BACKGROUND Quality improvement literature usually conceptualises two principal dimensions of quality, technical and service. Technical quality is what the customers receive relative to what is known to be effective and largely reflects issues related to the health care providers. Service quality is how the customers receive the services and reflects the way and the environment in which health services are provided. This thesis proposes and tests a third principal dimension, Customer Quality, which is the characteristics that customers need for effective involvement in health care processes, decision making and action to improve the quality of care delivered and received. This model is applied in the context of care for people with Type 2 diabetes as an example of the high priority common chronic diseases and one of the most important public health problems in Australia and worldwide. The study also examines the feasibility of using patient reports of received care as a way of measuring service and technical quality on a population basis. OBJECTIVE The present study aims to assess the quality of delivered care as perceived by people with Type 2 diabetes. Specifically it aims to measure service quality, technical quality, customer quality; and finally an overall quality index by combining all three dimensions. METHODS A community based cross-sectional survey of 603 people with Type 2 diabetes was carried out in Queensland, Australia in 2005/06 using a self-administered questionnaire. The eligible participants were Diabetes Australia-Queensland members over 25 years old with diagnosed Type 2 diabetes at least one year prior to the study. Adherence to the eleven clinical, lifestyle and management indicators, derived from standard Diabetes Australia Guidelines, were measured from the patients’ reports as a representative of technical quality to explore the likely gap between received services and what should have been received in the 12-month period. Focus Group Discussions were used to determine the elements of service quality that were important from the patients’ perspective. Twelve service quality indicators, derived from the review of the literature and the focus groups, were assessed to calculate service quality as perceived by people with Type 2 diabetes. The validated, reliable and practical 13- item Patient Activation Measure was used to evaluate customer quality in terms of customers’ knowledge, skills and confidence. Demographic and disease related information was obtained using a self-reported questionnaire. Two types of outcome variables were used in this study: participantreported binary variables (having complications, continuity of care and diabetes control status) and calculated continuous variables (technical quality rating, service quality and customer quality scores and, finally, the overall quality index). RESULTS The response rate from the 1500 mailed out questionnaires was 40%. Nonrespondents were a little younger (P<0.001) than study participants and matched on gender (P> 0.05). Participants were mostly over 65 years old, over 50% were male, almost half of them were obese and a quarter were studying or had completed tertiary level of education. Almost two-thirds reported well controlled diabetes and 60% had diabetes for more than five years. Most of them were not treated by specialists and maintained continuity of care for their diabetes management. The majority of participants were treated with insulin or oral agents (72%) and 37% reported diabetes complications. Overall adherence rate for top 5 clinical and top 3 management and lifestyle indicators were 49.7% and 18.8% respectively. Over 90% of participants reported an appropriate level of checks of HbA1c, blood pressure and serum cholesterol. For lifestyle and management indicators, reported adherence rates to guidelines were lower than for clinical indicators. Participants who reported care as recommended for blood pressure measurements; feet examinations; self-management, diabetes knowledge and nutritional consultation reviews were more likely to report their diabetes as being well controlled. Participants maintaining continuity of care also reported fewer complications and well controlled diabetes. Of the twelve service quality indicators, the highest service quality score were for support group, basic amenities, dignity and confidentiality. Inadequate quality was identified for overall service quality (86.2), choice of care provider, continuity, timeliness, safety, prevention and accessibility. Younger participants reported lower service quality scores (P=0.001) and participants with good control of their diabetes had higher scores (P<0.001). Overall reported Customer Quality score was 64.5. Ten percent of participants did not achieve the Customer Quality score for the confidence stage and 26% did not reach the actual action stage. Nearly three quarters of respondent reported the capacity to take action for self-management but only 38% reported the highest Customer Quality score equating to perceived ability to change the action by changing health and environment. Participants with a higher level of education and those who maintain continuity of care reported a higher Customer Quality score. Participants with a higher Customer Quality score were also more likely to report well controlled diabetes status. An overall imperfect Quality Index score (70) reflects significant room for overall quality improvement of diabetes care services. The younger participants reported lower Quality Index scores than older ones. Higher Quality Index scores were highly significantly associated with reporting better diabetes control status and continuity of care. There were no significant differences in the Quality Index scores in terms of gender, participants’ education level and diabetes complications. CONCLUSION Customer quality appears to be a useful third dimension in conceptualising quality in health care, particularly in the context of chronic disease where good selfmanagement can improve the outcomes of care. A substantial proportion of Queensland adults with Type 2 diabetes reported receiving suboptimal care. From the perspective of people with Type 2 diabetes there is a notable gap between their expectations and what they have actually received in most aspects of provided care. The overall service quality and choice of care provider, accessibility, prevention, continuity, timeliness and safety were identified to be of inadequate quality. Participants also reported relatively low customer quality scores based on the personal knowledge, skills and confidence as well as low overall quality score for delivered diabetes care. Thus, there was a significant opportunity to improve the quality of diabetes care on all three dimensions. The study demonstrated that a patient selfadministered survey is a potentially useful way of measuring all three dimensions of quality of care for diabetes.

The purpose of this study was to develop a set of guidelines to enable teachers to support children with diabetes. The aspects of support include the physical, emotional, social and cognitive aspects that have an effect on a child with diabetes. A literature study and an empirica l investigation were und ertaken to investigate which factors would enable teachers to become better sources of support in school. Semi - structured interviews were conducted with teachers to determi ne their knowledge about diabetes . Parents who have children with diabetes were also interviewed to determine what support they required from teachers. The results of the study culminated in a set of guidelines for teachers. / Psychology of Education / M. Ed. (Psychology of Education)

The purpose of this study was to develop a set of guidelines to enable teachers to support children with diabetes. The aspects of support include the physical, emotional, social and cognitive aspects that have an effect on a child with diabetes. A literature study and an empirical investigation were undertaken to investigate which factors would enable teachers to become better sources of support in school. Semi-structured interviews were conducted with teachers to determine their knowledge about diabetes. Parents who have children with diabetes were also interviewed to determine what support they required from teachers. The results of the study culminated in a set of guidelines for teachers. / Psychology of Education / M. Ed. (Specialisation in Guidance and Counselling)