Medication-related problems (MRPs) are a common issue that lead to suboptimal healthcare outcomes and increased healthcare cost. Overall, older adults have a high risk of experiencing MRPs due to large medication consumption and recession of biological functions. One approach to reduce such a risk is for elderly patients to use comprehensive medication reviews (CMRs), the fundamental service of Medication Therapy Management (MTM). The Centers of Medicare and Medicaid (CMS) has been promoting CMRs among Medicare Part D beneficiaries since 2009, such as offering of an annual free CMR to eligible MTM beneficiaries and making “CMR completion rate” a quality rating (Star) measurement for Part D plans. However, statistics from the report of CMS 2017 Star rating measures showed that the CMR completion rate among MTM eligible was still low. Even though Medicare Part D beneficiaries ultimately make the decision, there are insufficient U.S. studies examining patient perceived factors affecting their use of CMRs. Thus, there is critical need to better understand decision making for using CMRs from a consumer perspective. This dissertation project aimed to explore Medicare Part D beneficiaries’ perceptions on using a CMR, using a conceptual framework adapted from consumer decision making, which consisted of internal need, external influence, perceived risks of using CMRs, and alternative comparison. The dissertation project also aimed to describe how CMR recipients and non-recipients were different and to identify main factors associated with Medicare Part D beneficiaries’ decision making for using CMRs. To achieve these objectives, this study used an exploratory sequential mixed-method approach in a cross-sectional setting. Semi-structured personal interviews were conducted as the qualitative phase followed by self-administered mailed survey as the quantitative phase. Both interview questions and survey items were developed based on the conceptual framework, though findings from qualitative phase informed the survey item generation as well. Survey items and administration were further refined using a panel of expert review and pilot study. A convenient sample consisted of older adults recruited from one pharmacy in Iowa and a senior registry maintained by University of Iowa was used for the qualitative phase (n = 13). The quantitative study sample were randomly selected from each sampling frame: 1) elderly residents of the States of Florida (n = 320), Washington (n = 320), Wisconsin (n = 320), and Pennsylvania (n = 320) covered in a commercial mailing list; and 2) older adults included in the same senior registry used for the qualitative phase (n = 460). The study inclusion criteria were: 1) must be at least 65 years old in 2016, 2) must be taking at least one prescription currently, and 3) must be a Medicare Part D beneficiary. A thematic analysis was conducted for qualitative data, using MaxQDA version 12. Descriptive analysis and multiple logistic regression modeling were used to analyze data of the quantitative phase, using SAS version 9.4. A total of 13 study participants were included in the qualitative analysis, of which 5 were CMR recipients. The thematic analysis yielded five themes, which supported the use of the conceptual framework (i.e. internal need, external influences, perceived risks of using CMRs, and alternative comparison) to understand Medicare Part D beneficiaries’ decision making for using CMRs. Plus, consumers who received a CMR expressed a positive attitude towards them. Safety worriers or knowledge seekers appeared more likely to use CMRs while physician believers or privacy worriers are more likely to not use CMRs. Meanwhile, awareness of CMRs remains low after being available for 7 years, possibly due to an infrequent marketing activity. An overall usable response rate of 26.8% and an overall completion rate of 89.4% were obtained in the mailed survey phase. Of the study sample, 381 respondents who were Medicare Part D beneficiaries, were using at least one prescription, and returned a complete survey were included for analysis. There were 27.56% respondents (n = 105) reported that they had a CMR in 2016 or before, which was consistent with the low CMR completion rate nationwide. Meanwhile, about two thirds of respondents never heard of CMRs, supporting findings from the qualitative phase. CMR recipients and non-recipients had several characteristics differences in the domain of internal need, external influences, and perceived risks of using CMRs. Compared to CMR non-recipients, CMR recipients took slightly more prescription medications (p = 0.0299), were self-reported less healthy (p = 0.0009), had better provider communication in previous pharmacy encounters (p < 0.0001), had higher overall satisfaction in previous pharmacy encounters (p = 0.0053), perceived more seriousness of MRPs (p = 0.0016), perceived more susceptibility of MRPs (p < 0.0001), expected more positive outcome from suing CMRs (p < 0.0001), were more likely influence by a physician’s opinion (p = 0.0184) or a pharmacist’s opinion (p < 0.0001) when considering the use of CMRs, were more likely received a physician recommendation (p < 0.0001) or a pharmacist recommendation (p < 0.0001), had less concern of psychological risk (p = 0.0170), functional risk (p < 0.0001), and social risk (p = 0.0016). The regression modeling further determined that a pharmacist or a physician recommendation, pharmacist’s communication in previous pharmacy encounters, perceived susceptibility of MRPs, and positive outcome expectancy were positively associated with Medicare Part D beneficiaries’ decision making for using CMRs at a significant level of .05, when holding other variables fixed. Meanwhile, perceived functional risk, access to general counseling in previous experiences, and family/friends influence were negatively associated with Medicare Part D beneficiaries’ decision making for suing CMRs at a significant level of .05, when holding other variables fixed. This study is the first to adapt consumer behavior frameworks to explore factors affecting Medicare Part D beneficiaries’ decision making for using CMRs. Unfortunately, it was found that CMR awareness among older population was still low after years’ of promotion efforts among Medicare Part D beneficiaries. Findings of this dissertation suggested that policy makers should not entirely focus on promoting CMRs through Part D plan sponsors, but seek for collaborations from healthcare professionals, particularly community pharmacists and physicians. Meanwhile, addressing key components and benefits of CMRs in an understandable way to general older population could help them establish a link between benefit expectation and their demand. Furthermore, using short surveys or phone interviews to obtain self-perceived internal need among older population could be used by Part D plans or other stakeholders to target potential CMR users more effectively.

Bakgrund: Depression är lika vanligt som demens hos äldre, men ofta inte lika studerat eller diskuterat. I dagsläget finns det flertalet olika bedömningsformulär för att finna dessa patienter men depression hos äldre är ofta odiagnostiserat. Konsekvenserna med en depression i sen ålder kan vara mycket ogynnsamma, både för individen och samhället. Allt eftersom den äldre befolkningen kommer att öka så kommer även depression att öka.Syfte: Syftet med denna studie är att undersöka olika metoder för att lindra depressiva symtom hos den äldre befolkningen. Metod: Beskrivande design med litteraturöversikt med systematisk ansats som metod.Resultat: Tolv originalartiklar med kvantitativ experimentell metod inkluderades. Fyra artiklar tog upp självhjälp och hjälp till självhjälp av olika slag som intervention, fyra tog upp fysisk aktivitet som intervention, två tog upp KBT som intervention, en använde samtalsterapi som intervention och två artiklar hamnade under mer än en underrubrik. Nio av artiklarna hade interventioner som visade sig fungera för att lindra depressiva symtom. Slutsats: Att kombinera motion med socialt umgänge, rätt kost och en aktiv vardag kan lindra depressiva symtom i stor utsträckning. Det viktigaste arbetet borde vara att upptäcka och börja sätta in åtgärder i ett tidigt skede, för att förhindra att en depression utvecklas. Detta kan leda till minskat lidande för patienten och minskade kostnader för samhället. / Introduction: Depression is as common as dementia in the elderly, but often not as well studied or discussed. At present, there are several different assessment forms for finding these patients, but depression in the elderly is often undiagnosed. The consequences of a late-age depression can be vary unfavorable, both for the individual and society. As the older population increases, so will depression. Aim: The purpose of this study is to investigate various methods to relieve depressive symptoms in the elderly population. Methods: Descriptive design with literature review with systematic approach as method. Results: Twelve original articles with a quantitative experimental method were included. Four articles addressed self-help and self-help of various kinds as intervention, four took up physical activity as intervention, two took up KBT as intervention, one used conversational therapy as intervention and two articles ended up with more than one sub-heading. Nine of the articles had interventions that were found to work to relieve depressive symptoms. Conclusion: Combining exercise with social interaction, the right diet and an active everyday life can greatly alleviate depressive symptoms. However, the most important work should be to discover and take measures at an early stage, to prevent a depression to develop. This can lead to reduced suffering for the patient and reduced costs for society.

The purpose of this research study was to explore Mexican women’s perceptions about utilizing mental health services and to explore the barriers encountered during the process. Previous research suggested Mexican women’s diverse experiences when seeking and utilizing mental health services. The study used a qualitative approach with open-ended and closed-ended questions. The sample size of this study was fifteen individuals who self-identified as Mexican women who reside in Southern California recruited using a snowball approach. Major themes identified included Mexican family values and beliefs, cultural barriers, structural barriers, Mexican women’s strengths, and community suggestions for social work practice. This study highlighted their perspective on mental health, cultural and structural barriers, their personal experiences of utilizing mental health services, techniques on managing difficult situations, support systems, identified mental health symptoms, coping methods, cultural values and suggestions to improve mental health services in the general Latino community.

Background: The South Western Sydney Area Health Service (SWSAHS) contains many areas of socio-economic disadvantage and ethnic diversity. It has a high incidence of lung cancer, which is the leading cause of cancer deaths. The aims of this study were to document lung cancer patterns of care (POC) for SWSAHS residents, compare POC before and after the opening of an oncology centre in SWSAHS and compare POC with other areas in NSW. Methods: The study population consisted of SWSAHS residents diagnosed with lung cancer in 1993 and 1996. A clinical audit of medical records was performed to extract details on patient demographics, management of lung cancer and outcomes. Collaborating investigators performed identical studies in the Northern Sydney Area Health Service (NSAHS) and the Hunter Area Health Service (HAHS) for lung cancers diagnosed in 1996. Results: The SWSAHS study population comprised 527 patients. Nine percent did not have a pathological diagnosis. Twelve percent did not see a lung cancer specialist. Twenty-eight percent did not receive any treatment throughout the course of their illness. The median survival was 6.7 months and five-year actuarial survival was 8% (95% CI 6%-10%). Increasing age and poorer performance status were associated with a lower likelihood of obtaining a pathological diagnosis, specialist referral and treatment. Socio-economic factors did not influence POC. The establishment of an oncology center resulted in more referrals to medical oncologists and palliative care services. Other aspects of POC and survival were similar. Variability in POC was noted between SWSAHS, NSAHS and HAHS. HAHS residents were almost twice as likely not to have pathological confirmation of diagnosis or treatment. Despite this survival was not significantly different. Conclusions: This study has identified deficiencies in the management of lung cancer. To improve outcomes, referral to specialists and utilisation of treatment, particularly radiotherapy and chemotherapy, needs to be increased. Ageist and nihilistic attitudes need to be overcome. Prospective data collection is necessary to ensure quality of patient care. The formation of national guidelines for the management of lung cancer will play an important role in achieving better outcomes.

This study investigated the nexus between multicultural policies and contract management within the Community Health Services in the Northern Metropolitan Region of the Victorian Department of Human Services. Access and equity of services to linguistic minority migrant groups is a central component of this study. The study drew on literature pertaining to social work theory and practice, with a particular focus on structural social work, the evolution of Australia's multicultural policy and the context of contract management. The data collection consisted of two stages. The first stage comprised of twenty-two semi-structured interviews with Chief Executive Officers and managers from the Community Health Services, government personnel from the Department of Human Services and key informants. The second stage of the study, a self administered questionnaire survey for service providers, was developed and designed from the key themes identified from the interviewee data. A total of 119 service providers responded to the questionnaire. Key findings of this study were first, that the Community Health Services have broad policies of inclusion. Secondly, that the multicultural policy may be considered a broader policy then just a policy relating to people of non-English speaking backgrounds or culture relating to ethnicity. Thirdly, funding arrangements appeared limited in their expectations regarding linguistic accessibility. Fourthly, service providers had a different perception of the quality level of service their organisation provided to English speakers and non-English speakers. Implications of this study included, first, having broad inclusive policies would require specific strategies of access. Secondly, multicultural policy as such may need to develop into a policy of 'structural cultural equity'. Thirdly, partnerships between government and Community Health Services can be further utilised to develop more innovative service delivery methods to respond to linguistic minority groups. Lastly, culturally sensitive practice modules may need to be considered as a central component in the health and welfare field of tertiary education. The study concluded that Community Health Services are ideally located to implement services, which not only address the notion of multiculturalism, but also address the issues of equity in the context of a dominant paradigm. In such an environment someone who speaks a language other than English is 'visible' and therefore, 'a woman without a word of English enters the Community Health Service' and receives the same service as an English speaker.

It is accepted protocol among Indigenous communities to identify one's link to land. I was born and raised in Brisbane. My birth grandmother is a Goreng Goreng woman, my birth grandfather is a Punthamara man. However, I was adopted by a Koombumberri man and an anglo-celtic mother after being removed at birth under the Queensland government policy of the day. The action of my removal and placement has had profound effects upon my growing and my place within my community today. For the last 15 years I have worked in the health sector. My current position is as a Lecturer within the Department of Nursing, Faculty of Science, University of Southern Queensland, Toowoomba. My areas of expertise are Indigenous Health and Primary Health Care. I have been employed in this capacity since January 2000. Prior to my full time employment as a nursing academic I have primarily been located within three areas of health which have directly impacted upon my current research. I was first positioned within health by undertaking my General Nurse Certificate through hospital-based training commenced in the late 1980s. For me this training meant being immersed within whiteness and specifically the white medical model. This meant learning a set of skills in a large institutionalised health care service with the provision of doctors, nurses, and allied medical staff through a hospital. Within this training there was no Indigenous health curriculum. The lectures provided on 'differing cultures' and health were on Muslim and Hindu beliefs about death. At that point I was painfully aware of the glaring omission of any representation of Indigenous health and of acknowledgment of the current outstanding health differentials between Indigenous and non-Indigenous Australians. I knew that the colonisation process inflicted upon Indigenous Australians was one of devastation. The decline in our health status at the time of colonisation had been felt immediately. Since this time our health has been in decline. While in the 1980s it was now no longer acceptable to shoot us, poison our waterholes, and incarcerate us on missions, we were still experiencing the influence of the colonisation process, which had strong repercussions for our current health status. Our communities were and remain rife with substance abuse, violence, unemployment, and much more. For Indigenous Australians these factors cannot be separated from our initial experience of the colonisation process but are seen as the continuation of it. However, there was no representation of this and I received my first health qualification.

Most health professionals are aware of the amazing diversity of the Australian population, which is made up of people from over 140 different countries. Of these, an increasing number have arrived as refugees under Australia's humanitarian resettlement program. Research indicates that at least 30% of the 12,000 or so people arriving in Australia under the humanitarian assistance programmes each year have been exposed to physical and emotional torture and trauma. They also have well documented health deficits relating to the health standards in their countries of origin, the level of deprivation experienced prior to arrival in Australia, and the time they have spent in transit before arriving in Australia. The purpose of this study was to review the health status of refugees from the former Yugoslavia, and to identify the perceived needs of this group, which represents one of Canberra's largest communities of recently arrived refugees. Utilising both qualitative and quantitative methodologies, findings showed that the cohort had significantly lower levels of both physical and mental health than the wider ACT and Australian population. The difficulties of socialisation of the refugees into the Australian lifestyle are highlighted. In particular, findings from the study have demonstrated the lack of appropriate information given to some refugees on arrival, and the struggles experienced by most of the group with learning a new language, and coping with unemployment and inadequate housing. The problem of covert political harassment in Canberra was also described during the interview process. Recommendations for improving the situation for these refugees were that information for refugees prior to, and following arrival in Australia needs to be consistent and readily available, and there needs to be provision of a formalised support system from the time of arrival, including a review of language facilities. The study also recommended that culturally sensitive health promotion and treatment programs should be incorporated into current health service provision. Nurses are identified as the appropriate health providers to take a leading role in developing such programs for refugees, although findings from this study indicate that current nurse education programs need to place more emphasis on a transcultural framework for the provision of care.

Background There is a widespread perception that the health status of rural Australians is poorer than that of urban Australians, characterised by higher mortality, lower life expectancies, and an increased incidence of some diseases. At present this perception is difficult to confirm or refute, in terms of mental illness, because of limited published data on the extent of mental illness in regional Australia. Australians from rural areas are also reported to have less access to appropriate health care compared to their urban counterparts; however, there is limited evidence to support such claims using large population-based epidemiological data. It is not known whether remoteness per se is an important determinant of health. Aim To determine if rural and remote South Australians were disadvantaged in terms of their mental health status and access to health care. The aims were to: 1) determine if prevalence of mental illness and comorbidity were associated with accessibility and remoteness; 2) examine the effects of accessibility and remoteness on health service utilisation; and 3) determine if remoteness per se was an important determinant of mental illness. Methods Prospectively designed, secondary analysis of data from a large cross sectional, population–based health survey, conducted in South Australia (SA) in 2000. In all, 2,454 adults, aged 18 years or more, were randomly selected and interviewed using the Computer Assisted Telephone Interview (CATI) system. CATI is a telephone monitoring system that is an efficient means of assessing self-reported aspects of population health, particularly in rural and remote areas. Psychological distress and depression were assessed using the Kessler 10 (K10) Psychological Distress Scale, the SF-12 measure of health status and self-reported, medically-confirmed mental illness, in the previous 12 months. Additional outcome measures included socio-demographic characteristics, a range of health services measures, psychosocial and health risk factors. Geographical variation in outcome measures was assessed using the Accessibility and Remoteness Index of Australia (ARIA). The data were analysed using SPPS and Stata statistical programs and weighted by region, age, sex and probability of selection in the household, using the 1999 total estimated resident population (ERP) figures supplied by the Australian Bureau of Statistics. Direct age-sex standardisation was applied to prevalence rates of mental illness, socio-demographic and health service utilisation data. Results Overall age-sex adjusted mental illness prevalence estimates were similar using the three measures of psychological distress (10.5%), depression (12.9%) and self-reported medically-confirmed mental illness (12.9%). For each measure, there was no significant variation in prevalence across ARIA categories, except for a lower than expected prevalence of depression (7.7%) in the accessible category. There was also no significant difference in the median number of uses of four types of health services across ARIA categories. Significantly fewer residents of highly accessible areas reported never using primary health care services (14.4% vs. 22.2% in very remote areas), and significantly more reported high use (6 visits, 29.3% vs. 21.5%). Fewer residents of remote areas reported never attending hospital (65.6% vs. 73.8% in highly accessible areas). Frequency of use of mental health services was low and not significantly different across ARIA categories. Very remote residents were more likely to spend at least one night in a public hospital (15.8%) than were residents of other areas (eg 5.9% for highly accessible areas). After controlling for the joint effects of stressful life events, perceived control of life events, socio-demographic characteristics and health risk factors, odds of mental illness did not vary by ARIA category (highly accessible: reference category; accessible: OR 0.9, 95% CI 0.60-1.31; moderately accessible: OR 0.80, 95% CI 0.45-1.43; remote/ very remote: 0.70, 95% CI 0.44-1.03). The most important predictors of mental illness in the multivariate logistic model were female sex; smoking; low consumption of vegetables; low exercise; a physical condition; perceived lack of control with: life in general, personal life, job security or health; and major stressful events such as family or domestic violence and the death of someone close. Conclusions Prevalence rates of psychological distress, depression and medically-confirmed mental illness in SA were high. However, there was no evidence that the prevalence of these conditions varied substantially across ARIA categories. The frequency of use of a range of health services was also broadly similar across the state. Remoteness per se was not associated with mental illness, either directly or indirectly as an important confounder in stressful life event/mental illness associations. Psychosocial factors were more important determinants of mental illness. The data do not support existing stereotypes of a rural – urban mental health differential in SA and point to potential mechanisms that may be responsible for poorer mental health outcomes.

Rekommendationerna är att spädbarn helammas i sex månader utan tillskott av annan föda. Trots att hälsoeffekterna för både mor och barn är välkända, har amningsprevalensen sjunkit i Sverige de sista åren. Syftet med denna studie var att undersöka om förstagångsmammor ammade så länge de tänkt sig, vilka orsaker som bidrog till att de slutade helamma respektive delamma och hur deras upplevelse av amningsstöd varit med speciellt fokus på barnhälsovården (BHV). En enkät skickades till 65 förstagångsmammor, vilket resulterade i 35 svar. Resultatet visade att knappt hälften av de mammor som svarade på enkäten hade avslutat sin amning tidigare än vad de tänkt sig. Hälften av de mammor som hade velat amma längre hade uppgett orsaker som kunde relateras till brist på stöd.  Resultatet visade även att många mammor söker stöd från det egna sociala nätverket och att stöd från mödrahälsovården (MHV) och förlossning/BB är viktigt för hur amningsstarten blir. BHV:s stöd är betydelsefullt när amningen ska etableras och upprätthållas vilket påverkar amningstidens längd. Det finns ett behov av fortsatt utbildning för vårdpersonal och amningsstödjare, gällande betydelsen av amning och bröstmjölk för att ge efterfrågat stöd till mammor som vill amma sina barn. / The health benefits of breastfeeding are well documented and guidelines for infant feeding have supported exclusive breastfeeding during the first 6 months. The breastfeeding prevalence has decreased in Sweden during the last ten years. The aim with this study was to find out if primaparous mothers could breastfeed as long as they had planned to do, reasons for stopping breastfeeding and how the mothers had perceived breastfeeding support, especially the support from the child health care. A questionnaire was sent out to 65 primiparous women and 35 mothers participated in the study. Almost half of the mothers had stopped breastfeeding earlier than they wanted to do. The result showed that many mothers looked for support in their own social network. The support from antenatal care, delivery and maternity ward, child health care was important in initiating breastfeeding as well as to maintain breastfeeding. There is a need of more education in breastfeeding and breast milk to health professionals and breastfeeding supporters to be able to support those mothers who want to breastfeed their babies.

Official-language minorities in Canada may face specific issues in accessing health care services that can lead to negative consequences on their health, utilization of health care services and satisfaction with the health care system. A secondary data analysis of the 2006 Survey on the Vitality of Official-Language Minorities revealed significant differences between the Anglophone minority (n=5,161) and the Francophone minority (n=12,029) with regards to general health, and access to and use of health care services. Important predictors of these outcomes included age, education level, household income, marital status and place of residence (urban/rural). Access to health care services in the minority language was associated with self-perceived health in the Anglophone minority only. Health policy recommendations elaborated in light of the findings include working on both the supply and the demand of health care services offered in the two official languages, while taking into consideration important contextual differences between regions.