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.

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.

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).

Adolescents spend a large proportion of their everyday life in school, and schooling is vital for future success and well-being. One group that are in risk for reduced school success are children with disabilities or long-term illnesses. The aim of this study is to investigate whether the factors age, gender, self-perceived relationship with teachers, self-perceived relationship with peers and parental bonding can predict school engagement of students with self-reported long term health conditions and impairment. School engagement is defined as having three aspects, behavioral, emotional and cognitive. HBSC (Health behaviors in School Children) data from Sweden is used. The result shows that self-perceived relationship with teachers and age are related to all three components of school engagement, behavioral, emotional and cognitive in this study.  Self-perceived relationship with peers is related to emotional school engagement only. Gender is related to cognitive engagement. Parent bonding cannot predict any of the three aspects of school engagement. This study demonstrated that school environment, especially teachers, is important for the school engagement of students with long-term health condition and impairment. Dispite the inconsistent results with previous reseach which focus on typical functioning students, School and educators should focus on how to maintain and improve and promote school engagement of students with long-term health condition and impairment in mainstream school setting.

Made available in DSpace on 2014-06-11T19:32:57Z (GMT). No. of bitstreams: 0 Previous issue date: 2011-02-04Bitstream added on 2014-06-13T19:22:52Z : No. of bitstreams: 1 velosojunior_rr_dr_jabo.pdf: 691663 bytes, checksum: f6b98360dc2bdb01bfaffd1d7739d51e (MD5) / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) / Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) / A importância dos psitacídeos como animais de estimação, o grande número de espécimes criados e os problemas desencadeados pela falta de informações sobre suas necessidades nutricionais em cativeiro, especialmente os aspectos relacionados à saúde a longo prazo das espécies com longa expectativa de vida, têm estimulado a comunidade científica ao aprofundamento sobre este tema. Os objetivos deste trabalho foram avaliar: os efeitos da inclusão de teores crescentes de fibra de cana (0, 7, 14 e 21%) sobre os coeficientes de digestibilidade aparente dos nutrientes, coeficiente de metabolização da energia bruta, energia metabolizável aparente e matéria seca das excretas; os processos de extrusão e peletização na produção de alimentos para araras; e o efeito das rações extrusadas ou peletizadas, com baixo e alto teor de fibra, sobre a ingestão de alimentos, parâmetros de bioquímica sérica e peso corporal. Foram utilizados 24 casais de Araras-Canindé. O ensaio de digestibilidade teve duração de 24 dias e adotou-se delineamento em blocos, com dois blocos de 24 unidades experimentais cada, em esquema fatorial 2 x 4 (dois tipos de processamento x quatro níveis de inclusão de fibra). O ensaio sobre os parâmetros de bioquímica sérica teve duração de 105 dias e foi utilizado delineamento inteiramente casualizado, num esquema em parcelas subdivididas, sendo as parcelas um fatorial (dois processamentos x dois níveis de inclusão de fibra x sexo das araras) e a subparcela, os resultados para o 25º e 130º dias de consumo das rações. Concluiu-se que a inclusão de fibra às rações e a diminuição da energia metabolizável resultam em redução linear na digestibilidade dos nutrientes, elevação no consumo de matéria seca e água, e redução nos níveis séricos de colesterol. Rações peletizadas demonstraramse melhores que as rações extrusadas, com menor... / The importance of parrots as pets, the growing number of specimens kept as pets and the problems caused by the lack of information about their nutritional needs in captivity, especially the aspects related to long-term health of species have a long life expectancy, has stimulated the scientific community to a depth on this topic. Our objectives were to assess: the effects of adding increasing levels of sugar cane fiber (0, 7, 14 and 21%) on apparent digestibility of nutrients, metabolism coefficient of gross energy, metabolizable energy and dry matter excreta, the processes of extrusion and pelletization to produce food for macaws and the effect of extruded or pelleted diets, with low and high fiber content on food intake, serum biochemical parameters and body weight. We used 24 pairs of blue and yellow macaw. The digestibility trial lasted 24 days and adopted block design with two blocks of 24 experimental units each in a factorial 2 x 4 (two types of processing x four levels of inclusion of fiber). The test on the parameters of serum biochemistry lasted 105 days and was used a randomized design in a split plot scheme, and the plots were a factorial (two processes x two levels of fiber x sex of macaws) and sub-plot, 25 th and 130 th days of consumption of rations. It was concluded that the inclusion of fiber in diets and the metabolizable energy decrease results in linear decrease in digestibility of nutrients, high in dry matter intake and water, and reduction in serum cholesterol. Rations proved to be better than the extruded feeds, less feed wastage and greater reduction in serum glucose and cholesterol. Diets for macaws should be based on metabolizable energy. And the reduction in energy and fat content of diets provides reduction in serum glucose, cholesterol and triglycerides, so excess energy and fat causes metabolic damage to Araras. The energy requirement ... (Complete abstract click electronic access below)

This thesis examines the relationship between childhood exposure to air pollution and long-term health. The research is based on an earlier study (1978-1986) that examined the relationship between exposure to air quality and respiratory health for a cohort of elementary school-aged children (n=3,202). These children resided in four distinct neighbourhoods in Hamilton, Ontario, which exhibited significant gradients in air pollution levels. Informed by the Life Course Health Development model, a survey was developed and administered on a reconstructed cohort (n = 395). The following objectives were addressed: 1) to determine the current health status of the reconstructed cohort; 2) to assess the potential relationship between childhood exposure to air pollution and adult respiratory health; and, 3) to explore factors mediating this relationship. Data was collected for a range of variables including residential and occupational histories, socio-demographic variables, and health outcomes. The dataset was merged with data from childhood on respiratory health, exposure to air pollution, and socio-demographic variables. Results indicate that a relatively high percentage of respondents had asthma in childhood (11%) compared to the original cohort (5.5%). In addition, prevalence rates of most health outcomes were higher than those of the Canadian population. Despite the gradient in air pollution levels, there were no significant differences in health status across neighborhoods. However, results of bi-variate and multi-variate analysis indicate possible significant associations between childhood exposure to S02 and hospital visits for asthma, asthma incidence in adulthood, and ever being diagnosed with asthma for females. For males, results suggest that childhood exposure to S02 is not linked to respiratory health. Factors related to the macro and micro environments also play significant roles in long-term health. This thesis made significant contributions to knowledge by suggesting that childhood exposure to S02 may impact long-term respiratory health for females, and may be linked to inflammatory diseases. / Thesis / Doctor of Philosophy (PhD)

Resumo: A importância dos psitacídeos como animais de estimação, o grande número de espécimes criados e os problemas desencadeados pela falta de informações sobre suas necessidades nutricionais em cativeiro, especialmente os aspectos relacionados à saúde a longo prazo das espécies com longa expectativa de vida, têm estimulado a comunidade científica ao aprofundamento sobre este tema. Os objetivos deste trabalho foram avaliar: os efeitos da inclusão de teores crescentes de fibra de cana (0, 7, 14 e 21%) sobre os coeficientes de digestibilidade aparente dos nutrientes, coeficiente de metabolização da energia bruta, energia metabolizável aparente e matéria seca das excretas; os processos de extrusão e peletização na produção de alimentos para araras; e o efeito das rações extrusadas ou peletizadas, com baixo e alto teor de fibra, sobre a ingestão de alimentos, parâmetros de bioquímica sérica e peso corporal. Foram utilizados 24 casais de Araras-Canindé. O ensaio de digestibilidade teve duração de 24 dias e adotou-se delineamento em blocos, com dois blocos de 24 unidades experimentais cada, em esquema fatorial 2 x 4 (dois tipos de processamento x quatro níveis de inclusão de fibra). O ensaio sobre os parâmetros de bioquímica sérica teve duração de 105 dias e foi utilizado delineamento inteiramente casualizado, num esquema em parcelas subdivididas, sendo as parcelas um fatorial (dois processamentos x dois níveis de inclusão de fibra x sexo das araras) e a subparcela, os resultados para o 25º e 130º dias de consumo das rações. Concluiu-se que a inclusão de fibra às rações e a diminuição da energia metabolizável resultam em redução linear na digestibilidade dos nutrientes, elevação no consumo de matéria seca e água, e redução nos níveis séricos de colesterol. Rações peletizadas demonstraramse melhores que as rações extrusadas, com menor ... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: The importance of parrots as pets, the growing number of specimens kept as pets and the problems caused by the lack of information about their nutritional needs in captivity, especially the aspects related to long-term health of species have a long life expectancy, has stimulated the scientific community to a depth on this topic. Our objectives were to assess: the effects of adding increasing levels of sugar cane fiber (0, 7, 14 and 21%) on apparent digestibility of nutrients, metabolism coefficient of gross energy, metabolizable energy and dry matter excreta, the processes of extrusion and pelletization to produce food for macaws and the effect of extruded or pelleted diets, with low and high fiber content on food intake, serum biochemical parameters and body weight. We used 24 pairs of blue and yellow macaw. The digestibility trial lasted 24 days and adopted block design with two blocks of 24 experimental units each in a factorial 2 x 4 (two types of processing x four levels of inclusion of fiber). The test on the parameters of serum biochemistry lasted 105 days and was used a randomized design in a split plot scheme, and the plots were a factorial (two processes x two levels of fiber x sex of macaws) and sub-plot, 25 th and 130 th days of consumption of rations. It was concluded that the inclusion of fiber in diets and the metabolizable energy decrease results in linear decrease in digestibility of nutrients, high in dry matter intake and water, and reduction in serum cholesterol. Rations proved to be better than the extruded feeds, less feed wastage and greater reduction in serum glucose and cholesterol. Diets for macaws should be based on metabolizable energy. And the reduction in energy and fat content of diets provides reduction in serum glucose, cholesterol and triglycerides, so excess energy and fat causes metabolic damage to Araras. The energy requirement ... (Complete abstract click electronic access below) / Orientador: Nilva Kazue Sakomura / Coorientador: Aulus Cavalieri Carciofi / Banca: Carlos Eduardo do Prado Saad / Banca: Manoel Garcia Neto / Banca: Euclides Braga Malheiros / Banca: José Mauricio Barbanti Duarte / Doutor

<p>Syftet med studien är att undersöka huruvida interna och externa variabler påverkar personers friskhet samt utreda hur långtidsfriska skiljer sig från övriga medarbetare. Undersökningen genomfördes med ett frågeformulär bland personal med olika arbetsuppgifter. 150 medarbetare besvarade enkäten. De undersökningsvariabler som ingår i den interna skalan är personlighetsdrag, locus of control, KASAM och optimism. Den externa skalan består av krav, kontroll, stöd, ledarskap samt organisationskultur. Resultatet visar att långtidsfriska är mer optimistiska, stresståliga och självsäkra än övriga. Den interna skalan har ett signifikant samband med långtidsfriskhet och ledarskap är den bästa prediktorn tillsammans med kontroll, optimism och locus of control. En slutsats är att både interna och externa variabler är viktiga för hälsan och för att nå friskhet är det viktigt att arbeta med alla delarna.</p> / <p>The purpose of this study is to investigate whether internal and external variables affect individual’s health and examine how long-term healthy people differ from other co-workers. The examination was carried out with a questionnaire among employees with different work. The internal scale contains variables of personality trait, locus of control, sense of coherence and optimism. The external scale contains demand, control, support, leadership and organizational culture variables. The result shows that long-term healthy people are more optimistic, self-confident and endure stress better than others. The internal scale has a significant relation with long-term health, and leadership is the best predictor for long-term health together with control, optimism and locus of control. One conclusion is that both internal and external variables are important for the health and it is important to work with all parts to achieve health.</p>

Syftet med studien är att undersöka huruvida interna och externa variabler påverkar personers friskhet samt utreda hur långtidsfriska skiljer sig från övriga medarbetare. Undersökningen genomfördes med ett frågeformulär bland personal med olika arbetsuppgifter. 150 medarbetare besvarade enkäten. De undersökningsvariabler som ingår i den interna skalan är personlighetsdrag, locus of control, KASAM och optimism. Den externa skalan består av krav, kontroll, stöd, ledarskap samt organisationskultur. Resultatet visar att långtidsfriska är mer optimistiska, stresståliga och självsäkra än övriga. Den interna skalan har ett signifikant samband med långtidsfriskhet och ledarskap är den bästa prediktorn tillsammans med kontroll, optimism och locus of control. En slutsats är att både interna och externa variabler är viktiga för hälsan och för att nå friskhet är det viktigt att arbeta med alla delarna. / The purpose of this study is to investigate whether internal and external variables affect individual’s health and examine how long-term healthy people differ from other co-workers. The examination was carried out with a questionnaire among employees with different work. The internal scale contains variables of personality trait, locus of control, sense of coherence and optimism. The external scale contains demand, control, support, leadership and organizational culture variables. The result shows that long-term healthy people are more optimistic, self-confident and endure stress better than others. The internal scale has a significant relation with long-term health, and leadership is the best predictor for long-term health together with control, optimism and locus of control. One conclusion is that both internal and external variables are important for the health and it is important to work with all parts to achieve health.

Abstract Background. It is relatively well established in previous research that unemployment has direct health consequences in terms of mental and physical ill health. Recently, knowledge has emerged indicating that unemployment can lead to economic consequences that remain long after re-establishment in the labour market. However, few empirical studies have been able to apply a life course perspective asking whether there are also long-term health consequences of unemployment, and, when and in which context unemployment may affect the individual health status across the life course. The aim of this thesis was to analyse the relationship between unemployment and illness across the life course, and how it relates to individual and structural factors in the geographical setting of northern Sweden. In particular, three main areas have been explored: youth unemployment and illness in adulthood (Paper I and Paper II), contextual unemployment of national unemployment rate and neighbourhood unemployment (Paper II and Paper III) and lastly, social determinants of health inequality between employment statuses (Paper IV). Methods. This thesis is positioned in Sweden between the early 1980s and the mid-2010s, following two comparable cohorts sampled from northern Sweden (26 and 19 years follow-up time respectively from youth to midlife) and a cross-sectional sample from 2014 of the four northernmost counties in Sweden. The two longitudinal cohorts comprised the Northern Swedish Cohort and the Younger Northern Swedish Cohort, consisting of all pupils in the 9th grade of compulsory school in Luleå municipality in 1981 and 1989. The participants responded to an extensive questionnaire on socioeconomic factors, work and health, in 5 and 2 waves respectively of data collections. Neighbourhood register data from Statistics Sweden was also collected for all participants in the Northern Sweden Cohort. At the latest data collection, 94.3% (n=1010) participated in the Northern Sweden Cohort and 85.6% (n=686) in the Younger Northern Sweden Cohort. The cross-sectional study Health on Equal Terms is a national study, administered by the Public Health Agency together with Statistics Sweden and county councils with the aim of mapping public health and living conditions in the country over time. In this thesis, material from 2014 has been used for northern Sweden with a response rate of around 50% (effective sample n=12769). The statistical analyses used were linear regression, multilevel analysis and difference-in-difference analysis to estimate the concurrent and long-term health consequences of unemployment, and a decomposition analysis to disentangle the inequality in health between different labour market positions. The health outcomes in focus were functional somatic symptoms (the occurrence of relatively common physical illnesses such as head, muscle and stomach ache, insomnia and palpitation) and psychological distress. Results. Among men only, as little as one month of youth unemployment was related to increased levels of functional somatic symptoms in midlife, regardless of previous ill health or unemployment later in life, although only during relatively low national unemployment (pre-recession) when comparing with youth unemployment during high national unemployment (recession). This was explained by the health promoting effect of more time spent in higher education during the recession period. Furthermore, the health impact of neighbourhood unemployment highlights the importance of the contextual setting for individuals’ health both across the life course and at specific periods of life. Lastly, employment-related mental health inequalities exist for both men and women in all life phases (youth, adulthood and midlife). Economic and social deprivation related to unemployment and illness varied across different phases in life and across genders. Conclusion. The key findings of this thesis paint a rather pessimistic vision of the future: one’s own and others’ unemployment may cause not only ill health today but also ill health later in life. Importantly, the responsibility of unemployment and the associated ill health should not be placed on the already marginalised individuals and communities. Instead, the responsibility should be directed towards the structural aspects of society and the political choices that shape these. In other words, health inequality manifested by the position in the labour market is socially produced, unfair and changeable through political decisions. The results of this study therefore cannot contribute to any simple or concrete solutions to the concurrent or long-term health consequences of individual or contextual unemployment, as the solution is beyond the areas of responsibility and abilities of research. However, if there are long-term health consequences of one’s own and other people’s unemployment, labour market and public health policies should be initiated from a young age and continue throughout the life course to reduce individual suffering and future costs of social insurance, sick-leave and unemployment benefits.