Despite growing evidence that anxiety can be a significant problem in late-life, information regarding the use of mental health services by older adults for anxiety is lacking. The current research project consists of three studies focusing on this issue. The first study examines the rates of mental health service use among older adults with anxiety disorders and high levels of anxiety symptoms, as well as individual characteristics associated with this use. The second study examines various aspects of social support as correlates of anxiety disorders in older adults, and the role of social support as an enabling resource for mental health service use. Finally, the third study examines three important outcomes of service use among older adults: treatment satisfaction, perceived treatment effectiveness, and dropout. The data for these studies came from the Canadian Community Health Survey: Mental Health and Well-Being (CCHS 1.2), a national population-based survey that includes 12,792 respondents aged 55+ years. This research found that older adults with significant anxiety were less likely to use services than those with mood disorders, and that indicators of need for services were the strongest predictors of use. Lower levels of functional social support were related to the presence of anxiety disorders among older adults, and lower levels of perceived emotional/informational support and positive social interactions predicted greater use of services for adults throughout the lifespan. Finally, older adults were generally satisfied with services, perceived them as helpful, and were likely to remain in treatment. Analyses indicated that individual characteristics likely play only a small role in these outcomes. In general, this project provides new and important information that can inform policy, clinical work, and future research regarding late-life anxiety.

Despite growing evidence that anxiety can be a significant problem in late-life, information regarding the use of mental health services by older adults for anxiety is lacking. The current research project consists of three studies focusing on this issue. The first study examines the rates of mental health service use among older adults with anxiety disorders and high levels of anxiety symptoms, as well as individual characteristics associated with this use. The second study examines various aspects of social support as correlates of anxiety disorders in older adults, and the role of social support as an enabling resource for mental health service use. Finally, the third study examines three important outcomes of service use among older adults: treatment satisfaction, perceived treatment effectiveness, and dropout. The data for these studies came from the Canadian Community Health Survey: Mental Health and Well-Being (CCHS 1.2), a national population-based survey that includes 12,792 respondents aged 55+ years. This research found that older adults with significant anxiety were less likely to use services than those with mood disorders, and that indicators of need for services were the strongest predictors of use. Lower levels of functional social support were related to the presence of anxiety disorders among older adults, and lower levels of perceived emotional/informational support and positive social interactions predicted greater use of services for adults throughout the lifespan. Finally, older adults were generally satisfied with services, perceived them as helpful, and were likely to remain in treatment. Analyses indicated that individual characteristics likely play only a small role in these outcomes. In general, this project provides new and important information that can inform policy, clinical work, and future research regarding late-life anxiety.

Palliative radiotherapy (PRT) is proven to be effective in palliation of symptoms for end-stage cancer patients. However, little is known about its utilization at the end of life. This research aims to examine the utilization and the practice patterns of PRT at the end of life for cancer patients in British Columbia using population-based data. The pattern observed for PRT1Y dose-fractionation practice in BC are in line with published clinical guidelines and evidence from the literature, which advises “proper” use of PRT in BC as delivered to cancer patients at the end of life. However, after controlling for age, primary cancer site, and survival time, geographic access is found to be significantly associated with PRT1Y utilization. Variations found in PRT1Y rates by geographic access, which is operationalized by the Health Services Delivery Area (HSDA) and travel time, suggests potential underutilization of PRT1Y for patients with suboptimal access. / Graduate / 0992 / 0769 / 0574 / jinhuang@uvic.ca

The factors that influence the ultimate level of success or failure of systems development projects have received considerable attention in the academic literature. Two particularly significant areas of interest have been the importance of applying best practice during systems development and the need to explicitly consider organisational issues to ensure a positive organisational impact. However, despite the existence of a well developed best practice literature and an emergent organisational issues literature, many projects still fail. The record of the NHS has been particularly poor in terms of the successful development and implementation of information systems and it was thought that this area would provide a fertile domain for information system research. Whilst the use of information systems in community healthcare has increased greatly over the last ten years the majority of existing research has been conducted in acute hospital environments with little attention devoted to the community sector. Consequently, this research project has two main aims: To identify the key best practice variables and areas of organisational impact associated with the development, implementation and use of a Community Information System (CIS) in National Health Service Trusts; and to examine the relationships between these two sets of variables and the system's resultant level of effectiveness. This research project has a number of positive methodological attributes in that it studies a homogenous organisational sector using a common type of information system and so minimises the potentially confounding influences of sector and system. In addition, the research design involves a three stage approach, combining both quantitative and qualitative research approaches. The research project has produced several key findings. A positive relationship was identified between the adoption of best practice and system effectiveness and similarly, there was a positive relationship between the level of organisational impact and system effectiveness. In order to ensure a positive organisational impact it was found that the successful treatment of key organisational issues is required. In addition, two new variables have been identified, user ownership and positive user attitudes, that play an important mediating role in ensuring system effectiveness. Finally, it was also recognised that the adoption of best practice variables had a dual role, directly influencing the level of perceived system effectiveness but also as a method of effectively managing organisational issues, user ownership and user attitudes. In summary, this study has emphasised the importance of adopting best practice and assessing and managing organisational impact during a community information system development project to ensure system success. These results will be of particular interest to practising IM&T Managers in the NHS and to the wider academic community. A series of practical recommendations are presented at the end of the thesis.

Thesis (Ph. D.)--University of New South Wales, 2004. / Also available online.

Orientador: Antonio Luiz Caldas Junior / Resumo: A condição da acessibilidade aos serviços básicos de atenção à saúde envolve um conjunto de variáveis, tais como: distância entre a moradia e o serviço de saúde, a capacidade de oferta do serviço, a receptividade do funcionário para com o usuário, o intervalo de tempo entre o agendamento e a obtenção da ação de saúde requerida pelo usuário, a necessidade do usuário, entre outras. Como estas variáveis se apresentam e se relacionam entre si, merece ser conhecido, analisado e disponibilizado a todos aqueles que se interessam pelo bom funcionamento do sistema de saúde. O presente trabalho reúne informações que contextualizam teórica e conjunturalmente o objeto de estudo, qual seja, acessibilidade à rede pública de atenção básica à saúde de Botucatu, que aqui é estudada analisando-se o Centro de Saúde "Dr. Sebastião de Almeida Pinto". Para o desenvolvimento deste estudo, realizaram-se 269 entrevistas domiciliares entre moradores da área de abrangência do Centro de Saúde. Também foram coletadas opiniões dos membros da equipe deste serviço estudado através de questionário. Os resultados obtidos indicam, entre outros aspectos, que dos moradores entrevistados na área de abrangência do serviço estudado, 69,5% (IC 90% 64,9% - 74,1%) são usuários e 30,5% (25,9% - 35,1%) não são usuários. Quanto às características demográficas dos moradores entrevistados, tanto usuários, quanto não usuários se concentram na faixa etária compreendida entre 20 e 50 anos de idade. Em relação ao sexo, entre os usuários, a clientela é majoritariamente feminina 84,5% (80,2% - 88,8%), ao passo que entre os não usuários, a distribuição do sexo é mais... (Resumo completo clicar acesso eletrônico abaixo) / Abstract: The accessibility to primary health care comprises a set of variables such as: distance between the house of the user and the health service, service offer, receptivity of the employee towards the user, the time spent between setting the appointment and the assistance required by the user and his necessities. How these variables occur and relate to one another is not only worth being studied and analyzed but it should also be provided to those interested in the appropriate management of the health system. This research gathers information which contextualize in theory and in practice the object of study that is, accessibility to public health service in Botucatu, which is studied through the evaluation of the Health Center "Dr. Sebastião de Almeida Pinto". Two hundred and sixty nine interviews were made in the houses of the population of the area assisted by the Health Center and the opinion of the staff of this service was heard through questionnaires. The results show that among the dwellers of this area 69,5% (CI 90% 64,9% - 74,1%) are users, and 30,5% (25,9% - 35,1%) are non users. As to demographic characteristics, users as well as non-users, the age ranges from 20 to 50 years old. As to gender, among the users, the clientele is mostly female 84,5% (80,2% - 88,8%) but among the non-users sex distribution is more balanced 40,2% (31,4% - 49,1%) men and 59,8% (50,9% - 68,6%) women. Considering the relationship to the Health Center mainly the... (Complete abstract click electronic access below) / Mestre

This thesis is a critical and post-structural exploration of the discourse of managerialism in the NHS secondary care sector in Wales. Its central intent is to destabilise the dominant thinking about NHS management practice and to evoke intellectual debate about alternative discourses of management that ontologically perceive the organisation as a complex adaptive human system. The emergent theoretical framework conjoins the discipline of Complexity with post-structural conjecture, posing a novel conceptualisation of a fractal self where relations of power are seen as essential for harmonising diverse influences and legitimising a local discourse that informs and regulates practice. Using Foucault’s insights on power and knowledge the thesis critiques the strategic nature of NHS discourse, exposing the discursive dominance of managerialism and its inherent relations of power and debates what this predicates for a local negotiation and a flexible, safe and innovative environment. The methodological approach employs a reflexive and micro-level interpretative strategy to emphasise the singularity of agents and to explore the way in which the discursive constitution of the self influences agent practice. My profound experience of the secondary care system requires I situate my self reflexively within the context where I explore and liberate my own voice in conjunction with my participants. The research adopts a biographical narrative method of data collection and uses Foucauldian discourse analysis as a framework for exploring the underlying discourse in agent stories. The findings demonstrate the polyphonic nature of the secondary care context and reveal the demonstrate the polyphonic nature of the secondary care context and reveal the diverse ways in which agents legitimise, negotiate or resist the conflicting truth claims of various discourse in order to strategically sustain an image of health care historically constituted in their self. The results portray a web of discourses that endorse conformity or complicity through oppressive mechanisms of disciplinary control and surveillance, perpetuating authoritative and dualist structures, dissipating relations of trust and removing intellectual thinking from the front-line. The conclusion asserts that this significantly jeopardises the ability of agents to legitimise local ‘discourse’, severely limiting their capacity for adaptive practice and the generation of new order.

There is growing evidence that the way patients and families relate to healthcare professionals influences their experience of illness and healthcare, and may affect their psychological and physical wellbeing. Relationships between professional groups may also have a significant impact on healthcare provision to children and families. Previous research has focused on dyadic relationships within paediatric healthcare (mother and child, nurse and parents, doctors and nurses), but little has been published concerning the complex inter-relationships and roles of family members, doctors and nurses. The aim of this research was to undertake a systemic analysis of the roles and relationships of nurses and doctors with children, adolescents and families. A qualitative methodology was used to explore how the three groups (nurses, doctors and families) understand their respective roles and relationships in the care of ill children within a tertiary paediatric hospital. While systemic and social constructionist theory informed the overall conception of the study, grounded theory was the method used for structuring data collection and analysis. Data collection involved semi-structured interviews with doctors, nurses and families. These were audio-taped and each set of transcripts analysed according to grounded theory principles. Theoretical coding then allowed comparisons to be made across each set of data. Two theoretical categories describing key processes involved in the care of ill children emerged from the analysis. These were: “Building emotional connections and focusing on medical goals: complementary or contradictory relationship discourses for families and staff?” and “Shifting relationships around expertise and power: the gains and losses associated with new positionings” The first category highlights that both professionals and families appear to draw on particular societal discourses to inform their roles and relationships. These discourses (about the therapeutic value of emotional connections between staff and families and the need for ‘medical professionalism’) can appear at odds with each other. creating tensions and dilemmas for each group. The second theoretical category highlights that power relationships between nurses, doctors and families are in a process of change. Fundamental change may be hard to achieve however, as each group may experience losses and well as gains in their emerging positions. It is further argued that changes in government policy relating to these core processes creates challenges for each participant group as they struggle to balance positive working relationships, the medical care of the child and status and power issues. Change in any one aspect of these professional and family roles and relationships may have both adverse and beneficial effects, which need to be recognised. These findings raise important questions about the feasibility and desirability of family centred care. The implications of this research for training, consultation and future research are explored. The research adds to a small but growing body of literature focusing on the interface between professionals, patients and families in healthcare settings.

Orientador: Maria Isabel Pedreira de Freitas / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas / Made available in DSpace on 2018-08-11T17:51:54Z (GMT). No. of bitstreams: 1 Costa_LidianaFloraVidotoda_M.pdf: 1945007 bytes, checksum: a09edb1f7acc4bb62ac78e8b301c3723 (MD5) Previous issue date: 2008 / Resumo: O reprocessamento de artigos críticos é realizado nas Unidades Básicas de Saúde (UBS). A complexidade desse processo e suas implicações, exigem que o responsável faça-o com habilidades e conhecimento técnico-científicos, dentro de métodos e critérios preestabelecidos para controle e monitorização de cada etapa, seguindo diretrizes norteadoras e legais. Quando realizado sob condições adversas, pode colocar em risco a saúde dos usuários submetidos aos procedimentos invasivos comprometendo, portanto, a qualidade e segurança ao usuário do Sistema Unificado de Saúde (SUS). Objetivos: Identificar como o reprocessamento dos artigos críticos vem sendo realizado nas UBS. Método: Estudo descritivo-exploratório, com dados obtidos pela aplicação de um questionário previamente testado, aos responsáveis pelo reprocessamento de artigos críticos nas UBS. Resultados: A coleta de dados ocorreu entre março e dezembro 2006. Das 46 UBS foram estudadas 34, das quais os responsáveis pela realização do reprocessamento dos artigos críticos foram entrevistados e as áreas físicas, destinadas a esse processo, observadas. Dos procedimentos invasivos que utilizavam artigos reprocessados nas UBS encontram-se: odontológicos e curativos (100%), ginecológicos (97%), suturas (94%), pequenos procedimentos cirúrgicos (76%) e drenagens de abscessos (59%). Os ocupacionais responsáveis pela realização do reprocessamento eram na maioria, auxiliares de enfermagem (88,23%). Além de realizarem o reprocessamento de artigos críticos, exerciam concomitantemente atividades como: imunização (11,74%), curativos (26,4%) e coletas de exames (23,52%). Desses ocupacionais, 32,4% receberam treinamentos no início das atividades com reprocessamento e 8,82% durante o exercício dessas atividades, há menos de um ano. Durante a limpeza desses artigos, todos os ocupacionais realizavam a limpeza manualmente com água, solução detergente neutra e esponja e nenhum fazia uso de todos os EPI recomendados. O agente usado para a esterilização tem sido o vapor saturado sob pressão (88,24%). O invólucro usado para os artigos, foi o papel Kraft (100%), os campos duplos de algodão (21%), caixa metálica aberta (11,76%) e papel alumínio (11,76%). Os métodos usados para a monitoração da qualidade do processo de esterilização, era o indicador químico classe I (97,06%) e o indicador biológico autocontido (91,18%), sendo esse de forma sistemática em 55,8% das UBS. Houve referências ao uso do teste de Bowie e Dick em 5,24% das UBS. Observou-se que todas as UBS possuíam uma área destinada à limpeza dos artigos críticos sendo que dessas: 70,59% exclusivas, 2,94% compartilhadas a área de limpeza e com a do preparo de artigos para a esterilização e 26,47% compartilhadas entre a área de limpeza, com a do preparo e com a da esterilização dos artigos críticos. 52,95% possuíam uma área para a limpeza desses artigos igual ou maior o recomendado (4,8m2). Das UBS estudadas, 70,59% possuíam barreira física entre a área de limpeza e de esterilização. Das áreas destinadas à limpeza, todas possuíam cubas com torneira e água fria, bancada, ponto para escoamento de resíduos líquidos, 91,17% possuíam janelas sem telas, porém não havia, em nenhuma, instalação de água quente. Sobre o acabamento das áreas destinadas à limpeza: 76,47% dos pisos eram do tipo granilite, 14,7% de cerâmicas vitrificadas, 2,95% pintados e 2,95% de cerâmicas rústicas; das bancadas, 85,3% eram constituídas de pedra, 11,75% de alvenaria revestida por azulejos, e 2,95% de aço inoxidável; as paredes, 91,17% eram revestidas por azulejos rejuntados, 5,88% pintadas e 2,95% revestidas de azulejo do piso até a parede central e pintadas do centro até o teto. Sobre a área destinada à esterilização, todas as unidades possuem este local, porém todas compartilham essa área com outras etapas do reprocessamento de artigos: 23,53% compartilhavam com o preparo dos artigos, 50% compartilhavam com a do preparo e com a de armazenamento dos artigos e 26,47% compartilhavam com a área de limpeza, com a área do preparo e a de armazenamento dos mesmos. Sobre a dimensão das áreas de esterilização, 81,18% era igual ou maior que o recomendado (3,2 m2). Das instalações dos ambientes destinados à esterilização, 70,59% das UBS possuíam barreira física entre a área de limpeza e de esterilização, 88,24% possuíam água fria e escoamento de resíduos líquidos, 8,82% apresentaram ponto para água quente, 91,18% com janelas sem telas e 8,82% sem janelas. Dos acabamentos utilizados no ambiente destinado à esterilização, o piso, 79,41% eram em granilite, 14,7% em cerâmicas vitrificadas, 5,9% em cerâmicas rústicas; as bancadas, 85,3% eram feitas em pedra e 14,7% em alvenaria revestidas por azulejos; as paredes, 91,17% eram revestidas por azulejos rejuntados, 5,88% pintadas e 2,95% revestidas de azulejo do piso até a metade da parede e do centro até o teto com tinta. Da área destinada ao armazenamento, 8,82% possuíam uma área exclusiva. Conclusão: Nas UBS estudadas, o reprocessamento de artigos críticos vem sendo realizado de forma assistemática, necessitando de revisão, avaliação processual e de intervenções para capacitação profissional dos ocupacionais responsáveis. As áreas físicas destinadas ao reprocessamento devem contemplar critérios mínimos recomendados á fim de se assegurar a qualidade desse processo. O reprocessamento de artigos críticos não deve se tornar fator limitante e de interferência no controle de infecção cruzada nesses locais, devem porém contribuir com a segurança da população usuária do sistema de saúde. / Abstract: The reprocessing of critical items is conducted at Basic Healthcare Units (Unidades Básicas de Saúde - UBS). The complexity and implications of such processes demand that the person responsible conducts it with technical and scientific skills and knowledge, according to pre-established methods and criteria, for control and monitoring of each stage, following procedural and legal guidelines. When done under adverse conditions, reprocessing may endanger the health of the users who undergo invasive procedures, thus compromising the quality and safety of the services provided to National Healthcare System (Sistema Unificado de Saúde - SUS) users. Objectives: Gather data to identify how the reprocessing of critical items is being conducted at UBS and compare to existing legislation, as well as scientific criteria. Methodology: Descriptive study, exploratory, with data obtained through the application of a previously verified questionnaire, to those responsible for reprocessing critical items at UBS. Statistical analysis of data was done with the help of Minitab 15® software. Results: Data collection occurred between March and December 2006. Among the 46 existing UBS, 34 were surveyed; where the individuals responsible for reprocessing critical devices were interviewed, and the areas, designated for processing, observed. Invasive procedures that used reprocessed items at UBS were as follows: dental and dressings (100%), gynecological (97%), sutures (94%), small surgical procedures (76%) and abscess drainage (59%). The majority of staff responsible for conducting reprocessing was nursing auxiliaries (88,23%). Besides reprocessing critical devices, they executed concurrently activities such as: immunization (11,74%), dressing (26,4%) and collection of exam samples (23,52%). Among these staff members, 32,4% had undergone training when they started conducting reprocessing activities and 8,82% during the conduction of such activities, at least, during the previous year. During the handling of such devices, all staff members conducted cleaning manually, with water; inert detergent solution and cleaning pad, and none used all the PPE recommended. Sterilization agent was saturated vapor under pressure (88,24%). Containers used for all devices were Kraft paper (100%), double cotton fabric (21%), open metallic box (11,76%) and aluminum foil (11,76%). Methods employed for monitoring sterilization process quality, were class I chemical marker (97,06%) and biological selfcontained marker (91,18%), the latter being systematically used in 55,8% of UBS. There were references to use of Bowie & Dick in 5,24% of UBS. We were able to observe that all the UBS had an area designated for cleaning of critical devices, among which 70,59% were exclusive, 2,94% shared the cleaning area with the area for preparation of items for sterilization and 26,47% shared areas for cleaning, preparation and sterilization of critical devices. 52,95% had an area for cleaning such items, which was equal or larger than recommended size (4,8m2). 70,59% of UBS had a physical barrier between the cleaning and sterilization areas. All the cleaning areas had sinks with cold water, bench and a drain for outflow of liquid residue, 91,17% had windows without nets, however there wasn't any hot water line. Floor finishing in the cleaning areas was as follows: 79,41% had granolith flooring, 14,7% had vitrified ceramic, 2,95% had rough finish ceramic and 2,95% were painted. The benches were as follows: 85,3% made of stone, 11,75% were made with bricks covered with tiles, and 2,95% in stainless steel. 91,17% of the wall finishing was done with grouted tiles, 5,88% were painted and 2,95% were covered with tiles halfway to the ceiling, and the remaining surface was painted. In relation to the sterilization area; all of the units have a designated sterilization area, but all shared this areas with other reprocessing phases: 23,53% shared it with the preparation of devices, 50% shared with preparation and storage of devices, and 26,47% shared the cleaning area, with the areas for preparation and storage, as well. The dimensions of sterilization areas are as follows: 81,18% was equal or larger than recommended (3,2 m2). In 70,59% of UBS facilities, the areas designated for sterilization had physical barriers between the cleaning and sterilization areas, 88,24% had cold water and drainage of liquid residue, 8,82% had a hot water line, 91,18% had windows without nets and 8,82% had no windows. Finishing used in the areas destined for sterilization, was as follows: 79,41% had granolith flooring, 14,7% vitrified ceramics, 5,9% rustic ceramic; benches: 85,3% were made in stone, 14,7% brick covered with ties; walls: 91,17% were covered with grouted tiles, 5,88% were painted and 2,95% were covered with tiles halfway to the ceiling, and the remaining surface was painted. 8,82% had specific areas designated exclusively for storage. Conclusion: In the UBS surveyed, reprocessing of critical devices is being conducted in an unsystematic manner. This calls for a revision and reevaluation of procedures, and an intervention for professional capacitation of the staff involved. Areas designated for reprocessing must comply with minimum required criteria in order to ensure the quality of the process. Reprocessing of critical items, in these locations, must not become a limiting factor or interfere in cross infection control, but must contribute for the safety of the population who uses the healthcare system. / Mestrado / Enfermagem e Trabalho / Mestre em Enfermagem

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