Background: Youth and young adults have the highest incidence and prevalence of mental health issues, and most do not receive the services they need. Mental health is an essential component of wellness, and primary care providers (PCPs) serve a critical role in promoting mental well-being, identifying problems, facilitating and coordinating services, and managing and monitoring mental health outcomes. Many barriers exist to incorporating mental health into routine primary care for adolescents, and little is known about the specific nature of the obstacles that impede the quality improvement process related to integrating mental and physical health and how to overcome them. Objectives: The purpose of this DNP project was to gain insight into the PCP role, exploring perceptions, current practices, and barriers related to screening, identifying, and managing adolescent mental health needs, understand the challenges and opportunities, and guide future quality improvement projects that reflect and respond to the needs of adolescents in the local community in effective and sustainable ways. Methods: The project was designed as a needs assessment, and conducted as an anonymous 20 question survey that was distributed to 13 local PCPs that routinely provide primary care services to the community’s adolescent population. Results: Nine of the surveys were completed and returned. Time constraints and competing demands were dominant concepts, reported as primary barriers to screening, collaboration with mental health professionals, and addressing mental health in general. The participants articulated the need for high-quality professional mental health involvement, improved collaboration, inter-professional development, and inter-agency cooperation to successfully promote mental health and provide excellent care that improves outcomes. They also displayed an interest in innovative solutions and organizational restructuring to better coordinate mental health services. Conclusion: This project offered preliminary insight into the challenges faced by PCPs addressing adolescent mental health in primary care, and generated ideas for further exploration to guide quality improvement initiatives designed to support the providers' capacity to incorporate mental health into routine care, and contribute to the community’s efforts in promoting mental health for local youth. PCPs occupy esteemed roles in the community, and their perspectives and insight are invaluable.

Education is a key component of empowerment and has a significant impact on the economic and social development in any country. People who have intellectual disabilities are usually marginalized because they are considered limited in their abilities to contribute to the enhancement of the social and economic development in a country. The purpose of the research study was explore the perceptions of teachers and primary care-givers regarding strategies for empowering children with intellectual disabilities. The research design was qualitative in nature and a phenomenological methodology was adopted. Purposive sampling was used to recruit research participants from two primary schools for children with special needs in Katlehong on the East Rand. The sample size was twenty research participants; ten teachers and ten primary care-givers. The data gathered was analysed using Thematic Content Analysis. Results indicated that both teachers and primary care-givers are experiencing challenges empowering these children. Teachers require support, equipment and training to develop skills needed to address the educational needs. Primary care-givers need to be educated regarding how to support the educational programmes presented to their children, and encouraged to become personally involved in the educational lives of their children. The conclusion reached is that teachers’ efforts to empower children with intellectual disabilities are being obstructed due to many factors. Their voices need to be heard by the Department of Education on what strategies they perceive as being effective to empower children with intellectual disabilities. The primary care-givers need to gain a better understanding of concept ‘intellectual disability’ so that they can stimulate and support efforts made by the school to empower them.

It is well documented that some populations experience higher rates of certain diseases. While researchers have explored factors contributing to health disparities, attention has turned to the influence of social factors. For instance, stereotype threat has recently been applied to the health care setting in order to explain growing health disparities (e.g., Aronson et al., 2013). Health care stereotype threat (HCST) may arise when patients become aware that a negative health stereotype exists about a group or groups with which they identify, thus negatively impacting their utilization of health care services. Furthermore, patients with multiple marginalized identities have unique experiences of stereotyping and discrimination within the health care system. The purpose of the current study is to address Abdou et al.’s (2016) recommendation that researchers examine health care stereotype threat among individuals with multiple marginalized identities. The present study identified patients with a chronic illness and multiple marginalized identities including: (a) identifying as Black, (b) being considered overweight by medical community, and/or (c) identifying as Lesbian, Gay, Bisexual, and Transgender (LGBT). These identities were chosen based on research indicating that physicians hold implicit bias attitudes towards and stereotypes about these groups (e.g., Blair et al., 2013; Chapman et al., 2001; Sabin et al., 2009). I utilized qualitative research methodology to contextualize patients’ experiences of stereotyping in a health setting. In person, semi-structured interviews were conducted with eight patients. During the interview process, four major categories and 22 sub-level categories emerged. Grounded theory methodology (Corbin & Strauss, 2008) was used to analyze the data. The results of the study revealed a complex relationship between negative experiences with a provider (i.e., dismissive communication and perceived stereotyping) and health care utilization. Patients’ negative experiences with providers made it more difficult for patients to continue engaging in care. Systemic barriers as well as level of coping and social support influenced patients’ perception of stereotyping and discrimination. Level of support from other providers and use of coping skills also determined the extent to which patients continued to utilize available health care in the face of discrimination. Implications for future research and clinical practice are delineated.

The demands for high quality primary care have become strained by a deficit in the primary care physician supply and the complexity of delivering care to aging populations that are often living with complex co-morbidities. Provider co-management has emerged in practice to help alleviate some of the care delivery demands by having more than primary care provider (PCP) complete care management tasks for the same patient. There is extensive literature investigating two physicians co-managing patient care, and physician-physician assistant co-management, yet limited studies have investigated nurse practitioner (NP)-physician co-management. NPs currently are the fastest growing health care workforce in the United States. Several organizations support the expanded utilization of NPs in primary care. As more U.S. states are granting NPs independent scope of practice, which is free of physician oversight, the potential for NPs to co-manage patients with physicians, and alleviate some of the primary care strain, has increased. However, there are limited to no studies that have investigated NP-physician co-management in primary care. Further, there is a lack of evidence of PCP perspectives about co-managing care, its impact on patient and practice outcomes, or a tool to measure NP-physician co-management in practice or research. More evidence about NP-physician co-management is warranted and will be investigated in this dissertation. The purpose of this dissertation is to investigate NP-physician co-management in primary care by synthesizing the existing evidence, gathering data from PCPs about NP-physician co-management and to develop a valid and reliable tool to measure it. In Chapter 1, background of the current demands on primary care is presented and accompanied by a discussion about the need to expand the NP workforce in primary care to help meet the demand. Evidence about the history of provider co-management is presented and gaps in the literature are identified. Specific aims of the dissertation are introduced and tied to existing theoretical underpinnings. In Chapter 2, aim one of the dissertation is addressed by qualitatively obtaining data on the PCP perspective of NP-physician co-management. In Chapter 3, aim two of the dissertation is addressed. A systematic review of the literature was conducted to determine the effects of NP-physician co-management compared to a single physician delivering care. In Chapter 4, aim three is addressed. Based on the collective findings of Aim 1 and Aim 2, a new tool is developed and psychometrically tested to measure NP-physician co-management. Content validity and reliability testing of the tool is conducted. In Chapter 5, the results of the dissertation are synthesized. Practice, policy, and research implications are discussed, and strengths and limitations of the dissertation are presented.

Prescribing accounts for 11% of the total NHS budget. In the UK, there is an aging population who receive nearly half of all prescriptions, with the increasing age of the population, the prevalence of long-term conditions, cost and complexity of prescribing is likely to rise. Prescribing is influenced by numerous factors such as new drugs; aging populations; polypharmacy; and increased concern about adverse reactions. Although numerous initiatives are targeted at general practitioners to encourage application of research evidence the significant variation in prescribing quality and cost is difficult to explain. Previous studies have explored the influences of type of drug, focused clinical area, guidelines and the doctor/patient relationship. No study was found which has explored the details of the prescribing process using the ethnographic approach. This ethnographic study of three different general practices, involved participant observation, documentary review and semi-structured interviews. Analysis was an iterative process conducted in Atlas.ti by borrowing on grounded theory techniques and interpretative description. Practices were selected using prescribing quality indicators developed by Audit Scotland via PRISMS (Prescribing Information System for Scotland), which collects prescribing data for all practices in Scotland. Two practices which were ranked highly and one practice which was ranked low were observed. Practices made two different kinds of prescribing decision; macro and micro. Macro prescribing decisions are strategic, influenced by EBM and practice data, and consider the „average patient?. Micro prescribing decisions are made with an individual patient, considering their unique biology, context and perspectives. Practice pharmacists were instrumental in leading prescribing quality improvement in the larger practices and had an important role interpreting practice level data in light of the changing evidence. In the high ranking practices these changes were formulated into macro prescribing policy to rationalise and standardise their prescribing. The lower ranking practice suggested practices had to value collective decision-making and consistency in their prescribing behaviour to formulate a macro prescribing policy. Consistency in prescribing behaviour was facilitated by effective communication, which was important for shared values and practice identity. Practice identity influenced practice values, communication and organisation thus had a direct impact on their macro prescribing policy formulation and implementation. GPs used mindlines when making prescribing decisions at the micro prescribing level. GPs did not refer to explicit sources when seeking information but used personal prescribing formularies. These mindlines were iteratively developed from social networks with colleagues, secondary care and patient specific information from the practice pharmacist and from past experience. Through effective communication with colleagues these mindlines were shared.In conclusion, practices made two different kinds of prescribing decision; macro and micro. Both types of prescribing were dependent on effective communication channels, organisation, values and practice identity, illustrating the importance of communication for shared values, collective behaviour and prescribing decision-making.

Diabetes mellitus is a common chronic disease that affects approximately 382.8 million people worldwide. Globally, the Kingdom of Saudi Arabia (KSA) has the seventh highest prevalence of diabetes, with over one-fifth of the Saudi population diagnosed with diabetes. Poor understanding and low health awareness, in parallel with lifestyle choices are considered the main components behind the increase of diabetes and diabetes-related complications in KSA. There is also a lack of diabetes speciality centres, especially in remote areas of KAS. Moreover, diabetes management becomes more complicated during the Ramadan month because people observe fasting throughout the month. The month long fasting process complicates the disease status of Saudi diabetic patients with potential complications post the fasting period. In this thesis, we present the design and development of a novel and intelligent mobile diabetes management system tailored for type 2 diabetic (T2D) patients in Saudi Arabia with the focus on the integration of educational and compliance issues, which we name as the SAED system. The system was validated in two preliminary pilots in the Kingdom, one pilot being specifically dsigned to evaluate the system for diabetic patient during Ramadan fasting month. The outcomes of the clinical pilot indicated the clear effectiveness of the SAED system in lowering the HbA1c levels. The system was tested for its performance through a randomized control trial on 20 diabetic patients for a period of six months in Kingdom of Saudi Arabia. The outcomes of the pilot study showed improvements in the HbA1c levels of patients and also significant improvements in diabetes knowledge amongst the patients. The HbA1c levels of the diabetic patients in the SAED intervention group decreased from 8.76% to 7.85%. The diabetic knowledge test outcomes of the diabetic patients in the SAED intervention group significantly improved from 46.20% to 61.10%. Further, our study also tested the SAED system on diabetic patients during the Ramadan period. This is important because fasting is observed during the Ramadan month which can significantly affect the diabetes management and diagnosis amongst the patients. The study for the Ramadan period was conducted on another 20 patients using the similar approach described above. The results from the clinical trial indicated significant reductions in the number of hypoglycaemic and hyperglycaemic events during the month of Ramadan in patients who used the SAED system. The diabetes knowledge test outcomes also significantly rose from 44.60% to 64.10%. The SAED system for diabetes management using mobile technologies in KSA has been proven to be successful in improving the diagnosis and management of diabetes amongst the patients. The SAED system offers an inexpensive, practically feasible solution for diabetes self-management in KSA. Considering the social, economic, and political conditions in KSA, the SAED system can enhance the quality of healthcare provided to patients, lead to better utilization of resources, provide timely interventions, and improve the overall quality of life of diabetic patients and their family and friends.

The number of patients diagnosed with long term conditions in the UK is increasing with an expected number of 18 million patients by 2018, responsible for 69% of all spending on health and social care in England. These challenges cannot be solved solely by conventional approaches and other alternatives, such as cost-effective technological solutions, must be considered to increase patient's independence and quality of life, and produce cost savings for the authorities. This practice-based research explored the potential role of technologies in the care of patients with long term conditions, and aimed to evaluate the acceptance and effectiveness of a telehealth service provided to patients' with chronic obstructive pulomary disease and heart failure; to map and compare chronic obstructive pulmonary disease care pathways between different EU countries to better understand how technologies fit within the standard forms of care; to explore how m-health interventions can be developed and designed to support the care of cancer patients and survivors; and to provide data on UK cancer patients' ownership of and interest in m-health technologies. Mixed-mthod research approach was used in this study with a mixture of face-to-face and email semi-structured interviews, postal and online questionnaires, and data extraction from available databases. This approach was selected to harness the strengths of, both quantitative and qualitative methodologies. Seven nurses, working on telehealth for an average of 15 months were interviewed. Lack of resources and organisational support, patient selection criteria, and technological support were identified as barriers for effective implementation of telehealth. Telehealth reduced the number of both A&E and hospital admissions by 36% (P=0.03) and 28% (P=0.02), respectively. 27 patients responded to the postal questionnaire and were very satisfied with the service. They agreed that telehealth had improved their health, was a convenient form of healthcare delivery for them, and that it made them more involved in the decisions about their care or treatment. Five COPD-specialised HCPs were interviewed, and the COPD care pathway was compared between 5 EU countries including Germany, Greece, Ireland, Netherlands and England. Lack of communication among different healthcare providers managing COPD and co-morbities is a common feature of the studies care pathways. In all countries, the lifestyle management services provided were similar with no specific tools used to enhance patients' adherance, and no specified role/training existing for informal carers (partners, family & friends). Telehealth can play a role int he integrated care of long tem conditions by providing means communication allowing better communications between different healthcare providers managing LTCs and co-morbidities. Next, the role of m-health in cancer care was explored. A need for m-health platforms to support cancer patients and survivors was identified, and two m-health platforms were developed and designed using patient's centred approach and Waterfall system development model. MyAppPal and CanAdvice+ were designed to support colorectal cnacer srvivors set up on follow-up care plans and cancer patients receiving oral chemotheraphy at home, respectively. 12 colorectal cancer patients were interviewed and 69 patients responded to the postal questionnaire. Patients expereince with the support provided during follow up plan varied based on appointment type and location. They had problems remembering or accessing information as they moved away from their treatment, and reported needs for more specific and personalised information, more information on how to handle financial difficulties and social care, and more control over their hospital appointments. The usability scores of the developed apps were very positive, and they were seen as simple and attractive to use, and had very positive learnability and usability scores. Finally, 529 cancer patients completed surveys to assess their ownership of smart-technologies and interest in m-health apps. 90.5% of the patients had access to smartphone, tablet or both, and only patients' age significantly affected this ownership. Almost half of the patients showed an interest in the use of m-health apps, and two out of five were willing to download apps in were made available from the hospital. Five factors were found to significantly predict patients' willingness to use and download health applications, including age, health literacy, previous use of apps in general and health apps in particular, and previous use of smartphones/tablets to access related health information in the past six months. Ownership of smart-technologies and interest in m-health apps was independent from all other socio-economic factors. Technologies seem to be acceptable to patients with long term conditions, and can play an important role in improving their clinical outcomes if well designed, introduced, implemented and managed. Patients' perceptions of the usefulness and ease of use of these technologies seem to be a crucial factor in their acceptance of such interventions.

Children with Autism Spectrum Disorder (ASD) have increased rates for sleep problems compared with typically developing children. Although physicians practicing in pediatric primary care settings have the potential to detect and address sleep problems at an early age, research investigating the sleep management practices of pediatricians in primary care is scant and does not particularly address children with ASD. This study investigated the frequency of sleep screening measures utilized by pediatric providers during well-child examinations, the most frequently recommended treatments, the barriers and facilitators to screening for sleep problems, and the perceived confidence of pediatricians with regard to screening for sleep problems in children ages 2-10 years with ASD. Survey data from members of the Hillsborough County Medical Association were collected and analyzed. Seventy-three percent of participants reported almost always screening for a sleep problem during well-child examinations. Findings indicate that pediatric healthcare providers acknowledge the importance of managing sleep problems in primary care settings. Barriers to screening for sleep problems during routine exams included lack of time, resources, and awareness of screening tools. Facilitators to screening for sleep problems during routine exams included shorter sleep screening tools and longer exams. Pediatric providers were moderately confident in their ability to manage sleep problems in primary care settings. A significant relationship was found between confidence level and a number of perceived barriers. Implications of the findings are discussed.

Background: Type 2 diabetes is a common chronic disease worldwide. An important part of the treatment is monitoring and treating the elevated levels of blood glucose. But there is also a need for monitoringother risk factors that confer an increased risk for vascular complications. This thesis is based on four studies that explore different aspectsof monitoring blood glucose and obesity in patients with type 2 diabetes in primary care. Methods: To examine the cost and effect on glycaemic control of patients performing self-monitoring of blood glucose (SMBG) an observationalstudy was performed in the county of Östergötland and Jönköping 2003-2004. The study included all known patients with type 2 diabetes at 18 primary health care centres (PHCC), excluding patients in nursery homes. A structured observational intervention study of 98 patients with type 2 diabetes living at 17 nursery homes were done with monitoringof hypoglycaemic episodes followed by a controlled withdrawal of diabetes medication in patients with HbA1c ≤ 6.0 %. Baseline data from the cohort study; Cardiovascularrisk in type 2 diabetes – a prospectivestudy in primary care (CARDIPP), was analysed for correlation analyses between anthropometric status and early cardiovascular organ damage, measured by pulse wave velocity (PWV) and left ventricular mass index (LVMI). Results: When comparing users of SMBG to non-users, there was no association between improvedglycaemic control and use of SMBG. A plasma glucose profile for three consecutive days of the patients at nursery homes, indentified 31 episodes of plasma glucose levels≤ 4.4 mmol/l. A withdrawal of insulin and oral antiglycaemic medicine was performed, which after 3 months follow up was successful in 24 (75 %) of the patients. The mean annual cost per PHCC for visits to general practitioner and nurse, insulin, SMBG and oral antiglycaemic agents was586 € (SD 435) per patient. There was no correlationbetween costs and glycaemic control at PHCC level. In the CARDIPP study, both increased sagittalabdominal diameter and increased waist circumference were, independently of sex, age, blood pressure and HbA1c, associated to increasedPWV and LVMI. Conclusions: Use of SMBG in primary care confers a substantialpart of the treatment costs, but is not associated with improved glycaemic control. Systematic use of SMBG for patients not treated with insulin should not be recommended. At nursery homes, patients with type 2 diabetes are at risk for harmful hypoglycaemia and may benefit from a more frequent control of plasma glucose and a less strict glycaemic control. Increased abdominal obesity measured with either sagittal abdominal diameter or waist circumference is associated with early cardiovascularorgan damage. In addition to analyses of blood glucose, blood pressure and lipids, the monitoring of abdominal obesity is a feasible risk factor assessment tool, that provides further information about cardiovascular risk that goes beyond that of traditional risk factors.

This thesis examines hospitalizations for ambulatory care sensitive conditions among persons with an intellectual disability living in Manitoba from 1999 to 2003. Hospitalizations for ambulatory care sensitive conditions are considered an indicator of access to, and the quality of, primary care. Intellectual disability can be defined as a disability originating before age 18 characterized by significant limitations both in intellectual functioning and in adaptive behaviour as expressed in conceptual, social, and practical adaptive skills. Between 1 and 3% of the population has an intellectual disability. This thesis addressed three objectives: 1) To identify ambulatory care sensitive conditions that are applicable to persons with an intellectual disability; 2) To compare hospitalization rates for ambulatory care sensitive conditions between persons with and without an intellectual disability in Manitoba; 3) To identify factors associated with hospitalizations for ambulatory care sensitive conditions among adults with an intellectual disability living in Manitoba. An online survey of primary care providers with experience working with persons with an intellectual disability found consensus on fifteen ambulatory care sensitive conditions applicable to persons with an intellectual disability. Large discrepancies in hospitalization rates for these conditions were found between persons with and without an intellectual disability. Controlling for age, year, sex, and region, persons with an intellectual disability were 6 times more likely to be hospitalized for an ambulatory care sensitive condition. Future research should investigate reasons for the large discrepancy in rates between persons with and without an intellectual disability. Among adults with an intellectual disability, living in a rural area (odds ratio 1.3; 95% CI=1.0, 1.8), living in an area with a high proportion of First Nations people (odds ratio 2.3; 95% CI=1.3, 4.1), and experiencing higher levels of comorbidity (odds ratio 25.2; 95% CI=11.9, 53.0) were all associated with a higher likelihood of being hospitalized for an ambulatory care sensitive condition. Dwelling in higher income areas had a protective effect (odds ratio 0.56; CI=0.37, 0.85). The results suggest that addressing the socioeconomic problems of poorer areas and specifically areas densely populated by First Nations people would likely have an impact on hospitalizations for ACS conditions for persons with an intellectual disability.