The purpose of this study was to identify any barriers or enablers as influences on wound care self-management by Indigenous people. A qualitative, interpretive study sought to investigate how participants perceived their wounds and their general health, and to identify the influences on them accessing wound care services. There is a dearth of information on culturally appropriate practice in wound management for Indigenous Australians. This research project was therefore significant in attempting to bridge the gap in nursing knowledge of Indigenous clients' perceptions of barriers and enablers for seeking wound care services,especially in relation to lower leg ulcers. The lack of culturally sensitive wound management practices potentially impacts on Indigenous clients' behaviours in seeking treatment from their health service providers. Participant observations and semi-structured interviews with the research participants investigated the management of their wounds, and the ways in which their culture influences wound management. The main aim was to understand participants' comprehension of the importance of wound care through reflection. Understanding the enhancing or obstructive influences on wound management practices was expected to provide a foundation for teaching self care of wounds in Indigenous populations and inform health professionals' approach to health education. The data were analysed using thematic analysis, which generated common themes related to the research questions. These themes are: visibility, of the problem,4 perceived versus actual level of knowledge, acceptance of co-morbid health conditions and pre-determined path of ill health. These findings indicated that in one region, participants' perception of poor health was related to visibility of the problem. Participants chose to have their visible wounds managed by Silver Chain Nursing Association, whereas Diabetes and Hypertension and any other non-visible disorders were seen as appropriate to the Aboriginal Medical Service (AMS). Further to this finding, most participants displayed a sense of helplessness and hopelessness when sharing information about their diagnosis of diabetes, believing this was the norm. Many also believed that having a strong family history of a particular disease resulted in the participants also inheriting the disease. During post interview educational sessions many of the Indigenous participants were surprised by the evidence based-research reported to them by the researcher that diabetes is a manageable disease with life style changes. Another issue highlighted was the perceived level of knowledge the participants had about wound care. Reassurance was given by the participants that their level of knowledge about how to manage their wounds was adequate. However, none of the participants were concerned about the length of time that their wound/s had or were being managed, between 3 months and 5 years. This acceptance that although a wound is not getting any worse and not getting any better was the norm is cause for concern, and indicates a low level of health literacy. This theme was 'perceiving an imbalance in perceptions of wound care knowledge with actual knowledge'. The most important recommendation from the study findings is the need to consider health literacy more carefully in the development of health promotion and health education for Indigenous clients with wounds.

Thesis Summary COMMUNITY-BASED EVIDENCE ABOUT THE HEALTH CARE SYSTEM IN RURAL VIETNAM This thesis contributes further evidence for policy-making on health care system reform in Vietnam. The author aims to provide insights into the provincial rural health system ten years after health sector reform was launched, through assessing availability of health care services, patterns of access of health care services when people are ill, and the costs of care and the performance of public and private providers. The following questions are addressed: 1. Which health care providers, i.e., public or private, are dominant in providing curative services to rural people when they are ill? 2. How much inequality exists between the poor and the non-poor in access to health care services in general, and public health care services in particular, when they are ill? Which factors explain the gap in use of services between the poor and the non-poor? 3. What policy and strategies should Vietnam consider implementing in order to reach the goals of better equity and quality of care for rural populations? These research questions were addressed using community-based survey data collected in 2001 from Hung Yen province, in which three components of the system -- user, provider, and community context -- are described and linked together in analysis. In addition, a supplementary health care provider survey collected in 1999 in three other provinces (Thai Binh, Binh Thuan, An Giang) is used to provide evidence about the availability of healthcare services in general and of private health care providers. The thesis is divided into two parts with a total of 9 chapters. Part A (chapters 1-4) provides background for the research questions raised about the commune health care system in rural Vietnam, the framework used in evaluating this health care system, and the data sources used in this thesis. Part B consists of five chapters (chapters 5-9) that presents research results on various dimensions of the rural health care system. It also provides conclusions on the health care system in rural Vietnam, and proposes policies and strategies for strengthening this system toward equity and efficiency. Chapter 1 presents the research rationale and objectives. It examine the international context of health sytem research, the Vietnamese context of health sector reform since the ?Doi Moi?, and the current trend of health sector reform, and the previous research done so far related to health system reform in Vietnam. The research questions addressed by the thesis are presented at the end of this chapter. Chapter 2 describes the historical development of rural health care system in Vietnam. It startes with an overview of social changes in the rural Vietnam including revolution and wars and both the positive and negative impacts on the health of rural populations. The evolution of the rural health care system is then outlined, from the single national provider system (public) to the reforms of 1989 where a public-private model for rural health care was introduced. Chapter 3 provides frameworks for analysis of availability, health accessibility, quality and efficiency of the rural health care system, and inequality of healthcare service utilization. It starts with a statement about the concept of health care system used in this thesis. Then five theoretical models for assessing the health care systems (health service utilization model, triangular model, model for improve quality of care, health care services as an open system, and the World Bank?s framework for assessing the performance of the health sector in serving the poor) are presented. The strategy of using these frameworks to assess the rural health system in Vietnam is explained. The link between the research questions and methodology used was described. Chapter 4 provides detailed descriptions of the two data sources and analysis strategies used to address the thesis research questions. The design and data collection methods of the health care provider surveys and household surveys in the four provinces are presented, followed by the specific strategy of using information from each database for the thesis objectives. The chapter ends with a presentation of the overall strategy of data analysis. Chapter 5 assesses availability of the commune health care system in rural areas of Vietnam with empirical data from all the four provinces. The findings show that both public and private health care providers are available in rural Vietnam, with a slight dominance of private services. There were commune health centers (CHCs) in all communes with at least one private physician in the majority of the communes. The average number of private providers ranged from 2.7 to 7.7 per 10,000 population in the four provinces. Many of them practiced without formal registration and under limited government supervision. Chapter 6 estimates perceived need of care by measuring the burden of non-fatal health problems with data from 3,498 people of 900 households randomly selected in Hung Yen province. Compared to the better off, the poor suffered significantly more long-term health ailments (an excess of 78 cases per thousand population) and more short-term morbidity (an excess of 112 cases per thousand population). The study found that the gap in household wealth index contributed approximately 55% of the explained gap in prevalence of long-term health conditions, equivalent to the gap of 60 cases per thousand population, and also 55% of the explained gap in short-term morbidity, equivalent to the gap of 38 cases per thousand population between the two groups based on the Oaxaca decomposition (D=0). Gaps in education, gender, health insurance, and occupation played a minor role in explaining the wealth-related inequalities in non-fatal health burden. Chapter 7 describes patterns of use of health care services when people are ill by type of providers, by type of illnesses, and by poverty ranking level. Findings in this chapter reveal a high level of self-medication, greater access to private than public services, and less use of public services or any health care services by the poor in comparison to the better off. Self-funded purchases of drugs for self-medication and use of private curative services were even common in those with health insurance. A single private provider contact for treatment of illness costs on average 2.6% of the total annual expenditure per capita, and self-medication with drugs purchased at private health care facilities costs 1.0% of total annual expenditure per capita, similarly these at district hospitals and commune heath centers were similar. Finally, the percentage of ill people with no access to any health care providers during their illness episode was high, regardless of their wealth or health insurance status. Chapter 8 compares the quality of private and public health services using a framework proposed by the World Bank for evaluating the quality of health care in developing countries. Results from this chapter show that technical quality of care was poorer in the private sector than among public providers while costs for patients were similar in private and public facilities, and client satisfaction was similar in public and private facilities. Chapter 9 summarizes the results from Chapters 5-8 to identify the main characteristics of the rural health system with a view to system sustainability and proposes policies and strategies for strengthening the quality of the public health care sector and improving its equity and efficiency. The main features of the current rural health care system in Vietnam identified from the community-based evidence found in this research are: (1) primary health care services are available and there is equality in physical access; (2) financial resources for the CHC system are diversified with Government resources the key contributors; (3) private health care providers for outpatient services, public providers for inpatient services; (4) quality of treatment services is below the national standard; (5) public services are available but under utilized; (6) the rural health care system is not a pro-poor system; (7) direct payment is the main component of total health care expenditure; and (8) the economic relationship of the rural health care system is a user-provider model rather than a health care triangular model. Nine recommendations to strengthen the rural health care system were then developed based on a critical view of the objectives of the Vietnam health sector reform for the period 2001-2010 supported by evidence found in this research. This chapter ends with a section to remind readers about the limitations of this study and then proposes future research with specific questions covering three main dimensions of health care system reform in Vietnam (accessibility, quality of care, and overall management). A study with a sentinel site approach to follow-up the impact of the social and health sector reform policies is also proposed to help the government make timely adjustments to their policies to protect the poor. / PhD Doctorate

In 1978, Primary Health Care (PHC) was formally recognised, in the Declaration of Alma-Ata, as the key to achieving the World Health Organisation's goal of 'Health For All by the Year 2000' (HFA). PHC was seen as the solution to the inadequate illness management systems that had developed throughout the world. It was hoped that PHC would address some of the major inequalities in health observed both within and between countries by its balanced system of treatment and disease prevention. The WHO envisaged that PHC would take place as close as possible to where people live and work and be the first element of a continuing health care process. Additionally, health service collaboration and multi-professional partnerships were expected to replace professional boundaries and competition. Shortly after the Declaration of Alma-Ata, the World Health Organisation, supported by national and international nursing bodies, proposed that nurses would be the driving force behind the HFA movement as active partners in inter-professional teams, leaders in health care and resources to people rather than resources to other health professionals. In the ensuing years, although community health nurses were acknowledged by the government and the nursing profession as key players in PHC in Australia, practice nurses (nurses who are employed in general medical practices) were not identified within this group. Hence, it appeared as though these practice nurses were 'invisible', not considered important to PHC in Australia, or simply overlooked as a major influence on population health. The purpose of this study was to describe the current role of these nurses and to identify and analyse the factors that influenced their scope of practice and hence their contribution to PHC. The research was conducted as a case study of practice nurses in one Division of General Practice in southeast Queensland. The study was influenced by the constructivist paradigm of inquiry and utilised a complementary sequence of quantitative methods followed by qualitative investigation. The first stage of the study comprised a telephone followed by mail survey of general practitioners and practice nurses employed within the Division. This was followed by a second stage, which involved group and individual interviews of key informants and was supported by document review and observation. The study revealed that the practice nurse role is essentially one of assistant to the general practitioner wherein the nurse undertakes basic assessment procedures to aid the medical diagnosis, carries out delegated therapeutic procedures, and contributes to the administrative functioning of the practice. Autonomous nursing initiatives, which appear to be largely opportunistic and incidental to delegated activities, include physical and emotional support of patients, clarification and reinforcement of medical instructions, and the provision of health education. The practice nurse's role, and hence contribution to PHC, was found to be constrained by a number of factors. These factors include the current funding arrangements for general practice, the view that practice nurses are an option rather than a necessity, the general practitioners' control of the practice setting, the appropriation of nursing work to medical receptionists, the lack of professional development opportunities, and the practice nurses' passive acceptance of their circumstances. However, both general practitioners and practice nurses appreciate the value of nursing services in general practice and GPs would sanction the employment of more nurses, if given financial incentives, especially for the purpose of preventive care. The majority of practice nurses believe their role should be expanded to include autonomous functioning while most of the GPs were amenable to some extension of nursing practice but reticent or opposed to any independent interventions. There appears a need in Queensland for courses to prepare practice nurses for advanced practice if they want to expand their role in PHC beyond that of assistants to GPs. It would also seem to be in the nurses' interests to initiate a professional association of practice nurses as a vehicle to explore other issues relevant to their professional development. In addition, if PNs want to expand their role they will need to demonstrate improved patient outcomes and cost effectiveness.

Thirty years after the concept of primary health care (PHC) was declared the path to health for all, a crisis continues in human resources for health in Africa. This involves the low prioritisation of education and training for primary health care personnel (PHCP) which is crucial to effective practice in severely under-resourced settings. The curriculum required for this education, involving pictures and textual materials, must meet the needs and capacities of the learners so that learning transfer can occur and community health needs are met. This research set out to establish the basis upon which text and pictures should be incorporated into curriculum to address the requirements of community health nurses (CHNs) in The Gambia. A pragmatic, three phased, mixed methodological design was selected for this study. Curricula for African PHCP were first collected and examined using content analysis to determine the rationale for pictures and text. The second phase employed psychometric testing and statistical analysis to establish if learning style preferences for pictures and text were important in Gambian CHN learning. In the final phase, interviews with CHN students explored their preferences for pictures and text and how these preferences should be accommodated in curriculum. The research found that much of the PHCP curriculum analysed was generic, used traditional didactic approaches and focused on written knowledge-based assessment. Learning style preferences were not found to be a consideration and were unidentifiable in this context. Socio-cultural factors significantly impacted upon student CHN learning, but were not adequately addressed in the curriculum materials examined. In addition, CHNs preferred practical learning through primary, multi-sensory experiences. These findings support the conclusion that the localisation of CHN curriculum is required in order to provide a socio-cultural context for learning that is meaningful, rich, interactive and responsive to learner needs. This demands a reconnection with PHC principles of equity and participation which should underpin this curriculum. The thesis argues that an ecological framework better articulates the link between PHCP education and training, practice, and community needs, and should serve to guide curriculum design. Six strategies are identified that could be extended to African PHCP course design.

Funded by the Primary Health Care Initiatives Program. Bibliography: p. 161-170. This thesis examines the public health of breastfeeding from a feminist perspective, based on a qualitative longitudinal study. From reviewing the history of infant feeding, a number of discourses of breastfeeding are identified and their continuing influence on contemporary thinking is discussed.

<h1><h1>Abstrakt</h1><p> </p><p>Övervikt och fetma är idag ett världsomfattande hälsoproblem och fetma medför en klart ökad risk för att drabbas av olika sjukdomar, såsom hjärtkärlsjukdomar. I Gävleborg är andelen överviktiga och feta större än medelvärdet i riket. Syftet med studien, efter valda begränsningar, var att beskriva hälsosamordnarna arbets- och förhållningssätt gällande övervikt och fetma med avseende den vuxna befolkningen inom primärvården Gästrikland. Resultatet visade att gemensamma riktlinjer fanns för deras arbete och att dessa till största delen efterlevdes även om förhållningssättet till dem skiljde sig åt. Samarbetet med andra yrkeskategorier inom primärvården fungerade bra, dock har omstruktureringar i arbetssätt medfört att vissa brister fanns. Uppfattningen att hälsosamordnarnas utbildningsbakgrund påverkade deras arbetssätt gentemot patienterna kan skönjas. Samtliga lade stor vikt vid patientens eget ansvar gällande livsstil och levnadsvanor. En av de påverkansmetoder som användes var det <em>motiverande samtalet. </em>Flertalet hälsosamordnare använde sig av denna metod, men förhållningssättet till den skiljde sig åt. Hälsocentralerna där hälsosamordnarna verkade skiljde sig åt bland annat gällande storlek på upptagningsområde, social, ekonomisk och kulturell bakgrund hos patienterna. Detta medförde att de ibland arbetade på olika sätt och hade olika förhållningssätt till själva arbetet och de människor de mötte.</p></h1>

<p>The purpose of this study was to describe how nurses, working in primary health care and responsible for diabetes care, reflected on patient information and education, its’ content and experiences of providing it. The study had a descriptive design and seven nurses from seven health care units in the middle of Sweden participated in the study. Data were analyzed with qualitative content analysis. The results are presented in two main categories; <em>“The information”</em> and<em> “The procedure”.</em> The two subcategories; Adjusting information and Bring about knowledge and to live with the disease<em> </em>emerged from <em>“The information”</em>. The five subcategories; Specific situation information, Increased insight about lifestyle changes, Developed dialogues, Nurses’ and patients’ perspective of responsibility and Supporting and follow ups<em> </em>were formulated from <em>“The procedure”</em>. Individual adjusted information within dialogues was highlighted. The motivational interview technique was considered as contributing to possibilities for more successful treatment and lifestyle changes. The main result showed that nurses responsible for diabetes care in primary health care empathized the need of individual adjusted information and the procedure providing it, in order to support the patients’ daily life.</p>

Objectives To investigate if there is an association between dental health status and high blood pressure, to test the effectiveness of screening for high blood pressure and high blood glucose performed by the dental health care in collaboration with primary health care and to investigate the direct costs for this type of screening organisation. Study population and methods In Paper I 54 subjects with known hypertension and 141 with a high blood pressure in the dental office were compared with matched controls. In Paper II 1,149 subjects were screened for hypertension and in Paper III 1,568 subjects were screened for diabetes in dental care. Follow up was performed in co-operating primary health care centres. In paper IV the direct costs for screening and follow-up were calculated. Results There was a significant association between deep periodontal pockets and high blood pressure, even when the influence of age, sex, smoking and number of teeth was taken into account. Among those being screened for high blood pressure and high blood glucose 20.6% and 9.9% respectively were referred to primary health care, and a hypertension or a diabetes diagnosis was found in 32.1% and 5.8% of those screening positive. For every 18th subject screened a hypertension case was found (“numbers needed to screen” (NNS)), and for every 196th a diabetes case. NNS for combined hypertension and diabetes screening was 15. The total direct costs for screening and follow up per diagnosis found were 5,298 SEK for hypertension, 19,100 SEK for diabetes, and  4,116 SEK for combined blood pressure and blood glucose screening. Conclusions There was an association between dental health and hypertension. Screening for hypertension was highly efficient, while screening for diabetes was less so, because it is a less prevalent condition. Screening for both conditions appears to be the most efficient type of screening.

This thesis deals with a behavioural medicine approach to the management of patients with persistent musculoskeletal pain in primary health care physical therapy. The main aims of the thesis were; to develop, and evaluate the psychometric properties of, a screening instrument for risk of disability and; to evaluate the implementation and effects of a targeted and tailored treatment. The studies comprise four samples of patients with musculoskeletal pain exceeding one month. All subjects were recruited when consulting physical therapists in Swedish primary health care settings. For development and evaluation of the Pain Belief Screening Instrument (PBSI) four samples were used; two samples (n1 = 215 and n2 = 93) in Study I, one sample (n = 168) in Study II, and one sample (n = 45) in Study III. For evaluation of implementation and effects of targeted and tailored treatment the 32 patients who completed treatment in Study III were used. In Study IV treatment documents of 18 patient cases from Study III were studied to evaluate treatment integrity. The concurrent and predictive validity of the PBSI was good, and the instrument was therefore used to define subgroups with either a high or low risk for disability. A low treatment dosage of a tailored treatment for low risk patients was tried and found equally efficient as a longer treatment focusing physical exercise. Subjects who received a treatment tailored to individual patient characteristics perceived a better global outcome of treatment compared to subjects in the control group. However, no between-group differences in the disability measures were found. The evaluation of treatment integrity displayed low therapist adherence to the treatment rationale for the tailored treatment. The studies demonstrate ways to systematically integrate a behavioural medicine approach and physical therapy. The results indicate efficiency in managing patients with persistent musculoskeletal pain in primary health care.

Background and aims. In patients consulting for chest pain, it is of great importance to evaluate the possibility of ischemic heart disease (IHD). The aims in this thesis were to investigate the accuracy of the general practitioners’ clinical assessments and the applicability of exercise testing and myocardial perfusion scintigraphy (MPS) in patients consulting for chest pain in primary care. Statins are known to prevent IHD. A further aim was therefore to investigate if a relation could be detected on a population basis between the use of statins and the morbidity of acute myocardial infarction (AMI). Methods. All patients from 20 to 79 years, consulting for a new episode of chest pain in three primary health care centres, were included during almost two years from 1998 to 2000. The patients were managed according to the clinical evaluation. The presence of IHD was excluded either by clinical examination only, or if stable IHD was in question, by exercise testing and if the exercise test was inconclusive by an additional MPS. If unstable IHD or myocardial infarction was suspected, referral for emergency hospital examination was made. Correlations between statin sales and the morbidity of AMI in Sweden’s municipalities were analysed in an ecological, register based study. Adjustment was made for sales of antidiabetics, socio-economic deprivation indexes and geographic coordinates. Results. Consultations for chest pain represented 1.5% of all consultations in the ages 20 to 79 and were made by 554 patients. In 281 patients IHD was excluded by clinical examination only. In 208 patients stable IHD and in 65 unstable IHD was in question. Four patients (1.4%) evaluated as not having IHD, were diagnosed with angina pectoris or AMI within three months. Exercise testing was performed in 191 patients and revealed no IHD in 134 and IHD in 14 patients. In 43 patients the exercise test results were equivocal. Thirty-nine of these patients underwent MPS, which showed no IHD in 20 and IHD in 19 of the patients. In a follow up almost six years later, neither mortality rate nor prevalence of IHD differed significantly between the 384 study patients evaluated not to have IHD and the population controls. Statin sales and AMI-incidence or mortality showed no strong associations from 1998 to 2002. Conclusions. ·Primary care is an appropriate level of care for ruling out IHD as the cause of chest pain, with sufficient safety and for diagnostics of stable IHD. ·Exercise testing and myocardial perfusion scintigraphy are useful procedures when investigating chest pain patients in primary care. ·The results indicate that preventive measures other than increased statin treatment should be considered to further decrease AMI-morbidity.