Diabetes is emerging as a major threat to health, with global economic and social implications. Recent research has shown that the morbidity and mortality associated with diabetes can be reduced by timely and effective treatment. However, unless people with diabetes have access to this treatment, the impact of diabetes will continue to rise. This thesis therefore explores the current standards of care which people with diabetes receive. It also looks at factors likely to impact on delivery of diabetes care. Studies were conducted at two levels. In the studies described in Chapters 2 and 3, general data applicable to all or nearly all patients with diabetes were collected. This approach substantially eliminates selection bias but precludes the ability to examine clinical outcomes. In the other studies, detailed in Chapters 4, 5 and 6, specific aspects of diabetes care pertaining to more select groups of diabetic subjects were examined. This approach allows clinical parameters to be examined in more detail but is more subject to selection bias. It is hoped that the combination of these two approaches provides a more balanced view of the topic under examination. In Australia, the Medicare Program, a single government controlled universal health insurance fund, provides access to medical services for all residents. Medicare occasions of service data therefore represent the most comprehensive source of information regarding health service utilisation in Australia. The data does not account for people receiving diabetes care through public hospital based services. However, a survey of public hospitals within NSW (n=198), described in Chapter 2, showed that the number of individuals in this category is relatively small and represents only 5.2% of the diabetic population. Using Medicare item codes, and with the permission and assistance of the Commonwealth Department of Health and Aged Care, data were extracted on attendance to medical practitioners and utilisation of diabetes related procedures for people living in New South Wales (NSW) for the individual years between 1993 to 1997. All data were stratified by the presence of diabetes, gender and age group. Individuals were deemed to have diabetes if an HbA1c, which can only be ordered for a person with known diabetes, had been performed over the 5-year period and the sample size adjusted for the incidence of diabetes. Once adjusted, the number of people with diabetes in NSW for the individual years 1993 to 1997 were 143,920, 156,234, 168,216, 177,280 and 185,780. Comparison with 1996 census data confirmed a 91.7% capture of the total NSW population (5,495,900/5,995,545 individuals). The data were retrieved for NSW as a whole and for individual postcodes. Postcodes were then classified by population density as either major urban, urban or rural. On average over the study period, persons with diabetes accounted for 3.1% of the population but they used 5.5% of general practitioner services. As seen in Chapter 2, a large proportion of people with diabetes were also under the care of specialists and consultant physicians, up to 51.2% and 41.8% respectively, a 3 to 4 fold increase when compared with their non-diabetic counterparts. In regard to geographical location, once adjusted for age and gender, the odds ratio of attending a specialist was only slightly higher for people with diabetes living in areas of high population density when compared to people with diabetes living in rural areas. This ratio reached as high as 1.85 in regard to attendance to consultant physicians (Chapter 3). The odds ratio for the non-diabetic population was similar indicating that the difference in access to consultant physicians was not disease specific. Analysis of results showed that despite the increase in service utilisation, large proportions of people with diabetes were not routinely monitored in regard to diabetes and its complications across the State. By 1997, HbA1c was still not performed in over 40% of people with diabetes each year and only 11.6% of the diabetic population had undergone microalbuminuria estimation. Interestingly, the differences in levels of monitoring between rural and urban areas were surprisingly small. Monitoring of diabetes and its complications did improve in all parts of the State over the study period. However, the greatest improvement was seen in rural areas, despite rural patients having fewer attendances to general practitioners and fewer patients attending specialist care. In the face of finite resources and the rising prevalence of diabetes, an increasing number of patients will need to rely on general practitioners to provide diabetes care regardless of where they live. A 'shared care' approach which encourages and supports general practitioners to manage patients with diabetes, while giving them access to specialist services for those patients that require them, is increasingly being advocated as a way of maximising efficacy while minimising costs. Yet if health care professionals leave undone what they think is done by others, shared care can become neglected care. Chapter 4 reports a detailed audit of 200 randomly selected shared care patients who were assessed on two or more occasions. This study showed that the majority of specialist treatment recommendations are implemented by general practitioners. Doctors formally registered with the Diabetes Shared Care Programme and those who write longer referral letters were more likely to implement recommendations than their counterparts. Moreover, the average HbA1c and the complication profile of these patients were similar to those found in various studies around the world. This suggests that diabetes can be well managed by a shared care approach that is adequately integrated. To overcome the problem that data is lacking on those patients that did not return for specialist review, a further 200 shared care patients who were lost to follow up from the shared care system were traced. Information regarding whether treatment recommendations had been implemented was sought from both the referring doctor and the patient. Overall, information on 182 of the 200 patients could be obtained. As discussed in Chapter 5, comparison of the returned and non returned patients' demographic and clinical profiles at time of their initial specialist review showed that general practitioners differentiated between the 'more complicated' patients, choosing to re-refer those with macrovascular disease, while maintaining the care of 'less complicated' patients. Re-referral for specialist review was also dependent on the patient remaining under the care of their original doctor. Encouragingly, general practitioners seemed to take a more active role in the non-returned group. They included more details regarding type and duration of diabetes in the referral letters of patients who were not re-referred for specialist review. They also implemented more treatment recommendations in the non-returned group, with the difference in implementation rate for metabolic recommendations reaching statistical significance. This study also showed that movement of patients between doctors raises concern regarding continuity of care. The multi-factorial nature of diabetes means that best practice is not easily accommodated within a single appointment. Thus continuity of care becomes an important issue. To assess the current status, 479 consecutive patients referred to the Royal Prince Alfred Hospital Diabetes Centre in a 6-month period were recruited and underwent a detailed clinical assessment. They were also questioned regarding the number of general practitioners they attended and the length of time they had been under the care of the referring doctor. The results outlined in Chapter 6 showed that the majority of people with diabetes (87.7%) attended only one general practitioner and had been under the care of that doctor medium to long term. Younger patients, who were relatively healthy apart from the presence of diabetes, were more likely to attend several general practitioners or have changed their general practitioner within the last year. This lack of continuity had little difference on acute outcomes such as glycaemic and blood pressure control. Appropriately, continuity of care increased with increasing age and the increasing prevalence of diabetes complications, mainly macrovascular disease. These studies indicate that further efforts are required to improve the overall standard of diabetes care within Australia. At present there is a heavy dependency on specialist services. As the population ages and the number of people with diabetes increases, much of this burden will fall on general practitioners, as is already evident in rural areas. When provided with appropriate support and infrastructure, general practitioners are able to maintain standards of care through referral of patients with more complex medical problems and by maintaining the degree of continuity appropriate to the patient's needs. However, the collection of relevant information to monitor future trends in diabetes services provision is important. As shown in this thesis, Medicare data represents an easy and cost effective method with which to do so.

Diabetes is emerging as a major threat to health, with global economic and social implications. Recent research has shown that the morbidity and mortality associated with diabetes can be reduced by timely and effective treatment. However, unless people with diabetes have access to this treatment, the impact of diabetes will continue to rise. This thesis therefore explores the current standards of care which people with diabetes receive. It also looks at factors likely to impact on delivery of diabetes care. Studies were conducted at two levels. In the studies described in Chapters 2 and 3, general data applicable to all or nearly all patients with diabetes were collected. This approach substantially eliminates selection bias but precludes the ability to examine clinical outcomes. In the other studies, detailed in Chapters 4, 5 and 6, specific aspects of diabetes care pertaining to more select groups of diabetic subjects were examined. This approach allows clinical parameters to be examined in more detail but is more subject to selection bias. It is hoped that the combination of these two approaches provides a more balanced view of the topic under examination. In Australia, the Medicare Program, a single government controlled universal health insurance fund, provides access to medical services for all residents. Medicare occasions of service data therefore represent the most comprehensive source of information regarding health service utilisation in Australia. The data does not account for people receiving diabetes care through public hospital based services. However, a survey of public hospitals within NSW (n=198), described in Chapter 2, showed that the number of individuals in this category is relatively small and represents only 5.2% of the diabetic population. Using Medicare item codes, and with the permission and assistance of the Commonwealth Department of Health and Aged Care, data were extracted on attendance to medical practitioners and utilisation of diabetes related procedures for people living in New South Wales (NSW) for the individual years between 1993 to 1997. All data were stratified by the presence of diabetes, gender and age group. Individuals were deemed to have diabetes if an HbA1c, which can only be ordered for a person with known diabetes, had been performed over the 5-year period and the sample size adjusted for the incidence of diabetes. Once adjusted, the number of people with diabetes in NSW for the individual years 1993 to 1997 were 143,920, 156,234, 168,216, 177,280 and 185,780. Comparison with 1996 census data confirmed a 91.7% capture of the total NSW population (5,495,900/5,995,545 individuals). The data were retrieved for NSW as a whole and for individual postcodes. Postcodes were then classified by population density as either major urban, urban or rural. On average over the study period, persons with diabetes accounted for 3.1% of the population but they used 5.5% of general practitioner services. As seen in Chapter 2, a large proportion of people with diabetes were also under the care of specialists and consultant physicians, up to 51.2% and 41.8% respectively, a 3 to 4 fold increase when compared with their non-diabetic counterparts. In regard to geographical location, once adjusted for age and gender, the odds ratio of attending a specialist was only slightly higher for people with diabetes living in areas of high population density when compared to people with diabetes living in rural areas. This ratio reached as high as 1.85 in regard to attendance to consultant physicians (Chapter 3). The odds ratio for the non-diabetic population was similar indicating that the difference in access to consultant physicians was not disease specific. Analysis of results showed that despite the increase in service utilisation, large proportions of people with diabetes were not routinely monitored in regard to diabetes and its complications across the State. By 1997, HbA1c was still not performed in over 40% of people with diabetes each year and only 11.6% of the diabetic population had undergone microalbuminuria estimation. Interestingly, the differences in levels of monitoring between rural and urban areas were surprisingly small. Monitoring of diabetes and its complications did improve in all parts of the State over the study period. However, the greatest improvement was seen in rural areas, despite rural patients having fewer attendances to general practitioners and fewer patients attending specialist care. In the face of finite resources and the rising prevalence of diabetes, an increasing number of patients will need to rely on general practitioners to provide diabetes care regardless of where they live. A 'shared care' approach which encourages and supports general practitioners to manage patients with diabetes, while giving them access to specialist services for those patients that require them, is increasingly being advocated as a way of maximising efficacy while minimising costs. Yet if health care professionals leave undone what they think is done by others, shared care can become neglected care. Chapter 4 reports a detailed audit of 200 randomly selected shared care patients who were assessed on two or more occasions. This study showed that the majority of specialist treatment recommendations are implemented by general practitioners. Doctors formally registered with the Diabetes Shared Care Programme and those who write longer referral letters were more likely to implement recommendations than their counterparts. Moreover, the average HbA1c and the complication profile of these patients were similar to those found in various studies around the world. This suggests that diabetes can be well managed by a shared care approach that is adequately integrated. To overcome the problem that data is lacking on those patients that did not return for specialist review, a further 200 shared care patients who were lost to follow up from the shared care system were traced. Information regarding whether treatment recommendations had been implemented was sought from both the referring doctor and the patient. Overall, information on 182 of the 200 patients could be obtained. As discussed in Chapter 5, comparison of the returned and non returned patients' demographic and clinical profiles at time of their initial specialist review showed that general practitioners differentiated between the 'more complicated' patients, choosing to re-refer those with macrovascular disease, while maintaining the care of 'less complicated' patients. Re-referral for specialist review was also dependent on the patient remaining under the care of their original doctor. Encouragingly, general practitioners seemed to take a more active role in the non-returned group. They included more details regarding type and duration of diabetes in the referral letters of patients who were not re-referred for specialist review. They also implemented more treatment recommendations in the non-returned group, with the difference in implementation rate for metabolic recommendations reaching statistical significance. This study also showed that movement of patients between doctors raises concern regarding continuity of care. The multi-factorial nature of diabetes means that best practice is not easily accommodated within a single appointment. Thus continuity of care becomes an important issue. To assess the current status, 479 consecutive patients referred to the Royal Prince Alfred Hospital Diabetes Centre in a 6-month period were recruited and underwent a detailed clinical assessment. They were also questioned regarding the number of general practitioners they attended and the length of time they had been under the care of the referring doctor. The results outlined in Chapter 6 showed that the majority of people with diabetes (87.7%) attended only one general practitioner and had been under the care of that doctor medium to long term. Younger patients, who were relatively healthy apart from the presence of diabetes, were more likely to attend several general practitioners or have changed their general practitioner within the last year. This lack of continuity had little difference on acute outcomes such as glycaemic and blood pressure control. Appropriately, continuity of care increased with increasing age and the increasing prevalence of diabetes complications, mainly macrovascular disease. These studies indicate that further efforts are required to improve the overall standard of diabetes care within Australia. At present there is a heavy dependency on specialist services. As the population ages and the number of people with diabetes increases, much of this burden will fall on general practitioners, as is already evident in rural areas. When provided with appropriate support and infrastructure, general practitioners are able to maintain standards of care through referral of patients with more complex medical problems and by maintaining the degree of continuity appropriate to the patient's needs. However, the collection of relevant information to monitor future trends in diabetes services provision is important. As shown in this thesis, Medicare data represents an easy and cost effective method with which to do so.

Delivery of palliative care to patients in a patient’s home, where they live with their family or in a retirement or nursing home, is an improved, shared-care team approach of providing quality healthcare services at the end of a patient’s life to reduce pain and stress. The palliative care shared-care teams in the Local Health Integration Network (LHIN) for Hamilton Niagara Haldimand Brant (HNHB also called LHIN4) manage patient health care through documents and trackers created and retained by providers within the circle of care, using several different systems and communication tools. These systems are not currently integrated and are unable to connect in a way that enables the preview, transfer, and receipt of data between these systems to support the needs of palliative care users. The primary objective of this thesis is to provide a proposal to improve the user experience of palliative care users through enhancement and integration of some of the systems currently in use. These include OSCAR EMR (Open Source Clinical Application Resource Electronic Medical Record) Hospice – InfoAnywhere, CHRIS (Client Health Related Information System) and Clinical Connect. Integration of these systems will address other limitations the shared-care teams are facing, such as communication, system or organizational policies and privacy and information security concerns that stem from the sharing of patient information across the systems, to support a shared-care team’s ability to provide patient care. During this study, an extensive requirements gathering and analysis was carried out: in-person interviews and teleconference meetings, brain storming sessions on the current systems and review of the secondary data with key stakeholders in the palliative care community. The local hospice sites were visited and extensive input was received from hands-on palliative shared-care teams and hospices across the HNHB LHIN, to ensure that the project team implemented their expressed needs into the integrated solution. The used case and prototyping approach of gathering the requirements is then used on the initial requirements gathered by sending out an initial draft to the users and stakeholders for their review, changes and additional requirements, hence fostering communication between the business and the development teams each time the brain storming session is held to review the refined requirements, resulting in the development of a high-quality Business Requirement Document (BRD). The project manager, lead developer, software architect, and users/testers were all utilized throughout the entire delivery process to ensure they were all in sync with the documented requirements. This lays the foundation for programmers to implement a quality end product with a technical solution that will enhance and integrate the systems to improve the user’s experience at the point of care. / Thesis / Master of Science (MSc)

The aim of this research programme was to explore ehealth technology in pharmacy practice in Scotland and, by doing so, contribute original knowledge to this area. Strategists worldwide believe technology has the potential to promote quality, safety and efficiency in healthcare. This has been reflected in national ehealth policies designed to support collaborative working between medical and non-medical healthcare practitioners and, more recently, the whole health and social care team. A meta-narrative systematic review was conducted to explore and contextualise research related to healthcare professionals’ views of the adoption of ehealth technologies to support shared care. Findings indicate the importance of organisational development and training for core and optional ehealth services with pharmacists particularly under-represented in ehealth research. Socio-technical systems theory and the computer supported cooperative working framework were adopted to explore healthcare practitioners’ perceptions of ehealth in relation to integrated care. Findings from the review indicate ehealth research continues to focus on doctors and nurses. No ehealth application was perceived to be an unqualified success with the socio-technical gap still evident. Multiple case studies were conducted to develop explanatory theory around the digital literacy experiences, education and training related needs of pharmacy staff in the NHS Grampian area. Digital literacy levels were self-reported as basic with mixed views on the need for formal education and training. Findings indicate organisational and social factors may act as restraining forces against implementation of technology in pharmacy and associated digital literacy training. A final theory testing, systematic review was conducted into digital literacy training experiences of pharmacy staff applying Kirkpatrick’s four level model. It found a lack of evidence of specific, measurable digital literacy levels but indications that suggest digital literacy should be included in pharmacy education at all levels and career stages. This research provides novel insight into ehealth and digital literacy in pharmacy practice. Combined ehealth, education and pharmacy research has been demonstrated to be an under-researched area therefore these findings contribute original knowledge.

PURPORSE¡GThis purpose of the study is to investigate the effectiveness of diabetes shared care model (DSCM)and the factors associated with extent of glycemic control. METHOD¡GWe analyzed 212 patients who completed the five shared care visits and 739 patients who completed the second follow-up visit. Patients are recruited from a department of Endocrinology of medical center located in southern part of Taiwan. Data used in this study were collected from the patients¡¦ medical records. To evaluate effectiveness of diabetes shared care model¡]dietary compliance, exercise behavior compliance, clinical indicators¡^and to examine the factors associated with the hemoglobulin A1c is the purpose of the study. RESULT¡G In 212 patients completing the 5 visits, the compliance of carbohydrate consumption was significantly improved, however, there was no significant improvement in those of calories and fat consumption. Further analysis in 739 patients who completed the second follow-up visit, we found that the compliance of calories and fat consumption was significantly improved. The compliance of carbohydrate was improved, but not reaching significant difference. Although the compliance of 212 patients¡¦ exercise behavior was not significantly improved, the compliance of 739 patients¡¦ exercise behavior was significantly improved. The improvement of clinical indicators following participating the DCSM are as followed¡G 1.The hemoglobulin A1c¡]before¡G8.1% vs after¡G7.9%¡AP=0.04¡^¡Bfasting plasma glucose¡]before¡G164.1mg/dL vs after¡G136.8 mg/dL¡AP<0.01¡^¡Btotal cholesterol ¡]before¡G200.9mg/dL vs after¡G187.3 mg/dL¡AP<0.01¡^¡Blow density lipoprotein¡]LDL¡^¡]before¡G121.0mg/dL vs posttest¡G113.1 mg/dL¡AP<0.01¡^¡Bhigh density lipoprotein¡]HDL¡^¡]before¡G42.6mg/dL vs posttest¡G46.2 mg/dL¡AP<0.01¡^of 212 patients were significantly improved. On the other hand, the triglyceride¡]pretest¡G159.9mg/dL vs after¡G152.2 mg/dL¡AP=0.71¡^¡Bsystolic blood pressure¡]before¡G132.5mmHg vs after¡G137.3 mmHg¡AP=0.34¡^and diastolic blood pressure¡]before¡G79.5 mmHg vs after¡G78.4 mmHg¡AP=0.09¡^of 212 patients were not significantly improved. 2.In 739 patients who only completing the second follow-up visit, the hemoglobulin A1c¡Bfasting plasma glucose¡Bdiastolic blood pressure were significantly improved but the systolic blood pressure was remain unchanged. Finally, multivariate regression modeling was used to investigate the factors associated with extent of glycemic control improvement (first visit HbA1c-annual visit HbA1c) in 212 patients competing the annual visit. After adjusting for age and sex, patients¡¦ sex, level of first visit hemoglobulin A1c and level of first visit triglyceride was associated with the extent of glycemic control.

This study explored the quality of life (QOL) of advanced cancer patients before and after receiving hospital-based palliative shared care; also compared their quality of life with those of terminal ill patients in palliative care units. Sixty-eight cancer patients in a southern Taiwan hospital were selected, purposive sampling, as our study samples. Among these 68 patients in our study were under three care models; 20 patients were under general care, 17 patients were under hospital-based palliative shared care, and 31 patients were under palliative care. One week after their admission into care units, we evaluated their QOL using MQOL ¡VTaiwan version. The QOL data of these three groups of advanced cancer patients ,then grouped and compared as in general care unit, hospital-based palliative shared care unit, and palliative care unit. All data collected were analyzed using SPSS for Word 10.0 statistic software. Furthermore, we have in-depth interviewed with four chiefs of general care units, five patient caretakers, and one professional of hospital-based palliative share care. Contents of the in-depth interviews focused on in what aspects hospital-based palliative shared care provided help to terminally ill patients in terms of quality of life or life difficulty. Contents of the discussion were then analyzed and interpreted. Results of our analysis, measured by MQOL ¡V Taiwan version, showed there is no significant difference in QOL of advanced cancer patients between hospital-based palliative shared care and general care. But results of our in-depth interview with caretakers and caregives showed interesting aspects: 1. Physical symptoms of advanced cancer patients was brought under control. 2. Psychological symptoms of advanced cancer patients or their family was taken care of. 3. Advanced cancer patients or their family are all benefited from continued advice and instructions. 4. Provide cancer patients and their family with guidance and instructions as to preparing for death. 5. Support the emotional needs of family of advanced cancer patients. 6. Hospital-based palliative shared care offered palliative consultation, supporting patient caretakers and providing improvement QOL for cancer patients. 7. Mindset change to doctors: inform cancer patients or their family of developing cancer symptom so that early intervention can be ensued. 8. Caretakers of general care unit and hospital-based palliative shared care unit formed a joint team, enabling cancer patients and their family feel secured in treatment. In conclusion, hospital-based palliative shared care benefits patients and their family. Comparing with hospital-based palliative shared care, palliative care showed significant improvement in physical symptom domain, psychological domain, and the mean of four domains. In all palliative interventions, palliative care has better effect in improving QOL of cancer patients than hospital-based palliative shared care. By this study, we examined and evaluated the effectiveness of ¡§Hospital-based Palliative Shared Care Program¡¨ promoted by Bureau of Health Promotion, Department of Health, R.O.C. With the in-depth information revealed, we can improve this promotion program and ensure that patient¡¦s needs have been taken care of. We would also recommend any promotion program must focus on patients, and a model of combined effort of palliative shared care should be on top of all.

Shared custody has risen to the fore as one of the most contentious issues facing family law justice systems. Ongoing efforts to implement or contemplate legislative reforms to prescribe a rebuttable presumption for shared custody have been central. Drawing on in-depth, retrospective qualitative interviews with 28 young adults between 18 and 25 years of age, this researcher conducted a thematic analysis and examined children’s perspectives and motivations regarding transitions into and out of shared custody, relationships with parents, and their sense of fairness around decision-making. The dissertation research is presented in a ‘publications format’ and contains an introduction, three self-contained journal-ready publications and an overarching discussion. The introduction provided an overall review of the literature and presented a developing model for tying together the complex strands of existing theoretical and empirical literature. Paper one focused how and why transitions into and out of shared custody happen. Drawing on the metaphor of alchemy, the analysis illustrated that shared custody is not a short-cut to a successful custodial arrangement or parent-child relations. Shared custody blends together complex interactions among elements related to the child’s living situation, maturation and changing notions of fairness, flexibility, the push and pull of relationships, and in some instances, rigid enforcement. The second paper highlighted how participants’ utilized the business strategy of “managing-up” and illustrated how children are active agents in navigating post-separation family relations finding ways to exert their agency to help and protect siblings, manage parental conflict, maintain shared custody to shield their parents and siblings from emotional hurt and initiate contact to maintain parent-child relationships. Including children’s voices in custodial decision-making is predicated on a rights-based doctrine that children ought to have input on decisions that affect their best interests. Participants felt that young children (13 years or less) should have input in how their arrangements were constructed, but not the final say about the type of custodial arrangement. There was general consensus that adolescents (about age 14), should have considerably more input. A final overarching discussion chapter integrated the three papers with the model presented in the introduction and suggests implications for policy and practice.

Submitted by Filipe dos Santos (fsantos@pucsp.br) on 2017-03-28T10:24:48Z No. of bitstreams: 1 Evelyn Sayeg.pdf: 791317 bytes, checksum: d769ec141abe1e42999a647ec99934d1 (MD5) / Made available in DSpace on 2017-03-28T10:24:48Z (GMT). No. of bitstreams: 1 Evelyn Sayeg.pdf: 791317 bytes, checksum: d769ec141abe1e42999a647ec99934d1 (MD5) Previous issue date: 2017-03-17 / Conselho Nacional de Pesquisa e Desenvolvimento Científico e Tecnológico - CNPq / Pontifícia Universidade Católica de São Paulo - PUCSP / In order to discuss the intersectorial construction of Public Policies based on its historical and social construction, this master's thesis was based on analyzing the challenges and possible arrangements in the construction of the Mental Health and Work and Income Policies articulation as a project of achievement of the participation of users of mental health services in the social body. For this, we sought to analyze the experience of a work center belonging to the Network of Psychosocial Care of a municipality, in this case the Center of Work and Art of São Bernardo do Campo. The transformations about the Capital – Labor relationship act in the direction of an extension of the phenomenon of social inequality. At the same time it seeks to transform the understanding of society about the phenomenon of madness, understanding that this is part of the human condition and therefore, there is no way to eliminate the madness of society. However, it poses as a possibility of expanding the spaces of participation in the social body to the “crazy people”, while, it was possible to find more just, dignified and solidary work possibilities, based on the guidelines of the Solidary Economy. The challenges and shared care proposals that the analysis, found in the dissertation, point to processes of intersectoriality and transversalization of care. Breaking with the resistances that present themselves in the daily work process of the health services, fit and become part of the process of construction of the singular therapeutic project, the work ruling contributes to the expansion of the service's view, as well as its care practice . Making possible directions that talk about the limitation of the place of health in the conduction of the encounter with the citizenship and the power to expand the guidelines of the Anti Asylum Psychiatric Reform to new areas of the society / Em busca de discutir a construção intersetorial das Políticas Públicas a partir de sua construção histórica e social, esta dissertação de mestrado se pautou em analisar os desafios e os arranjos possíveis na construção da articulação da Política de Saúde Mental e de Trabalho e Renda como projeto de conquista da participação dos usuários de serviços de saúde mental no corpo social. Para isso, buscou-se analisar a experiência de um núcleo de trabalho pertencente à Rede de Atenção Psicossocial de um município, no caso o Núcleo de Trabalho e Arte de São Bernardo do Campo. As transformações acerca da relação Capital – Trabalho atuam na direção de um alargamento do fenômeno da desigualdade social. Ao mesmo tempo em que busca-se transformar a compreensão da sociedade acerca do fenômeno da loucura, entendendo que este é parte da condição humana e, portanto, não há como eliminar a loucura da sociedade. Contudo, coloca-se como possibilidade de ampliação dos espaços de participação no corpo social para os ditos loucos, ao passo que, imprimiu-se possibilidades de trabalho mais justas, dignas e solidárias a partir das diretrizes da Economia Solidária. Os desafios e propostas de cuidado compartilhado que a análise, encontrados na dissertação, apontam para processos de intersetorialidade e transversalização do cuidado. Rompendo com as resistências que se apresentam no processo de trabalho cotidiano dos serviços de saúde, encaixar e tornar parte do processo de construção do projeto terapêutico singular a pauta do trabalho contribui para a ampliação do olhar dos serviços, bem como, de sua prática de cuidado. Possibilitando direcionamentos que discorrem sobre a limitação do lugar de saúde na condução do encontro com a cidadania e a potência de expandir para novas áreas as diretrizes da Reforma Psiquiátrica Antimanicomial

Syftet med föreliggande studie var att beskriva vad personer med diabetes anser inverka på deras möjlighet och vilja att följa egenvårdsråd (patientperspektivet) och att beskriva omvård-nad som stöder följsamhet (sjukvårdsperspektivet). Studien har genomförts som en litteratur-studie. Det visade sig att alla krav för att hålla sjukdomen under kontroll innebär livsstilsför-ändringar, som kan vara så utmanande för patienten, att han kanske inte kan eller vill vidta dessa. Bristande kunskap om sjukdomen och om dess egenvårdskrav kan göra honom dåligt emotionellt anpassad till denna, det vill säga han har inte accepterat att han har sjukdomen och han vill inte låta dess egenvårdskrav inkräkta på det sociala livet. Detta ger honom för-sämrade möjligheter att hantera sjukdomen på ett bra sätt. Barriärer av olika slag kan uppstå mellan patient och vårdgivare. Det kan röra sig om en upplevd brist på information och stöd när diabetes diagnosticerats eller en känsla av att vara utsatt för läkarens eller sjuksköterskans stereotypa föreställningar och/eller att bli paternalistiskt behandlad. Till barriärer räknas även klinisk misskötsel, det vill säga att läkare/sjuksköterska inte följer vedertagna riktlinjer för be-handling.Vad som kan inverka positivt på följsamheten är patientens stöd av anhöriga eller andra i det sociala nätverket. Omvårdnad som stöder följsamhet visade sig varapatientundervisning, främst om den inriktades på att öka patientens självständighet genom att låta undervisningen pågå under en längre tid, så att patienten hinner integrera sin nya kunskap med det dagliga livet. Med eller utan patientundervisning tar det tid att bygga upp ett socialt stöd och ett förtroende mellan patient och vårdare.

This diploma thesis on the topic Benefits and risks of home sharing in the care of children with autism spectrum disorders is focused on children with autism spectrum disorders, their families and especially on the new home sharing service. This is a form of relaxation stay, which regularly takes place in the household of the so-called host. The work is divided into two parts. The first chapter of the theoretical part summarizes the existing historical facts from the description of autism spectrum disorders by Leo Kanner and Hans Aspergerm. It also presents current knowledge in the field of aetiology, diagnostics and classification options. The third chapter is devoted to a family and a child with ASD. The last chapter of the theoretical part presents shared care home sharing. It describes its beginnings in Ireland and its gradual expansion to other countries around the world, including the Czech Republic. The course of pairing and individual phases, without which this service cannot get along, is also described in more detail. The practical part is based on qualitative research. The original intention of the author was to map the experience with the benefits and risks of the home sharing service directly in the primary and host families. However, both of these groups are parts of the Home sharing...