Over the past decade, efforts led by the U.S. Department of Health and Human Services (HHS) have reduced healthcare-associated infections in acute care settings nationally. In 2013, HHS identified that the next phase of these healthcare-associated infection reduction initiatives would target long-term care facilities through the publication of a new chapter in the National Action Plan to Prevent Health Care Associated Infections devoted to this setting. Long-term care facilities are nursing facilities that provide “medical, skilled nursing and rehabilitative services on an inpatient basis to individuals who need assistance preforming activities of daily living, such as bathing and dressing”. These facilities are the primary residence for 2.5 million, predominantly elderly Americans and represented $143 billion nationally in healthcare costs as of 2010. Accordingly, it is a national priority to reduce healthcare-associated infections in this setting and protect this vulnerable population. Healthcare-associated infections caused by multidrug-resistant organisms (MDROs) are a particular burden in the long-term care population. These pathogens, usually bacteria, are defined as being resistant to one or more classes of antimicrobial agents. However, MDROs frequently exhibit resistance to nearly all antimicrobial drugs. Clinical infection control guidelines recommend isolation precautions to prevent MDRO transmission, based on evidence collected in acute care settings. However, the limited evidence that is available from studies in long-term care facilities suggests that isolation precautions may not be effective in this setting. Given that the reduction of antibiotic resistant infections is a priority of the HHS, The White House, Healthy People 2020, and the World Health Organization, it is necessary to confirm and support the appropriate use of isolation precautions for MDROs with evidence specific to long-term care facilities. Therefore, this dissertation describes the current evidence for and use of isolation precautions in long-term care facilities for MDROs. Further, it offers the most comprehensive descriptions of both isolation precautions use and predictors of MDRO infection in nursing homes (NHs), a specific type of long-term care residential setting. To assist the reader, Chapter 1 will provide background for these studies including context for current infection control and prevention practices in long-term care facilities, the importance of MDRO infections and the need for new evidence regarding isolation precautions in long-term care. It will also discuss the aims and significance of this dissertation in context of a conceptual framework, gaps in the literature and potential to improve clinical practice. Next, Chapters 2 and 3 of this dissertation systematically review the current evidence regarding effectiveness of isolation precautions against MDROs and the cost of infection prevention and control in this setting, respectively. These chapters outline how publications focused on long-term care are lacking in quality and quantity and offer suggestions for improvement in future research. Chapter 4 qualitatively describes decision-making process regarding use of isolation-based infection prevention techniques in NHs, which depends on four key considerations: perceived risk of transmission, conflict with quality of life goals, resource availability and lack of understanding. Chapter 5 builds on this qualitative analysis by quantitatively examining predictors of isolation precautions use for MDRO infection in a large, national dataset. This analysis confirms that isolation is rarely used and there is variation across NHs’ practice. However, NH staff may be tailoring infection prevention and control practice to the needs of specific residents, as would be expected based on the results of the qualitative analysis. Chapter 6 presents an analysis of MDRO infection predictors among elderly NH residents across the U.S. This study confirms concepts associated with MDRO infection in previous studies (e.g., low functionality) and provides more specificity in operationalization of these concepts than has been previously determined (e.g., needing support with locomotion), which can inform future use of isolation precautions in NHs. Finally, Chapter 7 contains a synthesis and discussion of these findings, as well as recommendations for health policy and future research regarding contact isolation precautions against MDROs in NHs.

Despite decades of research about educational interventions to correct parents' childhood fever management their knowledge remains poor and practices continue to be based on beliefs about harmful outcomes. The purpose of this thesis was to 1) identify Australian parents' fever management knowledge, attitudes, practices and methods of learning to manage fever and 2) undertake a theoretical exploration of the determinants of parents' intentions to reduce fever using the Theory of Planned Behavior (TPB). Two studies were undertaken: a qualitative study with 15 parents; and survey of 401 Queensland parents with a child aged between 6 months and 5 years. Parents determine childhood fever through behavioural changes they have learnt to associate with fever. Few were aware of the immunological beneficial effects associated with fever and most believed fever harmful causing febrile convulsions and brain damage. To prevent harm they monitored temperatures, used antipyretics, dressed children in light clothing and sponged them with tepid, cool or cold water. Despite believing antipyretics harmful most parents reduced temperatures of 38.3 degrees Celsius ± 0.6 degrees Celsius with antipyretics, alternating two antipyretics when fever was not reduced or returned. In addition to temperature reduction antipyretics were used to reduce distress or general unwellness and pain or discomfort. Multiple factors were used to determine antipyretic dosage including temperature, irritability and illness severity. Over one-third of parents had overdosed their child with too frequent antipyretic administration; more frequently with ibuprofen than paracetamol, 12:1. Fever management information was learnt from numerous sources. Doctors were the most frequently reported followed by personal experience. With the variety of information sources nearly half received conflicting information about how to manage fever increasing concerns and creating uncertainty about how to best care for their child. Despite this many believed they knew how to manage fever. Some parents' practices changed over time as a result of either positive or negative experiences with fever indicating more positive or negative attitudes toward fever. Positive experiences reduced antipyretic and medical service use; negative ones had the adverse effect with increase in antipyretic use including alternating antipyretics and double dosing with one antipyretic. Child medication behaviours also influenced attitudes and practice intentions. Parents of children who readily took antipyretics had more negative attitudes and intended to reduce their child's next fever with antipyretics. Negative attitudes were a significant determinant of fever management intentions. Parents' practices were strongly influenced by their perception that doctors and partners expected them to reduce fever. This expectation from partners is understandable; from doctors it is not and indicates doctors' propensity to recommend reducing fever. There is an urgent need to identify doctors' fever management beliefs and rationales for practice recommendations. Parents also learn to manage fever from nurses and pharmacists; their beliefs and management rationales must also be determined and addressed. There is an urgent need to educate parents about evidence-based fever management and reduce their unnecessary antipyretic use. They must be encouraged to delay antipyretic administration using them to reduce pain rather than fever. Findings from this thesis have identified the determinants of parents' intentions to reduce fever; negative attitudes and normative influences and positive child medication behaviours. Future studies should examine the efficiency and cost effectiveness of fever management educational programs for parents using different presentation methods in multiple settings.

Doctor of Philosophy / Aim and significance: The aim of this research was to explore the phenomenon of Australian nursing home care from the perspective of those who provide and receive it. Its focus is on the processes of ‘quality care’ provision and the meanings and evaluations that care providers attach to their work. In other words, its purpose was to shed light on the practices based on a conceptualisation of care that is entwined with the mechanisms of ‘care’ production and identity creation, or what actually happens in the daily life of the complex social phenomenon that is a nursing home. A related aim was to add to understandings of clinical nursing competence and develop tools that will assist nurses to conceptualise and implement positive change in this setting. Background: The provision of care to our elderly has become a major concern with the ageing of the world population. This is occurring in the context of decline in the capacity of families to take on the responsibility of elder care, and of increasing commercialisation of medical care. Governments have responded by shifting their responsibilities from direct care provision to become auditors of the business of care provision that is supported by public funding. However poor care delivery has largely been hidden from the public gaze. Governments present themselves as having systems in place, creating the illusion of rational control; in reality, like the market economy, there is a ‘black box’ of unknown factors driven by human impulse. The aim of this study was to open up the black box of ‘quality care’ to direct observation, drawing insights from the literature on organisational culture and with a focus on the frontline worker and the construct of quality assurance. Specific research objectives were to: • Document the beliefs and attitudes of care providers towards elderly people in general and the needs of nursing home residents in particular • Elicit the range of meanings and evaluations that care providers attach to their work • Describe their constructions of ‘care’ and ‘quality of care’ and the organisational factors they believe to impact (positively and negatively) on their ability to provide it. • Through in-depth understanding of a particular setting, generate grounded theoretical insights into the phenomenon of quality of residential care that are more widely applicable Method: The study adopted a paradigmatic bricoleur approach, seeking to develop connections between a diverse range of methodologies. These included combinative ethnography, phenomenology, hermeneutics and traditional grounded theory. Conceptual insights were drawn from organisational studies, psychosocial nursing and coping theory. The research site was an Australian for-profit suburban nursing home. The student investigator conducted more than 500 hours of participant observation, recording extensive field notes which were analysed through the perspective of a hermeneutic middle way horizon that directed an augmented constant comparison traditional grounded theory approach. Additional data were collected through formal indepth interviews with six key stakeholders. Interviews were tape recorded, transcribed in full and analysed to reveal themes that were brought within a hermeneutic circle that spiralled recursively from the whole to the part and back to the whole. Findings: Eight key interrelated factors in the production of care within the nursing home were identified: internal and external accountability (the accreditation system); economic considerations; management and training; advocacy; characteristic of residents; care providers’ working conditions and environmental stressors; organisational culture; and the work/care styles of individual care providers. I have categorised the latter into two main types: ‘tortoises’ and ‘hares’. This typology is then used to generate a process-driven schematic diagram that tracks a hypothetical novice care provider through the process of learning how to produce ‘care’. Specifically, I found that nursing home ‘care’ is the outcome of a complex social process involving the interplay between resident, relative, care provider, proprietor, quality assessors and government within the phenomenon of the nursing home. Such care, indeed the phenomenon of the nursing home itself, is not a stable, controllable entity but is in a constant state of flux – what I refer to as a moral ecology. In their everyday practice, care providers devise a construction of ‘quality care’ that is more clearly grounded in their own worldviews and the development of the own identity than in the formal quality assurance system of standards, guidelines and evaluations. Conclusion: Understanding the ‘black box’ of processes that produce care is the key to identifying courses of action that will improve care outcomes. The study findings also question the validity, assumptions and significance of the accreditation system, which only identifies some of the component variables, disregarding both the complexity within the ‘black box’ and failing to acknowledge that the quality of care outcomes is overwhelmingly dependent on individual care providers.

Univ. der Bundeswehr, Diss.--München, 2005. / Literaturverz. S. [263] - 282.

Submitted by MARCIA ROVADOSCHI (marciar@unifra.br) on 2018-08-22T12:30:27Z No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Dissertacao_SimoneBarbosaPereira.pdf: 1911161 bytes, checksum: 8274b42d34b16d295141ae46b63f2ed9 (MD5) / Made available in DSpace on 2018-08-22T12:30:27Z (GMT). No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Dissertacao_SimoneBarbosaPereira.pdf: 1911161 bytes, checksum: 8274b42d34b16d295141ae46b63f2ed9 (MD5) Previous issue date: 2016-12-20 / Good practices in childbirth and birth care do not constitute a new theme. They have gained notoriety due to the excessive use of invasive technologies and a high number of cesarean sections, in which Brazil ranks first in the world scale. One of the drivers of these changes was the launch by the World Health Organization in 1985 of the document entitled "Appropriate technologies for childbirth and birth". This document has promoted the adoption of good practices in care delivery and birth, capable of breaking with traditional models of intervention at delivery and birth, through new methodologies and intervention technologies aimed at the humanization of childbirth. Based on this proposal, the present study aimed as its general objective: To implement the good practices of attention to childbirth and birth, recommended by the World Health Organization, in a medium-sized Hospital Obstetric Unit. As specific objectives, this study considered: Know the professionals' perception professionals of an obstetric hospital unit on the good practices of attention to childbirth and birth, recommended by the World Health Organization; and, Describe the construction and validation steps of a construct of good practices of attention to childbirth and birth, to be implemented in an Obstetric Unit of habitual risk. In order to meet the first specific objective, a qualitative research was carried out, using the focal group technique, with the participation of the multidisciplinary team of the Obstetric Unit of habitual risk, of a medium-sized institution, from April to June 2016. The second specific objective was taken from a methodological survey, carried out between August and October 2016, with the participation of 12 judges from the obstetric area, national level, between the first and second round Delphi. From the data resulting from the first specific objective and codified by content analysis, three thematic categories emerged: good practices and their meanings; from the biological character to the singular and multidimensional care; from the punctual and fragmented conception to the network of attention to childbirth and birth. It was concluded that good practices in childbirth care and birth, in addition to making it possible to rethink the obstetric model and contribute to the organization of the maternal and child health care network, stimulate the role of women in their multiple dimensions. In response to the second specific objective, was obtained, in the judges' analysis, a return of 12 instruments evaluated in the first round and seven instruments in the second round Delphi. In the first round, significant suggestions for changes were made in relation to the items of the dimensions of the construct, in which the judges presented convergences in relation to the mission, vision and values, but suggested changes in the item "assignments of each professional in the team". The construct was considered valid, both in content and appearance, and could contribute to subsidize good practices of attention to childbirth care and birth in local and national territory. It is concluded that, besides the governmental initiatives, it is necessary that the health professionals are responsible for and assume the good practices of attention to childbirth and birth as a possibility of transformation of the obstetric model. As a way of broadening the reflections and qualifying the good practices of attention to childbirth and birth at the Obstetric Unit, the origin institution of the principal researcher, she presented to the managers and multi professional team the validated construct, in days and at times previously scheduled. In addition, a graphical representation of the Construct of Good Practices of Attention to Childbirth and Birth, validated by the Judges of the obstetric area, was prepared, which will be exposed at the main entrance of the Obstetric Unit in question. / As boas práticas de atenção ao parto e ao nascimento não se constituem em temática nova. Elas ganharam notoriedade pelo uso excessivo das tecnologias invasivas e elevado número de cesarianas, nas quais o Brasil figura em primeiro lugar na escala mundial. Um dos propulsores dessas mudanças foi o lançamento, pela Organização Mundial da Saúde, no ano de 1985, do documento “Tecnologias apropriadas para o Parto e Nascimento”. Este documento impulsionou a adoção de boas práticas na atenção ao parto e ao nascimento, capazes de romper com modelos tradicionais de intervenção ao parto e ao nascimento, por meio de novas metodologias e tecnologias de intervenção voltadas para a humanização do parto. Com base nesta aposta, o presente estudo teve como objetivo geral: Implementar as boas práticas de atenção ao parto e ao nascimento, preconizadas pela Organização Mundial da Saúde, em uma Unidade Obstétrica Hospitalar de médio porte. Como objetivos específicos este estudo considerou: Conhecer a percepção dos profissionais de saúde de uma unidade hospitalar obstétrica sobre as boas práticas de atenção ao parto e ao nascimento, preconizadas pela Organização Mundial da Saúde; e, Descrever as etapas de construção e de validação de um construto de boas práticas de atenção ao parto e ao nascimento, a ser implementado em uma Unidade Obstétrica de risco habitual. Para atender ao primeiro objetivo específico foi realizada uma pesquisa qualitativa, por meio da técnica de grupo focal, com a participação da equipe multiprofissional da Unidade Obstétrica de risco habitual, de uma instituição de médio porte, no período de abril a junho de 2016. O segundo objetivo específico foi atendido a partir de uma pesquisa metodológica, realizada entre os meses de agosto e outubro de 2016, com a participação de 12 juízes da área obstétrica, de âmbito nacional, entre a primeira e a segunda rodada Delphi. Dos dados resultantes do primeiro objetivo específico e codificados pela análise de conteúdo resultaram três categorias temáticas: boas práticas e seus significados; do caráter biológico ao cuidado singular e multidimensional; da concepção pontual e fragmentada à rede de atenção ao parto e ao nascimento. Concluiu-se que as boas práticas de atenção ao parto e ao nascimento, além de possibilitarem o repensar do modelo obstétrico e contribuírem na organização da rede de atenção à saúde materno infantil, estimulam o protagonismo da mulher em suas múltiplas dimensões. Em resposta ao segundo objetivo específico obteve-se, na análise dos juízes, um retorno de 12 instrumentos avaliados na primeira rodada e sete instrumentos, na segunda rodada Delphi. Na primeira rodada foram realizadas sugestões significativas de mudanças em relação aos itens das dimensões do construto, nos quais os juízes apresentaram convergências em relação à missão, à visão e aos valores, mas, sugeriram mudanças no item “atribuições de cada profissional na equipe”. O construto foi considerado válido, tanto em conteúdo quanto em aparência, e poderá contribuir para subsidiar as boas práticas de atenção ao parto e ao nascimento em âmbito local e em território nacional. Considera-se que, para além das iniciativas governamentais, é preciso que os profissionais de saúde se corresponsabilizem e assumam as boas práticas de atenção ao parto e ao nascimento como possibilidade de transformação do modelo obstétrico. Como forma de ampliar as reflexões e qualificar as boas práticas de atenção ao parto e ao nascimento na Unidade Obstétrica, instituição de origem da pesquisadora principal, a mesma apresentou para os dirigentes e equipe multiprofissional o construto validado, em dias e horários previamente agendados. Salienta-se, enfim, que foi confeccionada uma representação gráfica do Construto de Boas Práticas de Atenção ao Parto e ao Nascimento, validado pelos Juízes da área obstétrica, o qual ficará exposto na entrada principal da Unidade Obstétrica em questão.

Thesis subject: The Role of Family Carers in the Nursing Home for Persons with Cognitive Impairment. The theme of this thesis is the role of the family carers in the nursing home for persons with cognitive impairment. This topic is very actual due to the aging of society and to the increasing of life expectancy. A proportion of the old people in society increases but in the same time there is a decreasing number of people who could take care of them at home (due to negative population balance, disintegration of traditional family, economic situation and high requirements of the care etc.). Many seniors who are depending on the help of the others (such as people with dementia) spend their old age in institutional care. The qualitative research in this thesis shows that families continue in caregiving even after the admission of their relatives to a nursing home. The aim of this research was to describe the involvement of families in the institutional care and to identify factors that influence this phenomenon. Research was conducted in one nursing home for persons with cognitive impairment. Semistructured interviews were conducted with a sample of informants consisting of five professional nurses and four family carers. The analysis of data was carried out using the grounded theory. Research...

The purpose of this dissertation is to examine nursing homes‟ compliance with state minimum nurse staffing standards and its relation to quality-of-care deficiencies. Specifically, this study, reviewing staffing standards from 50 states and the District of Columbia for the year 2007, proposes a unique algorithm to calculate the states‟ expected nurse staffing levels for individual nursing homes in order to investigate their compliance with the state nurse staffing standards. By using hierarchical linear modeling method, this study attempts to capture the impact of the staffing standards on actual nurse staffing levels under resource dependence perspectives. Path analysis using structural equation modeling was conducted to investigate both direct and indirect effects of the staffing standards on nurse staffing levels and quality-of-care deficiencies. The major findings were as follows: (1) nursing homes in states with higher state staffing standards for the categories of RN, LN, and total nurse were found to have higher RN, LN, and total staffing levels, respectively; (2) higher nurse staffing levels resulting from higher state staffing standards were significantly associated with better quality of care (less quality-of-care deficiencies cited) in nursing homes; and (3) state staffing standards were found to have much stronger contribution to nurse staffing levels than any other organizational or contextual factors while nurse staffing levels, particularly licensed staff, were found to have stronger contribution to quality-of-care deficiencies than any other organizational factors. The study findings suggest that if the goal is to increase nurse staffing levels for better quality, increasing the stringency of both federal and state nurse staffing standards would be the iv most effective way. However, the staffing standards first need technical changes to reduce their ambiguity and ensure their fairness. If the goal is to achieve better quality, merely increasing nurse staffing levels may not be effective since the variation of the quality-of-care deficiencies explained by exogenous variables was smaller than random variation 5%. If state Medicaid reimbursements can be utilized for financial incentives for better performing nursing homes, nursing homes may improve their productivity by efficiently managing organizational personnel or increasing job satisfaction among nursing practitioners. Lastly, longitudinal analysis, considering variation in length of state staffing policy implementations, is encouraged to investigate the long-term effects of state staffing standards on nurse staffing levels and quality of care.

Alla människor har rätt till en lika vård men studier visar att personer med substansbrukssyndrom befinner sig i en utsatt position i mötet med vården. Substansbruk definieras enligt världsorganisationen WHO som ett sjukdomstillstånd. 275 miljoner människor beskrivs ha ett substansbruk, varav 36 miljoner av dessa människor har ett substansbrukssyndrom. Syftet med denna studie var att sammanställa kunskap om hur personer med substansbrukssyndrom upplever bemötandet och stigmatisering i vården. Metoden som valdes var en systematisk litteraturöversikt av studier med kvalitativ metod med metasyntes som analysmetod. Databaserna PubMed och PsycInfo användes. Efter kvalitetsgranskning inkluderades 16 artiklar. Resultatet av metasyntesen resulterade i tre slutteman:  Att bli särbehandlad och dömd. Att bli ignorerad och misstrodd. Att bli behandlad som en människa och uppleva att man får den vård man är i behov av. Resultatet visade att personer med substansbrukssyndrom upplever både ett negativt och ett positivt bemötande av vården. I resultatet framkom det en upplevd stigmatisering och en känsla av att bli misstrodd av vården, medan andra delar av resultatet visade att patientgruppen erhöll ett tillitsfullt bemötande och blev sedd som en människa bakom sin diagnos. Slutsatserna tyder på vikten av en personcentrerad vård och att ett individuellt bemötande kan vara grunden för att skapa en god vårdrelation för att förbättra vården för patienter med substansbrukssyndrom. Denna studie kan bidra till en ökad förståelse och kunskap om hur personer med substansbrukssyndrom upplever att de blir bemötta av vården. Studien kan få en betydelse för vårdpersonal, men också för patienter och anhöriga, genom att vården kan uppnå ett förbättrat förhållningssätt till denna patientgrupp.

Indiana University-Purdue University Indianapolis (IUPUI) / A move toward care of residents in nursing homes where they are respected and heard is finally emerging. Common strategies used in nursing homes to improve quality of care for residents are integration of person-centered care and assessing care using satisfaction surveys. Although approaches of integrating person-centered care and satisfaction surveys have been valuable in improving nursing home quality, strategies of care that include things that matter from residents’ perspectives while living in nursing homes need investigation. The purpose of this qualitative descriptive study was to describe things that residents age 65 and older state matter to them while living in the long-term care sections of nursing homes. A qualitative mode of inquiry using purposeful sampling led to a natural unfolding of data that revealed things that mattered to residents. Content analysis was used to reduce the data in a manner that kept the data close to the context yet moved the data toward new ideas about including things that mattered to residents in nursing care. The findings revealed residents’ positive and negative experiences and addressed the question: How can nurses manage residents’ positive and negative aspects of care in nursing homes? This study substantiated the importance of developing nursing care strategies derived from residents’ descriptions of care. Finding ways to promote nurses’ investment in attitudes about a person-centered care philosophy is essential for successful person-centered care implementation. Enhancing nurses’ knowledge, skills, and attitudes with an investment in person centeredness will be more likely to put nurses in a position to role-model care that is person-centered from residents’ perspectives.

A study entitled `Phenomenological study of ageing amongst the older persons in Zambia' was undertaken with the purpose of gaining an understanding of the ageing phenomenon within the Zambian context and provide frameworks that could be used by policy-makers and health professionals to formulate guidelines or interventions relevant to the lived experiences of older persons and the meaning attached to ageing or being old, and consequently maintain or improve the quality of life of older persons of Zambia. The objectives of the study were to describe (1) the lived experiences of the older persons of Zambia, and (2) the meaning they attached to ageing or being old within the Zambian context. A transcendental phenomenological design within the qualitative naturalistic approach was used to guide the research process and to assist the researcher to reach the purpose and objectives of the study. Focus group and in-depth individual interviews were conducted to generate data from twenty-seven (27) informants. Fifteen (15) informants participated in the focus group interviews and twelve (12) in in-depth individual interviews. In total, 24 in-depth individual interviews were conducted in term of two interviews per informants, and two focus group interviews. Data collection covered a period of three months. Coliazzi (1978) and Giorgi (1985) techniques for qualitative data analysis were used and verbatim excerpts form the transcribed interviews were used to support the themes that emerged from data and to provide a richer picture of the situation. Three frameworks derived from the findings of this study: (1) framework of the lived experiences of older persons of Zambia, (2) framework of the meaning of ageing or being old and (3) framework for understanding ageing within the Zambian context. The researcher believed that these frameworks would make a meaningful contribution toward the understanding and the development of policies and interventions that would assist in enhancing or maintaining the quality of life of older people of Zambia. The main findings of the results of this study indicated three most significant dimensions of the lived experiences of the older persons (health, socio-economic and psychosocial) that need to be taken into account when planning for any programs or interventions aimed at maintaining or improving the quality of life of older persons of Zambia. These interventions and programs should also address the negative feelings or meanings attached to the above experiences. The main findings of the results of this study also showed that the meaning of being old or ageing in Zambia does not depend on the health, socio-economic and psychosocial living experiences of the older person but it depends largely on the inner values of the older persons, such as spiritual, emotional and cultural beliefs. This means that maintaining or improving the quality of life of older persons in Zambia would require comprehensive programs or interventions that should take into account the health, socio-economic, psychosocial, spiritual, emotional and cultural needs of the older people. / Health Studies / D. Litt. et Phil. (Health Studies)