Health promotion interventions in schools have grown in popularity and have demonstrated varying degrees of effectiveness on the health of the school and its individuals. The School Based Youth Health Nurse (SBYHN) Program introduced in 1999 by Queensland Health into state secondary schools supports and encourages use of the Health Promoting Schools (HPS) approach in addressing health issues, in addition to providing individual health consultations to the school community. This Program is unique in that a health service is entering into the education system with a role of supporting implementation of a comprehensive approach to addressing health issues. The study investigates how SBYHNs support the implementation of the HPS approach in the secondary school setting and explores the health outcomes for the school community. A statewide survey of SBYHNs examines the variety of health promotion and HPS work being undertaken within schools and identifies key implementation and practice issues. Qualitative case studies of three schools further investigates the barriers faced by nurses in supporting HPS implementation, and explores the perceived outcomes of implementing the HPS approach that have begun to emerge within the school community. Results found that nurses have the capacity to support the implementation of whole-of-school health promotion, with the presence of enablers influencing the comprehensiveness with which schools address health issues or decide to adopt the HPS approach. The study also indicated several outcomes of nurse and school-supported, comprehensive school health promotion across three major areas corresponding with the HPS framework (curriculum, teaching and learning; school organisation, ethos and environment; partnerships and services) and the addition of outcomes in specific health issues. Implications for future developments in health promotion-orientated, school health service interventions and research into the evidence of effectiveness of the HPS approach are discussed.

Background: Links between later life depression (LLD) and adverse health outcomes are well-documented, with mental ill-health in rural older adults highlighted as a priority area for health care policy. In working age adults, models of depression show that specific psychological factors (e.g. hopelessness, neuroticism, extraversion and insecure attachment) interact with life stress to increase risk of depression. In older adults, however, the direct relationship between depression and hopelessness is inconsistently replicated. In addition, there is little evidence regarding how psychological factors interact with vulnerability to depression in older adults; and whether these factors act in the same manner as they do in working age adults. Objectives: A systematic review was carried out in order to determine the strength of the depression-hopelessness relationship, and the influence of personality traits (neuroticism/ extraversion) and insecure attachment (anxious/ avoidant) on this relationship. Next, an exploratory study was carried out to determine whether there was a direct relationship between depression and hopelessness in rural older adults living in the community and, secondly, whether this relationship was indirectly influenced by specific psychological factors (e.g. neuroticism, extraversion, and attachment styles). Methods: The systematic review was carried out using several databases (Psychinfo, Science Direct, EBCOS, Cohrane Library, PROSPERO, WEBCAT and Google Scholar). Studies relating to the variables of interest, meeting inclusion and exclusion criteria, were reviewed and evaluated for methodological biases. The pilot study asked older adults (N = 58) living in a remote and rural region to complete and return a packet of self-report questionnaires (Big Factor Inventory-10, Experiences in Close Relationships, Depression, Anxiety and Stress Scale, and the Beck Hopelessness Scale). Results: The systematic review identified twenty-one studies; four examining the depression-hopelessness relationship and seventeen investigating the effects of neuroticism, extraversion and insecure attachment styles on wellbeing, depression and/ or hopelessness. Findings from the pilot showed a direct relationship between depression and hopelessness in rural community dwelling older adults, with only neuroticism indirectly influencing this relationship. Conclusions: The systematic review suggests that it is not possible, as yet, to draw robust conclusions from the existing evidence base regarding the influence of psychological variables on depression and hopelessness in older adults. The findings were particularly sensitive to methodological limitations (e.g. variability between sampling methods and small effect sizes). Despite this, studies suggest some evidence for attachment and personality influencing on the depression-hopelessness relationship. Likewise, findings from the pilot study are limited by the small sample size and cross-sectional nature of the data. Preliminary findings, however, suggest that neuroticism, and not beliefs about insecure attachment, strengthens the relationship between depression and hopelessness in non-clinical, rural older adults. These findings are consistent with research on working age adults and could, potentially, represent an emerging relationship in non-clinical older adults. Further research, however, is required as to whether the same patterns are observed in clinical populations.

Submitted by Aline Batista (alinehb.ufpel@gmail.com) on 2018-04-19T14:07:40Z No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Dissertacao_Leonardo_Ferreira.pdf: 1173663 bytes, checksum: 384c6abb1e58fbe7d32878fbb1484979 (MD5) / Approved for entry into archive by Aline Batista (alinehb.ufpel@gmail.com) on 2018-04-19T14:45:26Z (GMT) No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Dissertacao_Leonardo_Ferreira.pdf: 1173663 bytes, checksum: 384c6abb1e58fbe7d32878fbb1484979 (MD5) / Made available in DSpace on 2018-04-19T14:45:34Z (GMT). No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Dissertacao_Leonardo_Ferreira.pdf: 1173663 bytes, checksum: 384c6abb1e58fbe7d32878fbb1484979 (MD5) Previous issue date: 2018-02-06 / Sem bolsa / O monitoramento do desenvolvimento dos indicadores de saúde e nutrição dos países depende de dados precisos e completos. Países de baixa e média renda dependem de inquéritos populacionais para tomada de decisões, já que seus sistemas de informação ainda são precários. Estes indicadores são desfechos de saúde que indicam a situação de uma intervenção, comportamento ou cuidado de saúde materno-infantil. Apesar de serem ótimas fontes de informação, os inquéritos populacionais também possuem informações incompletas que podem inviabilizar a construção destes indicadores de forma padronizada. O aprendizado de máquina surge como uma alternativa para completar estas lacunas existentes nos inquéritos com base em características sociodemográficas e preditores relacionados. Este trabalho avalia o desempenho de quatro técnicas de aprendizado de máquina (redes neurais, árvores de decisão, KNN e XGB) nesta tarefa, observando o comportamento de dois desfechos de saúde em quatro amostras diferentes. Os resultados apontam para a existência de uma grande variação no desempenho de acordo com o desfecho selecionado. A disponibilidade dos mesmos indicadores como preditores também é um desafio enfrentado. As técnicas de aprendizado de máquina estudadas apresentaram pouca variação de desempenho entre elas, o que sugere que a natureza dos dados é um fator determinante neste tipo de aplicação. Contudo, o primeiro desfecho apresentou resultados aceitáveis para uma aplicação prática, enquanto o segundo desfecho atingiu estimativas inferiores ao que especialistas consideram como um desempenho razoável. / Monitoring the development of countries’ health and nutrition indicators rely on accurate and complete data. Low-and middle-income countries depend on populational surveys for decision-making since their information systems are still unreliable. These indicators are health outcomes which point out the status of a maternal and child health intervention, behavior or care. Despite being great sources of information, the populational surveys also lack information which could prevent the creation of these standardized indicators. Machine learning arise as an alternative to fill the gaps found in the surveys based on sociodemographic characteristics and related predictors. This work evaluates the performance of four machine learning techniques (neural networks, decision trees, KNN and XGB) in this task by observing the behavior of two health outcomes in four different samples. The results indicate that a great variation can be found depending on the selected outcome. The availability of those indicators as predictors is also a challenge. The studied machine learning techniques presented a small performance variation between themselves which suggests that the nature of the data is determinant to this kind of application. Still, the first outcomes showed acceptable results for a practical application while the second outcome reached lower estimates compared to those which specialists consider as a reasonable performance.

Magister Pharmaceuticae - MPharm / The global movement towards enhancing inter-professional collaboration in patient care is in light of the increasing potency of drugs and complexity of drug regimens, particularly in the chronically ill where poly-pharmacy is rife, collaborative patient management by general practitioners and community pharmacists, in particular, has the potential to enhance patient therapeutic outcomes in primary healthcare. Literature from other parts of the world has enumerated the advantages of collaboration. South Africa with its unusual quadruple burden of disease and human resource deficient public healthcare system would benefit from collaboration between general practitioners and community pharmacists through expanded roles for community pharmacists to enable them to make more meaningful contributions to primary healthcare regimens. Particularly with the introduction of the National Health Insurance (NHI) programme. This dissertation aims to assess from general practitioners‟ perspectives: the current level and stage of collaboration (using the collaborative working relationship (CWR) model proposed by McDonough and Doucette, 2001) between general practitioners and community pharmacists in patient care, if general practitioners‟ perceptions of the professional roles of community pharmacists in patients‟ care can influence desired collaboration (prospects of enhanced future collaboration) and how do general practitioners envision enhanced future collaboration between them and community pharmacists in patient care, possible barriers to the envisioned collaboration between the two practitioners, and how general practitioners‟ demographic characteristics influence inter-professional collaboration with community pharmacists. Sixty randomly selected consenting general practitioners in private practice participated in a cross-sectional, face- to-face questionnaire study. The questionnaire contained a range of statements with Likert scale response options. Data was initially entered into Epi Info (version 3.5.1., 2008) and then exported to IBM SPSS Statistical software for analysis (version19, 2010). Medians were used to summarize descriptive data and Spearman‟s correlation coefficient, Mann-Whitney U Test and Kruskal-Wallis Test was used for bivariate analysis. Ethical approval was granted by the Senate Research and International Relations Committee, University of the Western Cape (Ethical Clearance Number: 10/4/29). The results indicated low-levels of current collaboration at stage 0 of the CWR model between general practitioners and community pharmacists. A statistically significant correlation was observed between general practitioners‟ perceptions of the professional roles of community pharmacists and desired collaboration (prospects of enhanced future collaboration), [p=0.0005]. Good prospects of enhanced future collaboration between general practitioners and community pharmacists were observed. General practitioners identified barriers to collaboration to include: the lack of remuneration for collaboration, absence of a government mandate or policy supporting collaboration, inability of general practitioners to share patients‟ information with community pharmacists and questionable professional ethics exhibited by community pharmacists particularly over financial gains. Most general practitioners agreed that joint continuing professional education organized by pharmaceutical companies or other groups will increase interaction and enhance collaboration. Enhanced Inter-professional collaboration between general practitioners and community pharmacists‟ can be possible in the future but hindrances need to be eliminated for this to be achieved. Future research can be aimed at exploring the perspectives‟ of community pharmacists to inter-professional collaboration in South Africa and interventions that will enhance collaboration.

Background Fewer than one-third of nursing home residents with atrial fibrillation were treated with the only available oral anticoagulant, warfarin, historically. Management of atrial fibrillation has transformed in recent years with the approval of 4 direct-acting oral anticoagulants (DOACs) since 2010. Methods Using the national Minimum Data Set 3.0 linked to Medicare Part A and D claims, we first described contemporary (2011-2016) warfarin and DOAC utilization in the nursing home population (Aim 1). In Aim 2, we linked residents to nursing home and county level data to study associations between resident, facility, county, and state characteristics and anticoagulant treatment. Using a new-user active comparator design, we then compared the incidence of safety (i.e., bleeding), effectiveness (i.e., ischemic stroke), and mortality outcomes between residents initiating DOACs versus warfarin (Aim 3). Results The proportion of residents with atrial fibrillation receiving treatment increased from 42.3% in 2011 to 47.8% as of December 31, 2016, at which time 48.2% of treated residents received DOACs. Demographic and clinical characteristics of residents using DOACs and warfarin were similar in 2016. Half of the 8,734 DOAC users received standard dosages and most were treated with apixaban (54.4%) or rivaroxaban (35.8%) in 2016. Compared with warfarin, bleeding rates were lower and ischemic stroke rates were higher for apixaban users. Ischemic stroke and bleeding rates for dabigatran and rivaroxaban were comparable to warfarin. Mortality rates were lower versus warfarin for each DOAC. Conclusions In nursing homes, DOACs are being used commonly and with equal or greater benefit than warfarin.

Low back syndrome affects 20% of people, and it is estimated that 30% of patients are unable to return to work after surgery. The monitoring of health care outcomes could improve the delivery of health services. The health performance conceptual framework, derived from the Donabedian model, was used to evaluate the functional outcome, clinical recovery, response to surgery, and physician performance of the surgical management of lumbar spine degeneration. A quantitative study (n=685) was undertaken using an administrative database in a repeated-measures design. The clinical and functional outcome improvements were analyzed using t tests. Surgical complexity on health outcome was examined with ANOVA. Predictors of patient satisfaction was explored using Pearson's correlation and regression analyses. The results demonstrated highly significant improvements in functional (mean change 30%; ODI=16.79 -± SD 19.92) and clinical recovery (mean change 50%; modified-JOA=6.983 -± SD 2.613) with surgery at 3 months; a >50% positive response to surgery; and a > 90% patient satisfaction, sustained over a 2 year period. Complexity of surgery did not impact health performance. Strong correlations between the health performance metrics were detected up to 6-months from surgery. Poor clinical recovery and persistent functional disability were predictive of patient dissatisfaction. The social change implications for health policy are that a constellation of health performance metrics could predict the potential for functional and clinical recovery based on presurgery disability while avoiding medical expenditures for procedures with no health benefit; aid in health quality monitoring, peer comparisons, revision of practice guidelines, and cost benefit analysis by payers.

U.S. working mothers experience frequent daily hassles, yet little is known about how working mothers have disproportionate abilities to handle stress. The purpose of this cross-sectional study was to determine the extent to which coping self-efficacy mediated the effect that cumulative daily hassles had on working mothers' health outcomes (i.e., physical functioning, role-physical, bodily pain, general health, vitality, social functioning, role-emotional, and mental health). The transactional model of stress and coping, social cognitive theory, and self-efficacy theory provided the theoretical foundations for this study. Daily hassles were used for this study as an additional theoretical approach for measuring stress. A total of 235 working mothers completed the Daily Hassles Scale, Coping Self-Efficacy Scale, and Short Form 36 version 2 (SF-36v2) on a secure online website. The respondents reported moderate confidence in their abilities to cope with life despite experiencing an average of 44 daily hassles per month. Simple regressions confirmed repeated exposure to daily hassles was significantly associated with reduced coping self-efficacy and health outcomes. Mediation with multiple regression analysis revealed that coping self-efficacy partially mediated the relationship between cumulative daily hassles and health outcomes, suggesting coping self-efficacy was a protective psychosocial factor for working mothers. This study contributes to positive social change by aiding practitioners in identifying protective psychosocial factors and helping working mothers to implement the findings with the intention of reducing daily hassles and improving health outcomes.

The current study sought to examine client outcome data for clients seen for outpatient psychotherapy services by graduate-level student therapists in doctoral psychology training clinics in order to better understand the change process occurring in such settings and to examine whether services being offered are meaningful for clients. One hundred ninety-nine clients seen by graduate-level therapists at a training clinic setting were assessed on a session-by-session basis using the Outcome Questionnaire-45 in order to identify the percentage of clients who met criteria for clinically significant change, reliable improvement, no change, or deterioration in outcomes across the course of treatment. Approximately 28% of clients seen for treatment met criteria for clinically significant change at the termination of treatment and 23% reliably improved. Survival analysis indicated that the median time required to attain clinically significant change was six sessions. Current findings are compared to earlier investigations in both training and nontraining settings. The implications of these findings for education and training, client care and clinical services, and policy are discussed.

In the summer of 2015, the East Tennessee State University (ETSU) College of Public Health and regional health systems serving 29 counties in Northeast Tennessee and Southwest Virginia began the process of identifying a set of high-impact health programs for inclusion in a ten-year regional plan to break the cycle of inter-generational poor health outcomes in this region. It was decided that selection of effective health improvement programming must be driven by a comprehensive and deliberate effort to garner input from communities and stakeholders across the region. More than 170 professionals representing 96 health-related agencies volunteered to form steering committees around four topic areas: healthy children and families, population health, mental health and addictions, and research and academics. Each committee was tasked with; 1) providing information to the health systems on regional health priorities, 2) identifying effective approaches to addressing them, and 3) pinpointing opportunities for cross-sector collaboration. Community input was secured by holding meetings in ten area counties using the World Café model; a format chosen to encourage and facilitate discussion between participants around their local community's health concerns. In addition to priority setting for the 10-year plan, cross-sector commitment and community buy-in was established during this process that will serve as the basis for organizational planning of a proposed accountable care community (ACC). Challenges and opportunities uncovered during our efforts to improve regional health outcomes through a collaborative approach may benefit other communities working on similar projects.

<p>  </p> <p><strong>OBJECTIVES:</strong> Medication synchronization (med-sync) aligns patients’ chronic medications to a predetermined routine pickup date at a community pharmacy. An appointment-based model (ABM) med-sync service includes a comprehensive medication review at the pharmacy. We had the following objectives: (1) To systematically characterize literature describing healthcare utilization, cost clinical, and humanistic outcomes for patients enrolled in medication synchronization, (2) to determine the characteristics of Medicare Part D beneficiaries’ receipt of medication synchronization program and (3) to compare healthcare utilization outcomes of Medicare beneficiaries enrolled in an ABM med-sync program to beneficiaries not enrolled in such a program.</p> <p><br></p> <p><strong>METHODS:</strong> A systematic literature review was conducted using electronic databases from January 2008 to October 2022. The retrospective cohort study analyzed Medicare claims data from 2014-16 for a sample of 1 million beneficiaries utilizing community pharmacies identified as offering a med-sync program. Medicare inpatient, outpatient, emergency, and pharmacy claims data were used to create med-sync and non-med-sync cohorts. We applied Andersen’s Health Services Utilization model to determine factors associated with med-sync enrollment. We constructed logistic regression models with med-sync enrollment as the dependent variable adding predisposing, enabling, and need variables. Descriptive statistics and bi-variate analysis were performed on the cohorts. All patients were followed longitudinally for 12 months before and after a 2015 index/enrollment month to calculate healthcare utilization. Difference-in-differences (DID) was used to compare mean changes in utilization outcomes between cohorts before and after enrollment.</p> <p><br></p> <p><strong>RESULTS:</strong> Through systematic review, we found limited studies related to costs and healthcare utilization. Med-sync programs have shown to increase drug adherence to medications and improve patient satisfaction. For our study with Medicare beneficiaries, we identified 13,193 beneficiaries in the med-sync cohort and 156,987 beneficiaries in non-med sync (control) cohort. As age of beneficiaries increased, likelihood of med-sync enrollment increased (AOR=1.003, 95% CI:1.001-1.005). There were ​higher odds of enrollment for beneficiaries residing in Northeast (AOR=1.094, 95% CI:1.018-1.175), South (AOR=1.109, 95% CI:1.035-1.188), and West (AOR=1.113, 95% CI:1.020-1.215) than the Midwest. Beneficiaries residing in non-metro areas had lower odds of enrollment​ (AOR: 0.914, 95% CI: 0.863-0.969) than metro areas. Beneficiaries with less previous inpatient hospitalizations (AOR=0.945, 95% CI:0.914-0.977) were less likely to be enrolled whereas those with higher outpatient visits (AOR=1.003, 95% CI:1.001-1.004) were more likely to be enrolled. Beneficiaries taking a higher number of oral chronic medications (AOR=1.005, 95% CI:1.002-1.008) had greater odds of enrollment in med-sync. After propensity matching, 13,193 beneficiaries in each cohort were used for analysis. Mean pharmacy utilizations increased before and after enrollment for both cohorts while mean outpatient utilization decreased before and after enrollment for med-sync cohort only. Healthcare utilization mean DID were significantly less in the med-sync cohort compared to the non-med-sync cohort for outpatient visits (DID: 0.01, p=0.0073) and pharmacy fills (DID: 0.01, p<0.0001). There was no significant DID for inpatient and emergency visits between cohorts.</p> <p><br></p> <p><strong>CONCLUSION:</strong> Disparities in age, geographic region, type of residence and prior health utilization for med-sync enrollment were identified. Outpatient and pharmacy utilization changes were significantly lower in med-sync cohort compared to the non-med-sync cohort in the 12-months after enrollment. Lower pharmacy utilization could be due to optimization of therapy during medication reviews of ABM med-sync. As Medicare is approaching to a value-based system, there needs to be a greater focus on systems such as med-sync that has shown to improve a patient’s adherence. </p>