Effective treatment of heart disease and an aging population have led to increases in the incidence of heart failure. Treatment requires complex medication regimes and recognition of symptoms. Best practice guidelines published by the American, European and Canadian cardiac societies promote self-care behaviours and skill building. No concrete examples of education programmes for clients were found in the literature. The purpose of the study was to develop, pilot and evaluate an education series for clients with heart failure within a primary care setting. “LEARN twice”, a three part education series with related resource material, was developed in the context of inter-professional collaboration and drew upon theories of health education, and literacy. The concept of co-management was incorporated as the philosophical basis in the design. The pilot-test used an experimental design, and incorporated pre and post-testing with standardized instrumentation including the Dutch Heart Failure Knowledge Scale and the Minnesota Living with Heart Failure Questionnaire. To pilot the education series, participants attended three education classes highlighting the essential skills for self management of heart failure. A qualitative descriptive component included brief semi-structured interviews with participants and educators to provide feedback about both the process and content of the educational series. Limited participant numbers did not permit statistical testing, however potentially promising results were found in the quantitative data collected. Descriptive participant data indicated that the education series was meaningful, and helped iii understanding of symptoms. Instructors rated the content as good to excellent and anticipate the adoption of the education series as standard practice in the clinic. The pilot test of the education series has provided a foundation for future research endeavours, in particular the replication and completion of this study protocol. As clients with heart failure have the potential to be in regular contact with a primary care provider, subsequent studies could include a longitudinal component to examine whether rates of re-hospitalization are reduced for clients who attend an education series.

Thesis (Ph.D.)--University of Wollongong, 2008. / Typescript. Includes bibliographical references: leaf 272-295.

Zugl.: Bremen, Univ., Diss., 2008

Zugl.: Bremen, Universiẗat, Diss., 2008.

Thesis (M.S. in Biomedical Informatics)--Vanderbilt University, Dec. 2006. / Title from title screen. Includes bibliographical references.

Asthma, gout and hypothyroidism are common chronic medical disorders encountered in general practice. Optimal disease management according to standard guidelines are fundamental to disease control. This study aimed to objectively and subjectively assess the quality of care provided in a private general practice to patients with asthma, gout and hypothyroidism by means of a practice audit and questionnaire based survey. These tools proved to be an effective measure for the quality of care provided and identified areas needing improvement. Patient’s understanding of the disease process plays an important role in both patient satisfaction ratings and success of disease control. The medical audit identified and highlighted specific areas of care that can be improved. Evidence from the practice audit showed that control for asthma based on the PEFR readings, gout based on the serum uric acid reading and hypothyroidism based on a blood TSH reading, was found at 56.7%, 43.3%, and 66.7 % respectively. In addition acute attacks of asthma and gout occurred in 22.7% and 32.8% respectively. This does not represent good control. Definition of disease control for each condition is placed in the text. The survey revealed overall patient understanding for the disease processes of asthma, gout and hypothyroidism to be 69.6%, 73.3% and 66.8% respectively. The patient survey satisfaction rating for asthma, gout and hypothyroidism was 93.1%, 93.9% and 89.2% respectively. Patient suggestions for improvement included three dominant themes: better assessment of disease control, education about their chronic disease and implementation of a clearer referral process. The study concludes that disease control can be achieved if patients are educated about their chronic disease and regularly followed up to assess disease control based on standard management guidelines. Patients' disease education was a major contributing factor for satisfaction rating bias. The study confirms that in spite of high satisfaction ratings, patients are not optimally managed with substandard disease control. It would be expected that as disease education improves, the quality of care will improve, but satisfaction ratings will decrease.

Background The number of people in Sub-Saharan Africa dying of heart failure is increasing. However, little is known about their experiences and needs. In Kenya, palliative care services are available for some people with cancer and HIV/AIDS, but these services may not be configured to meet the needs of patients dying with heart failure. Aims and objectives This study aimed to explore the experiences of patients living and dying with heart failure in Kenya. Specifically, it sought to understand how patients describe their illness experience, their experience of receiving treatment and care, and their perspectives on how their care could be improved. Methods Twenty patients admitted and diagnosed with advanced heart failure were purposively recruited from a rural district hospital. Serial in-depth interviews were conducted with patients at 0, 3 and 6 months after recruitment. Bereavement interviews were carried out with carers. All interviews were conducted and recorded in the local language of Kiswahili, transcribed into English and analysed thematically with the assistance of Nvivo software. Results Forty-four interviews were conducted. Three significant phases were identified in patients’ experience (i) coming to a diagnosis, (ii) living with heart failure and (iii) dying with heart failure. Before receiving the diagnosis of heart failure, many patients were mistakenly misdiagnosed with common serious infectious conditions such as pneumonia, tuberculosis, and malaria. Once treatment commenced and physical symptoms abated, many patients were hopeful of a full recovery, unaware that there would be a progressive deterioration in their health. Social relationships were a source of encouragement but were strained by the accumulating cost of care. Patients particularly those who were younger, felt anxious or depressed when symptoms failed to improve with treatment. Uncertainty was prevalent and underlay patients’ experiences from the time of diagnosis to the end of life. Very few patients spoke about the possibility of death believing that life and death are in the hand of God. Majority of patients had poor understanding of their illness and expressed a need for more information and better communication with health professionals. Conclusion Patients with advanced heart failure in Kenya have significant unmet physical, psychological, social, spiritual, financial, and information needs. Patients’ narratives pointed to how they could benefit from a holistic approach aimed at catering for their multidimensional wellbeing. There is need to improve patients access to information and support better communication with health professionals. Chronic disease management aimed at (i) early identification of patients (ii) improving treatment and care guidelines and (iii) promoting primary and secondary prevention to identify, treat and control common risk factors for heart failure is needed.

Tuberculosis (TB) is acknowledged as an epidemic in South Africa. Health care professionals (HCPs), including dieticians, are at an increased risk for TB-infection compared to the general population. Implementation of the World Health Organization (WHO) TB infection control measures can protect HCPs from contracting TB; however, many studies have shown poor adherence to guidelines by HCPs. The aim of the study was to determine dieticians’ knowledge, attitudes and experiences in relation to TB at the workplace. A descriptive quantitative, cross-sectional research design was employed. Convenience sampling was applied. The online survey was conducted between August 2014 and March 2015. Data analysis included descriptive and inferential statistics. Ethical principles were adhered to. The sample consisted of 102 registered dieticians in South Africa. Good knowledge was displayed as two-thirds of dieticians correctly identified the National TB Management Guidelines and the main signs and symptoms of TB. However, a critical knowledge gap regarding TB transmission was identified, as only 42% of dieticians knew that TB could spread by talking. Favourable attitudes towards TB and infection control measures were present, except towards inadequate staffing levels and being worried about TB. The respondents reported that the fear of contracting TB affected patient interaction. Poor adherence to infection control measures was found. Only 45% of dieticians reported having a written TB infection control plan at their workplace, and only 23% were trained on TB infection control measures. Coughing patients were not always triaged and education material was not always available for TB patients. The availability of N-95 respirators was reported by 76% of dieticians. Training on TB infection control measures could influence dieticians’ adherence to infection control measures, ultimately protecting them from contracting TB at the workplace.

Background: Health care needs to evolve to meet the needs of people living with HIV as they age and become a more diverse population. For HIV and other conditions, physician specialty and experience are often positively associated with disease-specific outcomes but negatively associated with primary care outcomes. The objectives of this thesis were to: 1) assess comorbidity prevalence among people living with HIV in Ontario; 2) describe the type and extent of care by physician specialty; 3) use a theoretical shared primary/specialist care typology to characterize this care; 4) measure the quality of care delivered related to this typology; and 5) assess the independent effect of family physician HIV experience. Methods: Population-based data were used to describe a cohort of 14,282 individuals living with HIV in Ontario. Health care visits to this cohort were categorized by physician specialty, physician HIV experience, and HIV-related versus HIV-unrelated care. A theoretically-based typology of care was developed by linking patients to usual family physicians and to HIV specialists with 5 possible patterns of care. Prevention and chronic disease management adherence, antiretroviral (ART) prescribing, and health care utilization were compared across typology models using multivariable hierarchical logistic regression analyses. The independent effect of family physician experience was also examined. Results: People with HIV had significant comorbidity. Family physicians provided the majority of care. Five patterns of care were described: exclusively primary care (45.4%); specialist-dominated co-management (30.7%); family physician-dominated co-management (10.1%); low engagement (8.6%); and exclusively specialist care (5.3%). After adjustment, HIV patients in exclusively specialist care had lower odds of colorectal cancer screening but higher odds of receiving ART. Odds of having an emergency department visit did not differ among models. Among HIV patients seeing only family physicians, those linked to family physicians with high HIV experience were significantly more likely to receive ART than those with lower HIV experience. Discussion: People with HIV in Ontario have substantial comorbidity. A typology of shared care between family physicians and HIV specialists had a strong influence on the quality of care delivered. These findings have important policy and practice implications and support emerging evidence that multi-specialty expertise is required to address the care needs of this population.

Thesis(Ph.D.(Medical Science)) -- University of Limpopo, 2016 / Background: Chronic disease management (CDM) is an approach to health care that keeps people as healthy as possible through the prevention, early detection and management of chronic diseases. This approach offers holistic and comprehensive care, with a focus on rehabilitation, to achieve the highest level of independence possible for individuals.The aim of this study was to develop an integrated, evidence-based model for the management of chronic non-communicable diseases in a rural community of the Limpopo Province, South Africa. Methods: The study was conducted at Dikgale Health and Demographic Surveillance System (HDSS) site is situated in Capricorn District of Limpopo Province in South Africa. This study followed mixed methods methodology with an aim on integrating quantitative and qualitative data collection and analysis in a single study to develop an intervention program in a form of model to improve management of chronic diseases in a rural area. Therefore, this included literature review and WHO STEPwise approach to surveillance of NCD risk factors for quantitative techniques and focus group discussions, semi-structures interviews and quality circles for qualitative techniques. In the surveillance of NCD risk factors standardised international protocols were used to assess behavioural risk factors (smoking, alcohol consumption, fruit and vegetable consumption, physical activity) and physical characteristics (weight, height, waist and hip circumferences, and blood pressure). A purposive sampling method was used for qualitative research to determine knowledge, experience and barriers to chronic disease management in respect of patients, nurses, community health workers (CHWs), traditional health practitioners (THPs) and managers of chronic disease programmes. Data were analysed using STATA 12 for Windows, INVIVO and Excel Spreadsheets. Results: The study revealed that epidemiological transition is occurring in Dikgale HDSS. This rural area already demonstrates a high burden of risk factors for non-communicable diseases, especially smoking, alcohol consumption, low fruit and vegetable intake, physical inactivity, overweight and obesity, hypertension and dyslipidaemia, which can lead to cardiovascular diseases. The barriers mostly mentioned by the nurses, patients with chronic disease, CHWs and THPs include lack of knowledge of NCDs, shortages of medication and shortages of nurses in the clinics which cause patients to stay for long periods of time in a clinic. Lack of training on the management of chronic diseases, supervision by the district and provincial health managers, together with poor dissemination of guidelines, were contributing factors to lack of knowledge of NCDs management among nurses and CHWs. THPs revealed that cultural insensitivity on the part of nurses (disrespect) makes them unwilling to collaborate with the nurses in health service delivery. x The model developed in this study which was the main aim of the study describes four interacting system components which are health care providers, health care system, community partners and patients with their families. The main feature of this model is the integration of services from nurses, CHWs and THPs including a well-established clinical information system for health care providers to have better informed patient care. The developed model also has an intervention such as establishment of community ambassadors. Conclusion: Substantially high levels of the various risk factors for NCDs among adults in the Dikgale HDSS suggest an urgent need for adopting healthy life style modifications and the development of an integrated chronic care model. This highlights the need for health interventions that are aimed at controling risk factors at the population level in order to slow the progress of the coming non-communicable disease epidemic. Our study highlights the need for health interventions that aim to control risk factors at the population level, the need for availability of NCD-trained nurses, functional equipment and medication and a need to improve the link with traditional healers and integrate their services in order to facilitate early detection and management of chronic diseases in the community. The developed model will serve as a contribution to the improvement of NCD management in rural areas. Lastly, concerted action is needed to strengthen the delivery of essential health services in a health care system based on this model which will be tasked to organize health care in the rural area to improve management and prevention of chronic illnesses. Support systems in a form of supervisory visits to clinics, provision of medical equipments and training of health care providers should be provided. Contribution from community partners in a form of better leadership to mobilise and coordinate resources for chronic care is emphasized in the model. This productive interaction will be supported by the district and provincial Health Departments through re-organization of health services to give traditional leaders a role to take part in leadership to improve community participation. / Medical Science Department, University of Limpopo in South Africa,International Health Unit, and Antwerp University