Thesis (M.S.)--University of Missouri-Columbia, 2004. / Typescript. Includes bibliographical references (leaves 103-106). Also available on the Internet.

Parenteral nutrition is a therapy that supplies patients with all their nutritional requirements intravenously, thus eliminating the need for oral alimentation. The therapy was first introduced in the United States to hospitalized patients in the late 1960's. The benefit of long-term parenteral nutrition was soon recognized, and a program for ambulatory or home parenteral nutrition (HPN) was developed. In British Columbia, the first HPN patient was begun on such therapy in 1972. Since then, more than 50 British Columbians have received HPN. In March 1986, there were 24 patients on the program. The average annual cost per patient was $29,278 and the total 1986 operating budget was $702,660, not including costs for equipment or hospital training. Up to now, there has been no analytical assessment of the HPN program in B.C. This thesis describes the current home parenteral nutrition situation in B.C. and makes recommendations for its improvement. It looks at overall clinical outcomes (both physiological and psychosocial), at the results with different subgroups of the population, and at the cost of the HPN program in B.C., and also considers the potential of this therapy for children. In Chapter 2, the literature is reviewed and organized to cover a general description of HPN therapy, a summary of the results obtained from a number of academic centers, a review of HPN therapy in childhood and the psychosocial issues of concern to HPN patients. Chapter 3 provides a detailed description of the current HPN situation in B.C. The study methodology is described in Chapter 4 and the results in Chapter 5. The study is a descriptive analysis. Due to the lack of any obvious control group, a comparative evaluation per se was not possible. However, a Seattle study by Robb, reported in 1983, does allow for some comparison. The main sources of data were: 1. A Patient Questionnaire: The questionnaire was modelled on that used by the Seattle group. 23 B.C. patients, either on HPN at the time of questioning, or previously on the therapy, were surveyed. 19 (83%) responded. 2. A Health Professional Questionnaire: This questionnaire was compiled especially for and sent to all known health care workers in B.C. in the HPN field. 19 professionals, including physicians, nurses, pharmacists, dieticians, and administrators, were surveyed. 17 responded for a response rate of 89%. The patient survey provided basic demographic information, a description of HPN therapy received, as well as data on clinical outcomes, both physiological and psychosocial. Results showed that patient age, length of time on HPN, numbers of hours per week devoted to HPN, occupation and place of residence were the most important variables for predicting patient outcomes. Thus, patients that were older, had been on HPN less than one year, or spent more than 80 hours per week preparing and administering HPN solutions, had more physiological complaints and showed interference with more daily activities and personal relationships. Patients who were employed, rated the HPN experience more positively. Overall, patients found the HPN experience to be a positive one, although this was not true for a small group of patients. Data also indicated that B.C. patients achieved physiological results similar to the Seattle group, and to other centers reported in the literature, but appeared to have more interference with daily activities and personal relationships than did patients from the Seattle study. The health professional survey indicated that professionals considered the current situation in B.C. to be good with respect to patient training and the complication rate achieved. However, patient follow-up and the psychosocial support provided to patients were rated only fair to poor. These health care professionals cited problems with the program's organization, the need to standardize service to all patients, and the need to provide patients with pre-mixed solutions. In conclusion, some recommendations are made for improvement in the B.C. HPN program. / Medicine, Faculty of / Population and Public Health (SPPH), School of / Graduate

The objective of this research is to reveal the implications of the choice of home- and community-based care as opposed to other policy choices and, using a gendered lens, to find a plausible way of assessing the social and economic effects of this care policy for households, families, and centrally for women. Women’s paid and unpaid work, the continuum of paid and unpaid health/care work, care work, the care economy and community care are reviewed, as well as household structure, unemployment and the provision of health and welfare services in South Africa. The costs of unpaid care provision, methods for and issues to do with measuring time-use, and approaches to valuing unpaid care work are also considered. Time-use and financial cost information obtained as part of the 2004 KwaZulu-Natal Income Dynamics Study qualitative study from 19 family caregivers of 17 terminally ill people in 16 households, is the central source of data. The qualitative study employed a modified extended case study method. The psychological, emotional, social and physical costs of unpaid care work are not counted. Instead, caregivers’ labour time spent in unpaid care work is counted and valued using four methods (average earnings, opportunity cost, generalist, specialist), and financial costs to households of unpaid care provision are also counted. In this way unpaid care work is assigned various costs, a necessary step if this work is to be included in policy making processes. The findings are not representative but make possible some speculation about home-based care in KwaZulu-Natal. Findings on financial costs suggest that the welfare grant to the poorest elderly is subsidising the health services. On average 10 hours are spent by household caregivers in unpaid care work per ill person per day, and women are accounting for the bulk of this time. Moreover, in terms of valuing, most appropriate to the poor in KwaZulu-Natal is the generalist method using the proportionate approach and median earnings rates. If family caregivers were paid for the time spent in unpaid care work and households were reimbursed for their financial costs, for 2004/5 using the low estimate it would cost approximately R585 per month per ill person for unpaid care provision that takes place seven days a week and 10 hours per day (R7,619 per month using the high estimate). When multiplied by the number of AIDS-sick people in KwaZulu-Natal, this spending on costed unpaid care provision exceeds the monthly health and welfare spending on home-based care in KwaZulu-Natal for 2004/5 of approximately R2 million by R104,025,512 million if the low estimate is used. These costs are compared to the costs of a selection of similar public and private interventions in South Africa. Without fail the costs of unpaid care provision do not exceed 26 percent of the costs of alternatives. The findings show that the home- and community-based care guidelines have inequality-creating effects: wealthier families may be able to buy in care if necessary, while poorer families have to provide this care themselves. Moreover, government is saving substantially on the health budget by limiting the provision of public inpatient care. Because of the high costs of operation of both high- and low-cost inpatient centres, as well as home-based care as delivered by NGOs/FBOs/CBOs, the potential for these interventions to deliver to all of those in need of such care, when compared with unpaid care provision, is not great from the perspective of a government seeking to cut costs. The findings show that home-based care is cost-effective for government but not for family caregivers who carry the bulk of care costs. Policy options such as payment for caregiving, the basic income grant and expansion of the expanded public works programme are presented. Since family caregivers are meeting a minimum standard of productive participation, it is argued that a citizen based model of social protection be adopted. Finally, what worked and did not work with regard to the study is used to inform recommendations for improved future research on unpaid care work in South Africa. / Thesis (Ph.D.)-University of KwaZulu-Natal, Durban, 2010.

Thesis (M.S.)--University of Michigan, 1986.

Thesis (M.S.)--University of Michigan, 1985.

Thesis (M.S.)--University of Michigan, 1988.

Thesis (M.S.)--University of Michigan, 1986.

Thesis (M.S.)--University of Michigan, 1988.

Thesis (M.S.)--University of Michigan, 1985.

Thesis (M.S.)--University of Michigan, 1991.