People are living longer and this increases the risk of encountering financial difficulties when trying to make fixed retirement incomes stretch over additional years. Increased life expectancies also increase the likelihood of encountering a health issue including cognitive or functional declines that can affect money management capabilities. There are government entitlement programs available to assist retired Canadians but these programs are under review and new policies are being considered in order to reduce fiscal pressures. At the same time, family roles and structures are changing and informal supports available to previous generations may be reduced. As well, if an older person’s money is poorly managed there will be fewer options for maintaining quality of life in the retirement years. This increases the risk of poverty for older Canadians. The goals of this research are to: understand individual risk factors including demographic, clinical and social support characteristics among Canadians age 55 and over who are experiencing poverty; to understand the predictive characteristics for moving into or exiting from poverty; and, to develop a comprehensive description of those who have great difficulty managing their finances. In order to achieve this, data from the interRAI Home Care (RAI-HC) assessment instrument were used. Three regions, Winnipeg Regional Health Authority (WRHA), Nova Scotia and Ontario, were analyzed in order to understand the characteristics of those making economic trade-offs (N=345,678). Data from the province of Ontario was used to understand predictors of poverty transitions (N=47,653) and to develop a profile of those having great difficulty managing their finances (N=321,816). In order to answer each question of interest multivariable logistic regression modeling was used. Results from the analyses found that those most at risk for making economic trade-offs were in the age 55 to 64 group, had three or more depressive symptoms and were separated or divorced. Gender was not a risk factor. Regional differences for poverty risks were also identified showing greater risks for those experiencing mental health issues in WHRA, for those with more clinical indicators in Ontario, and for younger residents (age 55 to 64) in Nova Scotia. The longitudinal analyses on poverty transitions revealed that females who had completed at least a grade eight education were more likely to exit poverty. The younger group (age 55 to 64 years) with three or more depressive symptoms and experiencing unstable health were more likely to enter poverty. Marriage and older age were protective from the risks of entering poverty. Results from the analyses of those likely to have great difficulty with financial management indicated that deficits in cognition, procedural memory and function increased the risk of being unable to manage personal finances. Gender and marital status were not associated with financial management difficulty. The development of a profile of those who are making economic trade-offs and those at risk of having difficulty with financial management provides the opportunity for early intervention. Those who have not reached the traditional retirement age of 65 have an increased risk of poverty. Understanding characteristics of those who exit poverty will help establish policies and programs that will assist older Canadians. These are important issues due to the increased number of post-employment years that Canadians are living and the national focus on fiscal restraints. The management of finances has received minimal scientific research and evidence is needed to understand when changes in capability occur and how these changes may be supported by appropriate levels of assistance and supportive devices.

Purpose: The purpose of this dissertation was to examine the determinants of unplanned emergency department (ED) use by home care clients, the profile of older ED patients, their transitions from the ED, as well as the determinants of post discharge outcomes among older ED patients. The goal of this dissertation was to create theoretically driven, evidence-based, and practical risk identification methods for home care and the ED. Methods: First, a multi-year, census-level cohort study was conducted on home care clients in two Canadian provinces (N=617,035). Census-level data from RAI-HC assessments were linked to census-level ED records. A needs-based decision tree model – the ED Model – informed by the Andersen Behavioural Model, was created using decision tree analyses. The final model was validated on a separate data partition and compared to the ERA Index and the CARS. Multilevel analyses were conducted to test regional variation in model performance. Disease stratified analyses were also conducted to test model generalizability across common disease classes. Regression analyses determined the effect of predisposing and enabling factors within ED Model strata. Second, a multi-site, multi-province prospective cohort study was conducted, termed the Management of Older Persons in Emergency Departments (MOPED) Study, using a clinically representative sample of 2,101 older ED patients. The interRAI ED-CA was used to assess older ED patients, and a 90-day disposition was collected. The profile of older ED patents was examined. Best-subset regression analyses identified person-level determinants of acute inpatient admission. Two needs-based decision tree models – the ALC/LTC and ED Revisit Models – were created using decision tree analyses to determine the risk of ALC designation or LTC placement, and unplanned repeat ED visits, respectively. Both models were validated on separate data partitions. Multilevel analyses were conducted to test site-level variation in the models’ performance. Results: Overall, 41.2% of home care clients had at least one unplanned emergency department visit within 6 months of an assessment. Previous ED use, cardio-respiratory symptoms, cardiac conditions, and mood symptoms featured heavily in the ED Model. The ED Model provided moderate risk differentiation and clinical utility. It achieved an area under the curve of 0.62 (95% CI: 0.61-0.62) and showed clear differentiation in Kaplan-Meier plots using validation data. Multi-level analyses showed no regional variation. The ED Model significantly outperformed the similar tools specific to primary care with respect to overall accuracy and perceived clinical utility. Predisposing and enabling characteristics provided little added differentiation beyond evaluated need. The majority of older ED patients were dependent on others for basic tasks of daily living, and many had fragile informal care or lived alone. Triage acuity generally did not differentiate chronic geriatric disabilities and conditions. Previous ED or hospital use was associated with chronic geriatric disabilities and conditions as well as informal caregiver distress. The Admission Model found that multiple factors were associated with admission to inpatient acute care, including: acuity, instability, changes in ADL function, cognition, nutrition, and anhedonia. Overall, 20.7% of older ED patients admitted to acute care were designated ALC or discharged to LTC; whereas 39.5% of older ED patients discharged home had one or more repeat ED visits within 90 days. Cognitive, functional, and informal care indicators were predictive of ALC/LTC; whereas functional status and symptoms were predictive of repeat ED use. The ALC/LTC and ED Revisit Models provided good risk differentiation, achieving AUC’s of 0.74 (95% CI: 0.69-0.79) and 0.69 (95% CI: 0.63-0.74), respectively. The ALC/LTC and ED Revisit Models showed clear differentiation in Kaplan-Meier plots. Multi-level analyses showed no site-level variation in each models’ performance. Conclusions: This dissertation produced tangible and empirically-based risk assessment models for clinical practice in home care and the ED. The models developed in this dissertation can support the targeting of preventative services as well as better communication strategies between the ED and community supportive care, primary care, and inpatient acute care. Key questions related to the prevention of the risk pathways identified in each risk assessment model remain unanswered, and should be a focus of future research.

国立情報学研究所で電子化したコンテンツを使用している。

国立情報学研究所で電子化したコンテンツを使用している。

国立情報学研究所で電子化したコンテンツを使用している。

Introduction: Studies show that women living in Sweden treated for coeliac disease have lower subjective health than other women. After showing signs of remission, adults who have coeliac disease and follow a gluten-free diet, are expected to handle the treatment without any further planned follow-up by health care. Aim: The overall aim of this thesis was to study aspects of living with coeliac disease in adults in the years beyond the diagnosis. Methods: Quantitative methods were used in Studies I, II and III. A qualitative content analysis was performed in Study IV. Results: The results show that women with coeliac disease have a lower level of well-being than men with coeliac disease. The women who have coeliac disease reported a high rate of gastrointestinal symptoms, although they followed a gluten-free diet, and they visited health care services more frequently than women who did not have coeliac disease. A low rate of gastrointestinal symptoms, a positive self-image and few comorbidity emerged as factors that positively affected well-being. Worries also seemed to be a companion of women diagnosed with coeliac disease in adulthood, typically evident when socializing with others. Conclusion: This thesis may provide evidence questioning the validity of declaring all women with coeliac disease showing a normalized intestinal mucosa to be in remission, and thus leaving them to self-management. Clinical implications: Health care professionals need to be aware of that the transition to a gluten-free life may vary for individuals. It does not seem enough to follow a gluten-free diet to reach a state of good well-being for all women. A major task for health care providers is therefore to support women with CD in reaching better subjective treatment outcomes. The results may also contribute to that health care system develops routines in order to optimise the care and treatment of these patients.

The purpose of the research project was to examine the effects of exercise and social support for postnatal women who reported experiencing Postnatal Depression (PND). PND is a serious condition that affects up to 10%-15% of women (O'Hara & Swain, 1996). Many previous studies have reported an improvement of depressive symptomatology following a pram walking intervention. However, no published research exists which assesses postnatal women who report experiencing PND. A randomised controlled trial was used, where pre-test data were compared to post-test effects. Two studies were conducted. In study 1 (n= 20) a multi-intervention group (exercise and social support) was compared to a control group who received no intervention. Study 2 (n= 19) was conducted 20 months later on a different group of women and involved a pram walking intervention group and a comparison social support group. Structured questionnaires assessing depressive symptomatology, general health and levels of social support were administered at pre-test phase, week 6 and 12. A sub-maximal fitness test was conducted the week before the program started and at week 12. The chief investigator was present at all sessions to guide the participants. Study 1 (S1): The multi-intervention group attended 3 pram walking sessions per week. After the exercise session the group met for refreshments in a local hall. The control group was only required to perform the fitness tests and answer the questionnaires. A 6-week alternative program of exercise and social support was offered to all the women at the completion of the intervention period. Study 2 (S2): The pram walking group met for 2 exercise sessions and were required to make up the third session independently. The comparison social support group met once per week for morning tea with the children. The samples for both studies were drawn from the Gold Coast region in Australia. Women of childbearing age who were experiencing depressive symptoms were recruited. For S1 their child had to be less than or equal to 12 months and for S2 the age cut off was increased to less than or equal to 18 months. The participants were screened to ensure that they did not have a medical condition that would prevent regular aerobic exercise and they were also excluded if they had a previous history of mental illness or could not speak English. Demographic data were obtained from each participant and details such as height, weight and age were collected for use in analysing fitness levels. The data for each study were collected across three time points (pre, week 6 and week 12) using widely tested instruments. Some additional questions relating to the participants experiences were collected at the completion of the study from the women allocated to the intervention groups. Data were also collected on fitness levels (pre and week 12) and the instrument was tested for its reliability. Both pram walking intervention groups were required to complete a weekly exercise diary. For each study, to test for the effect of the intervention over time, a two-way analysis of variance was conducted on the major outcome variables. Group (intervention versus control) was the between subject factor and time (pre-test, week 6, week 12) was the within subject factor or repeated measures factor. Due to the small sample size, further tests were conducted to check the assumptions of the statistical test to be used. The results showed that using Mauchly's Test, the Sphericity assumptions of repeated measures for ANOVA were met. Further, tests of homogeneity of variance assumptions also confirmed that this assumption was met. Data analysis was conducted using the software package SPSS for Windows Release 10.0. (Norusis, 2000). Overall, the findings from both S1 and S2 showed that the groups who received the pram walking intervention improved their depressive symptomatology and fitness levels when compared to those of the control (S1) and social support group (S2). Social support levels did not alter for either group from both studies. These results are encouraging and suggest that a pram walking program is an effective form of intervention for postnatal women experiencing depressive symptomatology.

Children and adolescents are now using online communication to form and/or maintain relationships with strangers and/or friends. Relationships in real life are important for children and adolescents in identity formation and general development. However, social relationships can be difficult for those who experience feelings of loneliness and social anxiety. The current study aimed to replicate and extend research conducted by Valkenburg and Peter (2007b), by investigating differences in online communication patterns between children and adolescents with and without selfreported loneliness and social anxiety. Six hundred and twenty-six students aged 10-16 years completed a questionnaire survey about the amount of time they engaged in online communication, the topics they discussed, who they communicated with, and their purposes of online communication. Following Valkenburg and Peter (2007b), loneliness was measured with a shortened version of the UCLA Loneliness Scale (Version 3) developed by Russell (1996), whereas social anxiety was assessed with a sub-scale of the Social Anxiety Scale for Adolescents (La Greca & Lopez, 1998). The sample was divided into four groups of children and adolescents: 220 were “non-socially anxious and non-lonely”, 139 were “socially anxious but not lonely”, 107 were “lonely but not socially anxious”, and 159 were “lonely and socially anxious”. A one-way ANOVA and chi-square tests were conducted to evaluate the aforementioned differences between these groups. The results indicated that children and adolescents who reported being lonely used online communication differently from those who did not report being lonely. Essentially, the former communicated online more frequently about personal things and intimate topics, but also to compensate for their weak social skills and to meet new people. Further analyses on gender differences within lonely children and adolescents revealed that boys and girls communicated online more frequently with different partners. It was concluded that for these vulnerable individuals online communication may fulfil needs of self-disclosure, identity exploration, and social interactions. However, future longitudinal studies combining a quantitative with a qualitative approach would better address the relationship between Internet use and psychosocial well-being. The findings also suggested the need for further exploration of how such troubled children and adolescents can use the Internet beneficially.

Vernacular houses reflect the social complexity of the times and region in which they exist. These houses are continually evolving in response to changes in the residents’ sense of well-being. However, the rapid progression of modernity and urbanization over the past fifty years has strongly altered the underlying cultural meanings of domestic well-being in traditional societies. This has caused the disappearance of vernacular houses in various localities. The present research is especially concerned with surviving Thai vernacular houses. Its aim is to establish an understanding of the relationship between changes of Thai residents’ experiences of well-being, or Khwam Phasook in the Thai language, and the physical and socio-cultural evolution of their vernacular houses. The study was conducted by examining the evolution of vernacular houses in Tambon Pakkran of Pra Nakhon Si Ayutthaya in central Thailand. Two main types of data were collected: evolution of the physical characteristics of vernacular houses, and the changes of patterns of use and the meanings attributed to them. The data obtained were analyzed and discussed through systemic taxonomy, cross-case analysis and graphical representation using multiple criteria. The residents’ narrations were also used to explicate the historical development of the houses investigated.

Background: People are living longer with chronic life-limiting illnesses such as cancer. Much is expected of lay cancer carers with the shift of complex non-acute care to the community and the pressures this can place on family relationships. The lay caregiving role does not appeal to all, yet willingness to care is often expected by others including health professionals. Carers who feel reluctant but committed to the role may experience adverse consequences. Reluctance to care is under-investigated, particularly in the cancer context, and its indicators may include a poor carer-patient relationship, perceived lack of choice and lifestyle disruption. Existing theories of caregiving do not adequately explain reluctance to care, and the concept remains under-developed. The assumptions underpinning this study are that: some cancer carers are reluctant to care, some carers may be reluctant toward specific aspects of the caregiving role or at different times during the cancer trajectory, and some reluctant carers will not want to reveal or discuss their unwillingness. Aim: The aim of the study was to gain a clearer understanding of lay carers’ reluctance to care for patients with recurrent cancer. Methods: A mixed methods design was used. In Phase I, data provided by a consecutive sample of carers (N = 98) of cancer patients corresponding to the patients’ final year were analysed to explore the context in which reluctance to care might exist or develop, and focusing on differences by spousal relationship and by gender in anxiety and depression, awareness of the stage of cancer, perceived social support, and perceived burden. In Phase II, a purposive sample of carers of patients with recurrent cancer (N = 16) were interviewed in-depth, using open-ended questions to generate qualitative data regarding their perceptions and experiences of caregiving and reluctance to care. Complementary data were obtained from a purposive sample of health professionals who interact with cancer carers (N = 13). The interview transcripts were analysed qualitatively to identify patterns and themes which would provide insights into the dimensions of reluctance to care. Results: In Phase I, spouses perceived greater family support but caregiving had a greater negative impact on their daily activities and social interaction. Non-spouses were more anxious than spouses, but reported greater social support, and less negative impact on their finances, daily schedule and health. Female carers were more anxious and depressed than males, who reported less burden and greater social support. Awareness of the stage of cancer was positively but weakly correlated with anxiety and depression. In Phase II, reluctance to care was experienced by both spouses and non-spouses and was not gender specific. Carers and health professionals held diverging perceptions and expectations of the lay caregiving role. Caregiving was an obligatory but invisible role and for some carers it led to exhaustion due to a lack of role boundaries. Carers were faced with forced choices. The lay caregiving role seemed to come as a non-negotiable package of expectations which gave carers the autonomy to accept their role rather than the choice to refuse it. Contextual factors which seem conducive to reluctance were overshadowed by carers’ commitment to the role, which suggests that their preferences were a lower priority despite the personal cost. There was indirect evidence of reluctance in others: family members distanced themselves from the caregiving situation, and health professionals were distanced from carers by their patient-centredness. Conclusions: This study has identified three fundamental dimensions of reluctance to care: the invisibility of the caregiving role, its lack of boundaries and its forced choices. Caregiving is often a sacrificial rather than reciprocal role, but reluctance is seen as an abnormal rather than realistic response to abnormal role expectations. The findings were limited by the extent to which carers disclosed reluctance and the extent to which reluctant carers remained in the role. As a result, reluctance to care may have been underestimated. Measuring this latent and taboo topic is likely to remain a challenge as the concept of reluctance to care continues to evolve. This study has established the importance of ongoing work on a topic which cannot remain hidden as the need for lay cancer care continues to expand.