Key institutions and services are suggested to contribute to remote communities in ways that extend beyond their primary function.  For example, schools and health services are suggested to have important, social, symbolic or economic roles in small remote communities.  There is little empirical evidence identifying the nature and extent of such roles.  Consequently, service reconfiguration driven by economic, political, technological and demographic change may have wider, but currently inadequately understood, impact on remote communities.  This is important for policy. This study explored the nature and extent of added-value contributions, using remote health services as an exemplar (Part 1).  A method for measuring the impact, on remote communities, of added-value contributions from any sector was then constructed (Part 2). Part 1: Eight remote community case studies in Scotland and South Australia explored the added-value roles of the health sector.  Cross-case findings present evidence of health professionals’ behaviour and residents’ perceptions of the social, economic and symbolic importance of remote health service to communities.  Findings revealed a distinction between health service institutions’ contributions (built environment, employer role, health professional status and competencies and symbolic aspects) and those attributable to health professionals as individuals. Part 2:  Institutional and personal added-value contributions were conceptualised as contributing to stocks of different categories of capital insofar as they constitute tangible and intangible resources available for use by individuals and communities.  This conceptual framework provided the basis for developing a prototype generic quantitative instrument (C-CAT) capable of measuring the added-value contributions of institutions and individuals to community stocks of human, social, economic, symbolic and institutional capital. Uniquely, study outputs provide a potential method of quantifying complex and intangible aspects of remote community life that  underpin an innate sense of community ownership, but which have hitherto not been explicitly conceptualised or been capable of measurement.

published_or_final_version / Public Health / Master / Master of Public Health

Aims To investigate the impact of organisational change on the delivery of health services in remote and rural Scotland using, as an example, changes in the organisation of out of hours primary care, and to identify the attributes of successful innovation in remote and rural health provision. Methods The thesis comprised a thematic literature review; in depth interviews with key stakeholders, and case studies based in remote communities. Results The literature review identified recurring attributes of successful innovation. Interviews with remote and rural GPs showed that working out of hours had been, or still was, an integral part of life as a GP. Most agreed there had been an impact on family life. Advantages and challenges of remote and rural working were identified; many GPs could not envisage a better way of delivering services. This was contested by managers. There were divergent views of the 2004 GMS contract. The GPs who opted out of 24 hour responsibility experienced a transformational change in working life. All in all, there was a lack of understanding, and trust, between organisations. NHS 24 and Scottish Ambulance Service were criticised. There had been little change in out of hours service delivery since 2005, and the present configuration was seen as expensive and unsustainable. Despite these acknowledged difficulties, the view was that difficult decisions had been avoided, and a long-term solution that fits the area was required. The case studies added detail and contextual understanding of delivery of services. This could vary even within a practice area. Service delivery on islands was different, with a stronger tie between community and practice, governed by transport logistics, and difficult to understand from an outside perspective. Conclusions. The delivery of out of hours services in remote and rural Scotland has been a difficult and contested issue. Context can have different impacts, even within a very small area. Failure to innovate was associated with lack of collaboration, lack of strategy, lack of understanding of local context, and avoidance of difficult decisions. The organisational change literature demonstrated that receptive contexts for change were not present.

Thesis (MAppSc)--University of South Australia, 1998

Thesis (MAppSc)--University of South Australia, 1998

Thesis (Ph.D.)--Aberdeen University, 2009. / Title from web page (viewed on Oct. 5, 2009). Includes bibliographical references.

Thesis--University of Iowa. / eContent provider-neutral record in process. Description based on print version record. Includes bibliographical references (leaves 478-491).

Thesis (Ph.D.) in History--University of Maine, 2006. / Includes vita. Includes bibliographical references (leaves 261-277).

No description available.

A THESIS Submitted to the School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, in fulfilment of the requirements for the degree of Doctor of Philosophy Johannesburg, South Africa 2016 / Background: South Africa has a dual high burden of HIV and non-communicable diseases (NCDs). In a response to the dual burden of these chronic diseases, the National Department of Health (NDoH) introduced a pilot of the Integrated Chronic Disease Management (ICDM) model in June 2011 in selected Primary Health Care (PHC) facilities, one of the first of such efforts by an African Ministry of Health. The main aim of the ICDM model is to leverage the successes of the innovative HIV treatment programme for NCDs in order to improve the quality of chronic disease care and health outcomes of adult chronic disease patients. Since the initiation of the ICDM model, little is known about the quality of chronic care resulting in the effectiveness of the model in improving health outcomes of chronic disease patients. Objectives: To describe the chronic disease profile and predictors of healthcare utilisation (HCU) in a rural population in a South African municipality; and assess quality of care and effectiveness of the ICDM model in improving health outcomes of chronic disease patients receiving treatment in PHC facilities. Methods: An NDoH pilot study was conducted in selected health facilities in the Bushbuckridge municipality, Mpumalanga province, northeast South Africa, where a part of the population has been continuously monitored by the Agincourt Health and Socio-Demographic Surveillance System (HDSS) since 1992. Two main studies were conducted to address the two research objectives. The first study was a situation analysis to describe the chronic disease profile and predictors of healthcare utilisation in the population monitored by the Agincourt HDSS. The second study evaluated quality of care in the ICDM model as implemented and assessed effectiveness of the model in improving health outcomes of patients receiving treatment in PHC facilities. This second study had three components: (1) a qualitative and (2) a quantitative evaluation of the quality of care in the ICDM model; and a (3) quantitative assessment of effectiveness of the ICDM model in improving patients‘ health outcomes. The two main studies have been categorised into three broad thematic areas: chronic disease profile and predictors of healthcare utilisation; quality of care in the ICDM model; and changes in patients‘ health outcomes attributable to the ICDM model. In the first study, a cross-sectional survey to measure healthcare utilisation was targeted at 7,870 adults 50 years and over permanently residing in the area monitored by the Agincourt HDSS in 2010, the year before the ICDM model was introduced. Secondary data on healthcare utilisation (dependent variable), socio-demographic variables drawn from the HDSS, receipt of social grants and type of medical aid (independent variables) were analysed. Predictors of HCU were determined by binary logistic regression adjusted for socio-demographic variables. The quantitative component of the second study was a cross-sectional survey conducted in 2013 in the seven PHC facilities implementing the ICDM model in the Agincourt sub-district (henceforth referred to as the ICDM pilot facilities) to better understand the quality of care in the ICDM model. Avedis Donabedian‘s theory of the relationships between structure, process, and outcome (SPO) constructs was used to evaluate quality of care in the ICDM model exploring unidirectional, mediation, and reciprocal pathways. Four hundred and thirty-five (435) proportionately sampled patients ≥ 18 years and the seven operational managers of the PHC facilities responded to an adapted satisfaction questionnaire with measures reflecting structure (e.g. equipment), process (e.g. examination) and outcome (e.g. waiting time) constructs. Seventeen dimensions of care in the ICDM model were evaluated from the perspectives of patients and providers. Eight of these 17 dimensions of care are the priority areas of the HIV treatment programme used as leverage for improving quality of care in the ICDM model: supply of critical medicines, hospital referral, defaulter tracing, prepacking of medicines, clinic appointments, reducing patient waiting time, and coherence of integrated chronic disease care (a one-stop clinic meeting most of patients‘ needs). A structural equation model was fit to operationalise Donabedian‘s theory using patient‘s satisfaction scores. The qualitative component of the second study was a case study of the seven ICDM pilot facilities conducted in 2013 to gain in-depth perspectives of healthcare providers and users regarding quality of care in the ICDM model. Of the 435 patients receiving treatment in the pilot facilities, 56 were purposively selected for focus group discussions. An in-depth interview was conducted with the seven operational managers within the pilot facilities and the health manager of the Bushbuckridge municipality. Qualitative data were analysed, with MAXQDA 2 software, to identify 17 a priori dimensions of care and emerging themes. In addition to the emerging themes, codes generated in the qualitative analysis were underpinned by Avedis Donabedian‘s SPO theoretical framework. A controlled interrupted time-series study was conducted for the 435 patients who participated in the cross-sectional study in the ICDM pilot facilities and 443 patients proportionately recruited from five PHC facilities not implementing the ICDM model (Comparison PHC facilities in the surrounding area outside the Agincourt HDSS) from 2011-2013. Health outcome data for each patient were retrieved from facility records at 30-time points (months) during the study period. We performed autoregressive moving average (ARMA) statistical modelling to account for autocorrelation inherent in the time-series data. The effect of the ICDM model on the control of BP (<140/90 mmHg) and CD4 counts (>350 cells/mm3) was assessed by controlled segmented linear regression analysis. Results: Seventy-five percent (75%) of the 7,870 eligible adults 50+ responded to the health care utilization survey in the first study. All 5,795 responders reported health problems, of whom 96% used healthcare, predominantly at public health facilities (82%). Reported health problems were: chronic non-communicable diseases (41% - e.g. hypertension), acute conditions (27% - e.g. flu), other conditions (26% - e.g. musculoskeletal pain), chronic communicable diseases (3% e.g. HIV and TB) and injuries (3%). Chronic communicable (OR=5.91, 95% CI: 1.44, 24.32) and non-communicable (OR=2.85, 95% CI: 1.96, 4.14) diseases were the main predictors of healthcare utilisation. Out of the 17 dimensions of care assessed in the quantitative component of the quality of care study, operational managers reported dissatisfaction with patient waiting time while patients reported dissatisfaction with the appointment system, defaulter-tracing of patients and waiting time. The mediation pathway fitted perfectly with the data (coefficient of determination=1.00). The structural equation modeling showed that structure correlated with process (0.40) and outcome (0.75). Given structure, process correlated with outcome (0.88). Patients‘ perception of availability of equipment, supply of critical medicines and accessibility of care (structure construct) had a direct influence on the ability of nurses to attend to their needs, be professional and friendly (process construct). Patients also perceived that these process dimensions directly influenced coherence of care provided, competence of the nurses and patients‘ confidence in the nurses (outcome construct). These structure-related dimensions of care directly influenced outcome-related dimensions of care without the mediating effect of process factors. In the qualitative study, manager and patient narratives showed inadequacies in structure (malfunctioning blood pressure machines and staff shortage); process (irregular prepacking of drugs); and outcome (long waiting times). Patients reported anti-hypertension drug stock-outs; sub-optimal defaulter-tracing; rigid clinic appointments; HIV-related stigma in the community resulting from defaulter-tracing activities; and government nurses‘ involvement in commercial activities in the consulting rooms during office hours. Managers reported simultaneous treatment of chronic diseases by traditional healers in the community and thought there was reduced HIV stigma because HIV and NCD patients attended the same clinic. In the controlled-interrupted time series study the ARMA model showed that the pilot facilities had a 5.7% (coef=0.057; 95% CI: 0.056,0.058; P<0.001) and 1.0% (coef=0.010; 95% CI: 0.003,0.016; P=0.002) greater likelihood than the comparison facilities to control patients‘ CD4 counts and BP, respectively. In the segmented analysis, the decreasing probabilities of controlling CD4 counts and BP observed in the pilot facilities before the implementation of the ICDM model were respectively reduced by 0.23% (coef = -0.0023; 95% CI: -0.0026,-0.0021; P<0.001) and 1.5% (Coef= -0.015; 95% CI: -0.016,-0.014; P<0.001). Conclusions: HIV and NCDs were the main health problems and predictors of HCU in the population. This suggests that public healthcare services for chronic diseases are a priority among older people in this rural setting. There was poor quality of care reported in five of the eight priority areas used as leverage for the control of NCDs (referral, defaulter tracing, prepacking of medicines, clinic appointments and waiting time); hence, the need to strengthen services in these areas. Application of the ICDM model appeared effective in reducing the decreasing trend in controlling patients‘ CD4 counts and blood pressure. Suboptimal BP control observed in this study may have been due to poor quality of care in the identified priority areas of the ICDM model and unintended consequences of the ICDM model such as work overload, staff shortage, malfunctioning BP machines, anti-hypertension drug stock-outs, and HIV-related stigma in the community. Hence, the HIV programme should be more extensively leveraged to improve the quality of hypertension treatment in order to achieve optimal BP control in the nationwide implementation of the ICDM model in PHC facilities in South Africa and, potentially, other LMICs. / MT2017