Many communities across the United States, including those from low-income and racial and ethnic minority groups, have less access to quality, timely, and preventative primary healthcare services. One factor contributing to this disparity is the shortage of primary care providers to meet demands in underserved areas. Nurse practitioners (NPs), or advanced-practice registered nurses trained to diagnose, treat, and manage health conditions, are a solution to meeting the nation’s primary care needs. Over the past decade, the NP workforce has grown significantly, doubling its number between 2010 and 2017. NPs frequently care for individuals from medically underserved communities, including those receiving care in community health centers (CHCs). CHCs are a network of safety-net healthcare organizations delivering comprehensive primary care in many rural and inner-city areas. However, the NP workforce can be further optimized in CHCs. Despite the growing national NP supply, CHCs struggle with adequate NP staffing. Furthermore, providers working in CHCs and other safety-net settings report insufficient resources to care for patients, high workloads, and elevated staff turnover; these challenges may create poor practice environment and predispose CHC NPs to poor workforce outcomes, such as burnout and job dissatisfaction.Literature has demonstrated that poor clinician workforce outcomes, particularly burnout, negatively affect the safety and quality of care patients receive. Poor care and disease management may also result in disease exacerbation and, subsequently, preventable healthcare use by patients such as emergency department visits and hospital admissions. Preventable healthcare use increases the nation’s healthcare costs and may expose patients to harm. Despite the contributions of NPs to CHCs, little is known about how to optimize their staffing and workforce outcomes (e.g., reducing burnout, turnover intention, and improving job satisfaction) to assure positive patient outcomes. The overall purpose of this dissertation is to understand ways to optimize the NP workforce in CHCs to potentially improve outcomes for CHC patients. Specific aims include: 1) examining factors that influence the recruitment and retention of NPs in underserved areas; 2) assessing the practice environment and workforce outcomes of NPs in CHCs; and 3) understanding the consequences of NP burnout on CHC patient outcomes. Dissertation Chapters and Findings The first chapter of this dissertation summarizes the background on the NP workforce and CHCs and details the problem under investigation. The second chapter is a scoping review examining the factors influencing recruitment and retention of NPs in underserved areas. Factors influencing recruitment and retention of NPs in underserved areas exist at various levels, from individual (e.g., growing up in underserved areas) to policy factors (e.g., autonomous scope of practice). However, current literature lacks rigorous, up-to-date, and NP-focused studies. The third chapter is a cross-sectional analysis of survey data from 269 CHC NPs. This chapter assessed the practice environment, job satisfaction, burnout, and turnover intention of NPs working in CHCs to better understand the current workforce conditions of CHC NPs; this chapter also examined the relationship between CHC NPs’ practice environment and workforce outcomes. CHC NPs reported generally favorable practice environment and high job satisfaction. When CHC NPs report good relationships with their administration, they are more likely to report higher job satisfaction and lower intention to leave their jobs. The fourth chapter aimed to understand the implications of a negative workforce outcome (i.e., burnout) in the CHC setting. Through a cross-sectional analysis of merged NP survey and Medicare claims data, we examined the relationship between NP burnout and preventable hospitalization and emergency department use in patients. Patients receiving care in CHCs with higher NP burnout are more likely to use the emergency department for preventable reasons. The fifth and last chapter discusses the findings of this dissertation and its implications for policy, research, and practice.

Emergency Medical Services (EMS) is provided in a variety of different ways in the United States. Methods of service delivery range from the purely private to the completely public and include mixtures that are not clearly one or the other. Based on a review of the literature, this variation is hypothesized to reflect, in part, variation in community characteristics. Using localities in the Commonwealth of Virginia, this hypothesis is tested by examining the characteristics of forty-seven communities in which emergency medical services are provided. Survey research was used to explore the association between public or private provision of EMS and five variable clusters: socioeconomic, medical resources, geographic, governmental, and unique local resources. Analysis of these variable clusters resulted in the conclusion that there is a statistically significant difference between the characteristics of communities with public service provision and the characteristics of communities with private provision. Thus, it seems highly likely that the public-private variation in EMS service delivery reflects to a certain extent differences in the communities themselves. Socioeconomically advantaged, urban communities with quick access to a large number of medical facilities are more likely to provide EMS through private means. On-the-other-hand, relatively socioeconomically disadvantaged, rural communities with fewer medical resources are more likely to publicly provide EMS service. The fact that this relationship between the characteristics or nature of the community and the method of service provision exists raises several issues. It indicates that rural communities are carrying the burden of public service provision while more urban areas have been able to recover some costs. It also raises the issue of service provision to the indigent in urban areas, since we are unsure as to whether or not a fee structure inhibits utilization by the poor. The relationship between access to the EMS system and the selection of a financing strategy of service provision deserves investigation. Perhaps most importantly, this effort points out how little we know about emergency medical services in the larger context of municipal services. / Master of Urban and Regional Planning

The demographics and perceived needs of the Comprehensive Health Investment Project participants were studied along with the interventions provided by the CHIP staff. Demographic information and perceived needs were calculated on 397 household heads. These families were followed for a year and the interventions provided to them during that year were recorded. Intervention records were collected quarterly and analyzed for comparisons with the family profile grid.Results show a unique demographic makeup of CHIP participants. Sixty percent of household heads had one or more years of college; 66 percent were employed at the time of the study; 73 percent were receiving federal financial assistance of some kind. Health and nutrition of the family were the main concerns of the clients. Other needs included financial assistance, employment, and housing. Eleven percent of interventions provided by CHIP throughout the study year were directed towards financial assistance. Ten percent of services were employment oriented. CHIP participants were also shown to use physicians during well times - not just during emergencies. Results and conclusions are discussed in detail. / Master of Science

No description available.

The World Health Organization (WHO) in 1979 declared a global goal of, "Health for all by the year 2000." Lesser-developed countries, including Honduras, struggle to meet the most basic health needs of their people. Problems of meeting health care needs in Honduras include uneven distribution of health services, inadequate numbers of trained health care workers, and lack or awareness of those in need of healthcare. Natural disasters such as Hurricane Mitch, which struck Honduras in November of 1998, have exacerbated the problems. The purpose of this educational project was to develop, implement, and evaluate an educational program taught by nurses to lay community health care workers in Tegucigalpa, Honduras. These lay health workers will be called 'Community Health Promotores' (CHP) The CHPs will voluntarily work with their neighbors to improve health promotion, increase self care abilities for minor health problems, monitor growth in children and identify serious health problems for referral to their nurse of physician supervisor. The CHP will assist to improve the self-care abilities of community members and finding those in need of health care. An instructional manual includes information on nutrition, hand-washing, first aide, disease states (hypertension, diabetes, heart disease, diarrhea, problems common in pregnancy and childhood, mental health), and skills in measuring blood pressure, temperature, pulse and respiration. Teaching strategies used in this project and pre and post course evaluation are discussed. The initial class was offered in March 1999. Eleven students completed the course and are volunteering in their communities.

Using a logistic regression model, this dissertation employed a macro level Gateway Provider Model to explore eight factors that may influence community health center HIV testing approach. The logistic regression model indicated that three variables related to community health center HIV testing approach. First, all else equal, the odds of offering routine HIV testing for community health centers that perceived their patients and community to be at average risk for HIV were 3.676 times the odds for those centers that perceived their patients and community to be at low or no risk for HIV. Further, the odds of offering routine HIV testing for community health centers that perceived their patients and community to be at high risk for HIV were 4.693 times the odds for those centers that perceived the community to be at low or no HIV risk. Second, all else equal, the odds of offering routine HIV testing for community health centers in which an HIV testing policy exists were 2.202 times the odds for those centers in which an HIV testing policy does not exist. Third, all else equal, the odds of offering routine HIV testing for community health centers that received funding specifically for HIV testing were 2.938 times the odds for those centers that did not receive such funding. No other individual predictor variables in the model were related to community health center HIV testing approach.

The purpose of this study was to explore HIV/AIDS client experiences with supportive services. The consumption of social services for individuals living with HIV/AIDS has assumed increasing importance. This is a crucial population that requires a multifaceted approach to treatment in order to remain active and productive for longer periods of time.

This research has examined how Information and Communication Technologies (ICTs) can promote healthy eating habits amongst African Americans in low-income neighborhoods, a population that faces disproportionately high rates of diet-related health problems. In this dissertation, I describe the formative research I conducted to obtain system design guidelines and how I used those guidelines to develop two applications: EatWell and Community Mosaic. I also describe the results of the in-depth field studies I conducted to evaluate each application. Both EatWell and Community Mosaic incorporate the cultural construct of collectivism, a social orientation in which interdependence and communal responsibility are valued over individual goals and independence. As researchers have generally characterized the African American culture as collectivistic and argued for the value of designing collectivistic health interventions for this population, I examined the implications of taking such an approach to designing health promotion technologies. EatWell and Community Mosaic are collectivistic because they empower users to care for the health of their local community by helping others learn practical, locally-relevant healthy eating strategies. I discuss the results of my formative fieldwork and system evaluations, which characterize the value, challenge and nuances of developing community-based health information sharing systems for specific cultural contexts. By focusing on health disparities issues and the community social unit, I extend previous health technology research within Human-Computer Interaction (HCI). In particular, my results describe 1) a set of characteristics that help make shared material useful and engaging, 2) how accessing this information affects how people view the feasibility of eating well in their local context, 3) the way in which sharing information actually benefits the contributor by catalyzing personal behavior reflection, analysis and modification and 4) how sharing information and seeing that information's impact on others can help to build individuals' capacity to be a community health advocate. In addition, my work shows how examining cultural generalizations such as collectivism is not a straightforward process but one that requires careful investigation and appreciation for the way in which such generalizations are (or are not) manifested in the lives of individual people. I further contribute to HCI by presenting a set of important considerations that researchers should make when designing and evaluating community-based health systems. I conclude this dissertation by outlining directions for future HCI research that incorporates an understanding of the relationship between culture and health and that attempts to address health disparities in the developed world.

M.Cur. / The purpose of the research study was to describe guidelines to improve the community health clinics as a learning context conducive to learning. The objectives of the study commenced by getting the perception of student nurses, community sisters and college tutors, to explore and describe the problems experienced in relation to community health clinics as a learning context for student nurses, especially when they are allocated for their clinical practicals to prepare them to become competent. The research design and method used, consisted of a qualitative approach to achieve the intended goal of the research study. The design was divided into two phases: Phase one consisted of a field/empirical study and phase two consisted of conceptualization. Phase one has three steps where each step indicates the research method, population and sampling, data collection and data analysis. Population and sampling for step I included all the fourth year students from a nursing college in Gauteng, who are in an educational programme leading to registration as a nurse (general, psychiatric and community) and midwife. Population and sampling for step II consisted of community sisters from ten community health clinics in the Southern Metropolitan Local Council. Population and sampling for step III consisted of community college tutors from a college in Gauteng; the sample size consisted of the whole population. In all the steps follow-up interviews were conducted to confirm the findings. To ensure trustworthiness Lincoln and Guba's (1985) model was implemented, and data analysis were according to Tesch's (1990 in Creswell, 1994:155) method, based on a qualitative approach. The major problems reflected in the research findings based on Step I, II, II indicate similarities and Step III only indicates some uniqueness. The conceptual framework was discussed, indicating a body of knowledge, based on the study and empirical findings from phase I, to give clear meaning and understanding regarding the research study. Problems from all the steps were used in an integrated manner as research findings and were compared with existing literature within the framework, to determine similarities and differences as literature control method. Guidelines were then formulated from phases I and II, to solve the indicated problems, based on the three different sample groups. Guidelines were supported by the conclusion statement from chapter four and the problem statement from chapter three. Essential actions were indicated for operationalisation. Ethical consideration was maintained throughout the research study. The study has been evaluated by means of positive and negative issues related to the actual research process. Recommendations related to nursing education, nursing practice and nursing research were indicated accordingly.

Thesis (MPA)--Stellenbosch University, 2000. / ENGLISH ABSTRACT: Sharp divisions featured between curative and preventative health care in the Public Health Services of South Africa before the democratisation process. There was fragmentation in authority structures and inequalities between urban and rural areas as well as along racial lines. This resulted in a situation where there was duplication and inequality in the distribution of resources amongst the different levels of health care which led to costly inefficient and ineffective health services. The introduction of the White Paper Towards the Transformation of Health System in South Africa in 1997, aims at the restructuring of health services towards a unified health system which is capable of delivering quality health care to all in a caring environment. The District Health System (DHS) is featured as the key to ensuring decentralised, equitable Primary Health Care (PHC) to all the citizens of South Africa. This study looks at the reorganisation of health services in the clinics and the day hospitals which are rendered by the Health Department of The City of Tygerberg and the Community Health Service Organisation (CHSO) of the Provincial Administration of the Western Cape(P AWC) in Khayelitsha with the aim of achieving comprehensive PHC services. Inthe absence of legislation for the integration of health services, initiatives for the achievement of quality comprehensive PHC within the district are envisaged. / AFRIKAANSE OPSOMMING: Openbare Gesondheidsdienste in Suid Afrika was voor die demokratieseringsproses gekenmerk deur 'n skeidig tussen kuratiewe en voorkomende gesondheidsdienste. Daar was fragmentasie van bestuurstrukture, ongelykheid tussen stedelike en landelike gebiede asook ongelykheid op grond van ras. Dit het gelei tot duplisering van, en ongelykheid in, die verspreiding van hulpbronne op die verskillende vlakke van gesondheidssorg. Die Witskrif op die Transformasie van Gesondheidstelsels in Suid-Afrika, 1997, fokus op die herstrukturering van gesondheidsdienste en het 'n verenigde gesondheidstelsel ten doel wat daartoe in staat is om gehalte gesondheidsorg in 'n sorgsame omgewing aan almal te lewer. Die Distriksgesondheidstelsel (DGS) word gekenmerk deur gedesentraliseerde, gelykmatige Primêre Gesondheidsorg (PGS) dienslewering aan al die inwoners van Suid-Afrika. Hierdie studie kyk na die herorganisering van gesondheidsdienste wat deur die gesondheidsdepartement van die Stad Tygerberg en die Gemeenskapsgesondheidsdiens organisasie van die Provinsiale Administrasie van die Wes-Kaap (PAWK) in die klinieke en daghospitale in Khayelitsha gelewer word met die doel om omvattende Primêre Gesondheidsorgdienste te voorsien. Weens die afwesigheid van wetgewing vir die integrasie van gesondheidsdienste word inisiatiwe vir die bereiking van gehalte omvattende Primêre Gesondheidsorg binne die distrik beoog.