The aim of this study was to investigate met and unmet palliative care needs for people living with HIV/AIDS in selected areas in Rwanda. The achieve this aim, the study, firstly, identified the palliative care needs of people living with HIV/AIDS, secondly, it identified the health care services available to meet these needs, and thirdly, it determined the extent to which palliative care needs were met.

It is estimated that nearly 14.5 million Americans are living with cancer today. A commonly overlooked component to quality cancer care, as defined by the Institute of Medicine, is the role of psychological and social support. Better known as psychosocial support, these needs reflect a broad spectrum of obstacles or assets in an individual’s personal life that may help or hinder their healing experience. Some psychosocial examples include coping skills, transportation to medical appointments, or appropriate knowledge to mitigate the physical impacts of the cancer process. Research has shown that by addressing these potential needs, a better health outcome may be achieved for cancer patients. Through participant observation at local psychosocial service establishments and through semi-structured interviews with service providers and adults diagnosed with cancer living in the Dallas-Fort Worth region, this thesis research seeks to explore how local cancer patients are learning of psychosocial services available to them, what barriers may exist in accessing these services, and what individuals may be doing to address their psychosocial needs, both formally or informally. Results yielded recommendations for local psychosocial providers to adjust their marketing of services and kinds of services offered as well as yielded recommendations for future academic research.

Submitted in fulfillment of the requirements for the Degree in Masters of Technology in Nursing, Durban University of Technology, Durban, South Africa, 2015. / Introduction Tuberculosis is still a leading cause of deaths in low and middle income countries especially those of Sub-Saharan Africa. The successful implementation of strategies to improve TB outcomes remains critical for South Africa as the country is faced with the burden of many TB related deaths. South Africa has included TB management as a priority programme for the country in its strategies to the achieve millennium development goals. The National Department of Health introduced the CCG programme to assist professional health workers in the control and management of various health conditions including TB. The competent management of the CCGs is central to meeting service delivery objectives. Aim of the study The aim of the study was to explore and describe the experiences of community care givers caring for TB clients. Methodology A qualitative, exploratory, descriptive design was used to conduct the study. Purposive sampling was used to recruit 24 community care givers that were employed by Department of Health receiving a stipend and had been working as community care givers for at least two years. Data was collected using semi structured interviews and was subsequently analysed using Tesch’s method of data analysis Results The themes that emerged from the interviews included: accessibility of kits and protective clothing to the CCGs, their safety and security, training and development, ii including financing of the CCG programme. The following sub-themes emerged as part of the themes: Insufficient supply of kits, alternative means of making kits available to the CCG’s, promotion and supply of uniforms for the CCGs, procurement and supply of protective clothing, alternative ways of getting protective clothes, vaccination against communicable diseases, safety allowance, transparency on criteria for further training and development, age limits regarding the selection of the CCGs, lack of career pathing, stipend received by the CCGs and employment benefits for the CCGs. Recommendations Recommendations were made with regards to institutional management and practice, policy development and implementation, and further research. These included establishing processes for: supply of kits, protective clothes and vaccines, pre and periodical medicals, criteria for further training and development, and issuing of stipend. A broader study involving all the CCGs affiliated to all PHC clinics in eThekwini district on the required support and supervision was also recommended. / M

A Masters Dissertation submitted to the Department of Speech Pathology and Audiology School of Human and Community Development, Faculty of Humanities University of Witwatersrand Johannesburg, in fulfillment of the requirements for the degree Master of Arts in Speech Pathology, November 2017 / Background: Traumatic Brain Injury (TBI) is a serious public health problem worldwide. It is a major cause of death among younger adults and is a leading cause of lifelong disability in persons who survive it. There are a large number of young adults living with life-long disabilities as a result of traumatic brain injury worldwide, with higher numbers existing in South Africa. Whilst previous research internationally has examined issues of community integration and difficulties experienced by persons with traumatic brain injury and their significant others or caregivers, a paucity of research of this nature exists in South Africa. This study intended to explore whether a gap in clinical practice exists with regard to aspects of intervention and support, underpinned by an ambiguous definition of community integration for survivors of traumatic brain injury and their significant others Method: The main aim of the study was to explore existing feelings of community integration and active participation in patients with traumatic brain injury who have been discharged from rehabilitation services in private practice in Johannesburg, South Africa. In this study, the sample comprised of 10 survivors of TBI and 10 significant others (SOs). The objectives were to describe and compare participants and significant others’ or caregivers experience of community integration and factors that influenced the perceptions by each (i.e. the patient and the caregiver) as well as to document barriers and facilitators to community integration and active participation within the, familial, social and work context. Lastly the study aimed to determine if the qualitative analysis of formal assessment measures (FIM and CIQ-R) match perceptions of persons with TBI with regard to Community Integration (Landrum et al., 1995). Results: Across various areas of comparison, participants who scored higher in the CIQ-Rand FIM measures, often expressed more subtle difficulties or challenges that landed up going undetected and ultimately contributed to their personal feelings of poorer community integration. Various studies, including the current study reveal that significant others have many unmet needs in terms of what they know and what they should expect with regard to handling their loved one with a TBI. Implications: This research has highlighted the fact that our South African context is lacking with regard to ongoing management of individuals surviving TBI, with reduced funding available for outpatient therapies, a lack of post discharge programmes and a general lack of education and information given to family members of TBI survivors upon discharge. As such this should be a major focus of health care providers in the future. This research revealed many subtleties that impact perceptions of community integration but go undetected by formal measures. Such subtleties could be used to direct specialised programmes, which should be made available to TBI survivors post discharge from rehabilitation services. Keywords: traumatic brain injury; community integration; rehabilitation; functional outcomes; private practice, developing countries, community resources, south Africa / XL2018

A research report submitted in partial fulfilment of the requirements for the degree of Master of Arts in Social and Psychological Research to the Department of Psychology, School of Human and Community Development, The University of the Witwatersrand, Johannesburg, South Africa, 2017 / Introduction. The provision of appropriate long term care facilities for people with acquired brain injury is a portentous issue internationally. There is a global lack of long term care facilities for people with acquired brain injury and they are often placed in facilities for the physically disabled or the elderly. It is unclear whether these facilities are suitable and what effect they may have on well-being and social isolation. Aim. This interpretive phenomenological study explored how adults with acquired brain injury experience living in such long term care facilities. Additionally, it described how such living arrangements impact on social isolation, a particularly devastating psychosocial consequence of acquired brain injury. Method. One-on-one, semi-structured interviews were conducted with seven adults who had acquired a brain injury. Each participant had been living in a long term care facility for at least one year. They were asked questions related to their general lived experience as well as specific questions to explore their experience of social isolation. Findings. Thematic content analysis of the interview data led to the following five categories of themes: overall evaluations (guarded approval, and disapproval); general lived experience (autonomy, choice, freedom, burden, boredom, and basic needs); social isolation (loneliness, companionship, and belonging); sources of isolation (living with the disabled, different disability, age differences, pets, and facility setup); and sources of well-being (positivity, and meaning). The main findings were that the general lived experience of people with ABI was mainly negative. The facilities generally met only basic needs and seldom met higher level psychological needs. Social isolation was commonly reported among residents with ABI in long term care facilities and was linked to age differences and having a brain injury in a facility geared for people with other disabilities. The findings were understood in relation to Bronfenbrenner’s ecological systems theory and Maslow’s hierarchy of needs. Conclusions. The findings of this study contribute towards filling a theoretical gap in understanding the lived experience of people with ABI in long term care facilities and how this contributes to social isolation. The findings have potential value to family members of people with acquired brain injury considering various living arrangement options. They can also be useful for long term care facilities housing people with brain injury to make changes that may result in greater well-being of their residents. / MT 2018

This study investigates the relationship of three protective factors : self transcendance, social interest, and spirituality to well-being among adults living with HIV or AIDS. It is the first study to explore the relationships of these protective factors to well-being. A convenience sample of 115 adults living with HIV or AIDS completed the Self-Transcendance Scale, the Social Interest Index- Short Form-Revised, the Spiritual Perspective Scale, and the Index of Well-Being. The participants were adults diagnosed with HIV or AIDS residing in a large southeastern U.S. city. Data were analyzed with correlational and multiple regression methods. Statistically significant positive moderate to strong relationships were found between well-being and self transcendance (r=.66, p<.001 ), social interest (r=.51, p<.001), and spirituality (r=.39, p<.001). A stepwise regression demonstrated that self transcendance held the highest variance on well-being among the three protective factors (43%). Additionally, self-transcendane and social interest accounted for 45% of the variance in well-being. In short, the hypothesized positive relationship among these protective factors with well-being was supported. This study provides theoretical and empirical support for linking self transcendance, social interest, and spirituality to well-being among adults living with HIV or AIDS. The clinical implications of these findings are also discussed. / by Jonathan J. Sperry. / Thesis (Ph.D.)--Florida Atlantic University, 2011. / Includes bibliography. / Electronic reproduction. Boca Raton, Fla., 2011. Mode of access: World Wide Web.

The elderly population is growing in nursing homes (NHs), with an estimated 3 million seniors to be residing in NH facilities by year 2030. Many of these seniors are potentially at risk for falls or infections. NH residents with Alzheimer’s disease or other forms of dementia are also increasing, and they are vulnerable to the adverse effects of medications. Psychotropics are overused in NHs, with approximately half to two thirds of residents receiving one or more psychotropics. Many negative health outcomes, e.g. falls and infections, have been associated with their use. The usage of psychotropic medications among NH residents has been a concern and topic of scrutiny for nearly three decades. In 1986, the Institute of Medicine published a landmark report that identified the overuse of psychotropic medications in NHs. The following year, the federal government passed the Omnibus Budget Reconciliation Act that included reform legislation to address psychotropic drug overuse. Since then, additional policies and initiatives have endeavored to rectify the problem, and scientists have conducted research regarding psychotropics and negative health outcomes. However, newer research within the last decade and at a national level is lacking. Therefore, this dissertation explores the association of psychotropic medications with falls and infections among NH residents using a national dataset, and this document is organized into five chapters. The first chapter discusses the background, significance, and current challenges surrounding psychotropic medication use in NHs. The second chapter delineates the search of the literature and relevant findings. The third chapter describes the methodology upon which this analytics of this dissertation was conducted. The fourth chapter outlines the results from the analyses. Lastly, the fifth chapter provides a synthesis and discussion of the findings and recommendations for health policy, practice, and future research.

Hospitalizations are a major driver of Medicare spending and adverse outcomes for the 5.3 million elderly Americans with dementia. This is a growing problem given aging and longevity trends. Within the home health care setting, about 3.5 million mostly frail elderly Medicare beneficiaries receive care and 27% are hospitalized annually. Estimates of dementia prevalence range from 31 to 60%, yet little is known about the hospitalization of home health care patients with dementia. This study addresses knowledge gaps on the prevalence, characteristics, hospitalization rate and risk factors of these patients, and explores whether hospitalization risk factors are moderated by dementia. A systematic literature review on hospitalization risk factors in the home health care setting was completed and the findings informed the selection of variables and hypotheses for this study. This was a retrospective cohort study and the sample was patients admitted to one large non-profit home health care agency during 2014 (n=57,888). Data were from the Outcome and Assessment Information Set and other home health agency data captured at the start of care. The conceptual framework guiding the analysis was Andersen’s Behavioral Model of Health Services Use. Because more than half of those who would meet clinical criteria for dementia are undiagnosed, the operational definition of dementia for this study was a diagnosis of dementia or Alzheimer’s disease, or an indication of cognitive impairment in the start of care assessment. Multivariable logistic regression was used to identify characteristics of dementia patients and hospitalization risk factors, and to explore dementia as a moderator of hospitalization risk factors. Prevalence of dementia among the study sample was 41.6%. Consistent with prior studies on the general dementia population, older age, Black and Hispanic race/ethnicity, Medicaid eligibility, fall risk, congregate living, more comorbidities, behavioral symptoms, depression, assistance with activities of daily living, and communication disabilities were associated with dementia. However, contrary to prior studies, serious health status, higher need for assistance with activities of daily living, and higher use of health services were negatively associated with dementia. The hospitalization rate for patients with dementia (12.9%) was significantly higher than the rate for patients without dementia (10.7%). Hospitalization risk factors of dementia patients that were consistent with prior studies among home health patients included male gender, Black race, Medicaid eligibility, number of comorbidities, higher need for assistance with activities of daily living, cardiovascular conditions, dyspnea, cancer, diabetes, renal disease, skin ulcers and higher health services use. The moderator analysis found that dementia attenuated the effect of some hospitalization risk factors and had no effect on others. This study was a first step toward better understanding the characteristics and hospitalization risk factors of home health care patients with dementia. Findings from this research can inform practice, policy and future research on home health care patients with dementia.

Background: Cancer treatment and management require complicated clinical decision making to provide the highest quality of care for an individual patient. This is facilitated in part with ever-increasing availability of medications and treatments but hindered due to barriers such as access to care, cost of medications, clinician knowledge, and patient preferences or clinical factors. Although guidelines for cancer treatment and many symptoms have been developed to inform clinical practice, implementation of these guidelines into practice is often delayed or does not occur. Informatics-based approaches, such as clinical decision support, may be an effective tool to improve guideline implementation by delivering patient-specific and evidence-based knowledge to the clinician at the point of care to allow shared decision making with a patient and their family. The large amount of data in the electronic health record can be utilized to develop, evaluate, and implement automated approaches; however, the quality of the data must first be examined and evaluated. Methods: This dissertation addresses gaps the literature about clinical decision making for cancer care delivery. Specifically, following an introduction and review of the literature for relevant topics to this dissertation, the researcher presents three studies. In Study One, the researcher explores the use of clinical decision support in cancer therapeutic decision making by conducting a systematic review of the literature. In Study Two, the researcher conducts a quantitative study to describe the rate of guideline concordant care provided for prevention of acute chemotherapy-induced nausea and vomiting (CINV) and to identify predictors of receiving guideline concordant care. In Study Three, the researcher conducts a mixed-methods study to evaluate the completeness, concordance, and heterogeneity of clinician documentation of CINV. The final chapter of this dissertation is comprised of key findings of each study, the strengths and limitations, clinical and research implications, and future research. Results: In Study One, the systematic review, the researcher identified ten studies that prospectively studied clinical decision support systems or tools in a cancer setting to guide therapeutic decision making. There was variability in these studies, including study design, outcomes measured, and results. There was a trend toward benefit, both in process and patient-specific outcomes. Importantly, few studies were integrated into the electronic health record. In Study Two, of 180 patients age 26 years or less, 36% received guideline concordant care as defined by pediatric or adult guidelines, as appropriate. Factors associated with receiving guideline concordant care included receiving a cisplatin-based regimen, being treated in adult oncology compared to pediatric oncology, and solid tumor diagnosis. In Study Three, of the 127 patient records reviewed for the documentation of chemotherapy-induced nausea and vomiting, 75% had prescriber assessment documented and 58% had nursing assessment documented. Of those who had documented assessments by both prescriber and nurse, 72% were in agreement of the presence/absence of chemotherapy-induced nausea and vomiting. After mapping the concept through the United Medical Language System and developing a post-coordinated expression to identify chemotherapy-induced nausea and vomiting in the text, 85% of prescriber documentation and 100% of nurse documentation could be correctly categorized as present/absent. Further descriptors of the symptoms, such as severity or temporality, however, were infrequently reported. Conclusion: In summary, this dissertation provides new knowledge about decision making in cancer care delivery. Specifically, in Study One the researcher describes that clinical decision support, one potential implementation strategy to improve guideline concordant care, is understudied or under published but a promising potential intervention. In Study Two, I identified factors that were associated with receipt of guideline concordant care for CINV, and these should be further explored to develop interventions. Finally, in Study Three, I report on the limitations of the data quality of CINV documentation in the electronic health record. Future work should focus on validating these results on a multi-institutional level.

This thesis covers research around the Medical Emergency Team (MET) system, describing its development, evaluation and other related research that evolved as a result of the MET concept. The basic problem that prompted development of the MET system was related to the inadequate care given to the seriously ill in acute hospitals. This thesis contains background research on some of the reasons why a MET system may be useful, including the limited skills and knowledge of medical training and the sort of acute problems encountered in a hospital at night. Research then describes how the MET system works, including published data on when and how often the team is called, the type of patient the team is called to, the interventions performed by the team, and the outcome of patients on whom a MET was called. At the same time research was being performed around outcome indicators used to measure the effectiveness of the MET system, resulting in the use of cardiac arrests, deaths and unanticipated admission to the Intensive Care Unit (ICU) as common end-points for research in this area. Further research demonstrated that potentially preventable antecedents were common before serious illness The thesis then concentrates on how effective the MET system was in reducing death and serious adverse events. The first study compared a hospital where a MET system had been implemented to two control hospitals and found there was a reduction in admissions to the ICU but after adjustment, not for deaths and cardiac arrests. The second study used a cluster randomised methodology, enrolling 23 hospitals across Australia, comparing the three end-points described above. The study found no difference between both groups. It did highlight some interesting areas around the importance of effective implementation in determining the effectiveness of systems in health. Other publications have described the importance of developing effective ways of caring for the seriously ill outside traditional areas such as ICUs. The MET system, or variations on it, is now implemented in many hospitals in Australia and around the world and there have been two international MET conferences held in North America and international guidelines on the MET concept established.