Objective: The prevalence of childhood overweight and obesity in southern Appalachia is among the highest in the United States (US). Primary care providers are in a unique position to address the problem; however, little is known about attitudes and practices in these settings. Methods: A 61-item healthcare provider questionnaire assessing current practices, attitudes, perceived barriers, and skill levels in managing childhood overweight and obesity was distributed to physicians in four primary care clinics. Questionnaires were obtained from 36 physicians. Results: Physicians' practices to address childhood overweight and obesity were limited, despite the fact that most physicians shared the attitude that childhood overweight and obesity need attention. While 71% of physicians reported talking about eating and physical activity habits with parents of overweight or obese children, only 19% reported giving these parents the tools they needed to make changes. Approximately 42% determined the parents' readiness to make small changes for their overweight or obese children. Physicians' self-perceived skill level in managing childhood overweight and obesity was found to be a key factor for childhood overweight- and obesity- related practices. Conclusion: Primary care physicians in southern Appalachia currently play a limited role in the prevention or intervention of childhood overweight and obesity. Training physicians to improve their skills in managing childhood overweight and obesity may lead to an improvement in practice.

This thesis is concerned with changes over time in the social characteristics of doctors who have entered prepaid group health plans. It focuses on the past social positions which these doctors have occupied and on their status, or rank. The general expectation is that both the rank and positions occupied by doctors prior to entering prepaid group plans have varied as the prestige of these plans has varied. The entrance of physicians into prepaid group health plans was conceptualized as mobility between different contexts of work. Blau’s exchange theory of mobility proved to be the most fruitful source of hypotheses for this study. Blau states that extrinsic rewards are the major incentives for mobility and that intrinsic rewards interact with extrinsic rewards in influencing mobility. From these basic propositions two hypotheses were generated: 1) As the status of prepaid group health plans increases, the status of physicians entering these plans will increase. 2) As the status of prepaid group health plans increases, high status recruits will less frequently come from positions offering intrinsic rewards similar to those found in prepaid group plans. The design of this research was a longitudinal case study. Data were obtained relevant to one prepaid group health plan, the Portland Kaiser Foundation Health Plan. The universe included all physicians who had practiced as full-time, salaried staff in Kaiser at any time since 1945 when Kaiser was first opened to the public. Indicators were obtained from various sources of data. The Kaiser personnel records provided data on physicians’ social characteristics. Data on the status of Kaiser came from an official salary schedule and records of personnel advertisements. Informants were used to rank medical schools and the AMA’s Directory of Approved Internships and Residencies provided a ranking of teaching hospitals. The evidence for the first hypothesis was generally negative. The data indicated that although the status of Kaiser had increased over the years, the status of physicians entering Kaiser had decreased. This conclusion was reached on the basis of findings using prestige of medical school as an indicator for physicians’ achieved status as well as findings using nationality and length of practice as indicators for their ascribed status. Thus, the first hypothesis of this study had to be rejected. The evidence for the second hypothesis was inconclusive: it indicated that as the status of Kaiser increased, the percentage of high status recruits from certain positions with intrinsic rewards similar to Kaiser’s decreased, whereas the percentage from other positions increased. High status physicians have less frequently entered Kaiser a) having held positions emphasizing the scientific aspects of care, b) having memberships in scientific or specialty societies, c) having changed the location of their practice, and d) having changed their specialty. They have more frequently entered Kaiser a) having had postgraduate training b )having had at least five years of training, c) having held jobs in bureaucratic contexts, d) having graduated from medical schools in the North Central and Western states, and e) having engaged in two of more different types of activities. In sum, it was unclear whether the second hypothesis should be accepted or rejected.

Background: The United States has one of the lowest rates of breastfeeding in the world. Studies hypothesize that inadequate social support from healthcare providers, family members, and employers may have contributed to the low breastfeeding rate. This study aims to: 1) examine the importance of each individual (father, maternal grandmother, paternal grandmother, obstetrician, and pediatrician) within the social support network on breastfeeding initiation and duration, 2) determine the relationship between type of prenatal care provider and time to breastfeeding cessation, and 3) examine the role of breastfeeding intention and confidence as mediators in the association between workplace support and breastfeeding duration Methods: This study analyzed data from the Infant Feeding Practices Survey II. Breastfeeding duration was reported as number of weeks. Breastfeeding initiation was dichotomized (yes; no). Logistic regression was used to investigate breastfeeding initiation. Cox proportional hazards models was utilized to assess the relationship between social support and breastfeeding duration. Structural equation modeling was used to determine the role of mediators in the association between workplace support and breastfeeding duration. Results: Mothers whose prenatal care was provided by a midwife were more likely to initiate breastfeeding and breastfeed for a longer duration. The relationship between workplace support and breastfeeding duration is mediated by a mother’s confidence in attaining breastfeeding goals. Lastly, this study found that multiple individuals within a mother’s social support network are important for breastfeeding initiation and duration. Conclusion: This project shed light into various components of social support that are integral to mother’s breastfeeding behaviors.

Some managers of primary care provider (PCP) facilities lack the strategies to implement electronic health records (EHRs), which could decrease healthcare costs and enhance the efficiency and quality of healthcare that patients receive. The purpose of this single-case study was to explore the strategies PCP managers used to implement EHRs to decrease healthcare costs. The population consisted of 5 primary care managers with responsibility for the administration, oversight, and direct working knowledge of EHRs in Central Florida. The conceptual framework was the technology acceptance model. Data were collected from semistructured face-to-face interviews and the review of company documents, including training logs, activity records, and cost information. Methodological triangulation was used to validate the creditability and interpretation of the data in transcribing themes. Three themes emerged from the analysis of study data: implementation of EHRs, costs of implementing EHRs, and perceived usefulness of EHRs. Participants indicated that the implementation of EHRs depended on motivation, financial cost, and the usefulness of EHRs relating to training that reflected user-friendliness. The implications of this study for social change include the potential to lower the cost and improve the efficiency of healthcare for patients. The use of EHR systems could enhance the quality of care delivered to patients through improved accessibility, elimination of duplicative tests, and retrieval of accurate patient information. The use of EHRs can lead to a comprehensive preventative healthcare system resulting in a healthier environment.

This study examined the potential significant differences in the distribution of adverse drug reactions (ADRs) by reporter (consumer versus physician) and patient outcome at case and event level. This study also contains exploratory questions to evaluate reporting of ADRs by consumers versus physician by system organ class (SOC) and reporter demographics within the United States Food & Drug Administration Adverse Event Reporting System (FAERS). The theoretical foundation applied in this quantitative study was the social amplification of risk framework. Data from the second quarter of 2016 were obtained from FAERS, and a total of 87,807 ADR reports corresponding to 143,399 ADRs were analyzed by utilizing the chi-square test, the odds ratio, and logistic regression. Cross-sectional design was employed to compare reporting of ADRs at the case and event level (case-based and event-based analyses, respectively) between reporters (consumer versus physician), specifically, for patient outcome, as well as SOC and reporter demographics. For both the case-based and event-based analyses, findings revealed that consumers reported more serious ADRs in comparison to physicians. Furthermore, findings confirmed a difference in ADR reporting between consumers and physicians depending on SOC groups. Additionally, consumers reported more nonserious ADRs in comparison to physicians. The results from this study may have implications for positive social change by augmenting pharmacovigilance systems at a national and international level to identify risks and risk factors spontaneously reported after drugs have been on the market.

The profession of physicians' assistant was introduced in the 1960s to assist with physician shortages in the United States of America. Since then, some countries have introduced this profession to fill the gaps that exist in the physician shortages problem in their health care system. Yet, in many countries like Trinidad and Tobago, this role remains absent from the health care system. The objective of this study was to assess how professionalization supports the introduction of the physicians' assistant role in Trinidad and Tobago. Using the theory of profession as a theoretical framework, and through an evaluation of institutional, regulatory, and cultural norms and barriers associated with the health care system of Trinidad and Tobago, the role of jurisdiction, societal factors, professional competition, and legitimization was assessed using a qualitative, ethnographic design, with 22 participants. The data collection tools included a questionnaire and structured interview and content analysis of relevant documents to yield the data from which conclusions may be drawn. The results showed that jurisdiction, societal changes, interprofessional competition and legitimization can all influence the introduction of physicians' assistants. Evidence from this research may provide health care administrators with important information to assess the feasibility of the introduction of this vital role to improve patient care on the islands.

Thesis (MBA) --University of Limpopo, 2007 / If medical doctors are expected to function effectively and efficiently to provide the highest quality of care to the largest number of patients in rural hospitals, it is imperative that they derive job satisfaction from their work and thus perform well. The present study aimed to investigate whether the doctors in the target population have job satisfaction. The doctors were selected from the rural hospitals of the Waterberg District of the Limpopo Province. An exploratory qualitative research design was used, which included a self administered questionnaire enquiring about the demographic and work situation variables. Content analysis was used to analyse qualitative data. The main findings that emerged from the study were that the respondents were dissatisfied with their work environment. The most common theme that emerged was related to the bad working conditions, lack of support from management, lack of proper equipment, and the salary or incentives in proportion to the workload. These findings highlighted the issues that can be addressed by the employing organisation.

acase@tulane.edu

Background: Dissemination of evidence-based mental health clinical practice guidelines had not been studied in Australia prior to the National General Practice Guideline Implementation Program. This naturalistic research reports ten national interventions designed to disseminate the NHMRC 1997 Clinical Practice Guideline Depression in Young People for GPs (GDIYP-GP) through 123 Divisions of General Practice. The guideline covered depression and suicide in young people aged 13 to 20 years. Aim: To evaluate a 'coordinated link agent' and 'enhanced packaged approach' for disseminating a national guideline by engaging 20 Divisions in using 5 dissemination models and to measure Divisions' capacities in performing unfunded local dissemination to GPs. Method: An Implementation Kit was the main national intervention, housing the guidelines and 5 models: Education by the Division; Education by an external provider; 3) Clinical Audit; 4) Segmented Formats and 5) Appraisal. Five studies are reported: 1) an organisational census on guideline-related practices in all topics; 2) a Case Study Database of 3 consecutive interviews of 51 participating Divisions; 3) a Guideline Appraisal study of 9 cohorts of doctors; 4) a Clinical Audit study of 54 doctors involving 1200 patients; and 5) a 'Segmented Formats' documentary analysis of Division communications on GDIYP-GP. Results: Prior dissemination by most Divisions was administrative mail outs rather than planned programs. In all, 70 instead of the pilot 20 organisations participated (57% of the sector) using 10,000 guidelines: 45 participated by 7 weeks and 71 by 35 weeks and the majority used multiple active strategies showing fidelity to the Kit. Education by the Division, Segmented Formats and Appraisal were the most adopted models. GDIYP-GP was acceptable and relevant to the majority of Divisions and to 9 samples of doctors. Conclusion: Divisions are one appropriate system through which evidence-based mental health guidelines can be disseminated to general practitioners. Uptake can be rapid using a flexible enhanced package approach with link-agent support. 3-6 months is needed for organisations to begin effective interventions. Divisions reorient their approach with guidance toward evidence-based dissemination but Division and practice barriers

The provision of medical care to top-level athletes in New Zealand comes with a number of challenging ethical issues. Some of these arise out of the commercial interest present in sport that links sporting success with funding, sponsorship deals and media interest. The requirement that athletes stay at peak physical function in order to be successful can, at times, be at odds with concepts of well-being and good health. The employment structure under which doctors are engaged by teams and the employment contracts which define these relationships can be the source of divided loyalty for doctors. For example, sharing health information beyond the doctor-athlete relationship may be in line with contractual obligations, but at odds with what the athlete requests. Divided loyalties also exist when athletes wish to participate in sport despite high risk of harm. Here there is a difference between what the doctor understands as the athlete�s best interest, and the athlete�s consideration of best interest. This thesis adopts two strategies for examining the area of sports medicine in elite athletes in New Zealand. The first section utilizes qualitative research. Sixteen sports doctors were interviewed and the data analysed. The next section involves normative reflection. Here two issues (where a range of behaviours were exhibited by participants) selected from the data are considered and discussion is presented on how doctors should respond to these issues. An examination of the level of guidance offered to sports doctors from the Australasian College of Sports Physician�s Code of Ethics follows. The level of guidance offered is considered inadequate and the thesis ends with a call to attend to these concerns.