京都大学 / 0048 / 新制・課程博士 / 博士(農学) / 甲第19243号 / 農博第2140号 / 新制||農||1036(附属図書館) / 学位論文||H27||N4947(農学部図書室) / 32242 / 京都大学大学院農学研究科応用生物科学専攻 / (主査)教授 今井 裕, 教授 祝前 博明, 教授 松井 徹 / 学位規則第4条第1項該当 / Doctor of Agricultural Science / Kyoto University / DFAM

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Thesis advisor: Karen S. Lyons / OBJECTIVES: Individuals with severe persistent mental illness (SPMI), also referred to as serious mental illness (SMI), experience significant inequities in health care access and outcomes. These inequities may span the lifetime of an individual living with SPMI, and include poorer cancer outcomes, shorter lifespans, barriers to having their needs met in long-term care, and a decreased likelihood of receiving hospice care when indicated. The purpose of this dissertation was to explore the causes of the disproportionately poor health outcomes for individuals living with SPMI and describe current facilitators and barriers to providing care to this vulnerable population. METHODS: A qualitative descriptive study was carried out to explore health care professionals’ perception of the needs of long-term care residents with SPMI and chronic medical conditions. and barriers and facilitators to meeting the needs of this population. A narrative review was performed to identify what is currently known about cancer symptom clusters in individuals with schizophrenia. Lastly, an integrated review was conducted to identity factors associated with hospice use by individuals with SPMI and potential barriers to use of hospice services. RESULTS: Ten health care professionals were interviewed for the qualitative study. The themes that emerged were: coming to know the individual and their unique needs takes time; being flexible and adapting approaches facilitates trust; respecting the inherent worth of each person contributes to caring. Participants described the importance of a person-centered approach when caring for long-term care residents with SPMI and chronic medical conditions. The narrative review of current literature pertaining to cancer symptom clusters in individuals with schizophrenia revealed that this phenomenon has been sparsely represented in research. No data directly pertaining to cancer symptom clusters in this population were identified. Data describing the related phenomena of health conditions that may influence cancer risk and outcomes, physical experiences of cancer, and emotional and behavioral symptoms which may impact ability to tolerate cancer treatments were identified. The integrated review of literature describing factors associated with hospice use among individuals with SPMI found that hospice and palliative care services may not be utilized by individuals with SPMI due to system-level barriers such as inadequate patient-provider communication, fragmented care, and absence of discussions around end-of-life care. CONCLUSIONS: Systemic problems such as miscommunication, fragmentation of care, and stigma contribute to the health inequities experienced by individuals living with SPMI. Nurses and other health care providers can work to ameliorate these systemic problems by promoting and participating in collaborative care models and utilizing assessment techniques appropriate to individuals who may have difficulty communicating about their health-related symptoms. Individuals with SPMI should be offered opportunities to participate in research when appropriate so that they may benefit from newer treatments for disease, and health care providers may improve their understanding of how to address the medical needs of this population. / Thesis (PhD) — Boston College, 2022. / Submitted to: Boston College. Connell School of Nursing. / Discipline: Nursing.

<p>The project explores decision making in the context of end-of-life (EOL) care choices among adults with few social and economic resources. Although most American adults believe that planning for EOL is important, only about 30% report making formal EOL plans such as Advance Directives, wills, trusts, or any other formal documentation. Using qualitative methodology, 25, participants who were all living at the same long term care facility, were interviewed during two different waves of data collection. The transcribed interviews were analyzed using thematic analysis and guided by Normative Rhetorical Theory framework. Remarkable conclusions were that without social and economic resources, participants reported they did not make choices about EOL and care, but rather their decisions were made by default.</p>

Indiana University-Purdue University Indianapolis (IUPUI) / Anatomy Academy (AA) is a service-learning program in which pre- and current health professional students (Mentors) work in pairs to teach anatomy, physiology, and nutrition to children in the community. The purpose of this study was to investigate the short- and long-term Mentor outcomes in personal, social, civic, academic, and professional domains. Former Mentors were invited to complete a survey of Likert-style and free response questions evaluating the perceived impact of their AA experience on: teaching skills, personal and interpersonal development, civic engagement, and academic and professional development. Follow-up interviews with a subset of survey respondents were performed. The survey was completed by 219 Mentors and 17 survey respondents were interviewed. Over 50% of former Mentors reported moderate or major impact of AA participation on elements of personal and interpersonal development (e.g., selfesteem [57.6%], altruism [67.9%], communication skills [60.1%], and ability to work with others [72.6%]) and community service participation (54.2%) that endures in the years after the program. Mentors who worked with low-income or Special needs populations reported unique impacts in personal, interpersonal, and civic domains. A majority of former Mentors agreed that AA participation helped them learn practical skills (76.3%) and factual knowledge (65.4%) relevant to the their careers, with several current health professionals reported that they regularly employ teaching and interpersonal skills learned while Mentors in their roles as physicians, nurses, or physician’s assistants. A majority of former Mentors reported that AA validated their choice to either pursue a healthcare career or not (59.7%), increased their confidence in performing professional tasks (64.7%), and helped shape their professional identity (58.9%). These results indicate that a health education-based service-learning program offers undergraduate, graduate, and professional students interested in or actively pursuing a healthcare career benefits across personal, interpersonal, civic, and professional domains that support their academic progress and preparation for professional practice. This study contributes much-needed evidence of the long-term student outcomes of service-learning to the literature, with a particular focus on how the pedagogy can supplement the education and professional development of pre- and current health professional students.

The population of elderly people in the United States is predicted to increase in large numbers within the next few decades. Many of them will be admitted to long-term-care centers in the waning years of their lives. Health care professionals will need to be prepared for this influx of the elderly into these institutions and for their demands of improved quality of life in these centers. Unplanned weight loss has become one of the major predictors of mortality in long-term-care residents. The purpose of the study was to compare the use of liberalized diets with the traditional therapeutic diets long advocated in long-term-care facilities in the United States. The objectives were to conduct a randomized clinical trial with a treatment group (subjects who consumed liberalized diets) and a control group (subjects who continued with their usual therapeutic diets), and to compare outcomes between the two groups. The randomized clinical trial was conducted for 18 weeks from April to August 2009 at a long-term-care facility in rural North Mississippi. Twenty-two persons ranging in age from 54 to 100 years were approved by their physicians for participation in the trial. All of these persons participated and completed the trial. Eleven of the participants received their prescribed therapeutic diet and 11 participants received a liberalized diet for the length of the trial study. At the end of the study, there were no significant differences (p>0.05) in mean body weights and laboratory values between the two groups. However, there was a trend of weight loss in the therapeutic diet group (mean weight loss of 2% (1.4 kg) during the 18-week trial), and although it was not significant (p>0.05), this supports the growing belief of those who advocate liberalized geriatric diets to improve quality of life and prevent unintentional weight loss. Participants in the liberalized diet group did not experience weight loss and gained 0.5 kg by the end of the study.

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This paper examines the funding procedure in Ontario long-term care facilities and seeks to identify whether current resources for protecting the elderly from mistreatment is allocated fairly and effectively. The research also observes how the political economy may influence the needs-based allocation built to protect seniors from mistreatment in institutional care settings and the consequences of these resources on residents’ autonomy. The topic is also viewed through the lens of the current COVID-19 pandemic. Five experts in the area of long-term care participated in this research work including academics, scholars and institutional or agency advocates. Interviews lasting up to 60 minutes interviews were conducted, transcribed and analyzed using a political economy lens. Participants described their knowledge and experience with the funding procedure for long term-care facilities, particularly in Ontario and provided their view on areas that they felt could be improved. The analysis identified four themes including whether the issue is under-resourced, poor allocation of resources; funding according to need; the struggle to define and assess the quality of care; and general work conditions in long-term care. The result of this research will help us to better understand the resource allocation of Ontario long-term care facilities which could in turn highlight improvements that could be made to create better quality of life for residents as well as frontline workers. / Thesis / Master of Arts (MA) / This paper examines the funding procedure in Ontario long-term care facilities and seeks to identify whether current resources for protecting the elderly from mistreatment is allocated fairly and effectively. The topic is viewed through the lens of the COVID-19 pandemic. The analysis of the five expert interviews identified four themes including whether the issue is under-resourced, poor allocation of resources; funding according to need; the struggle to define and assess the quality of care; and general work conditions in long-term care. The result of this research will help us to better understand the resource allocation of Ontario long-term care facilities which could in turn highlight improvements that could be made to create better quality of life for residents as well as frontline workers.

Introduction: Long term care (LTC) residents require complete or extensive support, including 24-hour nursing and personal care. LTC residents contribute a greater number of emergency department (ED) visits when compared to community-dwelling older adults. Little is known about which resident-level characteristics at admission are predictive of LTC resident transfer to the ED. The objective of this thesis was to identify which admission characteristics are associated with ED transfers in Ontario, Canada. Methodology: I conducted a population-level retrospective cohort study using the Resident Assessment Instrument Minimum Data Set Version 2.0 (RAI-MDS). The cohort included 56,433 LTC resident admission assessments from January 1, 2017, to December 31, 2018. Logistic regression and 10-fold cross-validation were used to identify adjusted associations between characteristics routinely collected during LTC admission assessment and ED transfers. Model performance was assessed using the area under the receiver operating characteristics curve (AUC). Outcomes of interest included any ED use, potentially preventable, and low acuity ED transfers. Results: A recent change in medical orders, previous ED visitation, female sex, the presence of an indwelling catheter, and the need for oxygen therapy were informative predictors for any, potentially preventable, and low acuity ED transfers. Deterioration in cognitive status and change in behavior was influential to any ED transfers only. Urinary tract infections, pneumonia, indictors of delirium, and change in mood are unique to potentially preventable ED transfers, and antibiotic resistance is unique to low acuity ED transfers. Similar discrimination was reached for any ED use (AUC = 0.630), potentially preventable transfers (AUC = 0.659), and low acuity transfers (AUC = 0.645). Conclusion: The factors associated with ED transfers may be modifiable, and closer attention to these factors may help reduce ED transfers. Although the discriminability of the models was poor, advanced knowledge of informative characteristics can support upstream decision-making for clinicians. Future studies are required to validate these findings, derive risk scales, and demonstrate the utility of this model in health service planning. / Thesis / Master of Science (MSc) / Long term care (LTC) provides residents with 24-hour nursing and personal care. When the care or clinical needs of the resident cannot be met in the LTC facility, they may be transferred to the Emergency Department (ED). However, the ED’s are poorly situated to manage the distinct needs of older adults, given the sole focus on medical acuity rather than geriatric complexity. Unwarranted ED transfers are burdensome for LTC residents and increase their risk for adverse health events, such as nosocomial infections, delirium, and injuries. Understanding characteristics associated with ED transfers can help identify which residents may be at a risk of an ED transfer. The objective of this thesis was to identify which LTC resident characteristics at admission are associated with ED transfers in Ontario, Canada. A recent change in medical orders, previous ED visitation, female sex, the presence of an indwelling catheter, and the need for oxygen therapy were informative predictors for ED transfers.