Thesis (Ph. D.)--University of Washington, 1995. / Vita. Includes bibliographical references (leaves [165]-175).

Thesis (M.S.)--Florida State University, 2005. / Advisor: James Whyte IV, Florida State University, School of Nursing. Title and description from dissertation home page (viewed Jan. 30, 2006). Document formatted into pages; contains viii, 52 pages. Includes bibliographical references.

Thesis (Ph.D.) - University of St Andrews, November 2009.

Thesis (M.Sc.)--Memorial University of Newfoundland, 2004. / Restricted until October 2005. Bibliography: leaves 45-48.

Thesis (M. Nursing)--Montana State University--Bozeman, 2007. / Typescript. Chairperson, Graduate Committee: Jean Shreffler-Grant. Includes bibliographical references (leaves 45-49).

Thesis (M. Communication Pathology)--University of Pretoria, 2008. / Includes bibliographical references.

Thesis (DTech (Electrical engineering))--Cape Peninsula University of Technology, Cape Town, 2007 / Telemedicine has been identified as a tool to distnllUte medical expertise to medically underserved rural community. However, due to the underdeveloped or non-existent telecommunication infrastructure, which is needed as the platform for telemedicine, the full benefits of telemedicine are yet to be realized in most parts of South Africa and Africa as a whole. This study aims to explore ways on how to provide lP-based lCI system that can be used as a communication platform for telemedicine in rural areas. In order to emulate the onsite face-to-face consultation experience, the rural telemedicine system must be able to provide quality video transmission. Quality video is also important in order for the physician at the distant end to be able to make correct diagnosis. Hence the main focus of this study is on ways ofproviding quality video over lP-based multiservice network. A conceptual model of a rural area network that can be used for rural telemedicine has been deVeloped, and different access technologies that can be used for rural areas are presented. Techniques for compesating IP best effort datagram delivery are provided. Factors that can affect the quality of video transmission on an lP-based packet network are identified, and a holistic approach to mitigate them is proposed. That includes adopting coding techniques that will provide coding efficiency, high quality video that is consistent at high and low bit rates, resilience to transmission errors, scalability, and network friendliness, which will result in perceived quality improvement, highcompression efficiency, and possibility of transportation over different networks. Secondly, it also includes mechanisms to compensate for packet networks idiosyncrasy, especially JP best-effort debilities, in order to meet the latency and jitter requirements of real-time video traffic. For video coding, H.264 is proposed as it meets most of the encoding requirements listed above, and for prioritising and protecting.video traffic from JP network's best-effort debilities a combination of differential services (DiflServ) and multi-protocol label switching (MPLS) have been adopted, where DiflServ is used for traffic classification and MPLS is used for traffic engineering and fast-rerouting in the event of route failure. To verify and validate the proposed solutions, modelling and simulation has been used, where the Network Simulator (NS-2.93) has been used to simulate network functions, and PSNR, VQM score and double stimulus impairment scale (DSIS) have been used for evaluating video quality.

M.Cur. (Community Health Nursing) / During employment as a registered nurse and while rendering mobile family planning services on farms in the Eastern Transvaal, it was found that appreciable time was spent on non-nursing tasks. The impression gained, was that the people who visited the clinics were only a part of the total farm community and that possibly a mutual communication gap existed between the formal health sector and the community. The purpose of this study was to establish whether the lay health worker should be formally recognised as a member of the primary health team. The research design was a descriptive, quantitative study in a contextual framework. Data was collected using a literature study and a survey using a questionnaire. The research has confirmed that a gap exists between the formal health sector and the rural community. This gap is bridged by the lay health worker, implying that she should be formally recognised as a member of the primary health team.

The study was undertaken when St. Bartholomew's Hospital, in Lytton, B.C., a 27 bed facility, was experiencing under-utilization and the threat of closure. This study examines the health and social services of the area, and suggests alternatives for the hospital. Three methods of investigation were used, involving survey methods, documentary analysis, and oral histories. Two survey instruments were prepared by the researcher and applied to a stratified sample of key informants from the community. The respondents in these surveys were divided into either provider or consumer categories, and stratified within each of these as to the degree of contact with the local hospital. Twenty-five such interviews were held with each major category for a total of fifty completed interviews. A comparative questionnaire was also given to patients of St. Bartholomew's Hospital, asking for specific comparison between that hospital and any other with which the patient may have had personal contact. Documentary analysis involved examination of data from three major sources. The hospital maintained records were examined to present utilization rates according to age, sex, diagnosis, residence location and ethnic origin of patients for specified years. Information from British Columbia Hospital Plan was relied on to provide similar information for the school district of South Cariboo, and for the Thompson-Nicola Regional District, for comparison with local rates. The Medical Services Commission of British Columbia was approached to supply information on the volume of physician visits in the local community for selected years. Oral histories were prepared from various persons in the local health field, and from many other individuals in the community. The purpose of these oral histories was to substantiate the factual material, and to generate new and different information not available from the data. The results of this study indicate that Lytton is probably not going to change much in the next decade, but that patterns of health care delivery, and modes of demand for health services are experiencing a significant change at the present time. The result is that the local hospital has become less favoured, and therefore less used by the local people in satisfying their health service wants. Five alternatives for this hospital were examined in some detail. Alternative A involved no change in the present system. From medical, economic and political viewpoints this alternative is not acceptable. Alternative B suggests a reduction in the present inpatient capacity of the hospital, a restructuring of the governing body, the attraction of a second primary health care worker to the area, and the placement of the present doctor and the additional primary care person within the hospital setting. The additional primary care worker could be either a nurse-practitioner, or a physician on salary to the hospital. This alternative has many strengths, but attempts to facilitate change in the hospital in isolation with little regard to the other health and social agencies in the area. Alternative C has all of the attributes of B but goes one step beyond to house the primary health care workers in a Community Clinic built adjacent to the hospital, and include most of the other health and social services available to this community. This alternative requires substantial initial capital, but represents the optimum for the people of Lytton. Alternative D suggests the closing of the inpatient services, and the creation of a comprehensive Diagnostic and Treatment Centre housing most of the health and social services. Alternative E would be for the hospital to close its doors, offer no services, and make no effort to meet the community's health care requirements. Similar to A, this alternative is deemed unacceptable. The last alternative suggests that the University of British Columbia Faculty of Medicine might take over the hospital as a teaching hospital providing rural exposure to a rotation of resident physicians as part of their formal education. The final report was presented to the Board of Directors of St. Bartholomew's Hospital for their consideration. / Medicine, Faculty of / Population and Public Health (SPPH), School of / Graduate

Mental health conditions, particularly substance use disorders, are a growing public health threat that affect millions of Americans. Drug use disorders (DUDs), a subset of substance use disorders, are chronic conditions characterized by clusters of behavioral, cognitive, and physiological symptoms related to the use of opioids, hallucinogens, stimulants, cannabis, anxiolytics/hypnotics/sedatives, inhalants, multiple drugs, other drugs, or unknown drugs. The prevalence of DUDs among older adults ages 65 and older is growing. In 2021, almost 2 million older adults in the United States (U.S.) had a DUD. DUDs have a detrimental effect on health, especially among older adults with DUDs, who are more likely to have comorbid chronic conditions such as chronic obstructive pulmonary disorder, diabetes, and chronic heart failure than older adults without DUDs or other age groups with DUDs. The medications and symptoms of these comorbid conditions can interact with DUD-associated drugs and cause high risk for falls, delirium, medication interactions, chronic disease exacerbations, and acute emergency department (ED) utilization. Thus, in addition to the alarming growth in the prevalence of DUDs in older adults, this population faces additional risks for poor health and acute ED utilization.Despite similar prevalence of DUDs among rural and urban older adults, older adults in rural areas have decreased access to DUD care. In rural areas, there is lower availability of DUD specialists and treatment centers. In 2019, 1,149 rural counties did not have a provider who could prescribe buprenorphine (a medication for opioid use disorder), compared to only 57 urban counties. Rural residents must drive an average of 49.1 minutes to receive DUD treatment, compared to just 7.8 minutes for urban residents. Enhanced availability of DUD treatment in primary care settings may fill the gap in access to mental health and substance use care in rural communities as older adults seek primary care providers for other routine care. Prior studies have shown that patients who seek and receive pharmacologic or psychological interventions in primary care settings may have improved DUD outcomes such as lower rates of relapse, increased retention in treatment, and abstinence. The Affordable Care Act increased funding for rural primary care practices to deliver integrated mental and physical health care, which may improve outcomes for older adults with DUDs. Yet, many rural older adults with DUDs do not receive DUD screening and treatment in primary care. Presently, only 45% of patients are screened for DUDs in the community. Primary care providers often report that they do not have the confidence to address DUDs. While some research shows that organizational support such as DUD-specific training and clinical resources are key to improving primary care provider confidence in addressing opioid use disorder, there is very little research focused on the unique needs of rural primary care providers in delivering DUD services. Research on organizational factors that influence the availability and quality of DUD services in rural primary care practices is needed to bolster primary care capacity to serve older adults with DUDs in rural areas. Rural primary care practices increasingly rely on the growing nurse practitioner (NP) workforce to deliver care. Over one-quarter of the rural primary care workforce is NPs. Most research on the rural primary care NP workforce and DUD services focuses on NP prescribing of buprenorphine, a medication for opioid use disorder. Half of the new buprenorphine providers in rural areas are NPs, and NPs treat more patients with buprenorphine than physicians in rural areas. Despite NPs’ contribution to DUD care for rural patients, studies show that many NPs practice in challenging work environments that negatively impact their ability to deliver patient care. The NP work environment is often characterized by a lack of resources, autonomy, and support, which affects the delivery of patient-centered care, high-quality care, and health services utilization among patients with chronic conditions. Studies have suggested that work environment factors such as teamwork and autonomy may influence NP prescribing of buprenorphine. Yet, no studies have focused on NP work environments in primary care practices and how they affect care for older adults with DUDs in rural areas. The overall purpose of this dissertation is to produce evidence on enhancing the primary care NP workforce’s ability to deliver mental health and DUD services. The first study in this dissertation (Chapter 2) was a systematic review of the literature focused on the effectiveness of NP care for patients with mental health conditions (i.e., anxiety, depression, and substance use disorders) in primary care settings. These conditions were included to identify the state of the literature base focused on NP mental health care delivery in primary care settings, particularly focused on gaps in evidence related to NP care for rural older adults with DUDs. The second study in this dissertation (Chapter 3) conceptualized primary care provider confidence in addressing opioid use disorder to understand how to support providers (i.e., physician, NPs, and physician assistants) in delivering DUD care through policy, practice, and research innovations. The third study of this dissertation (Chapter 4) assessed the relationship between the NP work environment and rural NP practices’ capacity to serve older adults with DUDs. Finally, the fourth study (Chapter 5) examined the impact of the NP work environment in rural primary care practices on ED utilization among older adults with DUDs. Findings from the studies included in this dissertation can be used to improve primary care delivery in rural areas and inform policy and research innovations to address the growing public health threat of DUDs among rural older adults. Materials and Methods This dissertation utilized novel materials and methods to inform the development of policy, practice, and research innovations that enhance the primary care NP workforce’s ability to deliver mental health and DUD services. The following presents the study design of each individual chapter to achieve the study’s aims. Study 1 | Chapter 2: This systematic review of the evidence addressed the effectiveness of NP care for patients with mental health conditions in primary care settings. We followed Joanna Briggs Institute (JBI) Manual for Evidence Synthesis for systematic reviews of effectiveness and reports results according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The review protocol is published with PROSPERO (ID = CRD42021269816). Study 2 | Chapter 3: This concept analysis followed the Walker and Avant framework to conceptualize primary care provider confidence in addressing opioid use disorder. Study 3 | Chapter 4: The goal of this study was to assess the impact of the NP work environment on the capacity of rural primary care practices to serve older adults with DUDs in rural areas. To achieve this aim, we conducted a secondary data analysis of cross-sectional NP survey data from 2018-2019 merged with Medicare claims from 2018. We conducted our statistical analysis using fractional logistic regression. Study 4 | Chapter 5: The goal of this study was to examine the association between the NP work environment and ED utilization among older adults with DUDs in rural areas. To achieve this aim, we conducted a secondary data analysis of cross-sectional NP survey data from 2018-2019 merged with Medicare claims from 2018. We conducted our statistical analysis using multilevel logistic regression. Conclusions This dissertation produced evidence that enhances the primary care NP workforce’s ability to deliver mental health and DUD services. In Chapter 2, the systematic review of the literature identified a lack of high-quality research focused on NP primary care for patients with mental health conditions, particularly among patients with substance use disorders in rural areas. Chapter 3 conceptualized primary care provider confidence in addressing opioid use disorder and found that teamwork, organizational culture, resources, and support may uniquely influence provider confidence, which is associated with positive patient outcomes, increased delivery of and access to opioid use disorder services, and provider attitude changes. In Chapters 4 and 5, our studies found that the NP work environment in rural primary care practices is associated with increased practice capacity to serve older adults with DUDs and reduced ED utilization in this population. These dissertation findings provide important insights that will allow policymakers, practice administrators, and researchers to invest in productive efforts to enhance the primary care NP workforce’s ability to deliver mental health and DUD services.