have been inconsistent on the role of infection in triggering autoimmune response and chronic disease. This study builds on the premise that pathogens can induce an inflammatory response and increase the risk for disease development. A representative U.S. sample from NHANES, a national population-based cross-sectional survey, was used to examine the relationship between HSVs infection and type 2 diabetes mellitus (T2DM) and cardiovascular disease (CVD). Results from the two-tailed, Pearson chi-square test and multiple logistic regression analyses found no significant association between HSV or multiple herpes virus infections and T2DM or CVD, which suggest rather a secondary phenomenon. However, all the risk factors examined in this study indicated an association with either T2DM, CVD or both. Two inflammatory markers, C-reactive protein (CRP) and serum ferritin, were significantly associated with T2DM and CVD. These findings have potential implications for social change as they support the premise that high levels of CRP and ferritin may be associated with T2DM and CVD. Existing guidelines for primary and secondary prevention of T2DM and CVD could be expanded (a) to include CRP and ferritin as part of the health assessment for T2DM and CVD in high-risk populations, and (b) to explore the effectiveness of CRP and ferritin as predictive biomarkers and prognostic tools for T2DM and CVD.

Thesis (M.Pharm) -- University of Limpopo, 2013 / Introduction: Many patients with chronic illnesses including asthma, hypertension, diabetes mellitus and HIV/AIDS, have difficulties adhering to their recommended regimens. This may result in sub-optimal management and control of the illness. What a patient understands about a specific regimen, including the reason for taking each medication and the intricacies of dosing schedules and administration requirements, can have a profound influence on adherence. Monitoring the effectiveness and safety of the treatment administered helps to decide whether this should be continued, changed or stopped. Any drug may produce unwanted or unexpected adverse reactions. The choice of drugs depends on many factors, such as the pattern of diseases, the treatment facilities, the training and experience of the available personnel, the financial resources available and demographic or environmental factors. The level of adherence to medication among with hypertension and diabetes mellitus or anti-retroviral therapy has not been studied in Limpopo province Aim: The aim of the study was to determine the adherence patterns and the factors contributing to the adherence to treatment by diabetic, hypertensive and HIV/AIDS patients at Mokopane Hospital. Methodology: This was a cross-sectional, descriptive study conducted through use of a questionnaire administered as an exit interview at the pharmacy after the patients had consulted the doctor and received their medication from the pharmacy. Results: The data was collected over a period of two months, where every patient was seen only once using their hospital numbers to avoid repetition. The study included a total of 307 participants, 201 (60%) were patients on ARVs, 48 (16%) were on anti-hypertensive, 35 (11%) on anti-diabetic, and 23 (8%) on both anti-hypertensive and anti-diabetics. The respondents were predominantly female (n = 234; 76%) while 73 (24%) male. Similarly of the 201 participants on ARVs treatment, 153 (76%) were females and 48 (24%) were males; among those on anti-hypertensives only 11 (22%) were males. For the diabetics 6 (17%) were males and 29 (83%) were females. Of participants with both hypertension and diabetes 9 (39.1%) were males and 14 (60.9%) were females. Seventy-nine percent (79%) of respondents on ART, 69% of those on anti-hypertensive, 72% of those on anti-diabetics, and 66% of those on both anti-diabetics and anti-hypertensives were adherent to their treatment. The younger patients (21 to 40 years) were less likely to have forgotten to take their treatment in the last one month (21% of respondents) than the older patients (41 to 87 years), 34% of whom forgot to take medication in the month prior to the study. Most respondents 250 (81%) reportedly used an alarm system/timer as reminder to take their medication. Most of them reported that they received information regarding their condition and medication, though some were not sure of the side effects or indications for the medications. Adherence was attributed to faith in the healthcare worker, fear of complications of the condition, and a desire to control the condition. Non-adherence was seen as an active decision, partly based on misunderstandings of the condition and general disapproval of medication which was only taken in order to facilitate daily life or minimize adverse effects. Conclusion: The levels of non-adherence (21% to 34%) among the patients on chronic medication are not acceptable. Elderly patients were more likely to be non-adherent to their treatment compared to the younger patients. Some information gaps were identified regarding their conditions and indications for medications. It is therefore important for the health professional to provide patients with full information about the indications, efficacy, and side effects of the medication given to them. Ways should be found to support elderly patients who are on chronic medications; for instance through directly observed therapy and/or using treatment supporters.

Thesis (M.A. ( Clinical Psychology)) --University of Limpopo, 2014 / A number of studies have indicated that psychological management of chronic diseases is important in order to assist a patient to cope with and manage their condition. The disease and the phenomenon around it can be explained as reasons why individuals move from one treatment facility to the other. This study explored the psychological strategies used by people in Ga-Dikgale community to manage chronic diseases. A qualitative approach was followed and participants were selected through purposive sampling. Ten participants (five males and five females) who are receiving health care services for their chronic diseases were requested to participate in the study. Data were collected using semi-structured interviews and were analyzed using interpretive phenomenological analysis. The results of the study are presented in terms of the following themes: participants‟ own explanations of chronic diseases; participants‟ subjective notions of the events or factors that could have led to their chronic diseases; what participants believe is the main causes of their disease(external or internal factors); pathways followed by the participants to manage their chronic disease; experiences of living with chronic disease; psychological coping strategies; the role of educational agencies; and implications for theory. The study revealed that chronic diseases are ambiguous in nature, with every individual explaining them in ways that relate to their personal experiences. For this reason there are different ways of managing or coping with them. Some people take on more active means of coping, while others are more passive. / VLIR project

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.

This naturalistic exploratory study focused on Australians living with chronic illnesses who chose to use complementary and alternative medicine (CAM). The purpose of this sociological study was to discover and illuminate the lived experience of using CAM by individuals living with chronic illnesses in an attempt to understand their reasons for choosing CAM for their health care needs within the social contexts of their lives. The research question guiding this qualitative study was: Based upon a reflection of lived experiences, why do individuals living with chronic illnesses choose to use CAM? The major finding of this study was that research participants turned to CAM to find practical solutions for coping with pain and the ongoing demands of living daily lives while suffering and living with chronic illnesses. Unlike existing research findings, participants in this study did not turn to CAM for ideological reasons, nor were they seeking a holistic approach to health and health care. As such, the findings of this study strongly suggest that individuals living with chronic illnesses initially choose to use CAM for pragmatic reasons rather than ideological dispositions. However, the findings also suggest that after their initial use of CAM, individuals appear to adopt, via enculturation processes, more holistic ideologies resulting in modifications to perceptions of self, illness and health. / Doctor of Philosophy (PhD)

This thesis explores the issue of men's access to chronic illness self management programs from a social constructionist perspective. A combination of research methodologies was used; a quantitative analysis to confirm gender differences in levels and patterns of service use; a qualitative analysis to gain an increased understanding of the factors affecting men's access; and a trial to test the application of the research findings. The clients and services of Arthritis Victoria were chosen as the setting for this research. The quantitative analyses were conducted on contingency tables and odds ratios and confirmed that men were under-represented as service users. The analyses also identified gender differences in patterns of service use. The qualitative analysis was based on a series of in-depth, semi-structured interviews. It was undertaken from a grounded theory approach to allow for the development of theoretical explanations grounded in the data. It was found that men's decisions to access chronic illness self management programs were strongly influenced by dominant social constructions of masculinity which constrained help-seeking and health management behaviour. However, the restrictive influence of hegemonic masculinity was progressively undermined by the increasing severity of the chronic condition until a crisis point was reached in terms of the severity of the condition or its impact on lifestyle. This resulted in a reformulation or rejection of hegemonic masculinity. The described conceptual framework was consistent for men from diverse social groupings, although it appeared less prominent in both younger and older men, suggesting that dominant social constructions of masculinity have the greatest influence on health decisions during the middle stage of adulthood when work and family obligations are greatest. The thesis findings informed the development of some guiding principles for reviewing the structure and delivery of chronic illness self management services for men. The guiding principles will have direct application in the planning of Arthritis Victoria programs, and implications for other chronic illness self management programs in Australia, and also in Western countries with a similar health and sociocultural setting to Australia.

Thesis (Ph. D.)--University of Washington, 1984. / Vita. Bibliography: leaves [124]-128.

<p>Chronic diseases of lifestyle (CDL) are on a raising trend in the world regardless of age, economic class or geographical location of a population. The mortality rate associated with CDL is alarmingly among the highest globally. Tanzania is not exempted from this development. Literature indicates that physical activity is a health practice that can prevent CDL. It is recommended that medical practitioners should hold the responsibility of counselling patients on physical activity. Some studies outside Africa found an association between doctors&rsquo / physical activity patterns and their counselling practices on the same. This study therefore sought to establish whether physical inactivity among medical&nbsp / doctors in Tanzania significantly influenced their counselling practices on physical activity. A cross sectional quantitative survey at the Muhimbili National Hospital and Muhimbili Orthopedic Institute was conducted to derive the required information. A self administered structured questionnaire was voluntarily answered by 144 medical doctors. The Statistical Package for Social Sciences (SPSS) version 17 was used for data capturing and analysis. Descriptive statistics were employed to summarize data and was expressed as means, standard deviation, frequencies and percentages. The students&rsquo / t-test was used to compare mean physical activity between different groups. Furthermore students&rsquo / t-test and analysis of variance tests were used to examine association between different variables. Chisquare tests were used to test for associations between categorical variables. Alpha level was set at p&lt / 0.05. Most of the participants in this study were sedentary in their leisure time and only active at work. When their quality of&nbsp / physical activity counselling was assessed, the majority of them were found to be poor physical activity counsellors. A significant association was found between physical activity and age, as well as physical activity and counselling practice (p&lt / 0.05). Participants mostly informed their patients about the intensity and duration of exercising more than any other idea of physical activity such as types of exercises, issuing of a written prescription and planning for a follow up. Lack of knowledge and experience about details of physical activity were reasons offered for failure to counsel. Participants also reported the inconvenience of physical activity facility&rsquo / s schedules, fatigue and tiredness to be their&nbsp / barriers to physical activity participation. Doctors in Tanzania lacked personal initiative to participate in physical activity and consequently lacked the motivation to counsel.&nbsp / Measures around enhancing this health practice should be enhanced by all stakeholders including medical doctors, physiotherapists and patients. The need for short term and&nbsp / long term training in matters related to physical activity are therefore necessary among the practicing doctors and those undergoing training in medical schools. Physiotherapists who are trained in movement science can offer valuable advice/information to medical doctors to ensure that medical doctors acquire physical activity prescription and&nbsp / counselling knowledge. Collaboration between stakeholders in campaigning against sedentary lifestyles should be enhanced. Further reasons for failure to counsel, hindrances to physical activity participation and modern approaches to counselling should be explored.<br /> &nbsp / </p>