Thesis (M.A.)--Regis University, Denver, Colo., 2009. / Title from PDF title page (viewed on Jun. 29, 2010). Includes bibliographical references.

Background: In South Africa, tuberculosis (TB) is the leading cause of death, and Cape Town is among the three cities in the country with the highest TB burden. Despite implementation of Directly Observed Treatment Short-Course (DOTS), and improvements in the organisation and delivery of TB care, poor treatment adherence challenges treatment outcomes and the health system's ability to reach international targets. TB requires long-term care, where the relationship with healthcare providers is one of the important influences on decisions to seek care and adhere to treatment. This study sought to explore and deepen insight into how trust is built and experienced between patients and healthcare providers for TB treatment in primary care settings from a gender perspective. Methods: The research was located in three local government-managed clinics in the City of Cape Town's Metropole health district, similar in TB patient load and performance indicators, but differing in level of TB-HIV integrated services. A case study design employing qualitative data collection approaches (non-participant observations in clinics, focus group discussions and in-depth interviews with patients and providers) was applied. Findings: Trust plays a central role for both patients and providers in treatment for TB. On the part of patients, many expressed a deep desire and motivation to complete their treatment. However, patient vulnerability, a complex outcome of intersecting factors at all levels (personal, community and health service level), across which gender was an underlying influence, emerged as a critical influence over patient trust in providers and the health system, with consequences for a range of outcomes including treatment adherence. The ability of providers and the health system as an institution to recognise and respond to patient vulnerability and needs beyond the illness, including to access socio-economic and psycho-social support for the patient, was critical for building trust and enabling adherence. On the part of healthcare providers, vulnerability was a consequence of a range of factors, including professional status and gender, with implications for how trust was built in patients and managers and its outcomes. Patient trustworthiness was based on judgements of competency, integrity and recognition. The ability of managers to mitigate the challenges healthcare providers faced, through providing a supportive and enabling work environment, had implications for providers' experiences and judgements of institutional trustworthiness. Conclusion: Reflecting on the findings within broader national, provincial and global health policy reforms, specific strategies for building patient and provider trust in each other, and in the health system, are proposed. Recommended strategies addressing both patient and provider vulnerabilities rooted in the personal, community and health facility environment are considered. While many of the recommendations are specific to the TB and TB/HIV model of care, they have wider relevance for building mutual trust between patients and providers and enhancing the responsiveness of the health system as a whole. This is important in the context of South Africa, where the vision espoused under proposed National Health Insurance reforms towards universal coverage is transformative, even revolutionary, but its implementation and ultimate achievements are likely to be dogged by challenges of patient and provider trust in the health system, unless themselves addressed. Globally, the study's conclusions also offer important insights about patient-provider trust relevant to health system development, as well as ideas for future, related research.

Aim: The overall aim of the thesis is to investigate whether a new care-model can be introduced – in which patients with primary care needs and not in need of hospital emergency department care can be referred directly to a healthcare centre – and respond to the patient’s need of trust and patient safety.   Methods: The four sub studies employ different methods: three are quantitative with varying approaches and one is qualitative. Sub study I is a retrospective explorative register study aimed to identify characteristics and frequency. Sub study II is an instrument development study aimed to measure patient trust. Sub study III is a randomized controlled trial, which compared the level of patient trust and patient-safety among low-priority ambulance patients who were randomized into two groups: the experimental group (care at the healthcare centre) and the control group (traditional care at Emergency department). Finally, sub study IV is a hermeneutic lifeworld study based on interviews with patients who participated in the new care model.   Main results: Sixteen percent of the patients to whom an ambulance was allocated could have received care at a healthcare centre instead of an emergency department. They were slightly younger and healthier as regards their histories, but were found at all priority levels and with almost all symptom codes. Patient trust in care did not differ regardless of whether they were cared for at a healthcare centre or at the emergency department. However, 59 patients of 188 overall (31%) fulfilled one or more of the given criteria for potentially reduced patient safety. The phenomenon of trust does not automatically involve medical care. However, attention to the patient’s lifeworld in a professional caring relationship enables the patient to trust the caregiver and the healthcare environment. It is clear that the “voice of lifeworld” enables the patient to feel trust.  Conclusion: One in six patients allotted an ambulance may get taken to primary care instead of the hospital emergency department. These patients are found at all priority levels and in most of the symptom codes.  An instrument has been developed that measures patient trust in the prehospital chain of care (Study I). The instrument has proved to be useful in this patient group and is based on two dimensions: Credibility and Accessibility (Study II). Patients’ trust in the prehospital care chain proved to be high and bore no relation to where they received care. Patient safety, on the other hand, appeared to be limited in view of the fact that an excessive proportion of patients were exposed to potential patient safety risks (Study III). Communication that appeals to a patient's lifeworld increases the opportunities for understanding and participation. In all, lifeworld communication creates trust in care at the right level of care as well as in care relationships and the healthcare environment (Study IV).

To address emerging challenges in empowering patients through telehealth, this dissertation has the following objectives: (a) find the key characteristics that enable patient empowerment [PE], (b) determining when will PE work as a solution, (c) find the optimal telehealth care method that enables PE, and (d) evaluate the impact of telehealth on health care outcomes (such as, patient satisfaction, patient trust with primary care providers, etc.) that ultimately enhances PE. These objectives are addressed in three studies presented here as three essays. Collectively, these essays contribute to the knowledge on PE, patient trust, and telehealth by providing insights on leveraging PE towards better health care services and delivery systems. Essay 1 aims to systemically map the concept of PE using principles of systems thinking with the Boardman soft systems methodology that enables a graphical visualization (i.e., systemigrams). Essay 2 investigates the practical and theoretical implications of connecting patients to empowerment care plans and minimizing wait times in healthcare service delivery using electronic prescriptions (s-scripts), phone calls, and video calls. In Essay 3, the mediating role of telehealth services between patient empowerment and patient satisfaction was analyzed, along with patient trust was assessed as a moderator between telehealth usability and patient satisfaction. Two hundred sixty-two responses from patients in North America with chronic illnesses were collected through an online survey questionnaire were analyzed using partial least squares-structural equation modeling (PLS-SEM). The findings of the research show that patients with chronic illnesses in North America feel empowered by using telehealth as they can get diagnosis of the illness even in remote areas and face no obstacle.