by Chong Yu Hoi. / Thesis (M.Phil.)--Chinese University of Hong Kong, 1995. / Includes bibliographical references (leaves 166-172). / Chapter 1. --- Introduction --- p.1 / Chapter 2. --- Background --- p.5 / Chapter 2.1. --- Evolution of Primary Health Care in Last TwoDecades 226}0ؤ An Overview --- p.5 / Chapter 2.2. --- Role of Primary Health Care --- p.11 / Chapter 2.3. --- Significance of Referral Between Primary and Secondary Health Care --- p.12 / Chapter 2.4. --- Attributes of Referral --- p.14 / Chapter 2.4.1. --- Referral Rate --- p.14 / Chapter 2.4.2. --- Referral Pattern --- p.19 / Chapter 2.4.3. --- Reason of Referral --- p.20 / Chapter 2.4.4. --- Appropriateness of Referral --- p.24 / Chapter 2.4.5. --- Referral Letter --- p.30 / Chapter 3. --- Situation in Hong Kong --- p.34 / Chapter 3.1. --- Health of the Society --- p.34 / Chapter 3.2. --- History of GOPC Service in Hong Kong --- p.35 / Chapter 3.3. --- Present Situation of GOPC Services --- p.37 / Chapter 3.4. --- Previous Surveys on Private Practice in Hong Kong --- p.38 / Chapter 3.5. --- Previous Surveys on GOPC Services in Hong Kong --- p.39 / Chapter 3.6. --- A Review of Data from 12 GOPCs --- p.44 / Chapter 4. --- The Study: Objectives and Method --- p.48 / Chapter 4.1. --- Objectives --- p.48 / Chapter 4.2. --- Materials & Method - The Framework of the Study --- p.51 / Chapter 4.3. --- Phase One --- p.52 / Chapter 4.3.1. --- Study Population --- p.53 / Chapter 4.3.2. --- Sampling Method --- p.53 / Chapter 4.3.3. --- Survey Method --- p.53 / Chapter 4.3.4. --- Data Analysis --- p.54 / Chapter 4.4. --- Phase Two --- p.55 / Chapter 4.4.1. --- Study population --- p.56 / Chapter 4.4.2. --- Sampling Method --- p.57 / Chapter 4.4.3. --- Survey Method --- p.57 / Chapter 4.4.4. --- Data Analysis --- p.58 / Chapter 4.5. --- Phase Three --- p.59 / Chapter 4.5.1. --- Study Population --- p.59 / Chapter 4.5.2. --- Sampling Method --- p.60 / Chapter 4.5.3. --- Survey Method --- p.60 / Chapter 4.5.4. --- Data Analysis --- p.60 / Chapter 5. --- Study Result: Phase One --- p.62 / Chapter 5.1. --- The Response Rate --- p.62 / Chapter 5.2. --- Profile of Patients --- p.63 / Chapter 5.3. --- Referral Rate --- p.64 / Chapter 5.3.1. --- The Spectrum In Hong Kong --- p.64 / Chapter 5.3.2. --- Relationship with Individual GOPC --- p.65 / Chapter 5.3.3. --- Relationship with Practice Size --- p.66 / Chapter 5.3.4. --- Relationship with the Day of the Week --- p.67 / Chapter 5.3.5. --- Relationship with Workload of the Day --- p.69 / Chapter 5.3.6. --- Relationship with Workload of Doctor --- p.70 / Chapter 5.3.7. --- Relationship with Basic Medical Training --- p.72 / Chapter 5.3.8. --- Relationship with Year of Experience --- p.73 / Chapter 5.3.9. --- Relationship with Higher Qualification --- p.73 / Chapter 5.4. --- Referral Pattern --- p.74 / Chapter 5.5. --- Reason of Referral --- p.75 / Chapter 5.6. --- Prescription Rate --- p.77 / Chapter 5.7. --- Investigation Rate --- p.78 / Chapter 5.8. --- Duration of Disease before Referral --- p.78 / Chapter 5.9. --- Number of GOPC consultation before Referral --- p.79 / Chapter 6. --- Study Result: Phase Two --- p.82 / Chapter 6.1. --- Response Rate --- p.82 / Chapter 6.2. --- Background of the Referral --- p.83 / Chapter 6.2.1. --- GOPCs of Referral --- p.83 / Chapter 6.2.2. --- Waiting Time for SOPC Appointment --- p.85 / Chapter 6.2.3. --- The patients --- p.86 / Chapter 6.3. --- Present Complaint --- p.87 / Chapter 6.3.1. --- Duration of Disease before Referral --- p.87 / Chapter 6.3.2. --- Number of GOPC Consultation before Referral --- p.89 / Chapter 6.4. --- Assessment of Referral --- p.90 / Chapter 6.4.1. --- Management of Referring Doctor --- p.90 / Chapter 6.5. --- Referrals with Inappropriate Necessity --- p.91 / Chapter 6.5.1. --- The Patients --- p.91 / Chapter 6.5.2. --- Referring GOPCs --- p.93 / Chapter 6.5.3. --- The Specialties --- p.94 / Chapter 6.5.4. --- "Diagnosis, Investigation & Treatment" --- p.95 / Chapter 6.5.5. --- Timing of Referral --- p.97 / Chapter 6.5.6. --- Duration of Present Attack --- p.97 / Chapter 6.5.7. --- Outcome of Referral --- p.97 / Chapter 6.6. --- Referrals with Inappropriate Timing --- p.98 / Chapter 6.6.1. --- The Patients --- p.98 / Chapter 6.6.2. --- The Referring GOPCs --- p.98 / Chapter 6.6.3. --- The Specialties --- p.100 / Chapter 6.6.4. --- Necessity of Referral --- p.101 / Chapter 6.6.5. --- Number of GOPC Visit before Referral --- p.101 / Chapter 6.6.6. --- Number of GOPC Visit with Specialty --- p.102 / Chapter 6.6.7. --- Duration of Disease --- p.103 / Chapter 6.6.8. --- Duration of Disease with Specialty --- p.104 / Chapter 6.6.9. --- "The Diagnosis, Number of GOPC Visit and Duration of Illness" --- p.105 / Chapter 6.6.10. --- Investigation & Treatment Prescribed --- p.107 / Chapter 6.6.11. --- Prognosis of the Referred Cases --- p.109 / Chapter 6.7. --- Referrals with Inappropriate Investigation --- p.110 / Chapter 6.7.1. --- The Patients --- p.110 / Chapter 6.7.2. --- The Referring GOPCs --- p.110 / Chapter 6.7.3. --- The Specialties --- p.112 / Chapter 6.7.4. --- The Diagnosis & Investigation --- p.113 / Chapter 6.7.5. --- Prognosis of Referral --- p.115 / Chapter 6.8. --- Referrals with Inappropriate Treatment --- p.115 / Chapter 6.8.1. --- The Patients --- p.115 / Chapter 6.8.2. --- Referring GOPC --- p.115 / Chapter 6.8.3. --- The Specialties --- p.117 / Chapter 6.8.4. --- The Diagnosis & Treatment --- p.118 / Chapter 6.8.5. --- Prognosis of the Referred Cases --- p.119 / Chapter 6.9. --- Assessment of the Referral Letter --- p.120 / Chapter 7. --- Study Result: Phase Three --- p.122 / Chapter 7.1. --- The Response Rate --- p.122 / Chapter 7.1.1. --- The GOPC Doctors --- p.122 / Chapter 7.1.2. --- The Specialists --- p.123 / Chapter 7.2. --- Profile of GOPC Doctors --- p.123 / Chapter 7.2.1. --- Years of Clinical Practice --- p.123 / Chapter 7.2.2. --- Qualification Obtained --- p.124 / Chapter 7.3. --- Profile of Specialists --- p.125 / Chapter 7.3.1. --- Years of Clinical Practice --- p.125 / Chapter 7.3.2. --- Qualification Obtained --- p.126 / Chapter 7.4. --- Workload of the Participating Doctors --- p.126 / Chapter 7.4.1. --- Number of outpatient Seen by GOPC Doctors --- p.126 / Chapter 7.4.2. --- Number of outpatient Seen by Specialists --- p.126 / Chapter 7.5. --- Referrals from GOPCs to Specialist Clinics --- p.127 / Chapter 7.5.1. --- Percentage of GOPC Cases Referred to Specialist Clinics --- p.127 / Chapter 7.5.2. --- Percentage of Specialist Cases Referred from GOPCs --- p.127 / Chapter 7.6. --- Communication between GOPC and Specialist Clinic --- p.128 / Chapter 7.6.1. --- Opinion of GOPC Doctors on Referral Letters --- p.128 / Chapter 7.6.2. --- Opinion of GOPC Doctors on Feedback from Specialists --- p.130 / Chapter 7.6.3. --- Opinion of Specialist on Referral Letters --- p.131 / Chapter 7.6.4. --- Opinion of Specialists on Their Feedback --- p.135 / Chapter 7.7. --- The Form of Feedback from Specialists --- p.136 / Chapter 7.8. --- Suggestions on Improving the Communication --- p.137 / Chapter 7.9. --- In Service Training for GOPC Doctors --- p.138 / Chapter 8 --- _ Discussion and Recommendation --- p.141 / Chapter 8.1. --- Limitations and Comments --- p.141 / Chapter 8.1.1. --- Representativeness of The Sample --- p.141 / Chapter 8.1.2. --- Response Rate --- p.141 / Chapter 8.1.3. --- Size of The Sample --- p.142 / Chapter 8.1.4. --- Short Duration of the Study --- p.142 / Chapter 8.1.5. --- Discontinuity of Phase One and Phase Two --- p.143 / Chapter 8.2. --- Discussion --- p.144 / Chapter 8.2.1. --- Referral Rate in Hong Kong --- p.145 / Chapter 8.2.2. --- Referral Pattern and Reason of Referral --- p.147 / Chapter 8.2.3. --- Appropriateness of Referrals --- p.149 / Chapter 8.2.4. --- Communication between GOPCs & SOPCs --- p.149 / Chapter 8.2.5. --- In Service Training for GOPC Doctors --- p.150 / Chapter 8.2.6. --- Waiting Time for SOPCs Appointment --- p.151 / Chapter 8.2.7. --- Prescription Rate --- p.152 / Chapter 8.2.8. --- Common Investigations Requested by Specialists --- p.153 / Chapter 8.2.9. --- Factors Associated with Referral Rates --- p.155 / Chapter 8.2.10. --- Factors Associated with Appropriateness of Referrals --- p.157 / Chapter 8.2.11. --- Factors Associated with Timing of Referrals --- p.158 / Chapter 8.3. --- Recommendation --- p.161 / Chapter 8.3.1. --- Further Study in Private Sector --- p.161 / Chapter 8.3.2. --- Further Study in Other Regions --- p.161 / Chapter 8.3.3. --- Further Study on the Appropriateness of those Non-referrals --- p.161 / Chapter 8.3.4. --- Improve Record in Specialist Clinics --- p.162 / Chapter 8.3.5. --- Upgrade of GOPC Drug Formulary --- p.162 / Chapter 8.3.6. --- Standard Referral & Feedback Form --- p.163 / Chapter 8.3.7. --- Shared Care Program between SOPCs & GOPCs --- p.163 / Chapter 8.3.8. --- Medical Record System in GOPCs --- p.163 / Chapter 8.3.9. --- Further Training for GOPC Doctors --- p.164 / Chapter 8.3.10. --- Principal Medical Officer for GOPC Service --- p.164 / Chapter 9. --- Reference --- p.166 / Chapter 10. --- Appendix --- p.173

Both employers and out-patient treatment centres are key role players in addressing workplace related substance abuse. On the one hand, employers are directly and indirectly affected by the huge problem of substance abuse. On the other hand, out-patient treatment centres provide, as their core goal, for the treatment of substance abuse and dependency. Due to the extent of the problem of substance abuse, collaborative intervention measures between employers and out-patient treatment centres are essential – especially the involvement of specialists in the treatment of substance abuse. Such a collaboration process requires specific, resolute measures, as well as a structured process in order to ensure sustainability and results. A networking programme that provides the opportunity to implement this collaborative process is proposed. Sound collaborations indeed provide the foundation to establish the networking programme for combating the problem of substance abuse in the workplace. A collaborative effort to address the problem of substance abuse in the workplace requires not only rallying the strengths and resources of both employers and out-patient treatment centres, but also developing a programme with well-defined processes beneficial to both. A qualitative research study by means of a grounded theory approach was conducted to explore how networking between employers and out-patient treatment centres might aid in addressing the problem of substance abuse in the workplace. Article 1 is a literature overview of substance abuse within the workplace and concerns the national directives, legislation requirements and measures of intervention aimed at dealing with the problem. The literature findings reveal clear national directives, legislation requirements and workplace policies, all aimed at providing a well-defined context for employers to manage substance abuse in the workplace. In addition, specialist treatment services are available to assist employers in addressing the problem in the workplace. Internal support structures in the workplace, however, often independently address the problem of substance abuse without involving the specialists. Literature findings indicate, though, that the personnel involved in the internal support structures are often not equipped to deal effectively with the problem. Research findings indicate positive treatment outcomes for employees with substance abuse problems. Statistics, however, indicate that the identification of employees with substance abuse problems is limited and that referrals of employees for treatment are infrequent. Underutilisation of out-patient treatment centres is therefore commonplace. Literature specifically indicates that the majority of employees are moderate drinkers and substance abusers, with only a small number being dependant. It is further indicated that the moderate drinkers and substance abusers account for almost half of the workforce. The critical factor, however, is that these categories of drinkers cause the majority of industrial accidents and are also responsible for the highest absenteeism rate. Prevention measures, sensitising the entire workforce to the early signs and dangers of substance abuse, facilitate the achievement of the best results in combating the problem. With an eye towards this, national directives advocate the following: intensified campaigns to educate people regarding the early signs and dangers of substance abuse, comprehensive prevention measures and increased rehabilitation efforts. Literature identified a limitation to effectively address substance abuse in the workplace, a problem catered for by specialist treatment centres. Article 2 reports the findings of a situation analysis regarding both the concerns and problems of employers and out-patient treatment centres, as well as resources needed to combat substance abuse in the workplace. Representatives from the employment sector, and out-patient treatment centres, participated in the situation analysis. Employees involved in substance abuse treatment programmes also participated in the study. A specific limitation, identified during the situation analysis, was the limited knowledge regarding the negative consequences of substance abuse in general. An unsupportive workplace environment, with regards especially to substance use and abuse, was also identified. Though empirical findings reported the existence of support structures in the workplace, these structures were found to be incapable of dealing with the problem. In the event of substance misconduct, employers are legally obligated to provide treatment and rehabilitation before considering dismissal; however, employers perceived these obligations as additional demands. Employers did not realise the possible benefits of treatment over dismissal. Misinformation and misinterpretation of the legal obligations were also identified during the research study. The stand against the problem of substance abuse in the workplace revealed a limited collaboration between employers and out-patient treatment centres. Employers were often not aware of specialist treatment centres and the available services. A lack of marketing and visibility – on the part of out-patient treatment centres – and an indifference and lack of support in the workplace were regarded as some of the causes for the limited collaboration between employers and out-patient treatment centres. Both ignorance in the workplace about the scope of substance abuse and a general lack of knowledge regarding the problem were identified as further limiting factors. A need for collaboration between employers and out-patient treatment centres was identified, especially if the problems of substance abuse in the workplace were to be successfully addressed. The development of a networking programme for employers and treatment centres was recommended and the core components to establish such a programme were identified. Article 3 discusses the components which were identified during the situation analysis and presents guidelines to develop a networking programme for employers and out-patient treatment centres. The components identified by the participants served as framework for the proposed networking programme. The programme comprises a specific purpose namely collaboration between employers and out-patient treatment centres, specific characteristics to sustain the programme, and the implementation of distinguishable procedures to establish and ensure sustainability of the programme. The purpose of the networking programme is to promote, between employers and out-patient treatment centres, a collaboration that will address the problem of substance abuse in the workplace. Involvement in the programme holds significant potential benefits for all relevant role players; the programme, in other words, advocates benefits for employers, employees and out-patient treatment centres. The proposed networking programme includes specific procedures for establishing and sustaining the programme: Firstly, assessing the limitations, needs and strengths of both the employment sector and out-patient treatment centres; secondly, establishing a network agreement that defines the roles and responsibilities of the role players; thirdly, collectively planning the networking activities and implementation of these plans; and, finally, collaboratively evaluating the impact and effectiveness of the programme. The aforementioned procedures also apply to both the evaluation of the limitations and progress of the treatment programmes, as well as to the evaluation of service delivery of the treatment centres. As it enables the revision of plans that provide individualised services, the continuous reassessment of the limitations and strengths of the networking programme is important. Out-patient treatment centres are considered responsible for initiating the networking programme. Effective collaboration between employers and out-patient treatment centres, as well as quality service delivery by the treatment centres, is regarded as critically important. Ultimately, the networking programme – regarded as a collaborative process between employers, employees and out-patient treatment centres – promotes a partnership geared towards combating the problem of substance abuse in the workplace. The researcher concluded the study with the formulation of a theory regarding the development of a networking programme as its end goal. Also, it is hoped that both out-patient treatment centres and the employment sector (employers and employees) may benefit from it in practice. Eventually, the proposed networking programme was based on the data collected from the situation analysis in this study, the researcher’s experience as a counsellor in substance abuse treatment and her exposure to different networking programmes, as well as supportive theoretical knowledge. A guideline for application of the networking programme in practice is included in the study alongside examples of projects to apply the programme. / PhD (Social Work), North-West University, Potchefstroom Campus, 2014

Both employers and out-patient treatment centres are key role players in addressing workplace related substance abuse. On the one hand, employers are directly and indirectly affected by the huge problem of substance abuse. On the other hand, out-patient treatment centres provide, as their core goal, for the treatment of substance abuse and dependency. Due to the extent of the problem of substance abuse, collaborative intervention measures between employers and out-patient treatment centres are essential – especially the involvement of specialists in the treatment of substance abuse. Such a collaboration process requires specific, resolute measures, as well as a structured process in order to ensure sustainability and results. A networking programme that provides the opportunity to implement this collaborative process is proposed. Sound collaborations indeed provide the foundation to establish the networking programme for combating the problem of substance abuse in the workplace. A collaborative effort to address the problem of substance abuse in the workplace requires not only rallying the strengths and resources of both employers and out-patient treatment centres, but also developing a programme with well-defined processes beneficial to both. A qualitative research study by means of a grounded theory approach was conducted to explore how networking between employers and out-patient treatment centres might aid in addressing the problem of substance abuse in the workplace. Article 1 is a literature overview of substance abuse within the workplace and concerns the national directives, legislation requirements and measures of intervention aimed at dealing with the problem. The literature findings reveal clear national directives, legislation requirements and workplace policies, all aimed at providing a well-defined context for employers to manage substance abuse in the workplace. In addition, specialist treatment services are available to assist employers in addressing the problem in the workplace. Internal support structures in the workplace, however, often independently address the problem of substance abuse without involving the specialists. Literature findings indicate, though, that the personnel involved in the internal support structures are often not equipped to deal effectively with the problem. Research findings indicate positive treatment outcomes for employees with substance abuse problems. Statistics, however, indicate that the identification of employees with substance abuse problems is limited and that referrals of employees for treatment are infrequent. Underutilisation of out-patient treatment centres is therefore commonplace. Literature specifically indicates that the majority of employees are moderate drinkers and substance abusers, with only a small number being dependant. It is further indicated that the moderate drinkers and substance abusers account for almost half of the workforce. The critical factor, however, is that these categories of drinkers cause the majority of industrial accidents and are also responsible for the highest absenteeism rate. Prevention measures, sensitising the entire workforce to the early signs and dangers of substance abuse, facilitate the achievement of the best results in combating the problem. With an eye towards this, national directives advocate the following: intensified campaigns to educate people regarding the early signs and dangers of substance abuse, comprehensive prevention measures and increased rehabilitation efforts. Literature identified a limitation to effectively address substance abuse in the workplace, a problem catered for by specialist treatment centres. Article 2 reports the findings of a situation analysis regarding both the concerns and problems of employers and out-patient treatment centres, as well as resources needed to combat substance abuse in the workplace. Representatives from the employment sector, and out-patient treatment centres, participated in the situation analysis. Employees involved in substance abuse treatment programmes also participated in the study. A specific limitation, identified during the situation analysis, was the limited knowledge regarding the negative consequences of substance abuse in general. An unsupportive workplace environment, with regards especially to substance use and abuse, was also identified. Though empirical findings reported the existence of support structures in the workplace, these structures were found to be incapable of dealing with the problem. In the event of substance misconduct, employers are legally obligated to provide treatment and rehabilitation before considering dismissal; however, employers perceived these obligations as additional demands. Employers did not realise the possible benefits of treatment over dismissal. Misinformation and misinterpretation of the legal obligations were also identified during the research study. The stand against the problem of substance abuse in the workplace revealed a limited collaboration between employers and out-patient treatment centres. Employers were often not aware of specialist treatment centres and the available services. A lack of marketing and visibility – on the part of out-patient treatment centres – and an indifference and lack of support in the workplace were regarded as some of the causes for the limited collaboration between employers and out-patient treatment centres. Both ignorance in the workplace about the scope of substance abuse and a general lack of knowledge regarding the problem were identified as further limiting factors. A need for collaboration between employers and out-patient treatment centres was identified, especially if the problems of substance abuse in the workplace were to be successfully addressed. The development of a networking programme for employers and treatment centres was recommended and the core components to establish such a programme were identified. Article 3 discusses the components which were identified during the situation analysis and presents guidelines to develop a networking programme for employers and out-patient treatment centres. The components identified by the participants served as framework for the proposed networking programme. The programme comprises a specific purpose namely collaboration between employers and out-patient treatment centres, specific characteristics to sustain the programme, and the implementation of distinguishable procedures to establish and ensure sustainability of the programme. The purpose of the networking programme is to promote, between employers and out-patient treatment centres, a collaboration that will address the problem of substance abuse in the workplace. Involvement in the programme holds significant potential benefits for all relevant role players; the programme, in other words, advocates benefits for employers, employees and out-patient treatment centres. The proposed networking programme includes specific procedures for establishing and sustaining the programme: Firstly, assessing the limitations, needs and strengths of both the employment sector and out-patient treatment centres; secondly, establishing a network agreement that defines the roles and responsibilities of the role players; thirdly, collectively planning the networking activities and implementation of these plans; and, finally, collaboratively evaluating the impact and effectiveness of the programme. The aforementioned procedures also apply to both the evaluation of the limitations and progress of the treatment programmes, as well as to the evaluation of service delivery of the treatment centres. As it enables the revision of plans that provide individualised services, the continuous reassessment of the limitations and strengths of the networking programme is important. Out-patient treatment centres are considered responsible for initiating the networking programme. Effective collaboration between employers and out-patient treatment centres, as well as quality service delivery by the treatment centres, is regarded as critically important. Ultimately, the networking programme – regarded as a collaborative process between employers, employees and out-patient treatment centres – promotes a partnership geared towards combating the problem of substance abuse in the workplace. The researcher concluded the study with the formulation of a theory regarding the development of a networking programme as its end goal. Also, it is hoped that both out-patient treatment centres and the employment sector (employers and employees) may benefit from it in practice. Eventually, the proposed networking programme was based on the data collected from the situation analysis in this study, the researcher’s experience as a counsellor in substance abuse treatment and her exposure to different networking programmes, as well as supportive theoretical knowledge. A guideline for application of the networking programme in practice is included in the study alongside examples of projects to apply the programme. / PhD (Social Work), North-West University, Potchefstroom Campus, 2014

Professional literature in the past five years regarding the care and treatment of deinstitutionalized chronic mentally ill (CMI) persons has presented growing concerns that services for some CMI persons are inadequate or nonexistent. A number of previous authors have suggested that there may be a consistent, as opposed to a random, bias in the traditional mental health service delivery system whose services are contingent upon client characteristics that, in the very least, assume foresight, independence, initiative, and consistency. Lacking these qualities, clients may not seek services to which they are entitled or they may be frustrated in maintaining those services. This study provides a description of a CMI population (n = 142) that received outreach services from a small county psychiatric hospital. These clients were selected because they were evaluated as severely disturbed, potentially impulsive, and had a history of not following through with traditional mental health services, i.e., they did not make or keep prescribed appointments for therapy or education. This group served as a model against which to compare characteristics of the traditionally engaged clients. Previous authors as well as this study found that the dropout populations were younger, less compliant with prescribed anti-psychotic medication, engaged in more alcohol and drug use, were more likely to live independently and to be rehospitalized with greater frequency. Increased hospitalization also correlated with less functional independent living skills. In other reported research several variables were found to discriminate the younger CMI. This study could only confirm an increase in substance abuse although several confounding factors are discussed. Finally, the outreach program itself was examined, some services were quantified, and some were related to specific client characteristics. For instance, 40 percent of this CMI population was primarily reliant on their outreach worker for all transportation beyond walkable distances; and those clients receiving the most number of outpatient visits were those rated most rejecting of services and those with the poorest independent living skills. The treatment population was found to have reduced their total number of admissions and days hospitalized during the two-year period of investigation.

Abnormal uterine bleeding (AUB) is one of the most common presenting complaints in our medical system with up to 30% of females affected by this condition. The current evaluation and management of AUB often requires multiple lengthy visits to both general practitioners and specialists. Advances in endoscopic technology have allowed clinicians to diagnose and treat women presenting with AUB in a single-visit within an outpatient uterine assessment and treatment unit (UATU). Unfortunately, the UATU is not the standard of care with very few locations in Canada providing this type of service. This thesis project aimed to synthesize data pertaining to efficacy and safety as well as to evaluate the cost-effectiveness of a UATU service model compared to usual care in diagnosing and treating AUB. To address the main aim for this thesis project, the first manuscript focuses on the hysteroscopic procedures that may be offered in a UATU. The manuscript includes a systematic review that synthesizes outcome measures surrounding efficacy, patient safety, and cost data of outpatient hysteroscopy compared to hysteroscopy performed in the operating room. The second manuscript is a cost-effectiveness modelling study that compares cost and effectiveness outcomes, including time to diagnosis and time to treatment of a UATU versus usual care for women who present with AUB. Data used to populate the cost-effectiveness model were obtained from a retrospective review of patient charts and the published literature. The systematic review found no statistically significant difference in the safety, efficacy, or patient tolerability between outpatient and intraoperative hysteroscopy procedures. This review helps provide further support for performing procedures outside of a traditional operating room without increasing patient harm or compromising efficacy. However, given the current available evidence and limited number of studies, findings should be interpreted with caution. The cost-effectiveness analysis found that a UATU is cost-effective when compared to usual care in diagnosing and treating patients who present with AUB. These two studies combined provide evidence to support that the UATU has the potential to improve gynecologic care by reducing wait-times to receiving diagnosis and treatment and to lower overall costs to the health care system.

O emprego da psicoterapia de grupo no atendimento em saúde mental, sobretudo em contextos institucionais, tem se expandido em ritmo acelerado em nossa realidade, não havendo uma expansão correlata de pesquisas na área, conforme aponta a literatura especializada. Esse estudo visa contribuir com o conhecimento sobre essa prática, estudando um grupo de apoio com pacientes psiquiátricos ambulatoriais (16 sessões), em condições naturais, em um serviço de saúde mental de Ribeirão Preto. Objetivou-se compreender as possibilidades e limites dessa intervenção descrevendo o desenvolvimento do grupo através das formas de manejo do coordenador e investigando os fatores terapêuticos presentes no grupo segundo a perspectiva de seus participantes. O grupo foi composto por dez pacientes de ambos os sexos, de 29 a 65 anos, predominantemente casados e com escolaridade de 1o grau incompleto. Com diagnósticos psiquiátricos diversos, tinham indicação prevalente de uso de medicação ansiolítica e/ou antidepressiva. Observação e registro audio-gravado do grupo e Questionário do Incidente Crítico (QIC) constituíram as principais fontes de dados. Consultas aos prontuários dos pacientes e notas de campo também foram realizadas durante o período de coleta de dados. Os dados foram analisados por procedimentos qualitativos e quantitativos. Efetuou-se, com base na transcrição e nos registros de observação das sessões, a descrição da temática e da dinâmica das mesmas. A análise do manejo do grupo foi realizada por procedimentos de análise categorial de conteúdo das intervenções do coordenador (N=1904). A análise das respostas dos pacientes ao QIC (N=112), foi realizada por procedimentos de análise categorial de conteúdo, tendo como base um sistema descritivo dos fatores terapêuticos proposto na literatura. Os dados dos prontuários e as anotações de diário de campo foram utilizados na contextualização dos dados derivados da análise das outras fontes. Os resultados da análise do manejo do grupo nos remetem a oito categorias de intervenção: reiteração (48%); investigação (16%); elucidação (13%); confrontação (11%); enquadre (7%); avaliação (2%); orientação (1%) e fala interrompida (2%). O sistema a priori de categorias de análise do QIC não se mostrou suficiente para a classificação de todas as respostas, levando à criação de novas categorias. Nossos resultados apontam para a presença de dez categorias derivadas da percepção dos pacientes sobre o grupo: universalidade (23%); aprendizagem vicária (22%); distanciamento (13%); desesperança (9%); instilação de esperança (7%); altruísmo (6%); aceitação (5%); auto revelação (4%); orientação (4%) e catarse (3%). Apenas 5% das respostas ao QIC foram não classificáveis. Estes resultados remetem à presença de fatores terapêuticos e não terapêuticos no grupo, tal como vivenciado pelos pacientes. Assim, este estudo possibilita uma compreensão sobre o modo como os pacientes vivenciaram o processo deste grupo – tendo em vista os sentidos que produziram a partir de sua participação neste – e, em conjunção com seus quadros clínicos e com o entendimento sobre o funcionamento do grupo através da descrição de seu manejo, situa algumas possibilidades e limites deste tipo de tratamento, considerando o contexto em que ocorre e a clientela que usualmente o integra. (FAPESP) / The use of group psychotherapy in mental health attendance, specially in institutional contexts, it has been expanding in a accelerated rhythm in our reality, with no correlate expansion of researches in this area, according to the specialized literature. This study aims to contribute with the knowledge about this practice, by studying in natural conditions, a support group with psychiatric outpatients (16 sessions) in a mental health center of Ribeirão Preto. It was objectified to understand the limits and the possibilites of this type of treatment, by describing group’s development through the cordinator’s handling and investigating the therapeutic factors existing on this group according to the participants’perspective. The group was composed by ten patients of both sexes, aging 29 to 65 years old, mainly married and having not complete junior hight school. With several psychiatric diagnoses, they pointed out the principal use of anxiolytics and antidepressant medication. Observation and audio-recorded tapes of the group, and the Critical Incident Questionaire (CIQ) constituted the main sources of data. Consultations to the patients'' files and field notes were also accomplished during the period of data collection. The data were analyzed by qualitative and quantitative procedures. Based on sessions’ transcription it was made the thematic and dynamic description of all the group’meetings. The analysis of the group’s handling was accomplished by procedures of categorial content analysis of the coordinator''s interventions (N=1904). The analysis of the patients’answers to the CIQ (N=112) was also accomplished by procedures of categorial content analysis, based on a descriptive system of the therapeutic factors proposed in the literature. The data origineted from the files and the fields notes were used on the comprehension of the data derived from the analysis of the other sources. The analysis of the cordinator’s handling of the group resulted in eight categories of intervention: reiteration (48%); investigation (16%); elucidation (13%); confrontation (11%); setting rules (7%); evaluation (2%); guideness (1%) and interrupted speach (2%). The descriptive system of the therapeutic factores used on the initial analysis of QIC was not sufficient for classification all the answers, driving us to new categories. Our results point for the presence of ten categories derived from the patients'' perception of the group: universality (23%); vicarious learning (22%); distant (13%); hopeless (9%); instilation of hope (7%); altruism (6%); acceptance (5%); self disclosure (4%); guideness (4%) and catharsis (3%). Just 5% of CIQ‘s answers were not classify. These results show us the presence of therapeutic and non therapeutic factors in the group, according to the patients’perspective. Thus, this study contribute to an understanding about the way patients lived the process of this group according to the meanings produced by them after the group’sessions and, in conjunction with their clinical condition and with the understanding of the group development through the description of the cordinator’handling, it shows some possibilities and some limits of this type of treatment, considering the context where it happens and the patients that usually compose those types of groups. (FAPESP)

Estudo descritivo, exploratório, tipo corte transversal com 178 pacientes em uso de anticoagulação oral em seguimento ambulatorial com os objetivos de: caracterizar os pacientes em uso de terapia de anticoagulação oral (TAO) segundo variáveis sóciodemográficas, clínicas e relacionadas à TAO; analisar a associação entre qualidade de vida relacionada à saúde com a idade e o sexo dos pacientes; analisar a associação entre qualidade de vida relacionada à saúde com o tempo de uso do anticoagulante oral (ACO), presença de complicações e indicação da TAO; analisar a associação entre a presença de complicações pelo uso de ACO com a presença de orientações prévias recebidas pelos pacientes. Os dados foram coletados por meio de entrevistas individuais e consulta aos prontuários dos pacientes, sendo a qualidade de vida relacionada à saúde, avaliada pelo instrumento SF-36. Os dados foram analisados por meio de estatística descritiva, teste t student, ANOVA e teste Exato de Fisher. Verificamos que a maioria dos pacientes era do sexo feminino; com idade média de 55,6 anos; aposentados (36,9%); com o primeiro grau incompleto (71,1%); renda familiar média de 896,3 reais; casados (65,2%); e procedentes de outras cidades do Estado de São Paulo (83,2%). As principais indicações para o uso de ACO foram uso de prótese cardíaca metálica (50,6%) e fibrilação atrial (33,1%). A maioria (83,0%) fazia uso da varfarina e a dose média dos ACOs foi 31,1 mg/semana, com o tempo médio de uso de 7 anos e valor médio do INR de 2,4 (de 0,5 a 6,8). A presença de complicações foi relatada por 74 participantes, sendo a maioria do tipo hemorrágica (94,6%) e que resultaram em 28 internações. A associação entre QVRS e a idade foi constatada nos domínios Capacidade funcional (p=0,017) e Dor (p=0,041) e com o sexo foi verificada nos domínios Saúde Mental (p=0,005) e Dor (p=0,020). Observamos que a avaliação dos pacientes na maioria dos domínios da QVRS foi melhor entre pacientes em tratamento a longo prazo (acima de 10 anos de uso do ACO). Mas, constatamos diferenças estatisticamente significantes entre os grupos apenas nos domínios Capacidade Funcional (p=0,000), Aspectos físicos (p=0,044) e Estado geral de saúde (p=0,044). Não confirmamos a associação da QVRS com a presença de complicações, mas constatamos essa associação quando analisamos indicação de ACO, sendo as diferenças estatisticamente significantes entre os grupos nos domínios Aspectos Físicos (p=0,028) e Capacidade Funcional (p=0,029). Outra associação verificada foi entre a presença de complicações pelo ACO e informações prévias recebidas pelos pacientes (p= 0,045). Avaliar a qualidade de vida relacionada à saúde e sua associação com variáveis sócio demográficas e clínicas nos possibilitou identificar aspectos importantes a serem considerados no planejamento da assistência dos pacientes em uso de anticoagulantes orais. / This descriptive and exploratory study, of transversal type, with 178 patients using oral anticoagulant in outpatient segment, aims at characterizing the patients undergoing oral anticoagulation therapy (OAT) according to sociodemographic and clinical variables and variables related to OAT. It also aims at analyzing the association between the quality of life related to health (QLRH) and the patients age and gender; the association between QLRH to the time of use of oral anticoagulant (OAC), OAT complications and indications; the association between complications with the use of OAC and previous orientations given by the patients. Data have been collected through individual interviews with the patients and consultations to their medical records. The QLRH has been evaluated with the instrument SF- 36. Data were assessed through descriptive statistical analysis, Students t-Test, ANOVA and Fishers Exact Test. It has been found that most patients were females; with average age of 55,6 years old; retired (36,9%); with first degree incomplete (71,1%); average family income of 896,3 reais; married (65,2%) and coming from other cities within the state of São Paulo (83,2%). OACs main indications were the use of metallic cardiac prosthesis (50,6%) and atrial fibrillation (33,1%). Most patients were in use of warfarin and the average dose of the OACs was 33,6 mg/week and an average time of use of 7 years and average value of INR of 2,4 (from 0,5 to 6,8). Complications have been reported by 74 patients, mostly of hemorrhage type (94,6%) resulting in 28 inpatient services. The association between QLRH and age was found in Functional Capacity (p=0,017) and Pain (p=0,041) and the association between QLRH and gender was found in Mental Health (p=0,005) and Pain (p=0,020). It has been observed that the patients evaluation in most domains of QLRH was better among those undergoing long-term treatment (over 10 years of OAC use). However, statistically significant differences have been found among the groups only in the Functional Capacity (p=0,000), Physical Aspects (p=0,044) and General Health State (p=0,044) domains. An association between QLRH and complications have not been found, but such an association has been found when analyzing the indication of OAC, having statistically significant differences among the groups in the following domains: Physical Aspects (p=0,028) and Functional Capacity (p=0,029). Another association found was complications due to the use of OAC and previous information given by the patients (p= 0,045). Evaluating the quality of life related to health and its association to sociodemographic and clinical variables enabled this study to identify important aspects that shall be stressed when planning medical assistance to patients in use of oral anticoagulant.

Two related program evaluations of the mental health system in Puerto Rico are conducted. Initially, research is carried out in two state psychiatric hospitals involving an organizational analysis of relevant systems variables as they impinge upon effective institutional functioning. In this scheme hospital effectiveness is predicted by success in achieving formally prescribed goals and in the adequacy of resource utilization. The basic assumption is that the psychiatric hospital reflects the patterning of reciprocal and interdependent behaviors of individuals which form a larger all-important pattern. The hospitals are studied by means of a questionnaire administered to staff to ascertain perceptions of the work environment, communication and coordination processes, overall hospital organization, and the treatment environment. The results of organizational functioning are presented in a profile analysis plotting institutional means over ten functional dimensions. Individual component variables are converted into standard scores and broken down by staff sub-groups. Each institution and staff sub-group differs uniquely across the dimensions. Overall the results point to excessive staff frustration and disillusionment with the organization's functions, and a treatment environment limited in patient autonomy, socio-emotional interaction, and therapeutic content. The complementary study of first releases from these hospitals examines background and performance characteristics of a sample of patients in an effort to distinguish those who complied with aftercare referrals from those who did not, and those who were readmitted from those still in the community one year after release. Bivariate analysis of the relationship between each of the two dependent variables and the several demographic and treatment variables at each hospital reveals that the strongest differentiation of compliers from non-compliers is having been active in pre-hospital outpatient care, while the extent of use of aftercare was the strongest predictor of remaining in the community. Implications for policy and for further research in mental health service delivery are discussed.

Introdução: A varfarina é um dos anticoagulantes orais (ACO) mais utilizados na atenção primária a saúde. Com janela terapêutica estreita, exibe grande variabilidade de resposta farmacológica, e maior suscetibilidade de eventos adversos, como sangramentos e tromboembolismo venoso. Entre os fatores que influenciam na variabilidade de dose destaca-se as interações tanto com medicamentos, como com a dieta e o polimorfismo genético. Objetivos: Estimar a incidência de eventos adversos relacionados ao uso de varfarina e descrever o itinerário do usuário pelo sistema público de saúde para resolução dos problemas. Métodos: trata-se de uma coorte prospectiva realizada por um período de 18 meses com usuários do serviço público de saúde, em uso de varfarina, do município de Ijuí/RS. Os dados foram coletados por entrevistas mensais nas residências e complementados com informações médicas obtidas na atenção primária e terciária. As interações medicamentosas foram checadas em bases de dados e os hábitos alimentares conforme metodologia validada. A estatística utilizada para associar sangramento e Time in Therapeutic Range (TTR) e os fatores de risco foi teste de Poison. O projeto foi aprovado no Comitê de Ética em Pesquisa da UFRGS, com parecer número 336.259/2013. Resultados: Foram entrevistados e acompanhados 69 pacientes, sendo que 64 concluíram o acompanhamento e 5 faleceram durante o estudo, 55,1% eram do sexo feminino, com idade média de 64,3 ±13,7 anos. O tempo médio de uso de varfarina foi de 5,5 anos, a dose média semanal foi de 30,69±15,19mg e o principal motivo para uso de varfarina foi prótese valvular (39,7%). A média de medicamentos utilizados por usuário foi de 9,6±4,5. Quanto aos eventos, os sangramentos tiveram incidência de 37,7/100 pacientes/ano, o tromboembolismo de 4,8/100 pacientes/ano e de óbitos de 4,8/100 pacientes/ano. Os sangramentos apresentaram associação com possuir mais que três interações medicamentosas com a varfarina (p=0,048) e com uso de medicamentos por automedicação (p=0,030). Já para o TTR houve associação com a idade inferior a 65 anos (p=0,032). E 67 usuários estavam suscetíveis a interações medicamentosasas com varfarina, com predomínio das moderadas, sendo a média de interações com este medicamento de 2,91±1,52. A maioria das interações agiam sobre o efeito anticoagulante da varfarina, aumentando a probabilidade de sangramento. Entre as interações que os usuários apresentavam, no momento do sangramento, as mais frequentes foram com: omeprazol, sinvastatina e paracetamol. A maioria dos entrevistados apresentou consumo baixo de vitamina K. Verificou-se que sangramentos e tromboembolismos venosos foram mais frequentes nos pacientes em início de tratamento. E todos os pacientes que foram a óbito durante o acompanhamento (5) eram pacientes com mais de um ano de uso de varfarina. Para a resolução de eventos adversos na maioria dos casos o paciente realizou cuidado domiciliar (53,4%), seguido por busca pela Unidades Básicas de Saúde, 7 pacientes buscaram o serviço de emergência e 5 realizaram internação hospitalar. Observou-se que aproximadamente metade dos pacientes não mostrou seus exames de INR (Razão Normalizada Internacional) ao médico. E na falta de varfarina na rede pública de saúde do município, que ocorreu entre os meses 13 e 16, entre 24,9 a 43,5%, deixaram de usar o medicamento. Os resultados do polimorfismo demonstram que 47 (71,2%) não apresentam polimorfismo ao genótipo CYP2C9, e 24 (36,4%) ao genótipo VKORC1. Avaliando os dois genótipos associados, verifica-se que 17 (25,8%) não apresentam polimorfismo a nenhum destes. Não foi observada associação estatística do polimorfismo com sexo e raça. Observou-se diferença significativa entre a dose utilizada para os diferentes polimorfismos (p=0,013). Da mesma forma, para o VKORC1, houve diferença significativa entre a dose e o genótipo (p=0,018). Conclusão: Estes resultados demonstram a necessidade de uma maior assistência a estes pacientes, buscando melhores resultados clínicos, com menos eventos adversos. / Introduction: Warfarin is an oral anticoagulant (OAC) most used in primary health care. With narrow therapeutic window, shows great variability in drug response, and greater susceptibility to adverse events such as bleeding and venous thromboembolism. Among the factors that influence the amount of variability highlights the interactions with both drugs, as with diet and genetic polymorphism. Objectives: To estimate the incidence of adverse events related to warfarin use and describe the user journey through the public health system to the problems. Methods: This is a prospective cohort study conducted over a period of 18 months with users of the public health service in the use of warfarin, the city of Ijuí/RS. The data were collected monthly interviews in homes and complemented with medical information obtained in primary and tertiary care. Drug interactions were checked in databases and eating habits as validated methodology. The statistics used to associate bleeding and Time in Therapeutic Range (TTR) and the risk factors was Poison test. The project was approved by the Research Ethics Committee of UFRGS, with opinion number 336259/2013. Results: We interviewed and followed 69 patients, 64 completed the follow-up and 5 died during the study, 55.1% were female, mean age 64.3 ± 13.7 years. The mean duration of warfarin use was 5.5 years, the average weekly dose was 30.69 ± 15,19mg and the main reason for warfarin use was valvular prosthesis (39.7%). The average per user used medications was 9.6 ± 4.5. As for events, the bleeding had incidence of 37.7 / 100 patients / year, thromboembolism of 4.8 / 100 patients / year and deaths of 4.8 / 100 patients / year. Bleeds were associated with having more than three drug interactions with warfarin (p = 0.048) and use of self-medication by drugs (p = 0.030). As for the TTR was no association with age less than 65 years (p = 0.032). And 67 users were susceptible to medicamentosasas interactions with warfarin, with a predominance of moderate, with an average of interactions with this drug of 2.91 ± 1.52. Most interactions acting on the anticoagulant effect of warfarin, increasing the probability of bleeding. Among the interactions that users had, at the time of bleeding, the most common were with: omeprazole, simvastatin and acetaminophen. Most respondents showed low consumption of vitamin K. It was found that bleeding and venous thromboembolism were more frequent in patients starting treatment. And all patients who died during follow-up (5) were patients with more than one year of warfarin use. For adverse event resolution in most cases the patient underwent home care (53.4%), followed by search for the Basic Health Units, 7 patients sought emergency services and 5 held hospitalization. It was observed that approximately half of the patients showed their INR test (International Normalized Ratio) to the doctor. And in the absence of warfarin in public municipal health, which occurred between the months 13:16, from 24.9 to 43.5% stopped using the drug. The polymorphism results demonstrate that 47 (71.2%) did not have the polymorphism CYP2C9 genotype, and 24 (36.4%) the VKORC1 genotype. Evaluating the two genotypes associated, it is found that 17 (25.8%) did not show any polymorphism thereof. There was no statistical association of the polymorphism with gender and race. A significant difference between the dose for different polymorphisms (p = 0.013). Likewise, for the VKORC1, a significant difference between the dose and genotype (p = 0.018). Conclusion: These results demonstrate the need for further assistance to these patients, looking for better clinical outcomes, with fewer adverse events.

Magister Artium (Psychology) - MA(Psych) / Substance use is a worldwide health concern that has received significant attention as it is often related to deleterious outcomes. Various treatment programmes have been made available to assist people and their families who misuse substances, to aid rehabilitation and equip people with the necessary tools with the aim of preventing possible relapse. The Western Cape Province has been identified as experiencing the highest increase of substance use, with Cape Town being disproportionately affected. Substance use treatment and prevention programmes are therefore an increasingly important means of addressing substance use and related harms. This study aimed to explore the lived experiences of individuals in relation to the treatment they received at a treatment facility in the Cape Town area. As such, the researcher made use of the phenomenological approach as a theoretical framework as it aims to describe the lived experiences of individuals in relation to a particular phenomenon. Furthermore, a qualitative methodological framework was utilised to explore the experiences of individuals who received substance use treatment. Ten participants were purposively selected from an outpatient substance use treatment facility in Cape Town. Focus group discussions were used to collect data and the data were analysed using Interpretive Phenomenological Analysis (IPA). Findings suggest that there were various reasons participants sought treatment. This includes the challenges they experienced in both their personal and occupational lives as well as the realization of the negative effects substance use had on them physiologically. Findings also revealed that the environmental setting individuals were in fostered their treatment; the various aspects of the programme provided by the treatment facility had a significant contribution to their recovery and improved relationships with others; receiving support from family and friends were important in service providers treatment retention as well as individuals ability to identify the changes within themselves since receiving treatment. Overall, results indicate that the treatment programme helped participants in their recovery and enhanced personal relationships, self-perception as well as personal and occupational growth. Findings suggest that there are various reasons as to why people seek treatment and although this may differ, the treatment modality they were provided with contributed substantially to their recovery. Furthermore, this study will contribute to the literature and understanding the ways in which treatment fosters recovery, personal growth and relationships.