Social science research on third sector organisations in the last two decades has emphasised their growing presence and importance in healthcare. This has occurred alongside significant reorganisation of health systems in the UK, including a continued policy emphasis on partnership-working between the public sector and the third sector. However, unanswered questions in the literature remain with regard to the specific roles that these organisations fulfil within partnership arrangements. This thesis examines the role of third sector organisations within Scottish services for the chronic, neurodegenerative condition Huntington’s disease (HD). The closely connected nature of Scottish healthcare and the multitude of professionals involved in HD mean these services are an important, but currently understudied, example of professional interaction around complexity. A multi-methods qualitative research framework was used to gather perspectives of key individuals working in the Scottish HD and wider health scene. Making use of the key concepts of expertise and boundary work, this thesis argues that third sector organisations have an extensive shaping role in 1) the positioning of healthcare organisations, 2) the identities of healthcare professionals, and 3) the meanings around illness and the remit of support. The research findings revealed that organisations and professionals in HD partnership arrangements engaged in processes of boundary work in the negotiation of the roles of themselves and others. Third sector professionals occupied many positions within services, as both experts and supporters of patients. In the process they and other professionals often took on identities as ‘key, committed professionals’. Understanding around HD was also shaped by these professionals as the wider aspects of illness and its support were brought into focus. Building on these findings, it is argued that third sector professionals in coordination roles are well placed to develop a type of expertise that I term ‘aggregate know-how’ (Pols 2014), based around both their professional skills and their extensive contact with patient experiential knowledge. The research builds on and extends influential previous models of third sector ‘partnership’ in healthcare (Rabeharisoa 2003), emphasising the key role of third sector organisations in knowledge production. It also offers insights of both theoretical and practical use with regard to service delivery in healthcare, showing the potential for genuine third sector/public sector partnership around expertise when there is adequate cultural support and resources.

abstract: Over the past century, the relationship between the built environment and people’s health and well-being has become central to the discussion and critique of healthcare design. The concept of such a relationship is not new; more than a century ago, Florence Nightingale promoted a particular vision for hospital design. Her concerns with naturalism, acoustics, ventilation, and aesthetics in the healthcare environment are as relevant today as they were in the mid-19th century. This dissertation examines Nightingale’s contributions to the development of the nascent field of healthcare interiors by: identifying major developments of healthcare interiors through the centuries; investigating Nightingale’s life, work, and principles on the healthcare environment; and examining whether certain contemporary hospital design approaches support, expand upon, or negate her principles. The research integrates material culture analysis of extant objects and content analysis of documents within the framework of a case study of two healthcare facilities in Tucson, Arizona. Findings show that the Nightingale era was seminal in the evolution of the healthcare environment, with key developments towards healthful interiors for the sick. Wide adoption of hospital design guidelines suggested by Nightingale—emphasizing physical elements such as ventilation, natural light, view, sanitization, and ambiance—occurred in various types of healthcare facilities, including military and tuberculosis sanatoria around the world. Additionally, analysis of the case study shows just how welcoming and supportive a 1920s healthcare facility, like the Desert Sanitarium, can be. The facility successfully adapts Florence Nightingale’s principles to the local climate and context, including indigenous pueblo architecture, traditional Southwestern materials, Native American artifacts, desert views, and even the traditional courtyard plan used by Spanish colonial settlers. This successful adaptation suggests that Nightingale’s principles may be valuable to and relevant within different places and times, even today. Thus, Nightingale contributed to the emerging field of healthcare interiors by: 1) functionally organizing the built environment affecting patients’ healing, 2) preventing healthcare-associated infection in the physical environment, and 3) supporting psychological health with aesthetic amenities. The findings advance interior design scholarship, education, and practice; and further the documentation and explication of Arizona’s history in the healthcare environment. / Dissertation/Thesis / Doctoral Dissertation Design 2015

Why do the healthcare facilities incur debt? What troubles the managers most? In what conditions do the healthcare professionals work? Is there space for improvement? Is it possible to deliver higher quality care? Nowadays, the healthcare providers are looking for solutions, which could help them satisfy more patients, reach lower costs and therefore increase own financial results and answer the abovementioned questions. Key element of such a solution is a business intelligence system, which supports decision-making and aligns enterprise objects with its progress and improves the overall performance. The thesis elaborates on the topic of business intelligence software QlikView in selected hospitals, which already implemented or are about to implement the business intelligence software. The intention was to find out ways in which the software is used in the hospitals, what key performance indicators the software usually measures and what could be the possible opportunities for its further use in the selected facilities. Research results indicate that the software significantly increased the work efficiency and that it contributes to more effective hospital management. However, such improvement in efficiency has also its drawbacks, namely it is the higher price per personal licence in comparison to the other business intelligence software on the market. Research also confirmed the fact that only usage of such software alone will not help to improve the overall bad state of Slovak healthcare system -- systematic measures such as DRG system have to be implemented in the first place in order to also effectively use the business intelligence software.

Introduction: Transgender is an identity term used to describe people with diverse gender identities and expressions that differ from their sex assigned at birth. People who identify as transgender have worse health outcomes than the cisgender or non-transgender populations. Limited healthcare access and chronic stress from discrimination all contribute to worsening health outcomes for this population. However, research regarding this population is limited, particularly in the rural southern United States. The purpose of this study was to assess physicians’, nurse practitioners’, and physician assistants’ experience with, attitude towards, and knowledge of transgender healthcare in the Northeast Tennessee region. Methods: Medical providers, including NPs, PAs, DOs and MDs from Family Medicine, Emergency Medicine, Internal Medicine, Pediatrics, and Obstetrics and Gynecology in both academic and community settings were surveyed regarding their attitudes toward, knowledge of, and experiences with gender, sexual orientation, and sexuality as they relate to healthcare. All potential participants were informed that participation was voluntary. Limited demographics were gathered and surveys were collected in a confidential manner. Data were analyzed for statistical significance. Results: Initial analyses showed the majority of providers had not received training in transgender healthcare and perceived they had few to no trans-identified patients. Over half of all respondents felt competent in providing healthcare to trans people and the majority felt comfortable treating this population. Providers indicated it is important to know their patients’ sexual practices, gender identity and sexual orientation; however, the majority of providers do not ask patients their gender identity, sexuality, or desired pronouns. Respondents were unsure whether gender confirmation surgery is covered by insurance and widely accessible. In assessing clinical knowledge of providers, there were a wide variety of responses suggesting varying level of competence amongst providers. Responses were split regarding whether access to healthcare is the same for the transgender population as it is for the general population. Pediatric providers were asked about comfort in prescribing hormones, knowledge of mental health support in the area, referrals and discussing gender identity with patients. These responses fell along a normal distribution, indicating a variety of training, experiences, and opinion regarding trans healthcare for the adolescent population. Conclusions: Overall results from the preliminary data demonstrate a contradiction between ideology and practice. With most participants responding they felt comfortable and competent providing care to the transgender population, yet their responses indicated a lack of training and absence of inclusivity in their health care practices. This suggests that education is needed within the healthcare community on transgender healthcare.

Abstract Introduction and Background: Minority populations struggle to gain access to equitable healthcare due to cultural variations and language barriers. It is paramount for providers to accommodate to the differing needs of underserved minority groups. Purpose Statement: We analyzed information on the effects of community-based interventions aimed at improving healthcare access for minorities. Literature Review: We used PubMed as our main database. For our search, we looked up the keywords “Healthcare Access AND Minorities.” Next, we filtered articles that had been published since 2017 and sorted to include clinical trials, randomized control trials, and meta-analyses. After that, we came across ninety-eight total articles, and picked five of the most critical. Findings: From the first two articles, patient navigators have been shown to be effective in helping minorities navigating the information and decisions presented to them in healthcare. The researchers in the third study found that minority groups are at a greater risk for a health literacy deficit. Our next article found that African Americans treated with computerized cognitive behavioral therapy saw a significant decrease in anxiety and depression. Our final document found that lack of access to healthcare resources decreased dementia outcomes by missing the early onset of symptoms. Conclusions: It is evident that minorities face healthcare disparities that keep them from receiving access to equitable healthcare. As a nurse, it is important to identify gaps in access to healthcare in minority patients. Interventions aiming to increase health literacy and access in minorities have shown to be effective.

Globally, higher healthcare demand strains existing systems, already overburdened by a lack of resources and funding while longer life expectancy and increased disease burden force higher patient loads. A majority of the South African population is medically uninsured and therefore depend on emergency care; consequently, the healthcare service demand easily exceeds available acute care to prevent life threat. When this happens, emergency centres suffer from overcrowding and long patient waiting times, which increases morbidity and mortality, associated patient risk. Moreover, critical resources such as staff and hospital beds are required for an even flow of patients through hospitals, but are distributed inefficiently. The South African healthcare system configuration therefore delays access to and compromises the delivery of equitable, unbiased life-saving healthcare in an environment moreover challenged by economic pressures. This calls for sustainable, cost-effective reform. Therefore, more efficient healthcare can save more lives by improving access to life-saving care. Research on current Healthcare Information Systems (HIS) shows an incoherent knowledge body with conceptual gaps in theories on healthcare, which disengages transformation potential. Comprehensive reform tactics thus require a priori concept discovery and diagnostics to make research practically useful. The systematic use of BPM theories allowed for the qualitative assessment of as-is process activity at patient touch-points at three hospitals – two public and one private – in the Western Cape of South Africa. Because a strategic Information Systems (IS) methodology, Business Process Management (BPM) poses business process activity improvement, this research draws from successful BPM activity as a means to improve patient flow processes in Emergency Centres (ECs). Success is evaluated by drawing from empirically supported enabler categories and prescriptive guidelines because BPM practice is not yet fully understood. The results show a clear correlation between the improvement areas at the three hospitals; improvements on aspects of actions and decisions taken during patient-flow process activity, therefore support a pragmatic approach to reform. The data confirms disparity between public and private healthcare. Healthcare appears to be a “doctor driven” service, which, based on qualitative decision-making, navigates patients along defined flows, enabled by supporting human capital and hospital assets. Optimal patient flow is a product of symbiotic working relationships and depends on efficient integration with wider hospital functions. Shorter waiting times and hospital stays reduce process burden. This leads to more efficient resource usage and regulated access to healthcare. However, integrated healthcare reform must consider the time demands and rigidity of clinical processes. The challenge lies in finding the space to invite parallel business agility to drive the reform of the stricken healthcare industry in South Africa.

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In recent years, there has been increased focus on rural and Appalachian health because of disparate chronic health outcomes when compared to the rest of the US. Appalachia, a subsection of the US, has even worse health outcomes related to chronic diseases. Although Appalachia is its own unique region, there is significant overlap with rural areas in terms of shared cultural characteristics (e.g., strong sense of community, distrust in outsiders, lack of trust in traditional medicine, and strong Christian religious affiliations and faith in God), limited access to healthcare services, and disparate health outcomes. The research presented in this dissertation is significant because it provides insight into and compares healthcare utilization rates in women in Appalachia and surrounding areas. Study 1: In addition to racial discrimination, Black Appalachian women often face other obstacles involving other types of negative interpersonal experiences when seeking healthcare. Despite these known disparities, Black women are frequently underrepresented in Appalachian health research. This study investigated healthcare experiences for sixteen Black Appalachian women using semi-structured interviews to identify and subsequently address ways to eliminate barriers to care. Interview questions utilized the theory of intersectionality and the Social Ecological Model to create a framework to describe the complexity of healthcare utilization and barriers to care while providing context into each participant's background and lived experience. Interview questions explored four topics: 1) barriers to medical care; 2) social support; 3) ideal and actual healthcare experiences; and 4) desired changes to improve quality of care. We used an inductive analysis process to create a robust thematic coding schema, organizing responses into 60 total themes and 141 codes, and reported the most frequent. Our results explore the ways in which one's intersectional identity as a Black Appalachian woman affects interpersonal interactions and experiences when engaging with the healthcare system. Participants frequently reported barriers related to scheduling conflicts and delays, experiences with rushed appointments and inhospitable providers and support staff, and desires for accurate collection of medical information. Participant responses often emphasized difficulties with the organization of the medical system, revealing specific areas for future intervention to improve quality of care for Black Appalachian women. Study 2: Use of the emergency department (ED) for low acuity conditions (e.g., back pain, dental pain, sore throat) and primary care places an additional strain on ED staff and resources, while increasing waiting and treatment times for high acuity patients. Factors such as race, gender, and insurance type have a strong association with the likelihood of a patient using the ED for a low acuity concern. Women are more likely to utilize healthcare services, which also holds true in the context of the ED. Using a sample of adult women from Virginia, West Virginia, Tennessee, North Carolina, and Kentucky, I investigated which demographic factors, age, race, geographic location (metro, nonmetro, rural), employment, and insurance coverage, affect a patient's likelihood to visit the ED for a low acuity condition within a southwestern Virginia hospital system. Log-binomial regression was used to estimate unadjusted and adjusted prevalence ratios of acuity level by race, age, rurality level, employment, and insurance type with corresponding 95% CIs. Our sample included 28,222 female patients who visited the ED between January 1, 2021 and September 30, 2022. Low acuity visits accounted for 15.9% (n=4,485) of visits during the timeframe. In summary, our results suggest that older age and location in non-metro area are the most salient factors contributing to a higher likelihood of low acuity ED visits among women. Race, a primary variable of interest, did not have the relationship to acuity that was expected based on previous literature; Black women patients were less likely to have a low acuity visit than white women patients. During our study period, overall number of visits remained steady, while there was an increase in proportion of low acuity visits. Further research is needed into the underlying causes to more definitively explain this increase. / Doctor of Philosophy / In recent years, there has been increased focus on rural and Appalachian health because of disparate chronic health outcomes when compared to the rest of the US. Appalachia, a subsection of the US, has even worse health outcomes related to chronic diseases. Although Appalachia is its own unique region, there is significant overlap with rural areas in terms of shared cultural characteristics (e.g. strong sense of community, distrust in outsiders, lack of trust in traditional medicine, and strong Christian religious affiliations and faith in God), limited access to healthcare services, and disparate health outcomes. Black/African Americans are another population with higher rates of chronic disease and poorer health outcomes compared to their white and Latinx peers. The combination of poorer health outcomes and higher rates of chronic disease negatively impacts life expectancy and quality of life. One driving factor in these poor health outcomes across all of these groups is low rates of healthcare utilization, whether due to decreased access (as is the case for many rural populations), or other as of yet unidentified challenges. Although literature exists about rural health outcomes, Appalachian health outcomes, and health outcomes focusing on Black women, there is very limited literature that examines the intersectional impact of these characteristics on health. Health disparity research in this region does not currently stratify differences in outcomes by both race and gender, which prevents a detailed analysis of the full extent of the gap in health outcomes. This research presented in this dissertation is significant because it provides insight into and compares healthcare utilization rates in women in Appalachia and surrounding areas across the lifespan. Knowing the contextual factors influencing healthcare seeking behaviors and utilization is the first step to designing effective interventions that improve women's access to care. Interventions need to be intentionally designed to consider, and ultimately, shift medical care and community attitudes to decrease health disparities in Appalachia. To successfully decrease health disparities, it is necessary to consider all of a patient's identities or characteristics. The same contextual factors that affect their healthcare utilization can also impact their care experience.

Prevention is a central tenet of modern healthcare. New ways of informing, educating, and allowing patients to keep track of their health are continually developing. Integrating technology that bridges the gap between healthcare providers and their patients is essential in today's digital age. One emerging idea is the use of home healthcare embodied agents. Embodied agents are conservational interfaces that can interact and look like human beings. They can exhibit both verbal and non-verbal language cues and be capable of having a natural conversation. This kind of technology could help both patients and healthcare providers by giving patients a helpful assistant that can educate and take care of particular healthcare needs through conversations with the patient. This could potentially improve patient outcomes, thereby reducing trips to the healthcare provider's office and relieving the burden on physicians and other healthcare providers. This research will focus on home healthcare embodied agents' priorities and the opportunities that this technology can present. A literature review was done to examine the current use of embodied agents in home healthcare settings to establish their present capabilities and applications. Additionally, the strategies/techniques used by home healthcare workers interacting with patients were investigated. By examining the provider-patient relationship and the use of home healthcare embodied agents in tandem, related findings were identified and potential gaps in current research were found that may help direct future exploration.

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