Referral practices within healthcare systems are seen as a means of heightening the quality of perinatal care and lessening perinatal mortality and morbidity. Perinatal death or the birth of child with a handicap can be debilitating for a family. Since January 2002 a new referral system has been instituted within Greenland sending all at risk pregnancy to the referral hospital in Nuuk. The aim of the study was to describe the women’s experience of referral by drawing on their experiences and using their voices to present referral from the women’s point of view. Interviews were conducted within arrival at the referral hospital and during fieldwork over a one-year period. Interviews were conducted, recorded and transcribed. The analysis of interview data was conducted within the narrative framework, using Coping theory and resiliency tools as the theoretical base for structuring the narratives. Through their narratives the women presented their identities as mothers, community members and caretakers. Acceptance of referral was described as a tool for protecting their unborn child. With acceptance of the referral the women found an inner source of strength to deal with their own anger joy anxiety and loneliness. Their ability to accept referral was directly connected to their family and community and the support that they found therein / Siden januar 2002 har Grønland instrumenteret nye perinatale retningslinier. Disse retningslinier har til hensigt til at nedbringe mortaliteten og morbiditeten hos de nyfødte og deres mødre. Projektet tager udgangspunkt i kvindernes oplevelse af visitationen. Det belyser de udfordringer som kvinderne præsenteres for samt de redskaber kvinderne er i besiddelse af, i forsøget på at besejre disse udfordringer. Kvinderne blev interviewet ved ankomsten til modtagelsessygehuset og under feltarbejde. Interviewene blev optaget på bånd og blev transskriberet løbende. Narrrative teorier er grundlag for analysen af interviewene og coping og resiliency faktorer er de teoretiske grundprincipper for præsentation af kvindernes tanker. Igennem narrativerne fremlagde kvinderne deres oplevelse af sig selv som mødre, som medborgere og omsorgspersoner. Det at acceptere visitationen beskrives som et redskab til at beskytte deres ufødte barn. Ved at acceptere visitationen oplevede kvinderne en indre styrke, som hjalp dem til at bearbejde følelser som vrede, glæde, bekymring og ensomhed. Støtte fra deres familier og deres lokalsamfund var afgørende for deres oplevelse af tiden på modtagelsessygehuset / <p>ISBN 91-7997-126-1</p>

Background Due to technological and medical advances, increasing numbers of pregnant and post natal women require higher levels of care, including maternity high dependency care (MHDC). Up to 5% of women in the UK will receive MHDC, although there are varying opinions as to the defining features and definition of this care. Furthermore, limited evidence suggests that the size and type of obstetric unit (OU) influences the way MHDC is provided. There is robust evidence indicating that healthcare professionals must be able to recognise when higher levels of care are required and escalate care appropriately. However, there is limited evidence examining the factors that influence a midwife to decide whether MHDC is provided or a woman’s care is escalated away from the OU to a specialist unit. Research Aims 1. To obtain a professional consensus regarding the defining features of and definition for MHDC in OUs remote from tertiary referral units. 2. To examine the factors that influence a midwife to provide MHDC or request the escalation of care (EoC) away from the OU. Methods An exploratory sequential mixed methods design was used: Delphi survey: A three-round modified Delphi survey of 193 obstetricians, anaesthetists, and midwives across seven OUs (annual birth rates 1500-4500) remote from a tertiary referral centre in Southern England. Round 1 (qualitative) involved completion of a self-report questionnaire. Rounds 2/3 (quantitative); respondents rated their level of agreement or disagreement against five point Likert items for a series of statements. First round data were analysed using qualitative description. The level of consensus for the combined percentage of strongly agree / agree statements was set at 80% for the second and third rounds Focus Groups: Focus groups with midwives across three OUs in Southern England (annual birth rates 1700, 4000 and 5000). Three scenarios in the form of video vignettes were used as triggers for the focus groups. Scenario 1; severe pre-eclampsia, physiologically unstable 2; major postpartum haemorrhage requiring invasive monitoring 3; recent admission with chest pain receiving facial oxygen and continuous ECG monitoring. Two focus groups were conducted in each of the OUs with band 6 / 7 midwives. Data were analysed using a qualitative framework approach. Findings Delphi survey: Response rates for the first, second and third rounds were 44% (n=85), 87% (n=74/85) and 90.5% (n= 67/74) respectively. Four themes were identified (conditions, vigilance, interventions, and service delivery). The respondents achieved consensus regarding the defining features of MHDC with the exceptions of post-operative care and post natal epidural anaesthesia. A definition for MHDC was agreed, although it reflected local variations in service delivery. MHDC was equated with level 2 care (ICS, 2009) although respondents from the three smallest OUs agreed it also comprised level 1 care. The smaller OUs were less likely to provide MHDC and had a more liberal policy of transferring women to intensive care. Midwives in the smaller OUs were more likely to escalate care to ICU than doctors. Focus Groups: Factors influencing midwives’ EoC decisions included local service delivery, patient specific / professional factors, and guidelines to a lesser extent. ‘Fixed’ factors the midwives had limited or no opportunity to change included the proximity of the labour ward to the ICU and the availability of specialist equipment. Midwives in the smallest OU did not have access to the facilities / equipment for MHDC provision and could not provide it. Midwives in the larger OUs provided MHDC but identified varying levels of competence and used ‘workarounds’ to facilitate care. A woman’s clinical complexity and potential for physiological deterioration were influential as to whether MHDC was assessed as appropriate. Midwifery staffing levels, skill mix and workload (variable factors) could also be influential. Differences of opinion were noted between midwives working in the same OUs and varying reliance was placed on clinical guidelines. Conclusion Whilst a consensus on the defining features of, and definition for MHDC has been obtained, the research corroborates previous evidence that local variations exist in MHDC provision. Given midwives from the larger OUs had variable opinions as to whether MHDC could be provided, there may be inequitable MHDC provision at a local level. Organisationally robust systems are required to promote safe, equitable MHDC care including MHDC education and training for midwives and precise EoC guidelines (so workarounds are minimised). The latter must take into consideration local service delivery and the ‘variable’ factors that influence midwives’ EoC decisions.

The present study attempted to assess the effectiveness of the Zimbabwean secondary school guidance and counselling services from school counsellors' and students' perspective. Available literature shows that students worldwide, including Zimbabwe, experience problems which schools should solve through the provision of guidance and counselling. It was therefore, important to the researcher to assess the effectiveness of the school guidance and counselling services in meeting students' concerns. The research design consisted of a literature and an empirical study. The survey method was used in the empirical study. A self constructed questionnaire was used. Three hundred and fourteen school counsellors and 636 students participated in this study. The SAS/STAT version 9.1 was used to analyse the data. One way and combined two way frequency tables were calculated. Ratios were calculated to establish the relative rating of each item. Chi-square tests were also calculated. The study revealed that there were differences between the level of the school guidance and counselling services in Zimbabwean secondary schools and the international arena. For example, school guidance and counselling services policy in Zimbabwe was not mandatory as compared to the international policies. The Zimbabwean school guidance and counselling services were not always planned for at the beginning of each year, Students and parents were not frequently involved in needs assessment while the services were not frequently evaluated in comparison with those in the international arena. The study also revealed that some biographical variables significantly influenced the way the respondents responded to given items while others did not. The study revealed that the majority of both school counsellors and students viewed the school guidance and counselling services as beneficial and school counsellors as effectively playing their role. The study further revealed that the effectiveness of the Zimbabwean secondary school guidance and counselling services was negatively affected by lack of resources and training in guidance and counselling and non-counselling duties performed by school counsellors. Recommendations for future approaches and strategies in secondary school guidance and counselling services in Zimbabwe are made. Areas for further research are proposed. / Educational Studies / D.Ed. (Psychology of Education)

A quantitative, descriptive, explorative design was applied to study the problems that hindered the Primary Health Care (PHC) nurses in rendering quality health care in the health facilities in Limpopo province South Africa. The sample consisted of 53 PHC nurses who completed a pre-tested questionnaire which covered various aspects related to the provision of quality PHC services. The data were analysed by computer using SPSS version 15 soft ware. The findings revealed that most of the problems could be attributed to financial constraints, poor budgeting, and shortage of staff to manage large number of patients, lack of enough support from other professional staff, unreliable referral systems and communication networks. PHC nurses work under difficult conditions and often have to improvise to care for patients, but unless more funds are allocated to rural health care facilities and these problems are addressed, more nurses will work under difficult circumstances. / Health Studies / M.A. (Health Studies)

Apart from isolated programs in private and public health care sectors, South Africa has no existing systematic public infant hearing screening program at community level. As a result, early identification of hearing loss is certainly not being attained for the majority of infants in South Africa with far-reaching effects for individuals, families and society at large. Screening programs at primary health care immunization clinics have been proposed as an alternative to hospital-based programs in South Africa. The objective of this study was to evaluate the first systematic community-based infant hearing screening program in a developing South African community in the Western Cape. A combined descriptive and exploratory research methodology was followed incorporating aspects of a program evaluation design. The study was of a quantitative nature and the required data were collected by means of a questionnaire and OAE testing conducted by clinic nurses on subjects. A community-based universal infant hearing screening program initiated at eight primary health care clinics in the Cape Metropolitan area was evaluated over a 19-month research period. During this time 6227 infants who were candidates for screening attended their 6, 10 or 14-week immunization visit at the relevant clinic. Clinic nurses were trained as screening personnel. A two-stage distortion product otoacoustic emissions screening protocol was utilized. The target disorder for this study was bilateral permanent congenital and early onset hearing loss and infants referring the first screen were scheduled for a 4-week follow-up visit at the clinic. Diagnostic audiological and medical evaluations were scheduled at referral hospitals when indicated. The study evaluated the efficacy of the program based on coverage, referral and follow-up rates and diagnostic outcomes according to guidelines specified by the Health Professions Council of South Africa 2007 Position Statement. Overall coverage rate across the eight clinics was 32.4% with 2018 infants (aged 0- 14 weeks) screened. The mean age of the sample at first stage screen was 3.9 weeks of age and 13.5 weeks of age for first hospital visit. Overall first stage screen referral rate was 9.5% with 62 subjects (3%) referred for diagnostic services at hospital level after a follow-up screen. The average follow-up rate for rescreens at clinic level was 85.1% and for initial diagnostic assessments at hospital level it was 91.8%. Although minimal hearing loss was not the primary focus of the screening program the outcomes did include those subjects with fluctuating conductive hearing loss and permanent unilateral hearing loss. Prevalence rates were 4.5/1000 with significant hearing loss, including sensorineural (1.5/1000) and conductive (3/1000) losses, and 12.9/1000 for subjects with middle ear effusion.<p-> The community-based infant hearing screening program was valuable in attaining high follow-up return rates but reaching sufficient coverage may require dedicated screening personnel as opposed to existing nursing personnel. Furthermore, consideration of an alternative community-based platform such as midwife obstetric units may improve coverage and referral rates and prevalence of permanent congenital and early onset hearing loss. / Dissertation (MCommunication Pathology)--University of Pretoria, 2013. / Speech-Language Pathology and Audiology / Unrestricted

Dans cette thèse, nous nous intéressons aux problèmes de découverte, de sélection et de composition de services. L'objectif est de satisfaire une requête complexe d'un demandeur de services. Pour ce faire, nous proposons une approche multi-agents fondée sur la confiance et les réseaux sociaux. Nous définissions un modèle de confiance en tant que concept compositionnel formé de quatre composantes: une composante sociale, une composante d'expertise, une composante de recommandation et une composante de coopération. La composante sociale juge s'il est intéressant de suivre un fournisseur avant d'utiliser ses services. La composante d'expertise estime si un service se comporte bien et comme prévu. La composante de recommandation vérifie si un agent est pertinent ou pas et si l'on peut compter sur ses recommandations. La composante de coopération permet aux agents de décider avec qui interagir dans une composition de services. Nous proposons un algorithme distribué pour la découverte de services utilisant la confiance entre les agents ainsi que les systèmes de références dans les réseaux sociaux. Nous développons également une nouvelle méthode s'appuyant sur un modèle probabiliste pour inférer la confiance entre les agents non adjacents tout en tenant compte des rôles des agents intermédiaires. Finalement, nous présentons un processus original de formation de coalitions qui est incrémental, dynamique et recouvrant pour une composition de services dans les réseaux sociaux. Les résultats expérimentaux montrent que nos approches multi-agents sont efficaces, plus performants que les approches similaires existantes et peuvent offrir des résultats plus dignes de confiance à faible coût de communications. / This thesis deals with service discovery, selection and composition problems. The aim is to fulfill a complex requester query. To do that, we propose a multi-agent approach based on trust and social networks. We define a trust model as a compositional concept that includes social, expert, recommender and cooperation-based component. The social-based component judges whether or not the provider is worthwhile pursuing before using his services. The expert-based component estimates whether or not the service behaves well and as expected. The recommender-based component checks whether or not an agent is reliable and if we can rely on its recommendations. The cooperation-based component allows agents to decide with whom to interact in a service composition. We propose a distributed algorithm for service discovery using trust between agents and referral systems in social networks. We also develop a new method based on a probabilistic model to infer trust between non adjacent agents while taking into account roles of intermediate agents. Finally, we present an original coalition formation process which is incremental, dynamic and overlapping for service composition in social networks. %In particular, our coalition formation process engaging self-interested agents is incremental, dynamic and overlapping. Experimental results show that our multi-agents approaches are efficient, outperforms existing similar ones and can deliver more trustworthy results at low cost of communications.

The purpose of this project is to support health promotion of children entering foster care, ensure that children receive all health care services needed, prevent the trauma of duplication of immunizations, and reduce disruption of health care as children move through the foster care system.

Business processes that are maintained in, and through, digital information chains are a widespread phenomenon in society. In these chains, several actors are active both in the production and transfer of information, where each actor is dependent on another actor's effective transmission to be able to perform his job. To explore this phenomenon, this study investigates an electronic referral process of the regional Health Care system in Sweden, that allows for the transfer of rights, duties and obligations between health care providers. In this process, effective information transfer is necessary to achieve high levels of patient safety and to prevent delays in care delivery. This study intends to unveil the technological and communicative challenges of information transfer faced by doctors who are involved in that process. The study draws upon primary data collected from nine interviews conducted with secondary care doctors working at the Uppsala University Hospital. The results were analyzed primarily using communication theories of representation and through a constructionist perspective of knowledge. The results show that most challenges are communicative, most of which, as well as the technological challenges identified, relate to mediation and sharing of meaning. Challenges also tend to be more or less prominent depending on the actors involved, and the nature of what is being transferred. In order to deal with the challenges, the referral process is circumvented and the methods of circumventing prove to be as institutionalized as the referral process itself. / Verksamhetsprocesser som upprätthålls i och genom digitala informationskedjor är ett utbrett fenomen. I dessa kedjor är flertalet aktörer aktiva i både produktionen och överföringen av information, där varje aktör är beroende av en annan aktörs överföring för att kunna utföra sitt arbete. I avsikt att närma sig detta fenomen, är syftet med studien att förstå vilka utmaningar som kan uppstå i en sådan verksamhetsprocess genom att undersöka det digitala remissförfarandet inom sjukvården. Remissförfarandet är en central process genom vilken patientvård samordnas via remisser och remissvar. För att uppnå hög patientsäkerhet, är processen beroende av effektiv informationsöverföring. Frågeställningen som studien ämnar besvara, är “Vilka informationsteknologiska och kommunikativa utmaningar kring informationsöverföring i remissförfarandet upplevs inom specialistsjukvården?”. För att besvara denna fråga har nio intervjuer med specialistläkare på Akademiska sjukhuset i Uppsala utförts. Intervjudatan har i huvudsak analyserats utifrån ett kommunikationsvetenskapligt angreppssätt som kombinerar ett konstruktivistiskt kunskapsperspektiv och representationsteori. Resultaten visar på att majoriteten av utmaningar är kommunikativa, varav de flesta, liksom de informationsteknologiska utmaningar som identifierats, relaterar till förmedling och delande av mening. Utmaningar tenderar också bli mer eller mindre framträdande beroende på vilka aktörer som deltar i informationskedjan samt karaktären på det som överförs. För att hantera utmaningarna kringgås remissförfarandet, där sätten att kringgå visar sig vara lika institutionaliserat som remissförfarandet självt.

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Abstract Word-of-mouth (WOM) personal referrals are more efficient and influential than other forms of advertising; however, there is a lack of information regarding the value of referral programs. The purpose of this qualitative case study was to explore the perceptions of business owners, staff, and customers of alternative health care organizations in a Midwestern U.S. state about efficient referral strategies, measuring the effect of those strategies, and motivations of consumers to make referrals. Maslow's hierarchy of needs theory of motivation and customer decision-making theories provided the conceptual framework. The research questions addressed how industry leaders perceived and ranked referral strategies and addressed customers' perceptions and motivations to make personal referrals. Data collection consisted of semistructured interviews with 4 business owners, 2 staff members, and 10 client participants. Data were analyzed using constant comparative analysis methods, and member checking enhanced the accuracy of the findings. Results indicated that participants viewed WOM personal referrals as the most efficient nontraditional strategy to make or receive referrals, and they perceived referrals from impartial and trustworthy sources as the most valued information. This research has implications for positive social change. Findings may be used to enhance business owners' understanding of the value of personal referrals in their marketing mix, and of the motivation for customers to make referrals. WOM personal referrals may be used as a marketing strategy to increase sales and lower costs of formal advertising, which may contribute to the growth of the business.