M.Tech.

The aim of this study was to explore factors contributing to the success of health communication strategies and supporting visual communication tool(s) designed to explain antiretroviral medication (ART) adherence, and motivate young people who live with HIV to follow an adherence regime. The study drew from the social sciences, including psychology, health sciences and communication. Currently there are an estimated 6.8 million people living with HIV in South Africa, making it the site of the largest HIV epidemic in the world (UNAIDS, 2014). Antiretroviral Therapy (ART) is the only effective treatment for HIV and is one of the most demanding medicine regimes, requiring a 90% compliance. Various studies have documented worryingly poor levels of adherence to ART, especially amongst adolescents and young adults in South Africa. The empirical research consisted of a qualitative case study in Khayelitsha, a periurban township on the edge of Cape Town. It focused on young people from Khayelitsha and health care professionals - doctors, nurses, HIV counsellors and pharmacists. Using grounded theory data collection was carried out during two phases of fieldwork, interspersed with periods for data processing and analysis. The principal methods used were focus groups, semi-structured interviews and participant observation. Two key factors emerged from the data that form the basis of a new theoretical understanding: first, concerning how young people become motivated to learn about treatment and adhere to it, and second, concerning how information about treatment can best be communicated to them. In relation to the first of these, findings showed that young people were traumatised by an HIV diagnosis, fearing both that they would get sick and suffer an early death and also that they would be rejected by their belonging groups. This meant that they could not take in the factual information offered, and in addition, had no motivation to do so because the diagnosis resulted in a loss of hope for their present and future lives. According to young people, motivation was an outcome of re-connecting to one or more trusted significant other(s) from within their belonging group, who accepted and supported them. This in turn affirmed their prior belonging identities of son, daughter, cousin or close friend and then reconnected them to their present and future hopes. This renewed motivation to live was the basis for their becoming motivated to learn about treatment and adhere to it. In relation to the second factor, this study found that current communications about treatment were not effective. Specifically, the use of metaphors, which was seen among clinicians as a method of simplifying the complexity of ART adherence messages, was in fact creating confusion. Also, the use of printed information in isolation was not effective; communication was much more effective when it provided a space for discussion. These two key factors form the basis of a health communication strategy for young people who live with HIV and need to adhere to ART. Following on from these findings the study included the production of a film and animation that were identified as the visual communication media that would best support young people's understanding and motivation to adherence. The film presents a case study of a young person who overcame their initial diagnosis shock and, through the acceptance and support of his family, learned to live a normal life with HIV. Young people had said that they wanted to be able to view a film of this kind soon after their diagnosis. The animation, which was designed using a participatory process, used 'iso-type' as the central visual language. It was piloted, and this showed that the best use of a visual communication tool was in a setting that allowed young people to talk about prior losses to HIV within their families and community and about their confusion about treatment, and to ask questions about the meaning of complex biomedical concepts such as an undetectable viral load. All young people who visited the clinics, irrespective of test results, said that they wanted to learn about ART so that they could support friends and family members who lived with HIV, change perceptions about HIV among peers and better prepare in the case of becoming HIV positive themselves. Therefore it is recommended that communication strategies should target patients, their belonging groups and the wider community. This substantive theory contributes knowledge relevant to how ART adherence is communicated to young people. More broadly, this thesis argues that an interdisciplinary approach is required if communication practitioners are to properly understand the meaning that a population attributes to a health challenge; especially in the context of motivation and understanding. It is only when those meanings are fully identified through consolidated social science research that a communication strategy and supporting visual tools can be successfully designed.

A research report submitted to the Faculty of Management, University of the Witwatersrand, in partial fulfilment of the requirements for the degree of Master of Management / Rapid Appraisal has gained popularity amongst policy makers, and is used in strategic planning of primary health care services. This study aimed at determining whether Rapid Appraisal is an appropriate planning tool for primary health care services in South Africa. This study compares Rapid Appraisal with a Regional Health Management Information System (ReHMIS), using the Northern Province as a case study, In comparison, Rapid Appraisal took half the time of ReHMIS for data collection, and used less resources in the process, There is significant difference between the two data sets and this is explained by the fact that Rapid Appraisal does not only determine whether the facility is there or not but it also identifies management issues. Rapid Appraisal is an innovative method that engages all the relevant stakeholders in planning their primary health care services, The findings proved that Rapid Appraisal is an appropriate planning tool for primary health care services. / AC2017

Thesis (M.S.)--University of Missouri--Columbia, 2000. / Typescript. Includes bibliographical references (leaves [32]-35). Also available on the Internet.

Diss. (sammanfattning) Linköping : Univ., 2001. / Härtill 4 uppsatser.

Background: Socioeconomic factors and gender may influence the quality of care received by patients with diabetes. Millions of people are diagnosed with diabetes and rates are expected to increase. The management of diabetes in primary care is important in optimizing health for all. Objectives: To investigate whether the selected diabetes quality of care indicators (haemoglobin A1c, low-density lipoprotein, blood pressure, abumin to creatinine ratio (ACR), and prescribed medication) are significantly different between those persons living in least and most materially and socially deprived neighbourhoods. Methods: A cross-sectional study design with a population sample of patients with diabetes from a primary care practice in Southeast Ontario. De- identified patient data from electronic medical records were retrieved from the Canadian Primary Care Sentinel Surveillance Network. Combined material and social deprivation scores were based on the Pampalon Deprivation Index. Results: The patients with diabetes largely resided in either the most or the least deprived neighbourhoods. Patients with diabetes living in the most deprived neighbourhoods were less likely than patients with diabetes living in the least deprived neighbourhoods to have their low-density lipoproteins within normal range (RR=0.84; CIs 0.73-0.98; p-value=0.026). There was no difference in management of diabetes between least and most deprived patients with diabetes regarding haemoglobin A1c, blood pressure, ACR, and medication prescribed; these were positive result for the clinical practice. Women with diabetes were less likely than men with diabetes to have their low-density lipoproteins under control (RR=0.71; CIs 0.62-0.81; p-value <0.001) and be prescribed ACE inhibitors or ARBs (RR=0.79; CIs 0.69-0.90; p-value <0.001). However, women with diabetes were more likely to have their most recent haemoglobin A1c within normal range (RR=1.24; CIs 1.10-1.40; p-value <0.001) and have their most recent ACR within normal range (RR=1.25; CIs 1.05-1.50; p-value=0.015). Conclusion: This study found that the quality of care for patients with diabetes was not influenced by whether a person lived in a deprived neighbourhood or not. However, the study identified some important gender differences related to whether a person’s diabetes was under control. The reason for these differences is unknown. / Thesis (Master, Community Health & Epidemiology) -- Queen's University, 2013-09-27 13:37:55.755

The study investigated the accessibility and use of health information within the lower echelons of Primary Health Care service delivery. Hence, it focused on women and health workers' experiences with information in rural Uganda. Face-to-face interviews were conducted using an interview schedule that consisted of open questions and one relating to health information critical incidents. The qualitative interviews added depth, detail and meaning at a very personal level of experience. A holistic inductive paradigm was used in the study with a grounded theory analysis. This approach was adopted because of its ability to generate findings inductively from empirical data. An 'Interaction-value model' emerged from the study. The model was driven by the value and impact of information unlike previous information models which have been driven by information needs. This study has demonstrated that although an information need could trigger off an information activity, the subsequent information process could only be sustained by the value of information. Hence, access and use of information depends on the value and impact of information to overcome or reduce constraints. The value of information is therefore the core category, while the moderation of constraints and interaction with sources for latent or apparent needs are the two main categories that make up the model. The study has also shown that not all information users are active seekers. The main difference between the two groups of interviewees was that health workers' needs were generally apparent and led to active information seeking, whereas the women's needs were generally latent. Women mainly accessed information passively. Passivity, however, was generally limited to the act of accessing information. After passive information access, the subsequent user behaviour was active. Hence, women passively accessed information, but actively used it. Women's information behaviour was therefore dynamic. This was confirmed throughout the study when, for example, their information needs changed from latent to active and vice versa. The difference in the findings appears to stem from the fact that for women, the process of information access and use was dependant on the relationship and interaction between their social and information environment in everyday life; while for the health workers, professional matters added a further dimension to their information activities. The ways in which women and health workers accessed and used information as elaborated in this study have a number of implications for improving information provision, policies, training of health workers, and further research.

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背景：中國在發展城市社區衞生服務/基層醫療的過程中，基於當地經濟社會發展情況和特點，主要形成了政府辦政府管、院辦院管、以及私營三種模式。近年來中國學者對大陸社區衞生服務/基層醫療的研究主要關注于服務的基本現狀與功能的描述性研究，以及患者主觀層面的滿意度調查等，對城市社區衞生/基層醫療組織形式與服務模式建設的研究相對缺乏。初級衞生評價工具( Primary Care Assessment Tool, PCAT) 由美國約翰霍普金斯大學初級衞生保健政策中心開發，將初級醫療的五個核心方面進行量化，從患者對社區衞生服務/層醫療服務的客觀體驗角度出發，客觀評價醫療服務品質。本研究關注於基層醫療服務的過程層面，作為珠江三角洲六城市基層醫療研究項目的一部分，聯合廣州醫學院公共衛生與全科醫學學院，在廣東省衞生署以及香港智經研究中心的大力支持下，其他學者將研究基層醫療服務的結構和結果層面。 / 目的：本研究關注從病人體驗角度出發，在城市社區衞生/基層醫療服務的過程層面，評價和比較三種不同的社區衞生服務/基層醫療模式，以及不同地區在實施國家初級衞生政策時的不同策略所導致的在初級醫療五個核心方面的差異。 / 方法：首先，本研究進行了全面的文獻檢索，回顧了PCAT工具在全球和地區的應用。其次，本研究根據國際上認可的跨文化翻譯過程將PCAT（成人簡化版）翻譯成中文官方語言（普通話）並使其與中國國情相適應，並通過問卷的信度和效度分析，證明中文PCAT成人簡化版在評價社區衞生服務/基層醫療的過程層面方面具有較高的可靠性和有效性。進而，本研究採用多階段整群抽樣方法，在珠江三角洲六個城市的社區衞生中心，由訓練有素的調查員進行現場訪談。最後，本研究採用多元線性回歸和多元方差分析統計分析，評估和比較了不同城市和不同模式下，社區衞生服務/基層醫療服務五個核心方面的PCAT分數的差異。 / 結果：中文PCAT（成人簡化版）包含了九個不同維度，從五個方面評價初級保健服務過程，具有良好的結構效度。克隆巴赫係數反映了問卷具有良好的內部一致性。本研究共調查了3,360名在社區衞生服務中心接受基層醫療服務的成人患者，問卷整體回收率達86.1。本研究基於PCAT 分數從不同城市和不同服務模式角度分別評價和比較了社區衞生服務/基層醫療服務的過程。研究發現，與院辦院管及私營模式相比，政府主導模式下的社區衞生服務/基層醫療服務使用者具有更好的病人體驗，主要是因為政府主導模式下，社區衞生服務在首診利用及基層醫療服務協調統籌維度層面達到更高的水準。 / 結論：本博士論文研究確立了中文PCAT（成人簡化版）在評價社區衞生服務/基層醫療服務過程的可靠性和有效性。本研究率先在中國大陸採用PCAT 工具對廣東省珠江三角洲地區城市社區衞生服務/基層醫療模式開展了大規模調查。該項研究可以填補目前中國大陸在PCAT應用以及城市社區衞生服務/基層醫療模式研究方面的空白，探索適合中國國情的社區衞生/基層醫療服務發展道路，為中國大陸進一步發展及完善初級衞生體系提供翔實的政策依據。 / Backgrounds: China’s current healthcare reform has an overall goal towards re-strengthening primary care. Establishment and expansion of primary care network based on community health centres (CHCs) in urban areas has been prioritized. Due to various socio-economic status of local population and policy context across urban areas in mainland China, primary care is delivered by three main organisational models: government-owned CHCs, hospital-owned CHCs, and privately-owned CHCs with each model being adopted in various localities. This PhD study focuses on studying the process of primary care provided under different CHC models in the six cities of Pearl River Delta (PRD) and it is part of a larger study entitled “A Study of Comparing Primary Care Services among Six Cities in the Pearl River Delta funded by Bauhinia Foundation Research Centre, in which other co-investigators have studied the structure and outcome of the primary care. / Objectives: This PhD study aims to use the Primary Care Assessment Tool (PCAT) within Donabedian’s framework of structure, process and outcome to measure and compare the quality attributes of primary care from patient’s perspective under different CHC models in the six cities of PRD where each city has different responses to the national policy for delivering primary care services. / Methods: A comprehensive literature search was conducted to review the utilization of PCAT both globally and locally. The PCAT - Adult Edition (short version) was translated into Mandarin Chinese following an internationally recognized procedure and was cross-culturally adapted into Chinese context. The reliability and validity of the PCAT instrument were evaluated through test-retest approach, exploratory factor analysis, and internal consistency reliability analysis. Multistage cluster sampling method was adopted to select CHCs in the six cities of PRD. All interviews were conducted on-site by trained interviewers. Statistical analysis including multiple linear regression and multivariate analysis of covariance were used to assess and compare the quality attributes of primary care (PCAT scores) provided by different organisational models of CHCs in the six cities of PRD. / Results: The Mandarin Chinese version of PCAT-AE (short version) contains nine primary care scales with good construct validity. Cronbach’s alpha within all the nine primary care scales achieved moderate to high internal consistency reliability. A total number of 3,360 adult primary care service users were surveyed on-site at CHCs with an overall response rate of 86.1%. Descriptive city-by-city analysis based on the PCAT scores was conducted to depict primary care process in each of the six cities. Primary care service users under government-owned CHC model reported receiving better primary care experiences than those under privately-owned CHC model and hospital-owned CHC model, largely because of the greater achievements in first contact utilization and better score in the coordination domain (information system). / Conclusions: The Mandarin Chinese version of PCAT-AE (short version) was found to be reliable and valid as a measure of primary care in mainland China from patients’ perspective. The study suggested that the government-owned CHCs had better quality attributes than other organisational models, and offered a direction for quality improvement in the five domains of primary care. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Wang, Haoxiang. / Thesis (Ph.D.)--Chinese University of Hong Kong, 2012. / Includes bibliographical references. / Abstract also in Chinese; some appendixes also in Chinese. / ABSTRACT --- p.i / ABSTRACT (IN CHINESE) 摘要 --- p.iii / ACKNOWLEDGEMENTS --- p.v / TABLE OF CONTENTS --- p.viii / LIST OF APPENDICES --- p.xii / LISTS OF TABLES --- p.xiii / LISTS OF FIGURES --- p.xv / ABBREVIATIONS --- p.xvi / PREFACE --- p.xvii / Chapter CHAPTER 1: --- BACKGROUND --- p.1 / Chapter 1.1 --- What is Primary Care? --- p.1 / Chapter 1.2 --- Why Primary Care? --- p.2 / Chapter 1.3 --- Healthcare Reform in mainland China --- p.3 / Chapter 1.4 --- Primary Care in Mainland China: A Brief History and Current Status --- p.8 / Chapter 1.5 --- Three CHC models of primary care delivery in urban areas --- p.13 / Chapter 1.5.1 --- Hospital and Hospital-owned CHCs --- p.13 / Chapter 1.5.2 --- Government and Government-owned CHCs --- p.14 / Chapter 1.5.3 --- Private sector and Privately-owned CHCs --- p.15 / Chapter 1.6 --- Pearl River Delta: an open window for primary care research --- p.16 / Chapter 1.7 --- Primary Care Assessment Tool: assessment of primary care from an international perspective --- p.21 / Chapter SUMMARY OF CHAPTER 1 --- p.23 / Chapter CHAPTER 2: --- LITERATURE REVIEW OF PRIMARY CARE ASSESSMENT TOOL --- p.25 / Chapter 2.1 --- Introduction --- p.25 / Chapter 2.2 --- Criteria for review and search strategy --- p.26 / Chapter 2.3 --- Key messages from the literature review --- p.28 / Chapter 2.4 --- Research gaps in the literature --- p.33 / Chapter 2.5 --- Conclusion --- p.34 / Chapter SUMMARY OF CHAPTER 2 --- p.36 / Chapter CHAPTER 3: --- ADAPTION OF PRIMARY CARE ASSESSMENT TOOL IN MAINLAND CHINA --- p.38 / Chapter 3.1 --- Introduction --- p.38 / Chapter 3.2 --- Methods --- p.39 / Chapter 3.2.1 --- Translation of PCAT --- p.39 / Chapter 3.2.2 --- Validation of the translation --- p.40 / Chapter 3.2.3 --- Face validity and peer evaluation --- p.40 / Chapter 3.2.4 --- Pilot test and test-retest reliability --- p.41 / Chapter 3.3 --- Results --- p.43 / Chapter 3.3.1 --- Translation of PCAT into Mandarin Chinese and validation of the translation --- p.43 / Chapter 3.3.2 --- Face validity --- p.46 / Chapter 3.3.3 --- Demographic characteristics of the survey sample in the pilot test --- p.46 / Chapter 3.3.4 --- Test-retest reliability --- p.48 / Chapter 3.4 --- Discussion --- p.48 / Chapter SUMMARY OF CHAPTER 3 --- p.51 / Chapter CHAPTER 4: --- VALIDATION OF MANDARIN CHINESE VERSION OF PRIMARY CARE ASSESSMENT TOOL --- p.53 / Chapter 4.1 --- Introduction --- p.53 / Chapter 4.2 --- Methods --- p.54 / Chapter 4.2.1 --- Study design and study subjects --- p.54 / Chapter 4.2.2 --- Scoring --- p.55 / Chapter 4.2.3 --- Factor analysis and construct validity --- p.57 / Chapter 4.2.4 --- Item analysis and internal reliability --- p.61 / Chapter 4.3 --- Results --- p.62 / Chapter 4.3.1 --- Demographic profile --- p.62 / Chapter 4.3.2 --- Analysis of the correlation matrix --- p.63 / Chapter 4.3.3 --- Factor analysis and construct validity --- p.63 / Chapter 4.3.4 --- Item analysis --- p.66 / Chapter 4.3.5 --- Internal reliability of the primary care scales --- p.67 / Chapter 4.4 --- Discussion --- p.68 / Chapter SUMMARY OF CHAPTER 4 --- p.70 / Chapter CHAPTER 5: --- PRIMARY CARE PROFILES IN SIX CITIES OF PEARL RIVER DELTA --- p.72 / Chapter 5.1 --- Introduction --- p.72 / Chapter 5.2 --- Methods --- p.73 / Chapter 5.2.1 --- The instrument to assess primary care --- p.73 / Chapter 5.2.2 --- Training of the interviewers and the assessment of inter-rater reliability --- p.74 / Chapter 5.2.3 --- Study location and sampling framework --- p.75 / Chapter 5.2.4 --- Target population --- p.76 / Chapter 5.2.5 --- Identification of primary care source --- p.76 / Chapter 5.2.6 --- Data collection --- p.77 / Chapter 5.2.7 --- Statistical analysis --- p.78 / Chapter 5.3 --- Results --- p.79 / Chapter 5.3.1 --- Inter-rater reliability, response rate, and demographic characteristics --- p.79 / Chapter 5.3.2 --- Comparison of primary care assessment scores in the six cities (city-by-city analysis) --- p.80 / Chapter 5.3.2.1 --- Primary care service users and primary care quality attributes in City A --- p.83 / Chapter 5.3.2.2 --- Primary care service users and primary care quality attributes in City B --- p.89 / Chapter 5.3.2.3 --- Primary care service users and primary care quality attributes in City C --- p.94 / Chapter 5.3.2.4: --- Primary care service users and primary care quality attributes in City D --- p.99 / Chapter 5.3.2.5 --- Primary care service users and primary care quality attributes in City E --- p.105 / Chapter 5.3.2.6 --- Primary care service users and primary care quality attributes in City F --- p.110 / Chapter 5.2.3 --- Factors associated with overall primary care experience --- p.115 / Chapter 5.2.4 --- Comparison of primary care assessment scores among the three CHC organisational models --- p.116 / Chapter 5.2.4.1 --- Presence of ‘hukou’ registry and primary care experience --- p.118 / Chapter 5.2.4.2 --- Presence of medical insurance and primary care experience --- p.119 / Chapter 5.2.4.3 --- Presence of chronic disease and primary care experience --- p.122 / Chapter 5.4 --- Discussion --- p.124 / Chapter 5.4.1 --- Patient characteristics and primary care profiles in the six cities --- p.124 / Chapter 5.4.1.1 --- Ageing --- p.126 / Chapter 5.4.1.2 --- Household registry --- p.126 / Chapter 5.4.1.3 --- Medical insurance --- p.127 / Chapter 5.4.2 --- Factors significantly associated with primary care assessment scores --- p.128 / Chapter 5.4.2.1 --- Healthcare utilization and health characteristics --- p.128 / Chapter 5.4.2.2 --- Socio-demographic characteristics --- p.129 / Chapter 5.4.3 --- Primary care experience in the government-owned CHC --- p.130 / Chapter 5.4.3.1 --- Separation between revenue and expenditure --- p.130 / Chapter 5.4.3.2 --- Central planning and multi-sectoral collaboration --- p.130 / Chapter 5.4.3.3 --- Towards health equality --- p.131 / Chapter 5.4.3.4 --- First contact --- p.132 / Chapter 5.4.3.5 --- Suboptimal service capacity --- p.132 / Chapter 5.4.4 --- Primary care experience in the privately-owned CHC --- p.133 / Chapter 5.4.4.1 --- Lower healthcare utilization --- p.133 / Chapter 5.4.4.2 --- Insufficient funding support --- p.134 / Chapter 5.4.5 --- Primary care experience in the hospital-owned CHC --- p.135 / Chapter 5.4.5.1 --- Large service capacity --- p.135 / Chapter 5.4.5.2 --- Tackling aging population with chronic diseases --- p.136 / Chapter 5.4.5.3 --- CHCs in the less socio-economic developed urban area --- p.136 / Chapter 5.4.5.4 --- Disparities due to socio-demographic status --- p.137 / Chapter 5.4.6 --- Study limitations --- p.137 / Chapter 5.4.7 --- What is already known and what this study adds --- p.139 / Chapter SUMMARY OF CHAPTER 5 --- p.141 / Chapter CHAPTER 6: --- CONCLUSION AND POLICY IMPLICATIONS --- p.144 / Chapter 6.1 --- Conclusion --- p.144 / Chapter 6.2 --- Policy implications for mainland China --- p.146 / REFERENCES --- p.150 / APPENDICES --- p.161

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