Type 2 diabetes (T2DM) is a health epidemic that continues to worsen. A major concern is that treatment adherence rates hover around 50%, despite the introduction of new medications, treatments, and technology. Lack of adherence by patients can lead to complications like blindness, kidney disease, and amputations. While there have been many studies conducted to evaluate patient factors related to adherence, fewer studies have been conducted to evaluate the role of the physician-patient relationship. The purpose of this study was to examine the correlation between the physician-patient relationship and patient treatment adherence, and examine the moderators of age, education, ethnicity, and income. Gender was included as a moderator in a secondary analysis. Two theories formed the theoretical framework of this study: biopsychosocial model and self-efficacy theory. This quantitative nonexperimental study was completed with survey data collected from 92 participants in the United States ages 18 or older who were under treatment for T2DM for at least a year, and who had seen their physician at least once in the previous year. Correlational and regression analyses were conducted using data from the modified Clinician and Group Survey and the Diabetes Management Self-Questionnaire. The physician-patient relationship predicted treatment adherence, and gender moderated the relationship. These findings suggest the importance of the physician-patient relationship as a factor in patient treatment adherence. This has important implications for social change because an understanding of which physician factors lead to treatment adherence may help improve patient outcomes, reduce T2DM complications, improve patient quality of life, and reduce healthcare costs.

Background Patients’ preferences, needs and desires are important when discussing treatment. In consultations between patients with atrial fibrillation (AF) and health professionals, knowledge, understanding and insight about communication patterns are of vital importance for strengthening patient involvement in decision-making about their care and treatment. Aim The general aim of this thesis was to describe communication patterns in consultations between patients with AF and health professionals. Specific aims (1) To describe (i) the topics patients with AF and their nurses and physicians discuss; (ii) the use of discursive space in consultations between these participants; and (iii) the frequencies with which patients and nurses/physicians introduce the identified topics. (2) To describe the types of patient resistance to accepting treatment with warfarin and how cardiologists respond to such resistance. Methods An inductive design was used. In study I, the sample consisted of 23 consultations between patients with AF (13 women and 10 men) and health professionals (5 women and 5 men) who were employed in six different cardiologic outpatient clinics. Content analysis was used to obtain a description of topics discussed. The patterns of dominance for the various topics and participant were explored from the framework of an analysis of dominance (I). In study II, the sample consisted of 11 consultations between patients with AF (7 women and 4 men) and cardiologists (2 women and 3 men). Conversation analysis was used to describe interactions concerning resistance to treatment with warfarin. Findings Study I. Four topics were introduced by both nurses and physicians during the consultations. These were “pathophysiology”, “treatment”, “diagnostic procedures”, and “activity”. In the nurse–patient consultations an additional topic, “routines related to the physician’s responsibilities”, emerged. With respect to the number of words and turns, the distribution of the discourse space was almost equal between nurses and patients, and unequal between physicians and patients. The patients were the dominant initiators of the topic “activity”, which refers to adaptation of activities in daily life in relation to AF. Study II. There were four types of patient resistance to accepting treatment with warfarin. These included “Giving reasons for their resistance”, “Suggesting other treatment options”, “Stating treatment preferences” and “Questioning or challenging the cardiologist’s treatment recommendations”. The cardiologists’ responses to the patients’ resistance included “Repeating the treatment recommendation”, “Negotiation with the patient”, “Providing additional information about the recommended treatment” and “Extending their explanation of the purpose of the treatment”. Conclusions The medical-driven agenda dominated over the patient-driven agenda in consultations between health care professionals and patients with AF. During conversations in consultations with nurses, the patients initiated discussion of living with AF and were more talkative than they were with physicians. An awareness of types of patient resistance to treatment would enable cardiologists to consider patients’ experience-based views about their treatment;

Depression is a nebulous term that is used in a variety of ways to account for a range of experiences usually characterized by low mood, lethargy, diminished pleasure from activities, among others. One prevalent way of making sense of depression in North America is through a biomedical discourse that constructs depression as resulting from an imbalance of neurotransmitters in the brain. Such an explanatory discourse supports antidepressants as the treatment of choice for depression, despite controversy associated with this discourse and disputes about the effectiveness and appropriateness of antidepressants for the treatment of most presentations of depression. In spite of challenges Western physicians face in diagnosing and treating depression, its management overwhelmingly occurs in primary care. Models of primary care treatment decision-making range from those that frame physicians as the principal decision maker (paternalism) to those that feature patients as more autonomous deciders (patient-directed approaches). Existing in the centre of the treatment continuum is a range of joint approaches that feature a more equal relationship between physician and patient. Over the last several decades, paternalism as the traditional approach to treatment decision-making has given way to joint approaches that are heralded as the best ways to manage complex disorders that involve multiple treatment approaches with variable risks and benefits, as depression is often framed. Requests for antidepressants can be considered either patient-directed or joint approach actions, depending on how they are presented. Research on this topic typically focuses on statistical analyses of whether or not patient requests for antidepressants are granted, and whether they help or hinder treatment. Little research has focused on qualitative explorations of how patients and physicians construct accounts about requests themselves. For Study 1, Dr. McMullen and I interviewed 11 family physicians and asked them whether they experienced, and how they managed, patient requests for antidepressants. I used a discursive analytic approach in analyzing the data from the interviews and argue that (a) physicians framed patients as autonomous treatment decision-makers while defining limits on these decisions, and (b) they framed denials of what they characterized as inappropriate requests for antidepressants through patient-centered (and persuasive) approaches to refusal. For Study 2, I interviewed 11 patients about their experiences requesting antidepressants from their physicians. Using a discursive analytic approach, I argue that (a) patients provided accounts of employing what can be considered a soft sell approach in requesting antidepressants, while framing their physician’s contribution to decision-making as necessary and important, and that (b) unexpected outcomes which followed requests for antidepressants (i.e., not having their request endorsed by their physician or having their request fulfilled too readily by their physician) can be understood as discrepancies between the patients’ preferred level of involvement in the process of decision-making and what they encountered. The results of Studies 1 and 2 suggest that these interviewees enacted a physician+ joint approach to treatment decision-making by constructing accounts of requests for antidepressants in ways that largely favour the physician as the lead role within a broadly joint approach to decision-making. Despite attempts to avoid conceptualizations of being overly directive or uninvolved in the process of decision-making, physician and patient interviewees framed conflict as inevitable and offer hints as to how conflict might be avoided or mitigated. To the extent that both patients and physicians are attempting to get their respective needs met from one another within the primary care consultation, I frame their accounts as evidence of a mutual or reciprocal persuasion that is characteristic of more equal relationships. Finally, I bring together some of the controversies associated with treating depression with antidepressants in a primary care setting and raise broader questions about the role of the general practitioner in the management of depression.

Shared Decision Making (SDM) in medical consultations has received significant attention in the literature over the past 10 years. Research indicates that patients’ desire both components of SDM, information sharing and behavioural involvement, to differing degrees (Flynn, Smith, & Vanness, 2006) and that matching medical care to these preferences may be associated with better patient health outcomes (Cvengros, Christensen, Cunningham, Hillis, & Kaboli, 2009). In this thesis, relationships between SDM preferences and patients’ personal characteristics (demographic factors and personality attributes) were investigated (Objective one), as well as associations between patient’s SDM preferences and the features of the health concern that they were seeking care for (Objective two). The current study used 158 Christchurch residents who were part of a longitudinal health and wellbeing study. They completed a questionnaire that measured their general SDM preferences, their demographic and personality characteristics and their preferences for SDM, given four hypothetical health complaints. These complaints varied in duration and perceived seriousness. Demographic variables and personality variables accounted for approximately the same amount of variance in participants’ general preferences for SDM, together describing 33% and 42% of the variance in information sharing and behavioural involvement. The strongest contributors were all three Health Locus of Control variables, sex and education level. Big Five personality traits and participant self-rated physical health did not account for a significant amount of variance in SDM preferences, once all variables were controlled for. In addition, the features of the health concern were marginally associated with participants’ SDM preferences for that specific consultation. Between-subjects analyses found that the duration or perceived seriousness of the health complaint were not associated with SDM preferences reported within the first scenario, once participants’ general SDM preferences were accounted for. Whereas, these two features described a significant amount of variance in participants’ information sharing preferences in the within-subjects analyses, when participants’ general SDM preferences were controlled for. Post-hoc analyses reported that chronic health complaints, that were perceived to be highly serious, elicited significantly greater preferences for information exchange than all other scenarios. No association occurred for participants’ preferences for involvement in final decision making across the four scenarios. The findings emphasise that differences occur in patients’ preferences for information sharing and behavioural involvement; both in regard to their general preferences and their specific preferences for these components of SDM within a given consultation. They also identify the central role that patients’ personality characteristics may play in determining their collaboration and involvement in healthcare; associations that are often overlooked by the SDM literature. The current findings contribute to our understanding of patient’s preferences for SDM and implications for practice and future research are discussed.

This research study is based on the cluster system model for effective management of schools in Namibia. with special reference to Erongo Education Region. The cluster system introduces a new perspective on the way the schools arc managed. It radically differs from the historically isolated school, employing individualistic approaches and management practices characterised by strong hierarchical structures and top down decision-making. The cluster system advocates shared decision-making, teamwork, collaboration. integration and networking. In other words clustering provides a superb climate for teachers, principals, parents and learners to interface with one another within a legitimate framework. Clustering is an effective management model that has also been implemented in developed countries such as England, the Netherlands and the United States of America. The research study involved 60 principals as respondents to a questionnaire on the cluster system, its problems and prospects. The major findings indicate that clustering enhances the quality of education through sharing of resources, exchange of ideas among teachers, and closer cooperation between schools. The study identifies numerous challenges in the implementation of the cluster system. These challenges include disparity between schools in the rural and urban areas, lack of reliable transport, lack of facilities and teaching materials in most schools, large distances between schools, teacher isolation and increased workload among personnel. However, if the challenges and prospects of clustering are put on a simple scale, the latter would probably outweigh the former completely. This means that clustering holds encouraging prospects for the education system in Namibia in general and Erongo Education Region in particular. An important finding in this regard is that the majority of the principals in the Erongo Education Region agree that the cluster system has the potential to champion and transcend in effective management of all schools within cluster centres. / Thesis (M.Ed.)--North-West University, Potchefstroom Campus, 2006.

The purpose of the study is to investigate the actual and desired levels of shared decision making in some private and secondary schools in Ankara, Turkey. The sample of the study consisted of 253 teachers from 12 private primary and secondary schools in Ankara. Shared Education Decisions Survey-Revised by Prof.Dr.Donna Ferrara was used to collect data. Descriptive statistics were applied to analyze data. The results revealed that teachers are consulted in some but not all areas of school decisions. They always participate in the decisions about the general issues of their schools. Other areas which they are consulted in are curriculum/instruction, student achievement, pupil personnel, and parental involvement. Likewise, the decisions which they sometimes participate in are in the areas of policy, staff personnel, and staff development. However, it seems that teachers think they rarely or never participate in the decisions about school/community relations, budget, and plant management. According to the results of the survey, teachers always desire to be consulted in most of the decisions. It is understood that only for the curriculum/instruction area some of them stated that they sometimes would like to participate in the decisions.

Background: In recent years, compounded bioidentical hormone therapy (CBHT) has emerged as a popular alternative to manufactured, FDA approved hormone therapy (HT)-despite concerns within the medical community and the availability of new FDA approved "bioidentical" products. This study aims to characterize the motivations for using CBHT in a U.S. sample of ordinary midlife women. Methods: We analyze data collected from 21 current and former users of CBHT who participated in a larger qualitative study of menopausal decision-making among U.S. women. Interviews and focus groups were audio-recorded, transcribed verbatim, and analyzed thematically using an iterative inductive and deductive process. Results: Although women's individual motivations varied, two overarching themes emerged: "push motivations" that drove women away from conventional HT and from alternative therapies, and "pull motivations" that attracted women to CBHT. Push motivations focused on (1) fear and uncertainty about the safety of conventional HT, (2) an aversion to conjugated estrogens in particular, and (3) and overarching distrust of a medical system perceived as dismissive of their concerns and overly reliant on pharmaceuticals. Participants also voiced dissatisfaction with the effectiveness of herbal and soy supplements. Participants were attracted to CBHT because they perceive it to be (1) effective in managing menopausal symptoms, (2) safer than conventional HT, (3) tailored to their individual bodies and needs, and (4) accompanied by enhanced clinical care and attention. Conclusions: This study finds that women draw upon a range of "push" and "pull" motivations in their decision to use CBHT. Importantly, we find that women are not only seeking alternatives to conventional pharmaceuticals, but alternatives to conventional care where their menopausal experience is solicited, their treatment goals are heard, and they are engaged as agents in managing their own menopause. The significance of this finding goes beyond understanding why women choose CBHT. Women making menopause treatment decisions of all kinds would benefit from greater shared decision-making in the clinical context in which they are explicitly invited to share their experiences, priorities, and preferences. This would also provide an opportunity for clinicians to discuss the pros and cons of conventional HT, CBHT, and other approaches to managing menopause.

Följande uppsats är en begreppsanalys med syftet att studera och beskriva innebörden av begreppet ”partnerskap” ur ett vårdvetenskapligt perspektiv. Begreppsanalysen gjordes för att bidra till en djupare kunskap och förståelse samt tydlig innebörd av begreppet inom hälso- och sjukvård. Metoden som användes var granskning av ordböcker, synonymordböcker och vetenskapliga artiklar där karaktäristiska, förutsättningar och konsekvenser av begreppet beskrevs. Genom att studera de vetenskapliga artiklarna fick vi en djupare förståelse för innebörden av begreppet i relation till kontext. Tre fallbeskrivningar utformades som illustration och förtydliga resultatet. I analysen identifierades fyra framträdande attribut av begreppet, patienten som ansvarstagande partner, förutsättningar för partnerskap, delta i beslutfattande och delad makt. Resultatet visar att partnerskap inom hälso- och sjukvård innebär ett delat ansvar mellan patient och vårdgivare, och vården måste anpassas efter båda parters respektive mål, expertis, och resurser. Partnerskapet skall förstås som en djupare relation av jämlika parter med ett gemensamt ansvarstagande och åtagande för de handlingar som ingår i partnerskapet. Parterna utbyter kunskap, expertis, teknik, erfarenheter, finansiella och emotionella resurser, för att bidra till att målen uppfylls. I diskussionen visar vi att begreppet används inom skilda områden och med liknande betydelse. Partnerskap i Hälso- och sjukvården bygger på ett samarbete mellan vårdgivare och patient där patientens berättelse är utgångspunkten. Detta påvisas i fallbeskrivningar och innebär att sjuksköterskan ansvarar att förvalta berättelsen och att bjuda in till delaktighet.

Att vara delaktig i vården kan innebära att samarbeta, engageras i beslut eller ha kunskap om sin sjukdom. Delaktighet är en rättighet som alla individer har. Depression är den främsta orsaken till ohälsa och funktionsnedsättning i hela världen. Trots att delaktighet visats gynna patienter i sin vård visar studier att patienter med depression exkluderas till delat beslutsfattande. Syftet var därför att från ett patientperspektiv beskriva delaktighet i kontakt med vården vid depression. Studien genomfördes som en allmän litteraturstudie med en induktiv design. Under databearbetningen framkom tre kategorier, informationens betydelse, stödets betydelse och tillitens betydelse. Resultatet i studien visar att information, stöd och tillit är mycket viktiga delar för att patienten ska kunna vara delaktig i sin vård och behandling. Brist på information kan leda till osäkerhet hos patienten samt en bristande tillit till hälso- och sjukvårdspersonal. Dessa förutsättningar är viktiga att känna till för att sjuksköterskan skall kunna involvera patienter till att vara delaktiga i sin vård. För att kunna tillämpa delaktighet i vården är det viktigt att sjuksköterskan får kunskap om vad delaktighet innebär för patienten. / Being involved in the care can involve cooperation, involvement in decisions or knowledge of the patients’ illness. Participation is a right that all individuals have. Depression is one of the main causes of health issues and disability throughout the world. Although patient participation has been shown to benefit patients in their care, studies show that patients with depression are excluded from shared decision-making. The purpose was therefore to describe patient participation in care of depression from a patient perspective. The study was conducted as a general literature study with an inductive design. Three categories emerged during the data processing, the importance of information, the importance of support and the importance of trust. The result of the study shows that information, support and trust are three very important elements for the patient to be able to participate in their care and treatment. Lack of information can lead to patient insecurity and lack of confidence in healthcare professionals. It is important to know these conditions, so that the nurse can engage patients to be involved in their care. To be able to apply patient participation in care, it is important that the nurse gets knowledge of what participation means for the patient. / ingen.

Background: Little is known about shared decision-making (SDM) interventions with Aboriginal Peoples. Purpose: To explore Aboriginal women’s SDM needs and engage Aboriginal women in culturally adapting an SDM approach. Methods: Three studies were guided by an advisory group, ethical framework and a postcolonial theoretical lens. 1. A systematic review of the literature to identify health decision-making interventions to support Indigenous Peoples. 2. An interpretive descriptive qualitative study using individual interviews with Aboriginal women to explore decision-making needs. 3. An interpretive descriptive qualitative study to culturally adapt and usability test the Ottawa Personal Decision Guide (OPDG) to support decision making by Aboriginal women. Results: 1. The only eligible intervention study was a randomized control trial conducted in the United States with 44 Indigenous students. Compared to baseline, post-intervention the students demonstrated increased knowledge and use of a four-step decision-making process. 2. Interviews with 13 Aboriginal women supported SDM. Shared decision-making needs were represented by four major themes and presented in a Medicine Wheel framework: To be an active participant; To feel safe with care; Engagement in the decision process; Personal beliefs and community values. Supports for each of the major themes focused on the relational nature of shared decision-making. 3. Aboriginal women participated in two focus groups (n=13) or usability interviews with decision coaching (n=6). For culturally adapting the OPDG seven themes were identified: “This paper makes it hard for me to show that I am capable of making decisions”; “I am responsible for my decisions”; “My past and current experiences affect the way I make decisions”; “People need to talk with people”; “I need to fully participate in making my decisions”; “I need to explore my decision in a meaningful way”; “I need respect for my traditional learning and communication style.” Conclusions: There is little evidence on SDM interventions with Indigenous Peoples. Although Aboriginal women support SDM, they may have unmet decision-making needs. The OPDG was culturally adapted to be combined with decision coaching and needs to be evaluated.