Urban homelessness is one of the most blatant forms of social exclusion in advanced capitalist societies. In Canada, the United States, and the United Kingdom, homelessness has become particularly entrenched due to systemic forces such as global economic recession, the restructuring of regional economies, the dismantlement of the welfare state, and the erosion of affordable housing that together have pushed more people towards economic marginality and housing insecurity. Despite years of advocacy and 'high profile' government investments, homelessness has persisted as an intransigent social problem. A central purpose of this doctoral thesis is to provide some insight into how homelessness is being 'managed' in one Canadian city. The papers gathered together in this dissertation are based on three years of ethnographic fieldwork (conducted between 2006 and 2009) in a medium-sized, de-industrializing city in the province of Ontario. The specific focus of the thesis is the emergency shelter system. Over the past ten years, a number of new social service models have emerged in response to rising rates of homelessness. As these have been adopted homeless shelter systems in many Canadian cities have undergone significant reconfigurations. This thesis focuses on some of the new 'management spaces' that are emerging in this unfolding policy context. The first paper explores the experiences of voluntary sector organizations and local state authorities. The second paper explores the experiential dimensions of a unique service environment providing emergency shelter and social services. The third paper examines the personal experiences of chronically homeless men as they adapt to life in an innovative 'special care' facility. / Thesis / Doctor of Philosophy (PhD)

No description available.

According to the Ministry of Health (1996:26), the most common chronic/terminal illnesses were cardiovascular disorders, diabetes, cancer, mental disorders, HIV/AIDS, tuberculosis and asthma. Long term treatment and care and the growing incidence of these conditions necessitated the introduction of home-based care (HBC). Consequently, family care givers play a major role in the provision of care to chronically/terminally ill patients and professional health care providers adopt a supervisory role. This study examined the quality of home care services provided in Botswana. The availability and accessibility of home-based care services and resources have a direct bearing on the quality of home-based care delivery system. The researcher used systems theory was used as the conceptual framework for this study. The study aimed to • determine the accessibility and availability of home-based care services in Molepolole East • investigate what the perspectives and experiences of family care givers, patients and professional health care providers of Botswana home-based care are • determine the roles of professionals health care providers, patients, and family care givers and their relationships in the context of home- based care • identify the needs of chronically/terminally ill patents and family care givers • determine the type of support given to family care givers and patients by professional health care providers and make recommendations for the improvement of home-based care • develop a model to prepare family care givers The research design combined quantitative and qualitative research methods. A sample of convenience was used to obtain information from patients' family care givers and professional health care providers. Interviews and questionnaires were used. A proposed care giving preparedness model is presented to meet needs of the family care givers. The study found that family care givers needs are neither known nor catered for by the professional health care provider. The family care givers were not adequately prepared before adopting the care-giving role. It is recommended that • The proposed preparedness care giving training model is considered for training of patients and family care givers before discharge and during HBC. • Increase patients and family care givers decision-making / Health Studies / D.Litt. et Phil. (Health Studies)

This research examines the relationship between health literacy among End Stage Renal Disease (ESRD) patients and its relevance for communication between patients and providers. The study was conducted among dialysis services providers at the Good Samaritan Dialysis Center and dialysis patients receiving care at the Center. Data collection techniques included individual interviews, surveys, and the Short Test of Functional Health Literacy in Adults (S-TOFHLA), which measured the health literacy level of the participants. The results of the study show that a large majority of the patients have "adequate" health literacy, which contradicts the provider's perceptions of the patient's ability to comprehend health information. Provider's perspectives are shaped by their training and work environment. The study suggests that structural barriers and communication issues impede effective patient-provider interactions. This issue is especially serious for those chronic disease patients who have limited self-management skills. / Graduation date: 2012

According to the Ministry of Health (1996:26), the most common chronic/terminal illnesses were cardiovascular disorders, diabetes, cancer, mental disorders, HIV/AIDS, tuberculosis and asthma. Long term treatment and care and the growing incidence of these conditions necessitated the introduction of home-based care (HBC). Consequently, family care givers play a major role in the provision of care to chronically/terminally ill patients and professional health care providers adopt a supervisory role. This study examined the quality of home care services provided in Botswana. The availability and accessibility of home-based care services and resources have a direct bearing on the quality of home-based care delivery system. The researcher used systems theory was used as the conceptual framework for this study. The study aimed to • determine the accessibility and availability of home-based care services in Molepolole East • investigate what the perspectives and experiences of family care givers, patients and professional health care providers of Botswana home-based care are • determine the roles of professionals health care providers, patients, and family care givers and their relationships in the context of home- based care • identify the needs of chronically/terminally ill patents and family care givers • determine the type of support given to family care givers and patients by professional health care providers and make recommendations for the improvement of home-based care • develop a model to prepare family care givers The research design combined quantitative and qualitative research methods. A sample of convenience was used to obtain information from patients' family care givers and professional health care providers. Interviews and questionnaires were used. A proposed care giving preparedness model is presented to meet needs of the family care givers. The study found that family care givers needs are neither known nor catered for by the professional health care provider. The family care givers were not adequately prepared before adopting the care-giving role. It is recommended that • The proposed preparedness care giving training model is considered for training of patients and family care givers before discharge and during HBC. • Increase patients and family care givers decision-making / Health Studies / D.Litt. et Phil. (Health Studies)

Indiana University-Purdue University Indianapolis (IUPUI) / Technology dependent children such as those who require a feeding tube, tracheotomy or ventilator are a special group of chronically ill children who require complex care on a daily basis. When these children are hospitalized, the accompanying parent and the nurse caring for the child on the inpatient unit must communicate together about the care of the child. Care for the technology dependent child is optimized when parents and nurses both understand the plan of care for the child. To discover the process of parent-nurse communication that results in mutual understanding of the child’s plan of care, a grounded theory study to explore the perspectives of the parents of previously hospitalized technology dependent children was undertaken. The Theory of Shared Communication emerged from the data and illuminates the parent-nurse communication process. The antecedents of the process are respect for own and others expertise. The communication process consists of six communication behaviors; ask, listen, explain, advocate, verify understanding and negotiate roles. The behaviors are nested within each other and all are not necessarily required for the non-linear process to result in the relational outcome of mutual understanding of the child’s plan of care. An integrative review of the literature regarding the process of communication between parents of hospitalized chronically ill children and their nurses shed light on the components of the process, but no study was found that explicated the entire communication process. A subsequent grounded theory study added the perspectives of the nurses to the original theory. No new components of the process were uncovered, but the nurse’s narratives added significantly to our understanding of the communication process. Additionally, parents of currently hospitalized technology dependent children confirmed the propositions of the Theory of Shared Communication.

INTRODUÇÃO: Com a melhora do prognóstico nos pacientes com lúpus eritematoso sistêmico juvenil novas recomendações são necessárias na reumatologia pediátrica, como avaliação da saúde bucal e do sistema mastigatório. O objetivo deste estudo é avaliar o comprometimento orofacial nos pacientes com lúpus eritematoso sistêmico juvenil e grupo controle, e avaliar possíveis associações entre o comprometimento orofacial e manifestações clínicas, exames laboratoriais e terapias da doença. MÉTODOS: Entre março de 2004 e julho de 2005 foram avaliados 48 pacientes com diagnóstico de lúpus eritematoso sistêmico juvenil, atendidos na Unidade de Reumatologia Pediátrica do ICr-HC-FMUSP. O grupo controle incluiu 48 crianças e adolescentes saudáveis atendidos na Divisão de Odontologia do HC-FMUSP. A pesquisa incluiu avaliação de dados sócio-demográficos, manifestações clínicas, exames laboratoriais, atividade da doença (SLEDAI), dano cumulativo (SLICC/ACR-DI) e terapias da doença. A avaliação orofacial incluiu questionário de anamnese, índice CPO-D, índice de placa, índice de sangramento gengival, relação dentária, perfil facial, índice de Helkimo e avaliação da articulação temporomandibular através da radiografia panorâmica de face em todos os pacientes e tomografia computadorizada apenas nos casos com achatamento e/ou destruição dos côndilos mandibulares. RESULTADOS: Os dois grupos foram homogêneos com relação à faixa etária, distribuição por gênero e classe sócio-econômica. A idade dos pacientes com lúpus eritematoso sistêmico juvenil variou de 87 a 218 meses (média de 161,9±38,4) e do grupo controle de 78 a 254 meses (média de 154,4±45,8; p=0,384). As medianas dos índices de placa e de sangramento gengival nos pacientes com lúpus eritematoso sistêmico juvenil foram superiores em relação aos controles (61,5X38,1; p=0,003 e 26,0X15,95; p=0,014). O índice de disfunção clínica e o índice de mobilidade mandibular mostraram-se mais alterados nos pacientes com LESJ versus controles (p=0,002, p=0,025). Correlação linear estatística foi evidenciada entre: tempo de doença e índice de sangramento gengival (p=0,017; r=0,11), dose cumulativa de prednisona e índice de placa (p=0,010, r=0,385) e dose cumulativa de prednisona e índice de sangramento gengival (p=0,001, r=0,02). A mediana do índice de mobilidade mandibular foi superior nos pacientes com lúpus eritematoso sistêmico juvenil em uso de um ou mais imunossupressores em relação aos que não utilizaram estas drogas (p=0). Apenas dois pacientes apresentaram radiografia panorâmica com achatamento e/ou destruição dos côndilos mandibulares e na tomografia computadorizada de ATM os achados foram: redução do espaço articular bilateralmente, erosões dos platôs articulares com aplainamento dos côndilos sugestivo de necrose avascular da articulação temporomandibular. CONCLUSÕES: Os pacientes com lúpus eritematoso sistêmico juvenil apresentaram uma precária higiene oral, maior freqüência de gengivite e disfunção da articulação temporomandibular em relação ao grupo controle. Os pacientes com maior tempo de doença e maior dose cumulativa de prednisona tiveram maior freqüência de gengivite e os que utilizaram imunossupressores apresentaram disfunção da articulação temporomandibular / INTRODUCTION: Given the enhanced prognosis of patients with juvenile systemic lupus erythematosus, new recommendations are necessary in pediatric rheumatology, such as the analysis of oral health and the masticatory system. The aim of this study was to compare dental and facial conditions of patients with juvenile systemic lupus erythematosus and a control group, and to evaluate a potential relationship between dental and facial endangering and clinical manifestations, laboratory tests and therapies for the disease. PATIENTS AND METHODS: A total of 48 children and adolescents with juvenile systemic lupus erythematosus attending the Pediatric Rheumatology Unit of the Children\'s Institute of our University Hospital were studied between January 2004 and July 2005. The control group included 48 healthy children and adolescents that were selected from the Odontology Division of our University Hospital. The search included the analysis of social and demographic data, clinical manifestations, laboratory tests, juvenile systemic lupus erythematosus disease activity and cumulative damage (using the SLEDAI and the SLICC/ACR-DI), and therapies. The dental and facial examination included the anamnesis questionnaire, DMFT index, plaque and gengival bleeding index, dental relationship, facial profile, Helkimo\'s index and evaluation of the temporomandibular joint through a radiographic panoramic examination of all patients and a computer tomography on those with flattening and/or destruction of the mandibular condyles. RESULTS: The two groups were homogeneous regarding age, gender and social-economic class. The age of the juvenile systemic lupus erythematosus patients ranged from 87 to 218 months (mean of 161.9±38.4) and of the control group from 78 a 254 months (mean of 154.4±45.8; p=0.384). The medians of the plaque and gingival bleeding indexes were higher in juvenile systemic lupus erythematosus patients than in the control group (61.5X38.10; p=0.003 and 26.0X15.95; p=0.014). The indexes of clinical dysfunction and mandibular mobility were higher in juvenile systemic lupus erythematosus patients versus the control group (p=0,002, p=0,025). A linear statistical correlation was evidenced between: juvenile systemic lupus erythematosus duration and the gingival bleeding index (p=0.017; r=0.11), cumulative dose of prednisone and the plaque index (p=0,010; r=0.385) and cumulative dose of prednisone and the gingival bleeding index (p=0.001, r=0.02). The median of the mandibular mobility index was higher in juvenile systemic lupus erythematosus patients that used at least one imunossupressive drugs compared with those that didn\'t use this medication (p=0). Only two patients showed a panoramic radiography with flattening and/or destruction of the mandibular condyles. The computer tomography revealed: narrowing of joint spaces bilaterally and erosions of joints plateaus with flattening of condyles that suggested avascular necrosis of temporomandibular joint. CONCLUSIONS: Juvenile systemic lupus erythematosus patients presented poor oral hygiene, higher incidence of gingivitis and temporomandibular joint dysfunction compared to the control group. Patients with longer disease duration and higher cumulative dose of prednisone had a greater incidence of gingivitis, and those who used imunossupressives drugs showed temporomandibular joint dysfunction

The continued development of the American health care system and evolving technology have led to an increased life expectancy within the general population. In fact, these advancements have also resulted in growing numbers of young people with chronic illnesses living into adulthood. Approximately one third of children ages 10-17 have a chronic disease, and the vast majority of these children will survive beyond their 20th birthday (Blum, 1995; Lotstein, McPherson, Strickland, & Newacheck, 2005; White, 2002). The main objective of this study was to explore the healthcare transition (HCT) practices of health care providers and the HCT experiences of chronically ill young adults living with sickle cell disease, cystic fibrosis, and/or diabetes. Meleis, Sawyer, Im, Hifinger Messias, & Schumacher’s (2000) theory on transition and Boykin and Schoenhofer’s (2001) theory of Nursing as Caring provided the theoretical lenses throughwhich study findings were viewed. This was a descriptive exploratory mixed methods design that consisted of survey data and used conventional content analysis to analyze the qualitative data. The quantitative portion of this study incorporated a 41-question survey that was completed by 33 health care providers working with chronically ill young adults in the southeast Florida region. Additionally, semi-structured interviews were conducted with eight young adults (18-24 years of age) living with a sickle cell disease, cystic fibrosis, and/or diabetes. Five themes emerged from an analysis of the data describing the healthcare transition (HCT) experience: Transition Confusion, Familial Reliance, Lost in Transition, Fiscal Stressors, and Transition Uneasiness. The findings of this study demonstrate that there are, at minimum, three general parts of the HCT process that remain deficient: educational preparation, consistent communication between all parties involved in the HCT process, and guidance for the independent negotiation of the present healthcare system. Recommendations for healthcare providers that work with chronically ill young adults include establishing a HCT framework that incorporates consistent communication among team members and patients/families, individualized educational formats, and guidance for navigational skills to negotiate the healthcare system. / Includes bibliography. / Dissertation (Ph.D.)--Florida Atlantic University, 2014. / FAU Electronic Theses and Dissertations Collection

Conclusions. The growing epidemic of type 2 diabetes and its cardiorenal complications place a major burden on our health care system. Diabetic kidney disease is of particular importance in Asian populations including Chinese. In this series of studies, using a large prospective cohort established since 1995, I confirmed the powerful predictive value of albuminuria on cardio-renal complications. Inhibition of the RAAS interacted with both modifiable and genetic factors, notably the ACE I/D polymorphism, on the development of cardio-renal complications. In addition, it was found that CKD predicts CVD independent of albuminuria. Based on two prospective studies, I confirmed the effectiveness of global risk-factor control using structured care protocol to prevent these devastating complications. (Abstract shortened by UMI.) / I then examined the possible independent and interactive effects of CKD and albuminuria on cardio-renal outcomes in the original cohort of 5,004 patients. Glomerular filtration rate was estimated (eGFR) by the Modification of Diet in Renal Disease equation. The frequency of CKD as defined by eGFR <60ml/min/1.73m 2 was 15.8% in the cohort at baseline, when 6% of patients had serum creatinine ≥150mumol/L. / In collaboration with colleagues, I have conducted a series of studies to examine the prognostic factors for cardio-renal complications in Chinese type 2 diabetic patients. The modulating effects of RAAS inhibition and the effectiveness of rnuitidisciplinary care to prevent ESRD are also examined. / Research Hypotheses. (1) Albuminuria is a prognostic factor on cardio-renal outcomes in type 2 diabetes patients; (2) Chronic Kidney Disease is associated with other metabolic risk factors and phenotypes and is a prognostic factor on cardio-renal outcomes in type 2 diabetes patients; (3) Angiotensin-converting-enzyme insertion/deletion polymorphism is a prognostic factor on cardio-renal outcomes in type 2 diabetes patients, and has an effect on treatment responses with RAAS blockage with ACE inhibitors; (4) Structured care models by risk stratification using various prognostic factors and adherence to care protocol can improve cardio-renal outcome in type 2 diabetes patients. / Results. In a prospective cohort of 5,004 patients, I examined the effect of albuminuria and ACE inhibition on survival and cardio-renal outcomes in 3,773 patients who had been observed for at least 6 months with a mean follow up period of 35.8 months. / Taken together, measurement of serum creatinine alone without GFR estimation may underestimate the frequency of CKD in Chinese type 2 diabetic patients. Estimated GFR was inversely associated wit-29h an increasing frequency of micro- and macrovascular complications cross-sectionally and an increased risk of all-cause mortality prospectively, independent of albuminuria and metabolic control. / So Wing Yee. / Source: Dissertation Abstracts International, Volume: 70-06, Section: B, page: 3422. / Thesis (M.D.)--Chinese University of Hong Kong, 2008. / Includes bibliographical references (leaves 203-243). / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Electronic reproduction. [Ann Arbor, MI] : ProQuest Information and Learning, [200-] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / School code: 1307.

INTRODUÇÃO: Com a melhora do prognóstico nos pacientes com lúpus eritematoso sistêmico juvenil novas recomendações são necessárias na reumatologia pediátrica, como avaliação da saúde bucal e do sistema mastigatório. O objetivo deste estudo é avaliar o comprometimento orofacial nos pacientes com lúpus eritematoso sistêmico juvenil e grupo controle, e avaliar possíveis associações entre o comprometimento orofacial e manifestações clínicas, exames laboratoriais e terapias da doença. MÉTODOS: Entre março de 2004 e julho de 2005 foram avaliados 48 pacientes com diagnóstico de lúpus eritematoso sistêmico juvenil, atendidos na Unidade de Reumatologia Pediátrica do ICr-HC-FMUSP. O grupo controle incluiu 48 crianças e adolescentes saudáveis atendidos na Divisão de Odontologia do HC-FMUSP. A pesquisa incluiu avaliação de dados sócio-demográficos, manifestações clínicas, exames laboratoriais, atividade da doença (SLEDAI), dano cumulativo (SLICC/ACR-DI) e terapias da doença. A avaliação orofacial incluiu questionário de anamnese, índice CPO-D, índice de placa, índice de sangramento gengival, relação dentária, perfil facial, índice de Helkimo e avaliação da articulação temporomandibular através da radiografia panorâmica de face em todos os pacientes e tomografia computadorizada apenas nos casos com achatamento e/ou destruição dos côndilos mandibulares. RESULTADOS: Os dois grupos foram homogêneos com relação à faixa etária, distribuição por gênero e classe sócio-econômica. A idade dos pacientes com lúpus eritematoso sistêmico juvenil variou de 87 a 218 meses (média de 161,9±38,4) e do grupo controle de 78 a 254 meses (média de 154,4±45,8; p=0,384). As medianas dos índices de placa e de sangramento gengival nos pacientes com lúpus eritematoso sistêmico juvenil foram superiores em relação aos controles (61,5X38,1; p=0,003 e 26,0X15,95; p=0,014). O índice de disfunção clínica e o índice de mobilidade mandibular mostraram-se mais alterados nos pacientes com LESJ versus controles (p=0,002, p=0,025). Correlação linear estatística foi evidenciada entre: tempo de doença e índice de sangramento gengival (p=0,017; r=0,11), dose cumulativa de prednisona e índice de placa (p=0,010, r=0,385) e dose cumulativa de prednisona e índice de sangramento gengival (p=0,001, r=0,02). A mediana do índice de mobilidade mandibular foi superior nos pacientes com lúpus eritematoso sistêmico juvenil em uso de um ou mais imunossupressores em relação aos que não utilizaram estas drogas (p=0). Apenas dois pacientes apresentaram radiografia panorâmica com achatamento e/ou destruição dos côndilos mandibulares e na tomografia computadorizada de ATM os achados foram: redução do espaço articular bilateralmente, erosões dos platôs articulares com aplainamento dos côndilos sugestivo de necrose avascular da articulação temporomandibular. CONCLUSÕES: Os pacientes com lúpus eritematoso sistêmico juvenil apresentaram uma precária higiene oral, maior freqüência de gengivite e disfunção da articulação temporomandibular em relação ao grupo controle. Os pacientes com maior tempo de doença e maior dose cumulativa de prednisona tiveram maior freqüência de gengivite e os que utilizaram imunossupressores apresentaram disfunção da articulação temporomandibular / INTRODUCTION: Given the enhanced prognosis of patients with juvenile systemic lupus erythematosus, new recommendations are necessary in pediatric rheumatology, such as the analysis of oral health and the masticatory system. The aim of this study was to compare dental and facial conditions of patients with juvenile systemic lupus erythematosus and a control group, and to evaluate a potential relationship between dental and facial endangering and clinical manifestations, laboratory tests and therapies for the disease. PATIENTS AND METHODS: A total of 48 children and adolescents with juvenile systemic lupus erythematosus attending the Pediatric Rheumatology Unit of the Children\'s Institute of our University Hospital were studied between January 2004 and July 2005. The control group included 48 healthy children and adolescents that were selected from the Odontology Division of our University Hospital. The search included the analysis of social and demographic data, clinical manifestations, laboratory tests, juvenile systemic lupus erythematosus disease activity and cumulative damage (using the SLEDAI and the SLICC/ACR-DI), and therapies. The dental and facial examination included the anamnesis questionnaire, DMFT index, plaque and gengival bleeding index, dental relationship, facial profile, Helkimo\'s index and evaluation of the temporomandibular joint through a radiographic panoramic examination of all patients and a computer tomography on those with flattening and/or destruction of the mandibular condyles. RESULTS: The two groups were homogeneous regarding age, gender and social-economic class. The age of the juvenile systemic lupus erythematosus patients ranged from 87 to 218 months (mean of 161.9±38.4) and of the control group from 78 a 254 months (mean of 154.4±45.8; p=0.384). The medians of the plaque and gingival bleeding indexes were higher in juvenile systemic lupus erythematosus patients than in the control group (61.5X38.10; p=0.003 and 26.0X15.95; p=0.014). The indexes of clinical dysfunction and mandibular mobility were higher in juvenile systemic lupus erythematosus patients versus the control group (p=0,002, p=0,025). A linear statistical correlation was evidenced between: juvenile systemic lupus erythematosus duration and the gingival bleeding index (p=0.017; r=0.11), cumulative dose of prednisone and the plaque index (p=0,010; r=0.385) and cumulative dose of prednisone and the gingival bleeding index (p=0.001, r=0.02). The median of the mandibular mobility index was higher in juvenile systemic lupus erythematosus patients that used at least one imunossupressive drugs compared with those that didn\'t use this medication (p=0). Only two patients showed a panoramic radiography with flattening and/or destruction of the mandibular condyles. The computer tomography revealed: narrowing of joint spaces bilaterally and erosions of joints plateaus with flattening of condyles that suggested avascular necrosis of temporomandibular joint. CONCLUSIONS: Juvenile systemic lupus erythematosus patients presented poor oral hygiene, higher incidence of gingivitis and temporomandibular joint dysfunction compared to the control group. Patients with longer disease duration and higher cumulative dose of prednisone had a greater incidence of gingivitis, and those who used imunossupressives drugs showed temporomandibular joint dysfunction