Purpose: To determine if a quality improvement project involving individualized, one-on-one Diabetes education will improve health literacy and Diabetes outcomes in adults with Type 2 Diabetes in a rural primary care clinic. Diabetes is a chronic condition affecting the United States with 9.6% of Virginia’s population living with Diabetes. Aims: To improve patient’s Diabetes literacy scores, BMI, and Hemoglobin A1c levels through Diabetes education. Processes: There are pre- and post-education phases. Data to be collected at the end of both phases consist of DNT15 scores, BMI, and A1c. In the pre-education phase, BMI was obtained, DNT15 was administered, and Diabetes education was provided. Then, A1c was obtained, and patients were scheduled to return in the month of May. Post-education phase starts at the follow-up where participants retake DNT15 and BMI and A1c will be obtained. Results: Only pre-education data has been collected from the participants. Post-education data will be collected throughout the month of May during 3-month follow-up appointments. Expected results include 10% improvement of BMI, A1C, and Diabetes literacy scores. Limitations: Increased use of GLP1 prescriptions in clinic could affect results. Some patients were sent to the ED after being seen requiring prompt follow-ups while others obtain A1c results from other disciplines and may not have results sent to this clinic by the end of the data collection period. There have also been several no shows. Patients and staff have been receptive to the quality improvement initiative. Conclusion: Education has been provided to 25 patients. Follow-ups are scheduled for post-education data collection in May.

Siu, Hon Kei. / "November 2011." / Thesis (M.Phil.)--Chinese University of Hong Kong, 2012. / Includes bibliographical references (leaves 80-88). / Abstracts in English and Chinese; appendix in Chinese. / Thesis/Assessment Committee --- p.1 / Abstract --- p.2 / Content --- p.5 / Acknowledgements --- p.7 / Introduction --- p.8 / Background --- p.12 / Defining continuity of care --- p.12 / Measuring continuity of care --- p.14 / Effects of continuity of care --- p.15 / Factors affecting the continuity of care --- p.16 / Health care system in Hong Kong --- p.18 / Health care service charges in public and private sectors in Hong Kong --- p.19 / Primary care service in public and private sector --- p.21 / Health status and health seeking behaviours of Hong Kong people --- p.22 / Summary --- p.22 / Objectives --- p.24 / Methods --- p.25 / Target population --- p.25 / Sample size --- p.25 / Data collection --- p.26 / Preparation of questionnaire --- p.26 / Questionnaire in detail --- p.27 / Ethics issue --- p.32 / Statistical analysis --- p.32 / Results --- p.38 / Survey findings --- p.38 / Detailed analysis - respondents claimed that they needed a family doctor --- p.44 / Detailed analysis - respondents claimed that they had a family doctor --- p.46 / Discussion --- p.50 / Limitations of the study --- p.50 / Strengths of the study --- p.51 / Discussion of the findings --- p.52 / Implications --- p.59 / Conclusion --- p.62 / Tables and figures --- p.64 / Appendix --- p.75 / Bibliography --- p.80

Rationale: Chronic diseases represent an important health burden that often involves major adaptations to manage the disease on a daily basis. Health professionals, such as the family physician, can help a person acquire more power over his or her health (enablement). While it would be useful to measure patient perception of enablement by the family doctor with a valid questionnaire, existing tools present important gaps. Aim and objectives: This study aimed at developing a self-administered questionnaire to measure the perception of patients with chronic diseases of enablement by their family physician. The objectives were: 1) To deepen the conceptualization of enablement by validating the proposed conceptual framework with patients presenting with chronic diseases and to specify the relative importance of its dimensions; 2) To operationalise the dimensions by proposing indicators of these dimensions (pool of items); 3) To verify the content validity of the questionnaire. Methods: An exploratory sequential mixed-method research design was chosen. The descriptive qualitative study (objectives 1 and 2) used in-depth interviews with 30 patients aged 35 to 75 presenting with at least one chronic disease, having the same family doctor for at least one year and recruited through maximum variation sampling. Taped interviews were transcribed and analyzed using Miles and Huberman's mixed coding method (2003a). A three-round e-Delphi study (objective 3) involved 15 Canadian experts in family medicine, able to read in French. The experts scored the items proposed on a 9-point scale (1 = Inappropriate to 9 = Very appropriate) and could suggest rewording and additions. Items scored 7-9 by the experts were considered consensual and were not presented in the following round. Items that were not consensual after the third round were decided upon by the team of researchers. Results: The partnership (the trusting relationship and decisions to be taken) that develops over time was found to be a major component of enablement. The enablement role of the physician goes beyond the medical consultation to defend the interests and safety of the patient's journey through the healthcare system. The trusting relationship combined with a good knowledge of the person may help the family physician better understand and legitimize the various feelings experienced while offering realistic hope . The family physician is in a privileged position to help patients develop their own expertise . Sixty-six items classified into six dimensions were submitted to the experts during the first round of the E-Delphi method. The first round was completed by 13 experts: 21 items were consensual; 25 items were resubmitted without any modification; 16 items were modified and four were rejected. Forty-one items were submitted during the second round, completed by 13 experts: eight items were consensual; 20 items were submitted without any modification; 12 items were modified and one item was rejected. Thirty-three items were submitted during the third round completed by nine experts: 29 items remained intact; three items were modified and one item was rejected. Conclusion: An initial 61-item questionnaire is proposed.

Incomplete understanding of attrition from the physician workforce has hampered policy-makers’ efforts to achieve optimal alignment of the supply of physicians with population demand for medical services. This longitudinal study of Ontario primary care physicians uses health administrative data to characterize changes in physicians’ practice patterns over time. We examined the workload and scopes of practice of 21,240 physicians between 1992 and 2013. We found that physicians reduce their workloads gradually as they age, retiring from clinical practice at an average age of 70.5. Furthermore, we found that 60% of family physicians who stop providing comprehensive primary care continue to provide clinical services for an average of three years, with reduced workloads, before retiring fully. Our findings clarify the process of physician attrition from the workforce and will help to improve estimates of attrition and make physician workforce planning more accurate and effective.

Orientador: Eliana Goldfarb Cyrino / Resumo: Introdução: A Residência Médica é considerada o padrão-ouro para a formação de médicos especialistas, tanto no Brasil quanto em outros países, sendo institucionalizada oficialmente a partir de 1977 no país. Um dos programas que mais cresceu nos últimos anos, em termos de vagas ofertadas, foi o de medicina de família e comunidade. Dentro da organização dos programas de residência consta a participação de um profissional responsável pela formação, o preceptor. Esse profissional pode ser considerado o principal responsável pelo residente em medicina de família e comunidade, pois estarão juntos por 2 anos consecutivos e exercerá a função de modelo, na prática do trabalho, na formação desse profissional. Contudo, o termo preceptor pode estar bem consolidado para outras residências, mas na medicina de família e comunidade há necessidade de maior exploração sobre o papel desse profissional. Assim, se reconhece a necessidade de se conhecer as características desse profissional, sua formação, tanto técnica (dentro da área) quanto pedagógica para exercer seu papel, quais as potencialidades e desafios que esse trabalho exige e se tem algum apoio pedagógico para tal. Objetivos: Identificar o perfil dos preceptores dos programas de residência médica em medicina de família e comunidade do estado de São Paulo, conhecendo suas características pessoais, profissionais e formação. Materiais e Métodos: Estudo exploratório, de caráter qualitativo e quantitativo, no qual foram aplicados questionár... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Introduction: The Medical Residency is considered the gold standard for the training of medical specialists, both in Brazil and in other countries, being officially institutionalized from 1977 in the country. One of the programs that most grew in recent years, in terms of vacancies offered, was the General Practice/Family Physician field. In the organization of the residency programs there is a professional responsible for the student training, the preceptor. This professional can be considered the main responsible for the resident in General Practice/Family Physician, as they will be together for two consecutive years and the preceptor will be the example, in the practice of work and in the training of this professional. However, the term “preceptor” may be well consolidated for other residences fields, but in the General Practice/Family Physician field there is a need for greater exploration on the role of this professional. Thus, it is necessary to know the characteristics of this professional, its formation, both technical (inside his area) and pedagogical, what the potentialities and challenges that this work requires and whether he has some pedagogical support. Aims: To identify the profile of preceptors in General Practice/Family Physician residency programs of the São Paulo state, knowing their personal, professional and training characteristics. Materials and Methods: This was a qualitative and quantitative exploratory study, in which questionnaires were applied to t... (Complete abstract click electronic access below) / Mestre

CoordenaÃÃo de AperfeiÃoamento de Pessoal de NÃvel Superior / Com a criaÃÃo e a expansÃo do Programa SaÃde da FamÃlia (PSF) no Brasil, a Medicina de FamÃlia e Comunidade (MFC), como especialidade mÃdica, ganhou destaque por ser a mais adequada para esse trabalho. Recentes parcerias entre os MinistÃrios da SaÃde e da EducaÃÃo tÃm procurado regular a formaÃÃo de recursos humanos em saÃde para atender Ãs demandas de consolidaÃÃo do Sistema Ãnico de SaÃde (SUS), no Ãmbito da graduaÃÃo e da pÃsgraduaÃÃo. Houve investimento no aumento no nÃmero de vagas de residÃncia em MFC, mas parece haver uma incongruÃncia entre o que os futuros mÃdicos almejam em suas carreiras e as necessidades do SUS, o que à demonstrado pelo nÃmero de vagas ociosas nesses programas. O objetivo inicial foi determinar fatores predisponentes à escolha da MFC como carreira. PorÃm, ao reconhecer o desinteresse por essa especialidade, buscou-se elencar hipÃteses explicativas para tal realidade. Foi, entÃo, realizado um estudo junto a 170 estudantes do Curso de Medicina de Sobral da Universidade Federal do CearÃ, que responderam um questionÃrio contendo 32 perguntas sobre dados sÃcio-demogrÃficos, escolha da especialidade, PSF e MFC e fatores que, na opiniÃo dos respondentes, influenciam a escolha da carreira a ser seguida. Encontrou-se que apenas um estudante referia jà ter escolhido a MFC como especialidade. Contudo, a grande maioria nÃo descarta a possibilidade de trabalhar provisoriamente no PSF. As provÃveis justificativas para esse desinteresse sÃo as precÃrias condiÃÃes de trabalho, desvalorizaÃÃo da atividade, baixos salÃrios, necessidade de interiorizar-se para ganhar melhor e poucas perspectivas de crescimento profissional. O currÃculo oculto, muito citado em trabalhos internacionais, tambÃm tem seu papel, mas nÃo foi adequadamente avaliado nesta pesquisa. Especialidades clÃnicas sÃo as mais almejadas por esses estudantes. Os fatores que mais influenciam a escolha da carreira, segundo os respondentes, sÃo interesses pessoais, compromisso Ãtico-social e possibilidade de realizar procedimentos diagnÃsticos ou terapÃuticos. Em conclusÃo, a escolha da carreira à multifatorial. O interesse pela MFC à modesto. Apesar de haver muitas propostas para aumentÃ-lo, estas nÃo trouxeram repercussÃo em alguns cenÃrios e nÃo estÃo confirmadas cientificamente. Mesmo assim, deve-se procurar identificar os fatores causais e sugerir ou ensaiar estratÃgias para reverter esse quadro. / The creation and expansion of the Family Health Program (FHP) in Brazil bring to Family Practice (FP), as medical specialty, highlight because itâs the more adequate one for that kind of work. Recent partnerships between Health and Education State Departments try to regulate the graduation and post graduation of health workers, attending the demands of consolidation of the National Health System of Brazil (NHS). Investments ware taken to increase FP residency position number, but maybe there is an incongruity between career intentions of future doctors and the needs of the Brazilian NHS, what is shown by the low number of positions filled in those programs. The initial objective of this research was to determine predisposing factors to choice of FP as career. However, upon recognizing the disinterest by that specialty, we try to list explanatory hypotheses for such reality. It was, then, carried out a study involving 170 medical students of Federal University of Cearà at Sobral, which answered a questionnaire containing 32 questions about demographic and social characteristics, choice of the specialty, FHP and FP and factors that, in the opinion of the students, influence the choice of career. It was found that only one student made a choice of FP as specialty. However, the great majority doesnât reject the possibility of work provisionally in the FHP. The probable justifications for this disinterest are the precarious conditions of work, depreciation of the activity, low income, better salaries in remote cities and few perspectives of professional growth. The hidden curriculum, cited by international articles, also play a role, but it was not evaluated accurately in this research. Clinical specialties are the most preferred by those students. The most influencing factors for career choice, according to students, are personal interests, ethical and social commitment and possibility of make diagnostic or therapeutic procedures. In conclusion, career choice has many influencing factors. The interest by FP is modest. Despite many proposals to increase interest, these did not bring repercussion in some settings and are not scientifically confirmed. Even so, such influencing factors it must be identified and strategies for revert that picture must be tried.

Thesis (M.Cur.) --University of Limpopo, 2013 / Indigenous knowledge (IK) originated from a particular community within a broader cultural tradition. It is stated that IK is socially transmitted shared knowledge, beliefs, and/or practices that vary systematically across different cultural groups. It is further indicated that IK is a critical determinant of human behaviour and health, and the intergenerational mother in the society. Indigenous forms of communication and organisation are seen as important to family and societal decision-making processes with regard to health related issues like care given to children from birth onwards and curing of childhood illness. The operational plan for Comprehensive HIV and AIDS Care, Management and Treatment (CCMT) South Africa points out that some South African citizens prefer to consult traditional health practitioners (THPs) on a regular basis for their health problems. The study conducted by Peltzer, Phaswana-Mafuya and Treger (2009) points out that THPs use indigenous practices to prevent and heal childhood illnesses. The aim of the study: To determine indigenous practices by mothers of children admitted in the paediatric unit of a Polokwane/Mankweng hospital complex in the Limpopo Province. The objectives of this study: To explore and describe the indigenous practices of mothers of children admitted in a paediatric unit of a Polokwane/Mankweng hospital complex, Limpopo Province, and to recommend guiding principles based on the study findings for healthcare professionals on the strategies that can be used to assist mothers of children admitted in a paediatric unit of a Polokwane/Mankweng hospital complex of the Limpopo Province. Design and Method: A qualitative, descriptive and explorative research design was conducted for the participants to describe the indigenous practices in relation to managing and treating childhood illnesses. Data were collected by means of unstructured one-on-one interviews at the Mankweng/ Polokwane hospital complex with mothers of children admitted at the paediatric unit. Criteria for trustworthiness were observed as stipulated in Babbie and Mouton (2009). Ethical standards by DENOSA (1998) were adhered to in order to ensure the quality of the study. Findings: Three themes with sub-themes emerged from the data analysis, using Tech’s open coding approach (Cresswell 2009:186), i.e. analogous indigenous practices in curing childhood illnesses, believes related to the indigenous healing process and THP treating of HIV infected children. It is recommended that healthcare providers need to have understanding of indigenous belief systems in relation to healthcare, and work towards incorporating this understanding into their service delivery to recognise and to embark upon the journey of working with THPs.

Doctor of Philosophy (PhD) / This thesis describes a study of the utilisation of computers by individual general practitioners (GPs) in Australia, and compares the practice behaviour of GPs who use a computer as a clinical tool, either by prescribing, ordering tests, or storing patient data in an electronic medical record format, with those who do not use a computer for these functions. A survey of individual GP’s use of computers was conducted among 1,336 GPs who participated in the Bettering the Evaluation and Care of Health (BEACH) program between October 2003 and March 2005. The GPs were then assigned to groups according to their clinical use (or not) of a computer, and were compared on a range of variables including the characteristics of the GPs themselves, their practices, their patients, the morbidity they managed for their patients, and the managements they provided. Their behaviour was also compared, using a set of quality indicators designed for use with the BEACH data, and applicable in a primary care setting, to determine whether the clinical use of a computer has an affect on the quality of care GPs provide to their patients. Finally, GPs who use clinical software with embedded pharmaceutical advertising were compared with GPs not exposed to advertisements via this media, to determine whether such advertising influences the prescribing behaviour of GPs to favour advertised brands. From 44 quality indicators examined, clinical computer users performed ‘better’ on four and ‘worse’ on four. For the remaining 36 they exhibited no difference. Exposure to pharmaceutical advertising embedded in clinical software did not influence the prescribing behaviour of the GPs so exposed. Despite the belief espoused in the literature that computer use will improve the quality of patient care, I have found no evidence to demonstrate that the use of a computer for clinical activity has (as yet) affected, either positively or negatively, the quality of care GPs provide to their patients. The current push to computerise general practice will mean that this method of assessment will be difficult to replicate in the future, given the absence of control groups. Other research methods will need to be developed.

Osteoporosis is a major public health concern, affecting over 200 million people worldwide. There is valid evidence outlining how osteoporosis can be diagnosed and managed, but gaps exist between evidence and practice. Graham’s “Knowledge to Action” (KTA) process for knowledge translation and the Medical Research Council (MRC) framework for complex interventions were used to address these gaps. The first 4 KTA steps were collapsed into 3 phases of the PhD research plan. In PhD Phase 1, a systematic review was conducted to identify tools that facilitate decision making in osteoporosis disease management (DM). Results showed that few DM tools exist, but promising strategies were those that incorporated reminders and education and targeted physicians and patients. PhD Phase 2 used the findings from the systematic review and consultation with clinical and human factors engineering experts to develop a conceptual design of the tool. Multiple components targeted to both physicians and patients at the point of care, and which could be used as a standalone system or modifiable for integration with electronic health record systems were outlined. PhD Phases 3a and 3b were devoted to the assessment of the barriers to knowledge. In Phase 3a, a qualitative study of focus groups was conducted with physicians to identify attitudes and perceived barriers to implementing decision support tools in practice, and to identify the features that should be included in the design. Findings from 4 focus groups combined with aging research, and input from design and information experts were used to transform the conceptual design into a functional prototype. In Phase 3b, each component of the prototype was tested in 3 usability evaluation studies using an iterative, participant-centered approach to assess how well the prototype met end users’ needs. Findings from the usability study informed the final prototype, which is ready for implementation as part of the post PhD plan to fulfill the requirements of the remaining steps of the KTA and MRC frameworks.

Osteoporosis is a major public health concern, affecting over 200 million people worldwide. There is valid evidence outlining how osteoporosis can be diagnosed and managed, but gaps exist between evidence and practice. Graham’s “Knowledge to Action” (KTA) process for knowledge translation and the Medical Research Council (MRC) framework for complex interventions were used to address these gaps. The first 4 KTA steps were collapsed into 3 phases of the PhD research plan. In PhD Phase 1, a systematic review was conducted to identify tools that facilitate decision making in osteoporosis disease management (DM). Results showed that few DM tools exist, but promising strategies were those that incorporated reminders and education and targeted physicians and patients. PhD Phase 2 used the findings from the systematic review and consultation with clinical and human factors engineering experts to develop a conceptual design of the tool. Multiple components targeted to both physicians and patients at the point of care, and which could be used as a standalone system or modifiable for integration with electronic health record systems were outlined. PhD Phases 3a and 3b were devoted to the assessment of the barriers to knowledge. In Phase 3a, a qualitative study of focus groups was conducted with physicians to identify attitudes and perceived barriers to implementing decision support tools in practice, and to identify the features that should be included in the design. Findings from 4 focus groups combined with aging research, and input from design and information experts were used to transform the conceptual design into a functional prototype. In Phase 3b, each component of the prototype was tested in 3 usability evaluation studies using an iterative, participant-centered approach to assess how well the prototype met end users’ needs. Findings from the usability study informed the final prototype, which is ready for implementation as part of the post PhD plan to fulfill the requirements of the remaining steps of the KTA and MRC frameworks.