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The current study was designed to test the utility of a multivariate model to predict adherence to the prescribed medical regimen, absenteeism, and participation in organized activities for children with asthma. The model included health status factors as well as psychosocial predictors (mother and child psychological and cognitive characteristics) and family functioning. Three dependent variables were used including physician estimates of adherence, absenteeism (partial and whole days for the current year), and participation in physical and social activities. Multiple regression analyses were performed to determine whether health status, child and mother psychosocial factors, and family factors would account for significant proportions of the variance in adherence, school absence, and participation in physical and social activities. Results indicated that family factors contributed significantly to the prediction of adherence to the medical regimen. Predictors of absenteeism included the child's perceived self-efficacy and adherence. and significant predictors of participation in physical and social activities included health status and maternal external locus of control. Suggestions for revising the model and recommendations for future research utilizing the model are included. / Master of Science

Background: The role of community matron (CM) was introduced to provide a single point of access to patients living with co-morbid long-term conditions who had, or were at risk of, frequent emergency admissions to hospital. CMs utilised case management as a means of managing this growing population of patients with fragile health. Since its inception, many changes in service delivery have impacted on the role. Aim: The aim was to undertake a mixed methodology study of the factors that have affected embedding of the community matron role in 3 geographical areas. Methodology: A pragmatic mixed methods approach (QUAL quan) was utilised. Settings and participants: The studies were based in health services within 2 cities and a rural area in central England. Participants for the qualitative components of the study were purposefully sampled. The sample comprised professionals: community matrons (n=21), managers (n=4), former commissioners (n=2) and GPs (n=3); and patients (n=10) and their family carers (n=5). Quantitative data for 212 people with long-term conditions were derived from the anonymised Patients at Risk of Rehospitalisation database (PARR data) held by area 1. Methods: Qualitative data were collected from participants using semi-structured interviews and audio diaries. For the quantitative component using PARR, some patient journeys within area 1 were explored. In addition, a sample of patients who were case managed by a CM (n=106) were matched with a set of patients who were not (n=106) and the data was examined. Findings: Participants were largely positive about the role of CM. However, difficulties with role setup had led to numerous changes which affected how the role has embedded. Additionally, this impacted understanding of the role by health care professionals, and caused practical and emotional difficulties for some CMs as they perceived the role to be eroded. The quantitative findings showed that CMs did not make a significant difference to hospital bed days used by patients on their caseload. Evaluating the role and finding an effective means of showing the work undertaken by CMs, which is often invisible, proved difficult. Conclusion: Embedding of the CM role has been affected by numerous changes in service delivery. Invisibility of community nursing rather than autonomy of the community matron role seems to be a key factor in the challenges of embedding the role. The significance of these findings is that using a mixed method approach and Liaschenko and Fisher’s adapted model may help CMs to improve the visibility of their role, and so helping the role to be less prone to the challenges of service redesign.

The Ytterby mine is located on Resarö island in the Stockholm archipelago. Mainly feldspars but also quartz were historically quarried in the mine, which is also the place of discovery of seven rare earth elements (REE). During the cold war era, the mine shaft was used as a diesel and jet fuel deposit for the Swedish Armed Forces. Recently, a spatial coupling between multiple sclerosis (MS), a chronic neurodegenerative disease in the central nervous system, prevalence and the quarry has been suggested. Previous studies show that adverse neurological health effects are associated with oral intake of REEs and there is support for a coupling between ionizing radiation and MS. The extent and character of health effects as a result of exposure to petroleum products are still debated. However, a substantial number of scientific reports support a coupling between neurodegenerative health effects and toxic constituents of jet fuels such as benzene, toluene, and n-hexane. My data show that a possible overrepresentation of MS patients within the Ytterby postal code area could be an indication of a spatial coupling between the mine and MS. Such a possible coupling could be associated with the REEs present in the local rocks, with the previous storage of diesel or jet fuel MC-77 in the mine and/or with zones of high natural radioactivity in the area. Water samples collected in 15 wells in the Ytterby village show traces of five REEs, i.e. scandium (Sc), yttrium (Y), lanthanum (La), neodymium (Nd) and samarium (Sm) and the majority of sample locations at low ground elevation show contamination of diesel which is the most recent fuel stored in the mine. Moreover, results from an analysis of a black substance leaking out of cracks in the mine corridors confirm that REEs are present in substantial concentrations in the local rocks and also appear to be mobile. This should be taken into account when considering a potential contamination of the local water supply. Measurements of natural radioactivity have also been made around the contours of the quarry and zones of high ionizing radiation have been identified. By using these zones of high ionizing radiation as a proxy for rare minerals containing rare earth elements, I further suggest that the REE occurrences are highly localized around the quarry and could be associated with, or remobilized by, younger faults.  My data show that a full investigation is warranted of a possible spatial coupling between neurological health issues, MS being one of them, and the mine.

This dissertation examines the relation between occupational exposure to the solvent methylene chloride and mortality in a cohort of cellulose fiber production workers. The first paper, entitled The Mortality of Cellulose Fiber Production Workers, presents the main results of the mortality follow-up of the cellulose fiber workers cohort through September 1, 1986. Mortality from neoplastic and non-neoplastic disease among cellulose fiber production workers is compared to that of the U.S. and local (county level) populations, while controlling for the effects of gender, race, calendar period, and age. Mortality from cancers of the lung, breast, and pancreas, and ischemic heart disease was less than expected. Excess mortality was observed for melanoma of the skin, cancer of the buccal cavity and pharynx, tumors of the liver and biliary tract, and accidental deaths. Three deaths from cancer of the bile ducts were observed (3 observed, 0.15 expected, SMR=20). This is the first known report of an association between exposure to methylene chloride and cancer of the bile ducts. [TRUNCATED]

Over the past several decades the number of youth living with a chronic health condition has drastically increased. A chronic health condition can be defined as an illness that lasts three months or more that can be controlled but not cured (Centers for Disease Control and Prevention [CDC], 2010). Although there is existing literature on youth with chronic health conditions, there are very few studies that examine the levels of health literacy, resiliency and support/advocacy within this population. The current study is a secondary analysis that utilized data collected from the 37-item Youth Health Literacy and Resiliency Scale (HLRS-Y version) in order to determine if there was a relationship between different categories of chronic health conditions and reported levels of health literacy, resiliency and support/advocacy. Ages of participants were also examined to determine if there was an interaction effect. The study consisted of a 143 youth between the ages of 13- 21 years old. All participants completed the Youth Health Literacy and Resiliency Scale (Bradley-Klug, Shaffer-Hudkins, Lynn, DeLoatche, & Montgomery, 2017) and were placed into one of three categories of chronic health condition: 1) Endocrine, nutritional, and metabolic diseases, 2) Diseases of the musculoskeletal system and connective tissue, and 3) Diseases of congenital malformation, deformations, and chromosomal abnormalities. The data were analyzed to determine if there was a difference in the reported constructs of health literacy, resiliency and support/self-advocacy among the three different categories of chronic health illnesses. The results indicated that there was a significant relation between support/self-advocacy and age. As participants increased in age, they reported having lower levels of support/self-advocacy. This finding was significant regardless of the category of chronic health condition that the participants were placed in. There were no other significant findings for the other constructs. This study contributes to the literature because it is one of few to examine health literacy, resiliency and support/self-advocacy levels among youth with chronic health conditions. In addition, it is the first study aside from the pilot, to utilize the HLRS. The findings from this study can be utilized to drive support/self-advocacy interventions for youth with chronic health conditions.

Self-management interventions enhance the health self-management techniques and physical and psychological health outcomes among people with long-term health conditions (LTHCs). Few individuals from South Asian backgrounds attended the pilot phase of one such intervention: the Expert Patients Programme (EPP), a community-based self-management course. This raised concerns about exacerbating health inequalities. South Asian people have increased prevalence and severity of certain musculoskeletal conditions, yet little is known about their experiences of living with and self-managing these. This research aimed to rectify these omissions, by describing Punjabi Sikh women's experiences of living with and self-managing arthritis, and identifying barriers and facilitators to EPP. Three studies explored White and Punjabi Sikh EPP tutors‟ experiences of delivering EPP to South Asian attendees, and Punjabi Sikh women's experiences of living with and self-managing arthritis, both before and after they attended a Punjabi-language EPP. White and Punjabi Sikh tutors' sometimes dichotomous experiences of delivering EPP to South Asians, captured barriers to South Asian people's attendance, engagement and self-management. Facilitators identified included the need for sensitive tailoring of the Course, involving the Punjabi Sikh community. The Punjabi Sikh women's vibrant experiential accounts revealed the detrimental psychological and physical consequences that arthritis had upon their lives. Highly versatile in their proactive arthritis self-management prior to attending EPP, participants' refined techniques encompassed combinations of medication and Indian remedies, empowered by their religious and spiritual values. Following EPP attendance, the participants reported psychological and physical improvements in their arthritis. Thus, this Study established Punjabi Sikh 4 Abstract women's inherent acceptance of the concept of self-management, and, notwithstanding its current limitations, the likely appropriateness of EPP. Every Study represents a novel contribution to knowledge. Meaningful engagement with Punjabi Sikh community-members may produce a culturally-competent intervention that could better improve this group's physical and psychological outcomes, thus addressing one small area of health inequalities.

By 2015, 149 million Americans are expected to be living with chronic health conditions (Anderson 2010). This number is expected to continue rising. Many chronic health conditions require those living with them to perform health self-management tasks on a regular basis. Nearly two in every five adults with one chronic condition and three out of every five adults with at least two chronic conditions track their health information. This paper investigates the use of mobile applications and the need to develop applications specifically designed for individuals living with chronic health conditions. Pew data are used to determine who is tracking their health information and how they are tracking it. Results from this analysis show that individuals with chronic health conditions have 69% greater odds of tracking health information than individuals who do not live with chronic conditions. Additionally, those with chronic conditions are 254% more likely than those without chronic conditions to track health indicators that are not related to diet, weight or exercise. These individuals are not, however, using mobile applications to track their health information. People with chronic health conditions have higher probabilities of tracking health information on paper or in their heads than their probability of tracking via a mobile application. However, the probability that individuals track health information via mobile apps increases when analyzing a subset of the population who own smartphones. After learning more about individuals with chronic conditions and their health information tracking habits, several mobile health applications are reviewed. The reviews of these applications include the features offered by the applications and their price. The paper concludes with several recommendations for developing and disseminating mobile health tracking applications to individuals with chronic conditions, as well as suggestions for future research. / text

The concurrent experience of multiple health conditions (often termed multimorbidity) has become an important issue in recent years. Most research on this topic uses clinical data (e.g. GP or hospital records) that lack important socio-contextual information about the lives of people with multiple conditions. Population health surveys can help to overcome these limitations, but identifying people who have multiple conditions is problematic. Decisions need to be taken regarding what is meant by a condition, which ones should be included, and how multiple should be defined. These decisions tend to be based on what data are available, rather than on any universal inclusion criteria or theoretical underpinnings. This thesis used an approach informed by sociological theory and principles drawn from critical realist philosophy to estimate the prevalence of multiple conditions among adults (16+) in the general population, using data from the 1998 and 2008- 2011 Scottish Health Surveys. It explicitly acknowledged the multiple, contested and constructed nature of health, illness and diagnosis; the limits of empirical enquiry; and the need to approach concepts such as multiple conditions critically. To support the decision-making process, longitudinal analyses of mortality were used to examine the impact of including various contested conditions on people’s long-term chance of survival (if there was no evidence of impact then the definition was rejected). The final measure of multiple conditions arrived at suggested that 24.9% of adults had multiple conditions (compared with 17.2% using the survey’s original, unadjusted, measure). This measure was then used to explore how this status related to people’s wellbeing, which helped to highlight importance differences in experiences. Among adults with multiple conditions, 33.5% of those in the most deprived areas had low wellbeing compared with 13.5% of those in the least deprived areas. Low wellbeing was also higher among people with multiple conditions aged under 65 than those aged 65 and over, especially for those living in areas of high deprivation. There was some evidence that having multiple conditions and additional vulnerabilities (e.g. psychological distress, living in a deprived area, having activity limitations) before the age of 55 increased people’s risk of mortality, which might result in older populations appearing to have better wellbeing due to less healthy people not reaching old age. Working-age people with multiple conditions were also more likely than people of the same age with no conditions to be economically inactive, to not live in an owner-occupied property, and not have a co-resident partner. All of which suggest that poor health at younger ages limits access to the social and economic norms enjoyed by most people. The approach adopted arguably helped to avoid over-classifying largely healthy people as having multiple conditions, while still ensuring that people’s own perspectives on their health were not under-privileged with respect to more traditional biomedically-focused approaches. However, it was also clear that the experiences of adults with multiple conditions are highly varied, and in particular, socially stratified. This heterogeneity has implications for research in this field, as well as clinical practice and public health policy. Recommendations for better reflecting this diversity in future studies included collecting more measures of functional capacity, aspirations, illness experiences, and social stressors (such as financial insecurity).

Introdução: define-se rede social como o grupo com quem a pessoa mantém algum vínculo social; já o apoio social refere-se ao grau de satisfação do indivíduo com suas relações, podendo ser agrupado em cinco dimensões: material, afetiva, emocional, de informação e interação positiva. Cuidar de um familiar dependente pode ocasionar várias mudanças na vida do cuidador, o que o leva a depender ainda mais do apoio de sua rede social. Objetivo: avaliar a rede e o apoio social de cuidadores familiares de pacientes dependentes atendidos por um Serviço de Assistência Domiciliária. Método: estudo descritivo, transversal, realizado em um Serviço de Assistência Domiciliária localizado na zona sul do município de São Paulo. A amostra foi constituída por 110 cuidadores familiares que realizavam a atividade há mais de três meses e que não recebiam remuneração pelo cuidado prestado. As entrevistas foram realizadas no período de março a novembro de 2011 e foram utilizados os seguintes instrumentos: formulário de caracterização sociodemográfica, Social Network Index, Medical Outcomes Study, Índice de Barthel e Genograma. A análise descritiva foi realizada através de cálculo de medida de tendência central e de dispersão e cálculo de frequências. Foi realizado teste U de Mann-Whitney, Kruskal-Wallis e correlação de Spearman. Foi adotado nível de significância de 5%. Todos os procedimentos éticos foram seguidos. Resultados: a maior parte dos pacientes era do sexo feminino, com idade média de 67 anos e totalmente dependente para atividades da vida diária. Os cuidadores eram, em sua maioria, do sexo feminino, com idade média de 52 anos, casadas e eram filhas do paciente. A rede social era composta principalmente pelos familiares, com média de quatro pessoas. O escore médio de apoio social total foi de 77,5. Cuidadores que não sabiam ler e que nunca haviam estudado apresentaram diferença estatisticamente significativa entre as médias na dimensão material, emocional, de interação positiva e de informação. Verificou-se diferença entre as médias na dimensão afetiva para a variável presença de dor; na dimensão interação positiva também se observou diferença entre o escore médio na variável presença de companheiro e a presença de sobrecarga. A dimensão material apresentou correlação estatisticamente significativa com a variável idade e o número de familiares e amigos apresentou correlação com todas as dimensões de apoio social. Conclusão: a avaliação da rede e do apoio social de cuidadores familiares pode auxiliar os profissionais de saúde no planejamento da assistência e contribuir para amenizar o impacto do cuidado ao familiar que exerce essa função. / Introduction: social network is defined as the group with whom the person has a social bond, whilst social support refers to the level of satisfaction of the individuals with their relationships and can be grouped into five dimensions: material, affective, emotional, informational and positive interaction. Caring for a dependent relative can cause several changes in the caregivers life, which make them to depend even more on the support of their social network. Objective: to evaluate the social network and the support of family caregivers of dependent patients attended by a Home Care Service. Method: descriptive, cross-sectional study, conducted in a Home Care Service located in the south of Sao Paulo city. The sample consisted of 110 family caregivers, who performed the activity for more than three months and did not receive payment for the care provided. The interviews were conducted from March to November 2011 and the following instruments were used: questionnaire of socio-demographic characteristics, Social Network Index, Medical Outcomes Study, Barthel Index and Genogram. A descriptive analysis was realized by calculating a measure of central tendency and dispersion and frequency calculation. The Mann-Whitney test U, Kruskal-Wallis and Spearman correlation were used. The significance level adopted was 5%. All ethical procedures were followed. Results: Most patients were female, with mean age of 67 years and totally dependent for activities of daily living. Caregivers were mostly female, with an average age of 52 years, married and daughters of the patient. The social network was composed mostly by family members, with an average of four persons. The average of the total social support was 77,5. Caregivers who could not read and who had no formal schooling showed statistically significant differences between the means presented in the material, emotional, positive interaction and information dimensions. There was a difference between the means in the affective dimension and the variable presence of pain; there was a difference in the dimension positive interaction between the mean score in the variable presence of companion and overload. The material dimension showed significant correlation with the variable age, and number of family and friends correlated with all dimensions of social support. Conclusion: The evaluation of social network and support of family caregivers can help health professionals in care planning and to mitigate the impact on the caregiver.