Introduction: Cancer survivors continue to experience psychological distress and challenges in their daily lives long after the completion of treatment. Caregivers play a pivotal role in the lives of cancer survivors by providing support in various domains of their lives. The cancer experience between support persons and cancer survivors is intertwined. The interdependence theory will serve as a theoretical framework to guide the purposes of this study. Objective:The purpose of this research was to gain a better understanding of unmet needs of caregivers supporting long-term cancer survivors and explore how fulfilling the needs of caregivers influenced the psychological well-being of cancer survivors. Specifically, an emphasis was placed on exploring the level of dependence present in marital relationships, and how this impacted the relationship between caregiver unmet needs and the psychological outcomes of cancer survivors. Method: Data was drawn from The Cancer Support Persons’ Unmet Needs Survey (SPUNS) (Campbell et al., 2009) and The Cancer Survivors’ Unmet Needs Survey (SUNS) (Campbell et al., 2009). Regression models tested for significant interactions between caregiver unmet needs and factors influencing survivor dependence with psychological distress in cancer survivors. Results: Findings revealed main effects between caregivers’ depression, anxiety, and stress with the respective psychological outcomes in cancer survivors. Caregivers’ concerns about the future predicted elevated depression in cancer survivors. Caregivers with needs pertaining to information or emotions predicted higher anxiety in cancer survivors. Information needs, future concerns, and health care access and continuity needs of caregivers predicted higher survivor stress. Conversely, work and financial needs of caregivers predicted lower depression, anxiety and stress in cancer survivors. Significant interactions were found for caregivers’ concerns about the future by recurrence of diagnosis with decreased survivor anxiety, health care needs of support persons by recurrence of illness with increased survivor anxiety, caregivers’ personal needs by severity of illness with higher survivor anxiety, support persons’ emotional needs by severity of illness with lower survivor anxiety, caregivers’ emotional needs by severity of illness and decreased survivor stress, and finally, support persons’ health care needs by severity of illness with higher survivor stress. Conclusion: Findings did not fully support the hypotheses of this present study. Nonetheless, the significant results revealed in the findings would be useful to generate alternative hypotheses in future studies regarding interdependence, unmet needs and psychological well-being. The findings for the present study will also provide direction towards improvement in treating caregivers and cancer patients as a conglomerate, and inform programs, services and policies in cancer care.

People are living longer and this increases the risk of encountering financial difficulties when trying to make fixed retirement incomes stretch over additional years. Increased life expectancies also increase the likelihood of encountering a health issue including cognitive or functional declines that can affect money management capabilities. There are government entitlement programs available to assist retired Canadians but these programs are under review and new policies are being considered in order to reduce fiscal pressures. At the same time, family roles and structures are changing and informal supports available to previous generations may be reduced. As well, if an older person’s money is poorly managed there will be fewer options for maintaining quality of life in the retirement years. This increases the risk of poverty for older Canadians. The goals of this research are to: understand individual risk factors including demographic, clinical and social support characteristics among Canadians age 55 and over who are experiencing poverty; to understand the predictive characteristics for moving into or exiting from poverty; and, to develop a comprehensive description of those who have great difficulty managing their finances. In order to achieve this, data from the interRAI Home Care (RAI-HC) assessment instrument were used. Three regions, Winnipeg Regional Health Authority (WRHA), Nova Scotia and Ontario, were analyzed in order to understand the characteristics of those making economic trade-offs (N=345,678). Data from the province of Ontario was used to understand predictors of poverty transitions (N=47,653) and to develop a profile of those having great difficulty managing their finances (N=321,816). In order to answer each question of interest multivariable logistic regression modeling was used. Results from the analyses found that those most at risk for making economic trade-offs were in the age 55 to 64 group, had three or more depressive symptoms and were separated or divorced. Gender was not a risk factor. Regional differences for poverty risks were also identified showing greater risks for those experiencing mental health issues in WHRA, for those with more clinical indicators in Ontario, and for younger residents (age 55 to 64) in Nova Scotia. The longitudinal analyses on poverty transitions revealed that females who had completed at least a grade eight education were more likely to exit poverty. The younger group (age 55 to 64 years) with three or more depressive symptoms and experiencing unstable health were more likely to enter poverty. Marriage and older age were protective from the risks of entering poverty. Results from the analyses of those likely to have great difficulty with financial management indicated that deficits in cognition, procedural memory and function increased the risk of being unable to manage personal finances. Gender and marital status were not associated with financial management difficulty. The development of a profile of those who are making economic trade-offs and those at risk of having difficulty with financial management provides the opportunity for early intervention. Those who have not reached the traditional retirement age of 65 have an increased risk of poverty. Understanding characteristics of those who exit poverty will help establish policies and programs that will assist older Canadians. These are important issues due to the increased number of post-employment years that Canadians are living and the national focus on fiscal restraints. The management of finances has received minimal scientific research and evidence is needed to understand when changes in capability occur and how these changes may be supported by appropriate levels of assistance and supportive devices.

Purpose: The purpose of this dissertation was to examine the determinants of unplanned emergency department (ED) use by home care clients, the profile of older ED patients, their transitions from the ED, as well as the determinants of post discharge outcomes among older ED patients. The goal of this dissertation was to create theoretically driven, evidence-based, and practical risk identification methods for home care and the ED. Methods: First, a multi-year, census-level cohort study was conducted on home care clients in two Canadian provinces (N=617,035). Census-level data from RAI-HC assessments were linked to census-level ED records. A needs-based decision tree model – the ED Model – informed by the Andersen Behavioural Model, was created using decision tree analyses. The final model was validated on a separate data partition and compared to the ERA Index and the CARS. Multilevel analyses were conducted to test regional variation in model performance. Disease stratified analyses were also conducted to test model generalizability across common disease classes. Regression analyses determined the effect of predisposing and enabling factors within ED Model strata. Second, a multi-site, multi-province prospective cohort study was conducted, termed the Management of Older Persons in Emergency Departments (MOPED) Study, using a clinically representative sample of 2,101 older ED patients. The interRAI ED-CA was used to assess older ED patients, and a 90-day disposition was collected. The profile of older ED patents was examined. Best-subset regression analyses identified person-level determinants of acute inpatient admission. Two needs-based decision tree models – the ALC/LTC and ED Revisit Models – were created using decision tree analyses to determine the risk of ALC designation or LTC placement, and unplanned repeat ED visits, respectively. Both models were validated on separate data partitions. Multilevel analyses were conducted to test site-level variation in the models’ performance. Results: Overall, 41.2% of home care clients had at least one unplanned emergency department visit within 6 months of an assessment. Previous ED use, cardio-respiratory symptoms, cardiac conditions, and mood symptoms featured heavily in the ED Model. The ED Model provided moderate risk differentiation and clinical utility. It achieved an area under the curve of 0.62 (95% CI: 0.61-0.62) and showed clear differentiation in Kaplan-Meier plots using validation data. Multi-level analyses showed no regional variation. The ED Model significantly outperformed the similar tools specific to primary care with respect to overall accuracy and perceived clinical utility. Predisposing and enabling characteristics provided little added differentiation beyond evaluated need. The majority of older ED patients were dependent on others for basic tasks of daily living, and many had fragile informal care or lived alone. Triage acuity generally did not differentiate chronic geriatric disabilities and conditions. Previous ED or hospital use was associated with chronic geriatric disabilities and conditions as well as informal caregiver distress. The Admission Model found that multiple factors were associated with admission to inpatient acute care, including: acuity, instability, changes in ADL function, cognition, nutrition, and anhedonia. Overall, 20.7% of older ED patients admitted to acute care were designated ALC or discharged to LTC; whereas 39.5% of older ED patients discharged home had one or more repeat ED visits within 90 days. Cognitive, functional, and informal care indicators were predictive of ALC/LTC; whereas functional status and symptoms were predictive of repeat ED use. The ALC/LTC and ED Revisit Models provided good risk differentiation, achieving AUC’s of 0.74 (95% CI: 0.69-0.79) and 0.69 (95% CI: 0.63-0.74), respectively. The ALC/LTC and ED Revisit Models showed clear differentiation in Kaplan-Meier plots. Multi-level analyses showed no site-level variation in each models’ performance. Conclusions: This dissertation produced tangible and empirically-based risk assessment models for clinical practice in home care and the ED. The models developed in this dissertation can support the targeting of preventative services as well as better communication strategies between the ED and community supportive care, primary care, and inpatient acute care. Key questions related to the prevention of the risk pathways identified in each risk assessment model remain unanswered, and should be a focus of future research.

国立情報学研究所で電子化したコンテンツを使用している。

国立情報学研究所で電子化したコンテンツを使用している。

国立情報学研究所で電子化したコンテンツを使用している。

Introduction: Studies show that women living in Sweden treated for coeliac disease have lower subjective health than other women. After showing signs of remission, adults who have coeliac disease and follow a gluten-free diet, are expected to handle the treatment without any further planned follow-up by health care. Aim: The overall aim of this thesis was to study aspects of living with coeliac disease in adults in the years beyond the diagnosis. Methods: Quantitative methods were used in Studies I, II and III. A qualitative content analysis was performed in Study IV. Results: The results show that women with coeliac disease have a lower level of well-being than men with coeliac disease. The women who have coeliac disease reported a high rate of gastrointestinal symptoms, although they followed a gluten-free diet, and they visited health care services more frequently than women who did not have coeliac disease. A low rate of gastrointestinal symptoms, a positive self-image and few comorbidity emerged as factors that positively affected well-being. Worries also seemed to be a companion of women diagnosed with coeliac disease in adulthood, typically evident when socializing with others. Conclusion: This thesis may provide evidence questioning the validity of declaring all women with coeliac disease showing a normalized intestinal mucosa to be in remission, and thus leaving them to self-management. Clinical implications: Health care professionals need to be aware of that the transition to a gluten-free life may vary for individuals. It does not seem enough to follow a gluten-free diet to reach a state of good well-being for all women. A major task for health care providers is therefore to support women with CD in reaching better subjective treatment outcomes. The results may also contribute to that health care system develops routines in order to optimise the care and treatment of these patients.

The purpose of the research project was to examine the effects of exercise and social support for postnatal women who reported experiencing Postnatal Depression (PND). PND is a serious condition that affects up to 10%-15% of women (O'Hara & Swain, 1996). Many previous studies have reported an improvement of depressive symptomatology following a pram walking intervention. However, no published research exists which assesses postnatal women who report experiencing PND. A randomised controlled trial was used, where pre-test data were compared to post-test effects. Two studies were conducted. In study 1 (n= 20) a multi-intervention group (exercise and social support) was compared to a control group who received no intervention. Study 2 (n= 19) was conducted 20 months later on a different group of women and involved a pram walking intervention group and a comparison social support group. Structured questionnaires assessing depressive symptomatology, general health and levels of social support were administered at pre-test phase, week 6 and 12. A sub-maximal fitness test was conducted the week before the program started and at week 12. The chief investigator was present at all sessions to guide the participants. Study 1 (S1): The multi-intervention group attended 3 pram walking sessions per week. After the exercise session the group met for refreshments in a local hall. The control group was only required to perform the fitness tests and answer the questionnaires. A 6-week alternative program of exercise and social support was offered to all the women at the completion of the intervention period. Study 2 (S2): The pram walking group met for 2 exercise sessions and were required to make up the third session independently. The comparison social support group met once per week for morning tea with the children. The samples for both studies were drawn from the Gold Coast region in Australia. Women of childbearing age who were experiencing depressive symptoms were recruited. For S1 their child had to be less than or equal to 12 months and for S2 the age cut off was increased to less than or equal to 18 months. The participants were screened to ensure that they did not have a medical condition that would prevent regular aerobic exercise and they were also excluded if they had a previous history of mental illness or could not speak English. Demographic data were obtained from each participant and details such as height, weight and age were collected for use in analysing fitness levels. The data for each study were collected across three time points (pre, week 6 and week 12) using widely tested instruments. Some additional questions relating to the participants experiences were collected at the completion of the study from the women allocated to the intervention groups. Data were also collected on fitness levels (pre and week 12) and the instrument was tested for its reliability. Both pram walking intervention groups were required to complete a weekly exercise diary. For each study, to test for the effect of the intervention over time, a two-way analysis of variance was conducted on the major outcome variables. Group (intervention versus control) was the between subject factor and time (pre-test, week 6, week 12) was the within subject factor or repeated measures factor. Due to the small sample size, further tests were conducted to check the assumptions of the statistical test to be used. The results showed that using Mauchly's Test, the Sphericity assumptions of repeated measures for ANOVA were met. Further, tests of homogeneity of variance assumptions also confirmed that this assumption was met. Data analysis was conducted using the software package SPSS for Windows Release 10.0. (Norusis, 2000). Overall, the findings from both S1 and S2 showed that the groups who received the pram walking intervention improved their depressive symptomatology and fitness levels when compared to those of the control (S1) and social support group (S2). Social support levels did not alter for either group from both studies. These results are encouraging and suggest that a pram walking program is an effective form of intervention for postnatal women experiencing depressive symptomatology.

Children and adolescents are now using online communication to form and/or maintain relationships with strangers and/or friends. Relationships in real life are important for children and adolescents in identity formation and general development. However, social relationships can be difficult for those who experience feelings of loneliness and social anxiety. The current study aimed to replicate and extend research conducted by Valkenburg and Peter (2007b), by investigating differences in online communication patterns between children and adolescents with and without selfreported loneliness and social anxiety. Six hundred and twenty-six students aged 10-16 years completed a questionnaire survey about the amount of time they engaged in online communication, the topics they discussed, who they communicated with, and their purposes of online communication. Following Valkenburg and Peter (2007b), loneliness was measured with a shortened version of the UCLA Loneliness Scale (Version 3) developed by Russell (1996), whereas social anxiety was assessed with a sub-scale of the Social Anxiety Scale for Adolescents (La Greca & Lopez, 1998). The sample was divided into four groups of children and adolescents: 220 were “non-socially anxious and non-lonely”, 139 were “socially anxious but not lonely”, 107 were “lonely but not socially anxious”, and 159 were “lonely and socially anxious”. A one-way ANOVA and chi-square tests were conducted to evaluate the aforementioned differences between these groups. The results indicated that children and adolescents who reported being lonely used online communication differently from those who did not report being lonely. Essentially, the former communicated online more frequently about personal things and intimate topics, but also to compensate for their weak social skills and to meet new people. Further analyses on gender differences within lonely children and adolescents revealed that boys and girls communicated online more frequently with different partners. It was concluded that for these vulnerable individuals online communication may fulfil needs of self-disclosure, identity exploration, and social interactions. However, future longitudinal studies combining a quantitative with a qualitative approach would better address the relationship between Internet use and psychosocial well-being. The findings also suggested the need for further exploration of how such troubled children and adolescents can use the Internet beneficially.

Vernacular houses reflect the social complexity of the times and region in which they exist. These houses are continually evolving in response to changes in the residents’ sense of well-being. However, the rapid progression of modernity and urbanization over the past fifty years has strongly altered the underlying cultural meanings of domestic well-being in traditional societies. This has caused the disappearance of vernacular houses in various localities. The present research is especially concerned with surviving Thai vernacular houses. Its aim is to establish an understanding of the relationship between changes of Thai residents’ experiences of well-being, or Khwam Phasook in the Thai language, and the physical and socio-cultural evolution of their vernacular houses. The study was conducted by examining the evolution of vernacular houses in Tambon Pakkran of Pra Nakhon Si Ayutthaya in central Thailand. Two main types of data were collected: evolution of the physical characteristics of vernacular houses, and the changes of patterns of use and the meanings attributed to them. The data obtained were analyzed and discussed through systemic taxonomy, cross-case analysis and graphical representation using multiple criteria. The residents’ narrations were also used to explicate the historical development of the houses investigated.