Thesis (Ph. D.)--University of Toronto, 2005. / Includes bibliographical references.

Introduction: Transgender is an identity term used to describe people with diverse gender identities and expressions that differ from their sex assigned at birth. People who identify as transgender have worse health outcomes than the cisgender or non-transgender populations. Limited healthcare access and chronic stress from discrimination all contribute to worsening health outcomes for this population. However, research regarding this population is limited, particularly in the rural southern United States. The purpose of this study was to assess physicians’, nurse practitioners’, and physician assistants’ experience with, attitude towards, and knowledge of transgender healthcare in the Northeast Tennessee region. Methods: Medical providers, including NPs, PAs, DOs and MDs from Family Medicine, Emergency Medicine, Internal Medicine, Pediatrics, and Obstetrics and Gynecology in both academic and community settings were surveyed regarding their attitudes toward, knowledge of, and experiences with gender, sexual orientation, and sexuality as they relate to healthcare. All potential participants were informed that participation was voluntary. Limited demographics were gathered and surveys were collected in a confidential manner. Data were analyzed for statistical significance. Results: Initial analyses showed the majority of providers had not received training in transgender healthcare and perceived they had few to no trans-identified patients. Over half of all respondents felt competent in providing healthcare to trans people and the majority felt comfortable treating this population. Providers indicated it is important to know their patients’ sexual practices, gender identity and sexual orientation; however, the majority of providers do not ask patients their gender identity, sexuality, or desired pronouns. Respondents were unsure whether gender confirmation surgery is covered by insurance and widely accessible. In assessing clinical knowledge of providers, there were a wide variety of responses suggesting varying level of competence amongst providers. Responses were split regarding whether access to healthcare is the same for the transgender population as it is for the general population. Pediatric providers were asked about comfort in prescribing hormones, knowledge of mental health support in the area, referrals and discussing gender identity with patients. These responses fell along a normal distribution, indicating a variety of training, experiences, and opinion regarding trans healthcare for the adolescent population. Conclusions: Overall results from the preliminary data demonstrate a contradiction between ideology and practice. With most participants responding they felt comfortable and competent providing care to the transgender population, yet their responses indicated a lack of training and absence of inclusivity in their health care practices. This suggests that education is needed within the healthcare community on transgender healthcare.

Social life, and particularly health care delivery, in a small isolated community is more complex and nuanced than has been reflected in much of the literature on physician retention, which has never extended the notion of the “workload” past the physician’s formal role in the health care setting. Despite having been acknowledged by provincial and national government policies, few of what Anderson and Rosenberg (1990) describe as “unidimensional solutions” have resolved the “multidimensional issues” of physician retention in northern Canada. This thesis employs a qualitative framework to investigate the practice and lifestyle experiences of general practitioners on the Queen Charlotte Islands (Haida Gwaii) to provide a local analysis of physician retention problems experienced by isolated communities. By including both physicians and community members as key informants, the project attempts to determine whether a difference exists between physicians’ perceptions of place and their roles and the voiced expectations of the communities they serve. The research uses a combination of in-depth interviews and questionnaires with physicians (n=6) and community members (n=12) to determine the various roles played by a physician in a small community. It queries whether the community in question expects physician to take up roles outside of the medical space, whether physicians are influenced by these expectations and whether these may contribute to the cessation of practice in remote communities. This thesis examines not only health care-related factors involved in medical practice, but also the informal settings of the community at large, including the general interactions that are incorporated into a physician’s character in a close-knit and isolated place. The findings of the thesis demonstrate that there are significant gaps between what community members and physicians believe is reasonable behaviour and the reality of physicians’ experiences in their respective island communities. The lack of boundaries perceived by physicians in their communities often leads to social isolation, which has the opposite intended effect of respite, instead leading to further disengagement from the local community, finally resulting in a decision to locate elsewhere. / Thesis (Master, Geography) -- Queen's University, 2009-09-26 18:55:16.51

To achieve Sustainable Development Goal 3 in developing countries, Good health and wellbeing for all, the health workforce is vital however the unpopularity of rural medical practice results in widening healthcare inequalities between urban and rural areas. This study determined the heterogeneity in valuations for rural facility attributes by final year medical students at one South African public university to inform cost-effective recruitment policy recommendations. Focus groups conducted identified facility attributes, a D-efficient design was generated with 15 choice sets, each with two rural hospital alternatives and no opt-out option. An online, unlabelled discrete choice experiment (DCE) was conducted, the results effects coded, and mixed logit models applied. The final sample size was 193 (86,16% of the class), majority female 130 (66.33%), with urban origins 176 (89.80%), unmarried 183 (93.37%) and without children 193 (98.47%). Most had undergraduate rural medicine exposure 110 (56.12%) and intended to specialise 109 (55.61%). The main-effects mixed logit found advanced practical experience, hospital safety, correctly fitted personal protective equipment (PPE) and availability of basic resources the highest weighted attributes with their mean utilities increasing by 0.82, 0.64, 0.62 and 0.52 respectively (p=0.000). In contrast, increases in rural allowance and the provision of housing provided smaller mean utility increases of 0.001 (p<0.01) and 0.09 (p<0.05) respectively. The interaction terms; female, general practise and prior rural medicine exposure, were associated with higher weighting for hospital safety, mean utility increases 1.59, 1.82, 1.42 respectively (p=0.000). Participants were willing to pay ZAR 2636.45 monthly (95%CI: 1398.55;3874.355) to gain advanced practical experience (equivalent to 65.91% of current rural allowance). Medical students’ facility preferences have been found to be influenced by their gender, career aspirations and prior experienced with rural medicine. The policy recommendations derived from this research include publicising rural health facility “draw-cards” among medical graduates, such as the opportunity to gain practical experience, improving the physical and occupational safety at rural health facilities and providing greater transparency about rural facility attributes to medical graduates.

Thesis (MPhil)--Stellenbosch University, 2013. / ENGLISH ABSTRACT: A portfolio assessment system was designed to meet the needs of a Rural Clinical School education platform, hosting final year MB ChB students for the duration of their final year. A study entitled “What can be learned from the implementation of a portfolio assessment system, to be used in the assessment of clinical reasoning of final MB ChB students placed in a Rural Clinical School in South Africa? “ was conducted. The experience of educators and students during this process was explored. The findings are in keeping with the literature. Van Tartwijk & Driessen 2009, Eley et Al 2002, Lake & Ryan 2004, Burch & Seggie 2008 claim that portfolios drive deep student learning and develop clinical reasoning. Burch & Seggie (2008) offer an assessment tool which has proved feasible within the South African setting on which this portfolio assessment system was modelled. The assessment tool design faced a number of challenges within the RCS setting which were addressed during a review process. The portfolio assessment system is viewed as a work in progress requiring further development. Despite the constraints and challenges, both staff and students unanimously supported the development of patient case studies within the design as a valuable learning tool. / AFRIKAANSE OPSOMMING: ‘n Portefeulje assesserings sisteem is ontwerp om die behoeftes van ‘n UKWANDA Landelike Kliniese Skool opvoedings program wat die gasheer van die MB ChB student tydens hul finale jaar is, na te kom. ‘n Studie genaamd “ Wat kan geleer word uit die implementering van ‘n portefeulje assesserings sisteem, wat gebruik gaan word om die kliniese redenering te bepaal van finale jaar MB ChB student wat geplaas is in ‘n Landelike Klinieke Skool in Suid Afrika? ” is uitgeoefen. Die ervaring van die dosent, so wel as die studente, is ondersoek. Die bevinding is in lyn met die literatuur. Van Tartwijk & Driessen 2009, Eley et Al 2002, Lake & Ryan 2004, Burch & Seggie 2008 beweer dat portfeuljes dryf student tot diep studie en ontwikkel kliniese redenasie. Burch & Seggie (2008) bied ‘n assesserings (hulp)middel aan wat toepaslik en uitvoerbaar is in die SA konteks , waarop die portfeulje assessering sisteem gebaseer is. Die ontwerp van die assesserings (hulp)middel het vele uitdagings binne die RCS opset in die oog gestaar. Dit is aangespreek tydens ‘n proses van hersiening. (Lather, 2006).Die portefeulje assesserings sisteem word gesien as ‘n werk onder hande en vereis verdere ontwikkeling. Ten spyte van die beperkinge en uitdagings het beide die staf en die student onomwonde die ontwikkeling van pasiente gevalle studies, binne die ontwerp, as ‘n waardevolle leermiddel gesien.

The primary aim of the research project was to develop conceptual models of rural ambulance service delivery based on different worldviews or philosophical positions, and then to compare and contrast these new and emerging models with existing organisational policy and practice. Four research aims were explored: community expectations of pre-hospital care, the existing organization of rural ambulance services, the measurement of ambulance service performance, and the comparative suitability of different pre-hospital models of service delivery. A unique feature was the use of soft systems methodology to develop the models of service delivery. It is one of the major non-traditional systems approaches to organisational research and lends itself to problem solving in the real world. The classic literature-hypothesis-experiment-results-conclusion model of research was not followed. Instead, policy and political analysis techniques were used as counter-points to the systems approach. The program of research employed a triangulation technique to adduce evidence from various sources in order to analyse ambulance services in rural Victoria. In particular, information from questionnaires, a focus group, interviews and performance data from the ambulance services themselves were used. These formed a rich dataset that provided new insight into rural ambulance services. Five service delivery models based on different worldviews were developed, each with its own characteristics, transformation processes and performance criteria. The models developed are titled: competitive; sufficing; community; expert; and practitioner. These conceptual models are presented as metaphors and in the form of holons and rich pictures, and then transformed into patient pathways for operational implementation. All five conceptual models meet the criteria for systemic desirability and were assessed for their political and cultural feasibility in a range of different rural communities. They provide a solid foundation for future discourse, debate and discussion about possible changes to the way pre-hospital services are delivered in rural Victoria.

No description available.

As the cost for health care delivery increases, so does the demand for access to care. However, individuals in a rural community often do not have access to the care they need. Shortages of rural health care professionals are an ever-increasing problem. The Affordable Care Act of 2010 sought to increase health care access by focusing on team-based care delivery. Thus, the need to educate health care students in the fundamentals of team-based practice has led to an increased emphasis on Interprofessional Education (IPE). While past research focused on urban IPE, a literature gap exists for the effects of a rural team-based educational experience on practice location decisions. This study examined how rural IPE influenced health profession students' perspectives of what it means to be a member of a rural health care team and explored what factors go into making decisions of where to live and provide care. Motivational Theory provided the framework for a mixed methods approach with data from student reflective journaling and a post-experience Q sort. Analysis yielded important understandings about the impact of rural IPE. Accordingly, having a rural IPE experience provided positive motivation for returning after graduation. Further, the time spent in rural IPE generated understandings of what it means to live and provide care to a rural community. One important new discovery gained is the clinical setting is not where most IPE took place. As a result, social interactions with fellow students and community members achieved the goals of rural IPE. Despite these influential findings, noted barriers to genuine rural IPE persisted. In the end, students, educators, and rural health care professionals need to be aware of the multiple factors that guide decisions of where to live and provide care.

Rural and remote areas of Australia remain the last bastion of health disadvantage in a developed nation with an enviable health score-card. During the last ten years, rural and remote health has emerged as a significant issue in the media and the political arena. This thesis examines print media, policy documents and interviews from selected informants to ascertain how they represent medical practitioners and health services in rural and remote areas of Australia, why they do so, and the consequences of such positions. In many of these representations, rural and remote medical practitioners are aligned with national and cultural mythologies, while health services are characterised as dysfunctional and at crisis point. Ostensibly, the representations and identity formulations are aimed at redressing the health inequities in remote rural and Australia. They define and elaborate debates and contestations about needs and claims and how they should be addressed; a process that is crucial in the development of professional identity and power (Fraser; 1989). The research involves an analysis and critical reading of the entwined discourses of culture, power, and the politics of need. Following Wodak and others (1999), these dynamics are explored by examining documents that are part of the discursive constitution of the field. In particular, the research examines how prevailing cultural concepts are used to configure the Australian rural and remote medical practitioner in ways that reflect and advance socio-cultural hegemony. The conceptual tools used to explore these dynamics are drawn from critical and post-structural theory, and draw upon the work of Nancy Fraser (1989; 1997) and Ruth Wodak (1999). Both theorists developed approaches that enable investigation into the effects of language use in order to understand how the cultural framing of particular work can influence power relations in a professional field. The research follows a cultural studies approach, focussing on texts as objects of research and acknowledging the importance of discourse in the development of cultural meaning (Nightingale, 1993). The methodological approach employs Critical Discourse Analysis, specifically the Discourse Historical Method (Wodak, 1999). It is used to explore the linguistic hallmarks of social and cultural processes and structures, and to identify the ways in which political control and dominance are advanced through language-based strategies. An analytical tool developed by Ruth Wodak, Rudolf de Cillia, Martin Reisigl and Karin Leibhart (1999) was adapted and used to identify nationalistic identity formulations and related linguistic manoeuvres in the texts. The dissertation argues that the textual linguistic manoeuvres and identity formulations produce and privilege a particular identity for rural and remote medical practitioners, and that cultural myth is used to popularise, shore up and advance the goals of rural doctors during a period of crisis and change. Important in this process is the differentiation of rural and remote medicine from other disciplines in order to define and advance its political needs and claims (Fraser, 1989). This activity has unexpected legacies for the rural and remote health sector. In developing a strong identity for rural doctors, discursive rules have been established by the discipline regarding roles, personal and professional characteristics, and practice style; rules which hold confounding factors for the sustainability of remote and rural medical practice and health care generally. These factors include: the professional fragmentation of the discipline of primary medical care into general practice and rural medicine; and identity formulations that do not accommodate an ageing workforce characterised by cultural diversity, decreasing engagement in full time work, and a higher proportion of women participants. Both of these factors have repercussions for the recruitment and retention of rural and remote health professionals and the maintenance of a sustainable health workforce. The dissertation argues that the formulated identities of rural and remote medical practitioners in the texts maintain and reproduce relationships of cultural, political and social power. They have also influenced the ways in which rural and remote health services have been developed and funded. They selectively represent and value particular roles and approaches to health care. In doing so, they misrepresent the breadth and complexities of rural and remote health issues, and reinforce a reputational economy built on differential professional and cultural respect, and political and economic advantage. This disadvantages the community, professions and interest groups of lower value and esteem, and other groups whose voices are often not heard. Thus, regardless of their altruistic motivations, the politics of identity and differentiation employed in the formulated identities in the texts are based on an approach that undermines the redistributive goals of justice and equity (Fraser 1997), and works primarily to develop and advantage the discipline of rural medicine.