Thèses sur le sujet « Administration and it Programs Health of the Family »

The study of policy implementation has recently garnered research and federal attention highlighting the importance of implementation in achieving desired policy and program outcomes (Durlak & DuPre, 2008; Meyers, Durlak & Wandersman, 2012; National Institutes of Health, 2013). Psychology is one discipline that is well poised to guide the study of policy implementation as it can inform the creation, development, and outcomes associated with the introduction of a policy (Esses & Dovidio, 2011; Fischhoff, 1990). Given that batterer intervention programs (BIPs) have been developed to prevent future intimate partner violence (IPV) and improve victim safety, ensuring these programs have successfully implemented state standards for practice is immensely important. Despite the widespread use of state standards to guide BIP practices (Maiuro & Eberle, 2008), only one study (Boal, 2010) has assessed the extent to which BIPs comply with standards and no research has evaluated program responses to standards or the process by which implementation occurs. Given this, the current study focused on four areas of inquiry: (1) program compliance with state standards; (2) current and former BIP representatives' response to standards, including the social psychological constructs of actual control, perceived control, retrospective accounts of attitude change, absoluteness, and legitimacy; (3) program compliance as it relates to these responses; and (4) the process of implementing standards. In order to address these topics, key program representatives were assessed using a sequential mixed-methods design, which consisted of a preliminary quantitative phase (i.e., Phase One) (n = 35, response rate = 74%) and principal qualitative phase (i.e., Phase Two) (current providers: n = 13, response rate = 87%; former providers: n = 5, response rate = 100%) (Morgan, 1998). Findings from Phase One indicate that programs complied with 75% of the assessed components of standards. Phase Two findings suggest that participants primarily voiced experiences with the standards consistent with a lack of actual control, perceived control, and legitimacy. Contrary to hypotheses a statistically reliable difference in actual control, perceived control, and legitimacy were not detected across high and low compliance participants. Participants retrospectively described responses to the standards consistent with changing and maintaining negative attitudes towards the standards (31% and 31% respectively) and as hypothesized, those who shifted negative initial attitudes to be positive (i.e., a proxy for rationalization) were primarily from high compliance programs (75%) and those who maintained negative attitudes (i.e., a proxy for reactance) were all from low compliance programs (100%). While participants generally perceived the standards as primarily absolute, this construct did not differentiate those who changed and maintained negative attitudes as predicted. Participants' utilized diverse strategies to implement the standards and have changed or attempted to change many program characteristics to better comply with state standards. Participants have experienced diverse enablers to compliance (e.g., positive community collaborations; participation in the research process) and barriers to compliance (e.g., negative or lack of community collaborations; challenges understanding the standards) while attempting to implement standards. Suggestions to better facilitate compliance aligned with the enablers and barriers and centered on the need for positive information-sharing relationships among providers. Finally, former providers tended to disagree that the standards were the primary reason for program closure. Together, these findings provide valuable insight into the manifestation of common social psychological constructs during the policy implementation process, as well as information regarding the logistics of implementation. The information gathered in this study can be applied to better understand the role of actual control, perceived control, retrospective accounts of attitude change, absoluteness, and legitimacy, as they are experienced in the real world in relation to an actual policy. This extends the study of these constructs out of a laboratory and experimental context and suggests aspects of these constructs that may be relevant in applied settings. Further, data regarding the policy implementation process is useful to inform policymakers about the diverse steps that can be taken to assist implementation efforts and increase compliance.

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In this work we presented a study concerning the popular participation in the local administration of the Programa Saúde da Família (PSF) (Health of the Family Program) (PSF), in the municipal district of Campina Grande-PB (Brazil), in the optics of three segments: community counselors of health, users and professionals of PSF. Starting from an approach report - conceptual on the triad: Politics of Health in Brazil, social Participation and PSF, we contemplated on the process of constitution of the popular participation in the politics of Brazilian health, specifically in the ambit of PSF. We accomplished the research in two Basic Units of Health of the Family of the districts, Pedregal and Tambor, respectively, in your Local Council of Health (CLS). We interviewed fourteen subjects, distributed in six professionals, four counselors and four users. We developed such research in a descriptive-analytic perspective, through a qualitative approach, tends as techniques of collection of data the semi-structured interview and the direct observation. Sistematizamos e analisamos os dados, a partir de três categorias, seguindo o método de análise de conteúdo, em Bardin (1977). The results indicated a significant progress in the process of popular participation in the administration of the actions of PSF, countersigned by the following aspects: good level of the community counselors' of health participation, being translated in the discussion, elaboration of proposals and direction of the specific subjects in the field of the health and us other existent problems in the community; effectiveness of the participation of the Educational Groups in the actions of PSF, in the perspective of the users' social insert as subjects in the process health-disease. However, we observed some limitations: the community representatives' of CLS non participation in the planning of the actions developed by the teams of PSF; difficulty of CLS in establishing dialogue with the community ones, countersigned by the lack of the community's participation in your meetings; non attendance of the counselors' solicitations and referring users to the largest amount of basic medicines to supply the community demand; and lack of permanent training for the professionals. Face to the obtained data, we considered that the experience developed by PSF it assumes dimension of fundamental importance in the field of the public health, because, in the measure in that CLS and the Educational Groups join leaderships and the community's people to face the process health-disease, they are configured as mechanisms for the construction of the popular participation, making possible in practice the objective of the democracy in the local administration of PSF.
Neste trabalho apresentamos um estudo acerca da participação popular na gestão local do Programa Saúde da Família (PSF), no município de Campina Grande-PB, na ótica de três segmentos: conselheiros comunitários de saúde, usuários e profissionais do PSF. A partir de uma abordagem histórico-conceitual acerca da tríade: Políticas de Saúde no Brasil, Participação Social e PSF, refletimos sobre o processo de constituição da participação popular na política de saúde brasileira, especificamente no âmbito do PSF. Realizamos a pesquisa em duas Unidades Básicas de Saúde da Família dos bairros Pedregal e Tambor e, respectivamente, nos seus Conselhos Locais de Saúde (CLS). Entrevistamos quatorze sujeitos, distribuídos em seis profissionais, quatro conselheiros e quatro usuários. Desenvolvemos tal pesquisa numa perspectiva descritivo-analítica, através de uma abordagem qualitativa, tendo como técnicas de coletas de dados a entrevista semi-estrutrada e a observação direta. Realizamos o processo de sistematização e análise dos dados a partir do estabelecimento de categorias, seguindo o método análise de conteúdo, em Bardin (1977). Os resultados indicaram um significativo avanço no processo de participação popular na gestão das ações do PSF, referendados pelos seguintes aspectos: bom nível de participação dos conselheiros comunitários de saúde, traduzindo-se na discussão, elaboração de propostas e encaminhamento das questões específicas no campo da saúde e nos demais problemas existentes na comunidade; efetividade da participação dos Grupos Educativos nas ações do PSF, na perspectiva de inserção social dos usuários como sujeitos no processo saúde-doença. Porém, observamos algumas limitações: a não participação dos comunitários representantes do CLS no planejamento das ações desenvolvidas pelas equipes do PSF; dificuldade do CLS em estabelecer interlocução com os comunitários, referendada pela falta de participação da comunidade em suas reuniões; não atendimento das solicitações dos conselheiros e usuários referentes à maior quantidade de medicamentos básicos para suprir a demanda comunitária; e falta de capacitação permanente para os profissionais. Face aos dados obtidos, consideramos que a experiência desenvolvida pelo PSF assume dimensão de fundamental importância no campo da saúde pública, pois, na medida em que os CLS e os Grupos Educativos agregam lideranças e pessoas da comunidade no enfrentamento do processo saúde-doença, configuram-se como mecanismos para a construção da participação popular, viabilizando na prática o objetivo da democracia participativa na gestão local do PSF.

Despite the emphasis of benefits on preventive health, many older adults are not receiving the recommended age specific, evidence based screenings and vaccinations. The Medicare Annual Wellness Visit (AWV) is designed to address modifiable risk factors with aging adults and close gaps in care not captured in routine office visits. Although a free Medicare benefit to patients, and a reimbursable service to health care providers, participation in the AWV is low nationwide. The purpose of the project is to introduce an AWV program to a rural health clinic in Northwest Illinois that has a population consisting of over 25% of people 65 years and older. The rural health clinic failed to capture a single AWV in the previous year, despite having 1300 active Medicare patients in the clinic. The clinical question asked whether the implementation of an AWV program by nurse practitioners can yield improved compliance with recommended health screenings and vaccinations and diagnosed previously unrecognized clinical conditions. The Iowa model, health belief model and Donebedian's structure-process-outcome model were utilized for the introduction and implementation of the practice change. Evidence was derived from chart review of 50 patients and administration of the SF-36 survey before and following the AWV. Findings and conclusions suggest that the AWV generated improved compliance of preventive services and improved patient quality of life. Addressing preventive health strategies for aging adults is relevant to nursing practice because of the complex and chronic health challenges of this age group. These efforts can reduce the burden of suffering from chronic illness, prevent exacerbation and decline, improve quality of life, and reduce federal and individual health care expenditures to minimize the cost of advanced disease treatment.

INTRODUÇÃO: A atuação de uma equipe de reabilitação junto à Estratégia Saúde da Família (PSF), iniciada na cidade de São Paulo no ano de 2001, inaugura um serviço singular de atenção a pessoas com deficiência na atenção básica. Tal projeto tem como objetivo estabelecer uma cultura de defesa dos direitos da pessoa com deficiência na busca do desmonte dos processos de exclusão social, construindo intervenções que articulem a prevenção de deficiências, reabilitação e educação por meio de ações intersetoriais (Fichino et al, 2008). Essa pesquisa visa conhecer e analisar aspectos da organização do trabalho desse serviço, à luz de aspectos do referencial teórico da gestão da operação de serviços. MÉTODO: Pesquisa qualitativa do tipo estudo de caso baseada nos princípios de Yin (2003) que combinou diferentes procedimentos de coleta de dados (pesquisa documental, entrevistas semi-estruturadas e aplicação de questionários). Foram realizadas sete entrevistas com trabalhadores de uma equipe de reabilitação no ano de 2007. Cada fonte de evidência recebeu tratamento diferenciado tendo em vista a finalidade de sua utilização e posteriormente foi realizado um diálogo dos resultados obtidos para construção de uma cadeia de evidências sobre a qual se construiu o estudo do caso. RESULTADOS: Foi verificado nesse estudo que o conceito do serviço pesquisado não se consolidou devido às mudanças nas políticas públicas de saúde que ancoravam essa experiência e a falhas no projeto do serviço, como por exemplo, o não detalhamento da organização do trabalho. Isso teve impacto para os trabalhadores que diante da fluidificação do conceito do serviço passam a organizar suas ações a partir de estratégias individuais ou de demandas pontuais se remetendo pouco aos pressupostos que fundamentam o serviço. Para os gestores tal quadro resulta na dificuldade de alinhar suas expectativas com o serviço realizado de fato. CONCLUSÃO: O hiato que existe entre a operação e o conceito precisa ser preenchido em duas vias: uma aproximando as proposições teóricas presentes no conceito do serviço da realidade cotidiana de quem desempenha o trabalho; e, na direção oposta, reforçando as premissas do projeto pelo refinamento e incorporação dessas pelos profissionais de linha de frente e gestores
The performance of a rehabilitation team together with the Family Health Program (FHP), begun in the city of São Paulo in 2001, launches a unique service to attend people with deficiencies in primary care. Such service aims to establish a consciousness of protection of the rights of disabled people in order to dismantle the process of social exclusion by creating actions to promote the prevention of disabilities as well as education and rehabilitation through intersectorial interventions. This research seeks to understand and analyze aspects of the work organization of this rehabilitation team based on the theoretical framework of the service operation management. METHODS: Qualitative research conducted by means of case study following Yins principles (2003) which combined different procedures for data collection (desk research, semistructured interviews and questionnaires). Seven interviews were conducted with employees of a team of rehabilitation in 2007. Each source of evidence received a differentiated treatment according to the purpose of its use. And, later, the results obtained were compared for the construction of a chain of evidences on which a case study was built. RESULTS: It has been verified in this study that the concept of the service was not consolidated due to: 1. changes in public health policies that anchored this experience; 2. flaws in the project of the service, such as, the lack of detailing the work organization. These results had an impact on the workers who, before the weakening of the concept of the service, began to base their actions on individual strategies or specific demands, referring very little to the directives that ground the service. For the managers such situation is result of a difficulty to align their expectation with the actual service. CONCLUSION: The gap that exists between the operation and the concept needs to be completed in a two-way street. One way, approaching the theoretical propositions in the concept of the service from the daily reality of who performs the work. And, on the other way, reinforcing the premises of the project by the refinement and incorporation of the front-line professionals and managers

Este estudo tem como objetivo caracterizar o processo de implantação das equipes de saúde da família (ESF) no Estado de São Paulo (ESP) no período de 1996 a 2001. Foram utilizados dados secundários referentes ao Estado, produzidos por uma pesquisa nacional realizada pelo Ministério da Saúde em 2001 e 2002. Esta pesquisa foi ampliada com questões específicas desenvolvidas pela Coordenação Estadual do Programa Saúde da Familia (PSF). Estes dados referem-se às 1058 ESF implantadas em 54% dos municípios do Estado, e foram estruturados abrangendo os seguintes aspectos: 1. caracterização das ESF; 2. infraestrutura (área física, equipamentos disponíveis e recursos humanos); 3. ações desenvolvidas pelas ESF; 4. instrumentos de planejamento e organização do atendimento do trabalho das ESF; 5. capacitações das ESF. As variáveis utilizadas no plano de análise foram o tempo de implantação das equipes e o porte dos municípios. Também foi desenvolvida uma classificação de adequação das caracteristicas estudadas que objetivou verificar maior ou menor aproximação com a situação ideal preconizada pelas diretrizes do PSF. Os resultados do presente estudo fornecem elementos que podem contribuir para implantação de novas ESF e servir como linha de base para estudos futuros.
The objective of this study is to evaluate the implantation of family health teams (FHTs) in the State of São Paulo (SSP), Brazil, during the period 1996-2001. Secondary data from the SSP obtained through a national survey carried out by the Ministry of Health in 2001-2202 were utilized. This survey was expanded by the State Coordination of the Family Health Program (PSF) to include specific questions. These data refer to 1058 FHTs implemented in 54% of the municipalities of the SSS, and were structured to encompass the following aspects: 1. characterization of the FHTs; 2. infrastructure (physical area, available equipment and human resources); 3. actions developed by the FHTs; 4. planning instruments and organization of the work of the FHTs; 5. FHTs training. The variables used for the analysis included time of implementation of the FHTs and size of the municipalities. An adequateness scoring classification for the studied characteristics was developed in order to assess greater or smaller approximation to the ideal situation envisioned by the Family Heath Program (PSF) of guidelines. The results of this study provide elements that may contribute to the implementation of new FHTs and serve as baseline data for future studies.

Orientador: Marcelo de Castro Meneghim
Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Odontologia de Piracicaba
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Resumo: A implantação do Programa de Saúde da Família (PSF), com as Equipes de Saúde da Família (ESF) e as Equipes de Saúde Bucal (ESB), representou uma possibilidade de mudança no modelo de atenção vigente no Brasil. Os modelos assistenciais em saúde implantados anteriormente não conseguiram dar uma resposta satisfatória às necessidades da população. Em Manaus, capital do Estado do Amazonas, o PSF, iniciou-se em março de 1999. Buscou-se neste trabalho descrever os aspectos administrativos e operacionais das equipes de saúde da família no município de Manaus. Todos os Coordenadores do PSF e todos os 387 profissionais de saúde, entre os quais, 167 Médicos, 167 Enfermeiros e 53 Cirurgiões-Dentistas, integrantes do PSF na cidade de Manaus, receberam dois tipos de questionários: um abordando aspectos administrativos, tendo sido dirigido aos coordenadores do programa, e o segundo abordando aspectos operacionais das ESF, aos demais profissionais; desse total, 103 profissionais do PSF aceitaram participar da pesquisa, perfazendo uma taxa de resposta de 26,6%, retornando, portanto os questionários. O percentual de Médicos respondentes correspondeu a 33,9% (35), de Enfermeiros respondentes 47,6% (49), e de Cirurgiões-Dentistas respondentes 18,5% (19). Todos os profissionais trabalham uma jornada de oito horas diárias de trabalho, 60.2% utilizavam mais de uma forma de agendamento dos usuários; 93,2% relataram atender gestantes e bebês, 91.3% dos profissionais Médicos, Enfermeiros e Cirurgiões-Dentistas relataram já ter participado de algum curso de capacitação no PSF; um total de (40.8%) respondeu não haver integração entre os profissionais das ESB e ESF, apenas (36.9%) das ESB participam de reuniões freqüentemente e 54.4% não utilizam prontuários únicos. Conclui-se que, como pontos positivos, a jornada de trabalho de oito horas diárias e a valorização por meio da qualificação profissional e, como pontos negativos, a precariedade da estrutura física dos módulos de saúde da família e a falta de envolvimento entre ESB e ESF
Abstract: The introduction of the Family Health Program (FHP), with the Family Health eam (FHT) and Oral Health Team, represented a possibility in changing the role model of health care previously installed in Brazil. The former health models did not achieve its results for population needs. In Manaus, the capital of the State of Amazonas, The FHP, began in March, of 1999. The purpose of this study is to describe the administrative and operational aspects of FHP, in the county of Manaus. All the Coordinators from the Family Health Program and all health professionals totaling 387 professionals, among them, 167 physicians, 167 nurses and 53 dentists, in the city of Manaus, received two kinds of questionnaires, a questionnaire including questions about the administrative aspects was applied to the coordinators of the program and the one with the operational aspects of FHP, was applied to the rest of the professionals. From those, 26.6% (n=103) of questionnaires were returned representing, 33.9% (35) of the physicians; 47.6% (49) of the nurses; and 18.5% (19) of the dentists. All health professionals, related to work a full-time journey in the program of 8 hours a day, 60.2% used more than one way to schedule the patients, 93.2% related to attend mostly pregnant women and babies, 91.3% of the professionals, Physicians, Nurses and Dentists informed that had attended some kind of Professional qualification with the FHP, a total of 40.8% replied that did have a lack of integration among professionals of OHT and FHT professionals and only 36.9% of OHT attended meetings on a regular basis and 54.4% did not use common charts. As a conclusion, on the positive aspects, the full-time journey at work and the valorization through continuing education program. On the negative aspects, the lack of infra-structure of the facilities of the FHT, and the lack of integration among, OHT and FHT
Doutorado
Saude Coletiva
Doutor em Odontologia

O PSF emerge para reordenar o modelo de atenção à saúde. Os objetivos deste trabalho são o de estimar o consumo dos serviços de saúde e identificar a capacidade de oferta de serviços da USF. Foram realizadas entrevistas sobre o consumo de serviços de saúde por amostragem na população adscrita a equipe 01 da USF Jd Pirituba no Município de São Paulo. A procura por serviço de saúde nos 15 dias que precederam a entrevista foi de 22%. O local mais procurado foi o Centro de saúde. O principal motivo de procura foi a consulta clínica (51%). A descrição e análise do consumo efetivo da população adscrita às equipes de PSF pode servir como um importante instrumento para o planejamento das ações da USF
Brazil still has a National Health System unable to meet the needs of the population. Since the year 2001 the city of São Paulo established the Family Health Care Program as a structural strategy for the municipal health system. The hypothesis of this research is that the Family Health Care Program, as the other models of health care, offers services without matching the people utilization of health supplies. To stimate the utilization of health care supplies of a population visited by the Family Program (1360 families) and to identify the care services provided by a Family Health Care team are the objetives of this survey. A community inquiry were carried out among a sample from the population assisted by a family health care team in the Distritct of Pirituba located in the north-west of the city of São Paulo. The supervisor and the general phisicyan were also interviewed in order to estimate the services provided by the health team. The results showed an adult population, low level of literacy and low income. Thirthy-one percent was the population having a supplementary private health insurances. Twenty-two percent of the population seek the care of a professional within 15 days before the interview. The primary care services has the skill to be a portal of entry to the health System. People suffering from hypertension, heart disease and depression use more health services than healthy population. Searching for a physician appointment was 51% of the reasons to go to a health service, showing a poor interdiciplinary teamwork culture. Self-medication was very high for those medicine causing important side-effects. Referring patients to a specialist, having access to high-technology procedures and finding a place at hospitals were the main dificultties found by the family health care team. The health care coverage of the family health care team do not consider the utilization of health services by tha area served by them keeping the old fashion way of planning health services. The services they provide are not enough to meet the needs of the population they visit. The metodology of measuring the needs of the population to be attended is one of the ways to organize and plan a better population-based halth care system.

The purpose was to examine the effect of a self-care educational intervention on nursing student resilience and thus the potential for compassion fatigue, depersonalization, burnout, depression, and inadequate self-care. A one-group pretest-posttest research design was applied to a convenience sample of 104 nursing students near the end of their last semester in a baccalaureate nursing program. The measurements were demographics, a psychometric resilience scale, program evaluation, and reflection question. The intervention was a standardized, intensive 30 min training program on the high degree of stress and burnout nurses face and the core self-care methods that can promote resilience to these hazards. The educational intervention had a strong positive effect on resilience scores (effect size of r=72%; p < 0.05). Eighty-six percent of the participants believed that the intervention increased their capabilities for self-care, especially in sleep, spending time outside, hydration, nutrition, and physical stretching exercises but not in journaling. Eighty-one percent stated that they would be likely to seek professional help if needed. Although this study must be repeated in other samples before it be implemented with full confidence, the standardized, high intensity, short duration, resilience training session can be recommended to nursing programs just prior to graduation and to hospitals for nurse orientation programs.

Doctor of Philosophy
Department of Family Studies and Human Services
Joyce Baptist
The purpose of the current study is to examine what factors contribute to how marriage and family therapy (MFT) programs address multicultural competency training and to understand the support mechanisms of the training process. A sequential explanatory mixed-method design was utilized to evaluate MFT training programs. First, a Multicultural Survey, adapted from the Multicultural Competency Checklist (Ponterotto, Alexander, & Griegor, 1995), was used to gain a preliminary understanding of the masters MFT field regarding multitcultural competency training. Out of the 70 MFT program directors contacted, 39 program directors or program representatives responded to the survey (55.71% response). Qualitative interviews from 8 participants (program directors, n = 7; program representative, n = 1) representing each geographical region (Northeast, n = 2; South, n = 2; Midwest, n = 2; West, n = 2) were used to examine programs’ multicultural competency training content, program context and training processes. Five themes emerged from the data: 1) internal program dynamic, 2) external program factors, 3) stakeholders, 4) faculty recruitment, and 5) cross-program collaboration. General systems theory, process theory and the logic model were utilized to conceptualize the results (Kellogg, 2004; Rossi, Lipsey, & Freeman, 2004; White & Klein, 2002).

Like most health interventions, National Immunization Programs (NIPs) are embedded within health systems. This means that NIPs and health systems exist in a constant interaction. Vaccine preventable diseases are widely recognized as the chief cause of morbidity, disability and mortality worldwide and NIPs are understood to be one of the most cost-effective interventions against this burden. In low and middle- income countries (LMICs), where the burden of disease is high, NIPs have been reported to perform at suboptimal levels. It has been suggested that this suboptimal performance of NIPs can be associated with the poor state of health systems in LMIC. Despite this, the interaction between NIPs and health systems is poorly understood. In addition to this, systematic evidence on how health systems constraints and facilitators impact on the performance of NIPs in LMICs is scarce. To address this evidence gap, a systematic review study was conducted, that involved an initial scoping review of the evidence-base on NIPs and health systems in LMICs from which a logic model was developed. This logic model was then applied as a guide for a qualitative systematic review aimed at assessing the health systems constraints and facilitators of NIP performance in sub-Saharan Africa. The findings of this review suggest that well-performing NIPs are those that operate within enabling health systems, characterized by the availability of strong political endorsement for vaccines, clear governance structures and effective collaboration with global partners. Despite this, significant health systems constraints persist and include the limited capacity of health workers in sub-Saharan Africa, weak country infrastructure, poor service delivery, inadequate vaccine communication and ineffective community engagement in immunization programs. This systematic review study contributes to our limited understanding of the interaction between NIPs and health systems. In addition, the findings show how system-wide constraints and facilitators impact on the performance of NIPs. These findings have relevance for ongoing health systems strengthening initiatives, especially where NIPs are concerned.

Employers adopt worksite health promotions to reduce the incidence of preventable diseases, reduce healthcare costs, reduce absenteeism and presenteeism, and improve productivity. The purpose of this qualitative phenomenological study was to explore the motivational factors affecting employee participation in employer-sponsored health awareness programs. The theory of planned behavior grounded the study and formed the conceptual framework. Data collection occurred through semistructured interviews with 24 participants in the northeastern United States with lived experiences in worksite health promotion. Participants answered open-ended interview questions regarding the motivations for engaging in health promotions. Data were transcribed and coded for trends and themes. During data analyses, 4 themes emerged, which included program recruitment and notification, employer commitment, employee motivations, and incentives and rewards. The implications for positive social change include the potential for employers incorporating the results to instigate enhanced employee participation in employer-sponsored health awareness programs. Higher employee rates of participation may aid employers in achieving the established benefits of worksite health promotion and may contribute to improving the health of employees.

Estudo exploratório, qualitativo, com o objetivo de analisar as reuniões de equipe da Estratégia Saúde da Família, à luz do referencial pichoniano de grupo operativo. Pontualmente, buscou-se caracterizar essa prática com relação aos aspectos organizacionais e logísticos, bem como identificar os aspectos dinamizadores e obstaculizadores da dinâmica grupal, a partir do olhar da equipe. Os dados foram coletados no período entre maio e agosto de 2007, em um município do Estado do Rio Grande do Sul, por meio das Técnicas de Observação Direta Não Participante e de Grupos Focais. Foram observadas cinco reuniões protocolares da equipe, tendo-se realizado cinco encontros de Grupos Focais. Participaram do estudo duas equipes da Estratégia Saúde da Família, caracterizadas como equipe dupla, agregando 18 sujeitos, entre eles: enfermeiros, médicos, dentistas, técnicos de enfermagem, auxiliares de consultório dentário e agentes comunitários de saúde. O material foi organizado conforme propõe Minayo (2007), tendo-se adotado a perspectiva pichoniana de grupo operativo para análise do mesmo. Os resultados preliminares, oriundos da observação, constituíram-se nos disparadores das sessões do Grupo Focal e os resultados, no conjunto, foram agrupados em três eixos temáticos: caracterização das reuniões de equipe quanto aos aspectos organizacionais e logísticos, aspectos dinamizadores e obstaculizadores da dinâmica grupal e alguns insights para romper com a estereotipia. Para os participantes, as reuniões de equipe são compreendidas como importantes espaços de encontro com vistas à construção coletiva do trabalho cotidiano. No entanto, a prática adotada centrava-se no atendimento de questões técnicas, tangenciando aspectos relacionados ao processo grupal, condição considerada necessária ao trabalho em equipe, na Estratégia Saúde da Família. Pela ótica dos sujeitos, os aspectos de organização e logística das reuniões de equipe não foram cogitados como relevantes, embora carecessem de certos cuidados, especialmente na elaboração da pauta, na utilização do livro-ata e no tempo de duração das reuniões. Dificuldades de expressar idéias e emitir opiniões contrárias emergiram como obstáculos na dinâmica grupal, indicando que a condição de adotar uma postura crítica levava à segregação do grupo, apontando que as principais fragilidades estavam associadas ao processo relacional da equipe. 9 Ao final, alguns insights favoreceram a tomada de consciência e, assim, desvelou-se a ilusão de “equipe perfeita”, havendo gradual reconhecimento de que esta concepção permanecia mais no plano da idealização do que, propriamente, da realidade. Em um movimento participativo com os próprios sujeitos, identificou-se que havia necessidade de instrumentação da equipe para manejar aspectos relacionados ao processo grupal, considerando que o conhecimento sobre o referencial de Grupo Operativo poderia contribuir para o trabalho que envolve grupos, pois se trata de uma iniciativa que tem se configurado numa tendência do trabalho em saúde, na atualidade. Desse modo, conhecer e conseguir identificar os principais fenômenos presentes no campo grupal, possibilita às equipes conduzirem suas reuniões de forma operativa, considerando-se não somente os resultados, mas, sobretudo, o processo percorrido pelos sujeitos até o alcance da tarefa, com vistas à aprendizagem grupal.
Exploratory qualitative study, to analyze the meetings of the Family Health Strategy team, considering the Pichonian reference of an operational group. It was sought to characterize this practice regarding the organizational and logistic aspects, touching on certain points, and also to identify the aspects that dynamize and create obstacles in group dynamics, based on the look of the team. The data were collected in May-August 2007, in a municipality of the state of Rio Grande do Sul, using the Non-Participant Direct Observation Techniques and Focus Groups. Five meetings conducted by the team according to a protocol were observed, and five Focus Group meetings were held. Two Family Health Strategy teams participated in the study, characterized as a double team, with 18 individuals, including: nurses, physicians, dentists, nurse technicians, dental office assistants and community health agents. The material was organized as proposed by Minayo (2007) and the pichonian perspective of an operational group was adopted to analyze it. The preliminary results of observation were the triggers for the Focus Group sessions and all the results were grouped into three thematic lines: characterization of team meetings regarding the organizational and logistic aspects, dynamizing aspects and those of obstacles to group dynamics, and a few insights to break down the stereotype. For the participants, the team meetings are seen as important meetings spaces with a view to the collective construction of day-to-day work. However, the practice adopted focused on responding to technical issues, touching on aspects related to the group process, a condition considered essential for team work in the Family Health Strategy. From the standpoint of the subjects, the aspects of organization and logistics of the team meetings were not considered relevant, although they lack a certain amount of care, especially when establishing the agenda, recording the minutes and meeting duration. Difficulties in expressing ideas and presenting contrary opinions emerged as obstacles in the group dynamics, indicating that adopting a critical attitude led to segregation from the group, showing that the main weaknesses were associated with the process of team relations. At the end, a few insights favored awareness, and thus the illusion of a “perfect team” was shown not to be true, with a gradual recognition that this concept was rather a matter of idealization than of reality, proper. In a participatory movement with the subjects 13 themselves, it was identified that the team had to be instrumented to manage aspects related to the group process, considering that knowledge on the referential of an Operational Group might contribute to the work involving groups, since this is currently an initiative that has become a tendency of health care work. Thus, getting to know and managing to identify the main phenomena present in the field of groups allows the teams to conduct their meetings in an operational form, considering not only the results , but above all the process used by the subjects until the task is fulfilled, with a view to group learning.
Estudio exploratorio, cualitativo, con el objetivo de analizar las reuniones de equipo de la Estrategia Salud de la Familia, desde el referencial pichoniano de grupo operativo. Puntualmente, se buscó caracterizar esa práctica con relación a los aspectos organizacionales y logísticos, bien como identificar a los aspectos dinamizadores y obstaculizadores de la dinámica grupal, a partir del punto de vista del equipo. Los datos fueron recolectados en el período entre mayo y agosto de 2007, en una municipalidad del estado del Rio Grande do Sul, por medio de las Técnicas de Observación Directa No Participante y de Grupos Focales. Fueron observadas cinco reuniones protocolares del equipo y realizados cinco encuentros de Grupos Focales. Participaron del estudio dos equipos de la Estrategia Salud de la Familia, caracterizados como equipo doble, agregando 18 sujetos, entre ellos: enfermeros, médicos, dentistas, técnicos de enfermería, auxiliares de consultorio dentario y agentes comunitarios de salud. El material fue organizado según propone Minayo (2007), siendo adoptada la perspectiva pichoniana de grupo operativo para análisis del mismo. Los resultados preliminares, oriundos de la observación, se constituyeron en los disparadores de las sesiones del Grupo Focal y los resultados, en el conjunto, fueron agrupados en tres ejes temáticos: caracterización de las reuniones de equipo en cuanto a los aspectos organizacionales y logísticos, aspectos dinamizadores y obstaculizadores de la dinámica grupal y algunos insights para romper con la estereotipia. Para los participantes, las reuniones de equipo son comprendidas como importantes espacios de encuentro con vistas a la construcción colectiva del trabajo cotidiano. Sin embargo, la práctica adoptada se centraba en la atención a cuestiones técnicas, pasando al lado de los aspectos relacionados al proceso grupal, condición considerada necesaria al trabajo en equipo, en la Estrategia Salud de la Familia. Según la óptica de los sujetos, los aspectos de organización y logística de las reuniones de equipo no fueron considerados relevantes, sin embargo carecían de ciertos cuidados, especialmente en la elaboración de la pauta, en la utilización del libro-acta y en el tiempo de duración de las reuniones. Dificultades de expresar ideas y emitir opiniones contrarias emergieron como obstáculos en la dinámica grupal, indicando que la condición de adoptar una postura crítica llevaba a la segregación del grupo, apuntando que las 11 principales fragilidades estaban asociadas al proceso relacional del equipo. Al final, algunos insights favorecieron la toma de consciencia y, así, se desveló la ilusión de “equipo perfecto”, ocurriendo gradual reconocimiento de que esta concepción permanecía más en el plano de la idealización que, propiamente, de la realidad. En un movimiento participativo con los propios sujetos, se identificó que había necesidad de instrumentación del equipo para manejar aspectos relacionados al proceso grupal, considerando que el conocimiento acerca del referencial de Grupo Operativo podría contribuir para el trabajo que envuelve grupos, visto tratarse de una iniciativa que se haya configurado en una tendencia del trabajo en salud actualmente. De ese modo, conocer y conseguir identificar los principales fenómenos, presentes en el campo grupal, posibilitan a los equipos conducir sus reuniones de forma operativa, considerándose no solamente los resultados, pero, sobretodo, el proceso recorrido por los sujetos hasta el alcance de la tarea, con vistas al aprendizaje grupal.

Health care consumers are under-represented in literature when defining patient and family engagement. The proportion of people living longer is rapidly growing. Future research is needed to evaluate which strategies of patient and family engagement are most useful in real-world health care settings for patient and families. The purpose of this study was to describe the lived experiences of patient/family advisors working within patient family advisory councils at an academic medical center in the Midwestern United States. The conceptual framework is based on Greenleaf's servant leadership and Bass's transformational leadership. The research questions examined how patient/family advisors describe patient and family engagement, their experiences from the advisor program, and what is most meaningful to them. A phenomenological design was employed with a purposeful sample of 19 interview respondents drawn from 5 different advisory councils. Data analysis consisted of interpretive phenomenological analysis and a detailed, in-depth account of participant experiences. Transcripts from semi structured face-to-face interviews were collected, coded, validated by member checking, and triangulated with emergent themes. Emergent themes included patient/family advisors' descriptions of patient and family engagement within the patient family advisory councils and organizational efforts most meaningful to patient/family advisors. The results of this study may help create social change by improving the standards and quality of patient and family engagement by preparing health care professionals to better meet the needs of health care consumers.

This quantitative survey study explored relationships between a law enforcement supervisor's personal characteristics and the attitude a supervisor had towards the Critical Incident Stress Management (CISM) program. The study solicited law enforcement supervisors (n = 6635) who were graduates of the Federal Bureau of Investigation's National Academy (FBINA). A modified survey instrument assisted in the collection of demographic data and the assessment of attitudes towards the CISM program. Descriptive statistics and inferential statistics in the form of an analysis of variance (ANOVA) statistical test and a multiple regression analysis that used a backwards-stepwise format assisted in the examination of the collected data. The results indicated time away from the duties of a line-level patrol officer, investigator, or detective, and time in law enforcement shared a weak relationship with a supervisor's attitude towards the CISM program. More specifically, the longer the time span for each, the more positive the supervisor's attitude should be towards the program. Unfortunately, while these variables may have been deemed significant, the results are virtually meaningless since the model resulted in only two percent of the variance in attitude. Although the study's findings only indicated a weak link between a law enforcement supervisor's characteristics and the attitude a supervisor has towards the CISM program, it also showed supervisors within the study overwhelmingly supported the program. Knowing this support exists could still provide stress management program managers with invaluable insight, as processes are developed to mitigate critical incident stress in law enforcement.

The Nurse Family Partnership (NFP) program is a home visitation program that targets low income parents expecting their first child. With the nurse delivering services, the program is designed to facilitate positive changes that improve health outcomes for the woman and her baby. Despite successful program implementation in mostly urban communities across the United States, obstacles exist to implement Nurse Family Partnership in rural communities. The purpose of this practice inquiry was to collaborate with Pima County Health Department and Nurse Family Partnership to evaluate the feasibility of implementing the Nurse Family Partnership program in Pima County rural communities. As part of this practice inquiry collaboration, the first aim completed a community assessment of Arivaca to identify rural community strengths and potential barriers to implementation and thus serve as an implementation prototype for Pima County Health Department. Descriptive statistics were utilized from the Arizona Department of Health Services Arizona Vital Statistics, U.S. Census Bureau, and Arizona Department of Health Services needs assessment data sets to assess population characteristics and the Nurse Family Partnership eligible population in Arivaca. Additionally, a windshield survey was conducted to assess community referral capacity and/or program champions, existing public/community health programs or services linkages, and issues due to rurality such as transportation challenges and driving time/distances. The second practice inquiry aim developed an implementation plan, including an evaluation component, alongside Pima County Health Department that expands Nurse Family Partnership into additional rural communities in Pima County. The Nurse Family Partnership implementation plan template was utilized to identify community need and population characteristics, Pima County Health Department mission and culture, organization capacity, nursing practice and support, community linkages, sustainability, and financing and fiscal policy support. Descriptive statistics were utilized from the Arizona Department of Health Services Arizona Vital Statistics, U.S. Census Bureau, and Arizona Department of Health Services needs assessment data sets to describe a community profile to complete the Nurse Family Partnership implementation plan template. This practice inquiry demonstrated that completion of a windshield survey and review of descriptive data sets in the proposed service areas helps to identify community referral capacity and/or program champions, existing public/community health programs or services linkages, and issues due to rurality. This process can be used as a prototype for Pima County Health Department prior to implementation in the entire proposed service area.

Obesity and substance abuse are two major public health issues in the United States, especially among low-income individuals. The United States Department of Health and Human Services has set forth the Dietary Guidelines, which encourage a diet rich in fresh fruits, vegetables, whole grains, legumes, lean meat, and low-fat dairy to help Americans obtain a healthy body weight. Substance abusers in recovery are at increased risk of weight gain, as their previous addiction may continue with the substance shifting from drugs or alcohol to sugary or high fat food. Nutrition interventions have been beneficial in recovery by improving outcomes and preventing relapse, however, possible barriers to obtaining fresh, healthy food items have been noted. There is limited research investigating females, especially mothers, in recovery and their access to healthy food items. The current study utilized a demographic survey and multiple Household Food Inventories (HFI) to assess the amount and variety of food items of mothers and their children in a residential substance abuse recovery facility. A sample of 11 mothers in rural, eastern North Carolina completed the survey and two separate HFI, two weeks apart to account for intra-monthly variability. Demographic information was entered into Statistical Package for the Social Sciences [SPSS] while HFI data were coded and categorized in Microsoft Excel. Results included all 11 mothers participated in at least two different federal food assistance programs, stated they face challenges grocery shopping, and seven households were food insecure. Fresh vegetables were slightly more common in households than fresh fruits, and canned, frozen, and packaged fruits (especially fruit juice), vegetables, and legumes, were more prevalent than fresh forms. Cheese was the most popular form of dairy, and most was full fat. The majority of protein was red meat or breakfast meat including bacon and sausage. Whole grain was less common than white, refined grain products. There was an abundance of pre-packaged, convenience food including chips, ice cream, cookies, and cakes. The results indicated that the HFI on two separate occasions was beneficial to explain variability among types and amounts of food items from one assessment to the next, especially among fresh fruits, fresh vegetables, and chicken. The lack of fresh fruits, vegetables, low-fat dairy options, lean meats, and whole grains in combination with copious sweetened, pre-packaged, high-fat food items form a diet associated with obesity and contradictive of the Dietary Guidelines. Possible barriers to obtaining healthier food options may include low or fluctuating income and federal assistance benefits, limited transportation, decreased storage space, infrequent grocery trips, or a lack of nutritional knowledge. Mothers and children in recovery could benefit from nutrition education and improved access to healthier food items. Future research should further investigate the barriers to obtaining fresh, healthy food items, as well as shifts in addiction from substance to food, food choice, disordered eating patterns, and subsequent weight and health issues to guide nutrition interventions for mothers and children in substance abuse recovery facilities.

The purpose of the study was to identify factors that were positively associated with persistence to graduation by students who were admitted to Health-Related Programs leading to the degree associate of applied science at Northeast State Community College. The criterion variable in this study was persistence, which was categorized into two groups the persister group (program completers) and the nonpersister (program noncompleters) group. The predictor variables included gender, ethnic origin, first- (or nonfirst-) generation-student status, age, specific major program of study, number of remedial and/or developmental courses taken, grades in selected courses (human anatomy and physiology I and II, microbiology, probability and statistics, composition I, clinical I, clinical II), and number of mathematics and science credit hours earned prior to program admission. The data for this ex post facto nonexperimental design were located in Northeast State's student records database, Banner Information System. The subjects of the study were students who had been admitted into Health-Related Programs of study at a 2-year public community college between the years of 1999 and 2008. The population size was 761. Health-Related Programs of study included Dental Assisting, Cardiovascular Technology, Emergency Medical Technology -- Paramedic, Medical Laboratory Technology, Nursing, and Surgical Technology. A combination of descriptive and inferential statistics was used in the analysis of the data. Descriptive statistics included measures of central tendency, standard deviations, and percentages, as appropriate. Independent samples t-tests were used to determine if the mean of a variable on one group of subjects was different from the mean of the same variable with a different group of subjects. It was found that gender, ethnic origin, first-generation status, and age were not significantly associated with persistence to graduation. However, findings did reveal a statistically significant difference in persistence rates among the specific Health-Related Programs of study. Academic data including grades in human anatomy and physiology I, probability and statistics, and composition I, suggested a relationship between the course grade and persistence to graduation. Findings also revealed a relationship between the number of math and science courses completed and students' persistence to graduation.

Sociology
Ph.D.
I used multiple methods to study gender issues associated with health lectures that hospitals offer to the public. My purpose was not to evaluate the health-related content, but rather to study the gender messages that accompanied the health messages. One main reason hospitals offered lectures was to attract clients. While many lectures were offered to both sexes, women's lectures outnumbered men's lectures ten to one. One reason to target women was because hospitals offered more services to women than to men. Yet a main finding is that many women's offerings were not based solely on providing services to benefit women themselves, but also on assumptions about women's caregiving of others. Thus, while men were generally marketed to as men, women were often marketed to as mothers or other caregivers. Most speakers engaged in marginalization: while both men and women lecture attendees were treated in ways that denied their status as competent adults, women were also marginalized as women, that is, treated as "other" to a male norm. Additionally, some speakers presented a single interpretation of procedures or conditions as the only interpretation, despite the fact that other interpretations were equally plausible. Examples included offering positive interpretations of unpleasant screening procedures or treatments; attributing gender roles to biology; and attributing women's stress to personality traits. Medicalization and other forms of boundary blurring between health and other topics occurred more frequently for women than men. While some of this difference did not represent gender inequality, some did, such as gender differences in the emphasis placed on physical appearance. Similarly, while all exhibits showing men's nudity were medically instructive, that is, used to demonstrate anatomy or self-examination procedures, some women's nudity was not medically instructive, and thus unnecessary While some caregiving resources were offered to both sexes, many were offered only to women. Targeting caregiving resources to women went beyond merely reflecting the gendered division of caregiving; it also symbolically reproduced it. Further, when "women's" health resources were intended to benefit children and husbands, the boundary between self and others was blurred for women in a way that had no counterpart for men.
Temple University--Theses

This study discusses the intergenerational impact of mass incarceration on families. The general literature repeatedly described the negative effects of mass incarceration among children who have an incarcerated parent by pointing to the difficulty of educational attainment, social exclusion, stigma, substance abuse, and the exacerbation of mental health issues such as depression, anxiety, and antisocial behavior (Kjellstrand & Eddy, 2011; Miller & Barnes, 2015; Turney, 2014). Unfortunately, most incarcerated individuals are parents and most incarcerated women are mothers (Scudder, A., et al., 2014, and Miller, et al., 2014). Through the use of art, service providers (artists, clinicians, etc.) that facilitate parent based programs in correctional facilities or re-entry programs can alleviate the trauma caused by incarceration that affect the emotional and mental well-being of families. Two organizations that provide art programs to incarcerated parents participated in a qualitative study about the effective use of art in their programs. Themes from the interviews discussed the value of cultural humility, as well as the role of social justice and restorative justice frameworks when providing art-based programs for parents. The lack of trust, compassion, and empathy were barriers in the process of delivering services to families. Since the creative process is inherently inclusive and actively engages its participants (e.g., therapists, patients, observers), the results of this study point to art creation as a vehicle that promotes trusts and supports family relationship restoration in order to intercept the cycles of intergenerational trauma.

Diabetes, a chronic disease with devastating but preventable consequences, is common in the United States, especially within African American communities. Earlier research has indicated that 21.7% of African American parents have children diagnosed with Type 1 diabetes in the Mississippi Delta Region. Researchers have examined coping, stress, and behaviors of African American parents of children diagnosed with Type 1 diabetes; however, there is a gap in literature regarding how African American parents can cope with stress and how changes in health behavior due to Type 1 diabetes impact African American families. The purpose of this qualitative phenomenological study was to explore the lived experiences of African American parents, examining how they can cope with stress and how their families are impacted by the changes in health behavior due to Type 1 diabetes. The transtheoretical model, used to evaluate a person's preparedness to pursue a new healthier behavior, was applied. Through semi-structured interviews, data collected from 13 families were recorded, transcribed, and coded into themes. Phenomenological data analysis was performed based on the descriptive technique, using a computer-based NVivo model and preset codes. In this study, African Americans are likely to accept and acknowledge the impact of denial as a coping mechanism, while accepting the behavioral changes, and this will likely alert professionals in this field of study. Also, this will lead to a positive social change in the study of Type 1 Diabetes.

Background: Despite consensus guidelines, only about half of at-risk relatives in families with Hypertrophic Cardiomyopathy (HCM) undergo clinical screening and even fewer undergo predictive genetic testing, leaving those unscreened at risk for sudden cardiac death. The use of qualitative inquiry to examine family communication and complex factors influencing uptake of screening may inform interventions to increase uptake and prevent sudden cardiac death. Purpose: The purpose of this study was to describe the engagement of at-risk relatives in family screening for HCM. Specific Aims: The specific aims were to (1) Describe the experience of communication of genetic risk of HCM in families with a causative variant for HCM; (2) Use the Theory of Engagement to identify facilitators and barriers to family screening in families with a causative variant for HCM; and (3) Identify strategies to increase uptake of clinical screening and predictive genetic testing in families with a causative variant for HCM. Framework: The Theory of Engagement, adapted from McAllister, was used as an initial framework for the study. Methods: A qualitative descriptive design with purposive and snowball sampling was used and data were analyzed using qualitative content analysis. Results: The overarching theme of Bringing Genetic Risk to the Foreground was comprised of three major themes: Cues to Action, Preferences for Knowledge and Gateways to Screening, reflecting factors that affect engagement with genetic risk and family screening throughout the lifespan. Conclusions: Integrated longitudinal care and access to genetic specialists are needed for patients and families with a causative variant for HCM.

Children with special health care needs (CSHCN) generally have physical, mental, or emotional conditions that require a broader range and greater quantity of health and related services compared to typical children. Care coordination (CC) and family-centered care (FCC) are necessary in the quality of health care for CSHCN. A gap exists in the literature regarding the impact of CC and FCC on children's functional ability (FA). Previous researchers have focused on met and unmet health care needs, but not on health outcomes or functionality. The purpose of this study was to determine if there was an association between CC, FCC, and FA in CSHCN. The design of this study was a secondary analysis of data from the 2005--2006 National Survey of CSHCN. The study was guided by an adapted socioecological multilevel conceptual framework. Statistical methods included univariate, bivariate, and multiple logistic regression analysis. Results indicated that CC was associated with FA in CSHCN. CSHCN that did not receive CC had a 53% increased risk (OR =1.53, 95%CI 1.21--1.94, p < 0.001) for a limitation in FA compared to CSHCN that received CC, controlling for age, gender, number of conditions, household poverty level, parental educational level, and health insurance. FCC was not associated with a limitation in FA in CSHCN ( p = 0.61). Findings from this study were consistent with the socioecological multilevel framework and the literature on care coordination. This study contributed to positive social change by providing information that can be used by public health officials, health care providers and policy makers in developing policies to assure that care coordination is provided to CSHCN and their families in order to improve their health outcomes and functionality.

In 2011, Medicare patients represented the largest share of total readmissions and health costs when compared to all other patient categories. Because patient-centered care drives the use of health services, the U.S. Patient Protection and Affordable Care Act outlined improving the patient experience to reduce readmission rates; however, the relationship between patient experience and readmissions is not well understood. Grounded in systems theory, the purpose of this correlational study was to determine if the relationship between patient experience and readmission rates in Medicare Shared Savings Program accountable care organizations. Data from the Consumer Assessment of Healthcare Providers and Systems survey were gathered from the Centers for Medicare and Medicaid datasets to analyze patient experience measurements and readmission rates, while accounting for variation among Medicare service regions, number of assigned beneficiaries, and performance year. Using multiple linear regression to analyze the data, the model was used to predict Medicare's all-condition readmission rate (per 1000), R-²= .242, F (13, 634) 15.59, p < .001. The research question was answered partially; variation in the patient experience domain did not support all hypotheses. Because the Medicare population represents the fastest growing patient population within the U.S. health care system, continuous evaluation of policy and performance provides an evidence-based analysis to health administrators and providers who have pivotal roles in the creation of positive social change. Findings may be used to improve quality and service while reducing costs, which contributes to the sustainability of the U.S. Medicare program and its beneficiary population.

This study examines the organizational and contextual factors associated with faculty mentoring programs in academic medicine within major research institutions in the United States, and explores the usefulness of organizational behavior theory in understanding these relationships. To date, many formal faculty mentoring programs are in operation in higher education, yet little is known about why certain practices are favored or thought to be more effective than others, as differentiated from mentoring programs in the business sector. The original conceptual framework of this qualitative multiple cross-case study was based upon faculty mentoring program success factors gleaned from the literature being grouped by one of three perspectives of organizational behavior theory, i.e., structural, political, or symbolic, and examining these variables through the perspective to which they were assigned. Using this approach, very few organizational similarities were found among the twelve faculty mentoring programs in this study. However, by reversing the conceptual framework, and examining each program variable from the three organizational perspectives, six multi-dimensional organizational themes emerged that transcend the program variables: commitment, expectations, responsibility, accountability, community, and transformation. Three of these themes are evident across all organizational perspectives: commitment, expectations, and responsibility. Accountability is evident from a dual structural/political perspective. Community is evident from a dual structural/symbolic perspective. And, transformation is evident from a dual political/ symbolic perspective. Although specific “how to” advice is limited, this study provides support for a multi-dimensional theoretical framework for academic organizations to optimize formal faculty mentoring relationships. This study demonstrates that maximizing these six dimensions within a faculty mentoring program, to the fullest potential within organizational constraints, provides the ideal faculty mentoring program format for that particular academic culture. This model also situates these six dimensions within an academic culture, which allows faculty development professionals to identify the organizational domains that exert the most influence over these dimensions within their faculty mentoring programs. The redesign of how organizational behavior theory was applied within this study revealed a new organizational understanding of faculty mentoring programs within academic cultures. This discovery provides a promising new direction for further study.

The purpose of this study is to identify student characteristics and academic program factors, which influence the student's ability to persist through degree completion within healthcare-related, associate degree programs within four urban, community colleges. To achieve this outcome, the Bean and Metzner (1985) model of non-traditional student attrition was adapted to analyze academic and demographic variables which may lead to degree completion within healthcare programs of study. Records of 3,237 students from four urban, community colleges, with healthcare-related programs of study and prerequisites of English, anatomy and physiology, and mathematics, were analyzed to determine predictors leading to program completion. The study employed a quantitative, ex post facto design using descriptive statistics, correlation, and logistic regression models to analyze the sample of 552 students. Out of the twelve independent variables for the six programs of study (diagnostic medical sonography, echocardiology technology, invasive cardiovascular technology, nursing, radiologic sciences, and respiratory care programs), cumulative and program grade point averages were found to be significant predictors of program completion. Recommendations included adding shorter certificate options within the programs of study, consider reducing the length of associate degree programs, assessing licensure success and length of programs in the healthcare sector, applying similar studies in university or rural settings, assessment of financial aid and completion in healthcare programs, and establishing pre-advising opportunities to determine the best program fit for students within the healthcare sector, thus increasing the student's ability to persist to program completion or graduation.

Remediation to improve student retention is rapidly becoming an important part of health science programs in higher education. A career college located in the midwestern United States implemented remediation for students to address declining enrollment health science professional-track programs. The purpose of this qualitative case study was to explore how remediation was carried out by college instructors and their perceptions of instructional best practices for students in health science programs in the context of current research. The conceptual framework that guided this study was based on constructivism and adult learning theory. Research questions focused on how instructors were carrying out the processes for remediation and explored their views of effective remediation practices. The sample of 11 participants included 4 program directors, 3 fieldwork coordinators, and 4 adjunct faculty members. Data were collected from individual interviews, classroom lab observations, and program documents. Data were open coded and analyzed for themes. Findings indicated that instructors who conducted remediation used instructional techniques that matched effective practices found in the current research literature, e.g. videos, case studies, patient simulation, mind-mapping, and mock practicals.- Based on the findings of best practices, recommendations were proposed for the development of a formal remediation plan for the health science programs to improve the success rate for student completion. This study may promote positive social change by standardizing the use of effective instructional techniques for remediation in the professional-track programs, thereby improving student retention and declining enrollment in the career college health science programs.

Although health care transitions have received some attention in the literature, few researchers have emphasized family relational experiences and communication during major changes while living with a chronic illness. The purpose of this phenomenological study was to understand the lived experience of parents and their adult children while transitioning from pediatric to adult care of a chronic illness. The bio-psychosocial theory, family systems theory, and attachment theory established the context for this study. A criterion-based sampling technique and snowball sampling were used to recruit 7 parents and 6 of their adult children aged 18 to 30 years who were diagnosed with cystic fibrosis or congenital heart disease, and who had either completed or were in the process of completing the transition from pediatric to adult healthcare. Semi-structured interviews were conducted, and content analysis was used to code and analyze themes that emerged from the experiences of participants. The themes that were identified included that parents were instrumental in maintenance of treatments during high risk periods of adolescence, healthy parent and child relations included collaboration that accommodated autonomy, and that early coaching helped reduce parental anxiety about non-adherence while increasing the self-efficacy of the child. This study contributes to positive social change by informing the design of current procedures to transition young adults with chronic illness by recommending flexibility in negotiations, early education, shadowing between facilities, and incorporating evidence-based practice based on feedback from each family member.

This exploratory mixed method convergent parallel study examined Connecticut Educational leadership preparation programs for the existence of mental health content to learn the extent to which pre-service school leaders are prepared for addressing student mental health. Interviews were conducted with school mental health experts and Connecticut school principals to learn what leadership competencies they believe are needed for pre-service school leaders to address the mental health conditions of students. Responses yielded 11 suggested leadership competency content categories which served as the basis of two researcher-developed surveys completed by Connecticut program course professors and pre-service school leader students rating the extent to which mental health content was included in course work and field experience. Program course syllabi were examined for mental health content. Findings from the three data sources suggest there is a dearth of mental health content in curricula, and insufficient attention to clinical internship experiences. Connecticut Educational leadership preparation programs could do better in preparing pre-service school leaders for addressing the mental health needs of students.

Although strategic planning has been used successfully in most major business institutions, higher education has been slow to adopt this management technique. Involvement in planning is a critical issue for allied health educational programs, such as physical therapy, which are relatively new to the academic environment. These programs face a continual need to update their curricula and clinical education based on rapid changes in the health care delivery system and the profession. The problem of this study was to determine the extent to which the strategic planning process is currently applied in institutions in the United States which offer accredited physical therapy educational programs. The population of this study was made up of the chief executive officers of the 115 public and independent institutions that offer physical therapy educational programs. Selected experts on strategic planning and chief executive officers were surveyed in two phases using a mailed questionnaire designed to measure the organization, characteristics, and impact of strategic planning in institutions that offer accredited physical therapy educational programs. Seventy-three percent of the chief executive officers responded, and 50.9 percent indicated their involvement with strategic planning by completing the questionnaire. The findings indicate that, although there is general agreement between the experts and the chief executive officers concerning the characteristics of strategic planning, differences exist. Differences were also identified between academic health centers and other types of institutions, between public and independent institutions, and between institutions by type of physical therapy degree offered. It was concluded that, in the opinion of the chief executive officers, strategic planning processes are being practiced in institutions that offer physical therapy programs, that this process is compatible with academic collegiality, that changes are made in policies and programs but not in the mission, that although faculty members including those from physical therapy are involved, the role and the involvement of these individuals is unclear, and that information-gathering and evaluation methods could be refined.

Chronic diseases are a significant cause of illness and mortality in the United States. Hereditary predisposition to chronic diseases is a useful indicator for identifying people at risk for disease development. An ideal tool for determining this predisposition is the CDC, NIH, and AAFP recommended third-degree family health history (FHH). The aim of this quantitative, cross-sectional study, based on the theoretical frameworks of social constructivism and the health belief model, was to assess the possible influence between the completed third-degree FHH and the participant's perception of disease risk. Two-hundred seventy-three participants were recruited from health care facilities and from the general population using convenience sampling. Bivariate and multivariate tests were applied to analyze the obtained data. Binary regression indicated a statistically significant association between the presence of heart disease, stroke, breast cancer, ovarian/cervical cancer, prostate cancer, colon cancer, and diabetes, and the perception of risk for the particular disease as noted in the FHH. A familial history of stroke appeared to be the strongest predictor of perception of disease risk. Moreover, increasing age, particularly within the age range of 40 to 57, was associated with increasing levels of perception of disease risk for heart disease, stroke, and prostate cancer. Individuals from the general population significantly indicated higher-than-average risk for colon cancer compared to those from health care facilities. Social change implication of this study may be the widespread implementation of a familial health history questionnaire that leads to an impactful, higher degree of disease risk awareness, prompting preventive action on the part of the individual, and leading to improved individual and population health.

Thesis (M.A.)--Kent State University, 2009.
Title from PDF t.p. (viewed Mar. 31, 2010). Advisor: Jason McGlothlin. Keywords: Childhood; obesity; overweight; weight management; parenting; mental health Includes bibliographical references (p. 149-178).

The increase of non-traditional students in higher education has been a topic of discussion and examination for over a decade. This study compared the non-traditional student with the traditional student in radiography programs in Virginia's community colleges. The purpose of this study was to determine if differences exist between traditional and non-traditional student performance in a structured radiography program. The study hypothesized that there were no differences in academic performance, national board examination scores, and program completion. Focus-group interviews examined themes related to success factors. t-Test analysis indicated significant differences in academic success between traditional and non-traditional learners. Non-traditional learners experienced greater success. Chi-square analysis did not show a significant difference between the traditional and non-traditional students in graduation rate and scores on the American Registry of Radiologic Technologist (ARRT) national examination. Findings in this study could serve as a baseline for further study regarding non-traditional and traditional student success in radiography programs.

This document reviews qualitative assessments used to explore the impact on art therapy interventions with patients in cancer treatment. The study explored the use of qualitative assessment in evaluating patient perspective on receiving art therapy adjunctly with cancer treatment. In addition, the research aimed to determine if art therapy interventions are perceived as effective in helping cancer patients reduce stress, cope, improve quality of life, express emotions, and reduce cancer-related symptoms during and after cancer treatment through qualitative assessment. Approximately 300 cancer patient experiences were reviewed through surveying qualitative studies that explored the effects of art making in cancer treatment through qualitative assessment such as interviews, questionnaires, observations, and open-ended questions. This archival research used a thematic approach to identify emergent themes in format, administration techniques, and impact in qualitative assessments to learn about the patient art therapy experience. The emergent themes were discovered while surveying information regarding types of formats and administration procedures used in qualitative cancer research. These findings suggest that qualitative assessments used in art therapy programs are a useful tool to determine how art interventions may help address patient's psychosocial needs, provide coping skills, and relieve cancer–related symptoms.

Purpose: The purpose of this study was to explore the way(s) in which family management of childhood asthma is affected by contextual influences as described in the Family Management Style Framework (FMSF) and to explore additional factors that affect family asthma management. Specific Aims: The specific aims of this study were 1) to describe the everyday experiences of childhood asthma management within families, 2) to explore the way(s) in which family management of childhood asthma is affected by contextual influences (social network, care providers & systems and resources) as described in the FMSF, and 3) to explore additional sociocultural factors (supported by the literature but not currently described in the FMSF) that affect asthma management in families. Framework: The Family Management Style Framework guided this study. Design: A qualitative descriptive design was used to gather data from a purposive sample of female primary caregivers. Demographic data were collected, and individual interviews were conducted using a flexible interview guide. Results: The findings support the contextual influences as described in the FMSF. An additional three contextual themes were identified: environment, emerging threats to health and work-life conditions. The themes are interrelated demonstrating the complexity of asthma management. Conclusion: Family management of asthma is challenging and complex. The findings move towards understanding the connection between family asthma management and the social determinants of health. Nurses can support families managing childhood asthma by considering each of the contextual influences when planning interventions and working on policy initiatives that support the health of children with asthma.

Job dissatisfaction is becoming a fundamental concern for employers. Employee engagement makes an organization more productive and can reduce absenteeism. The purpose of this quantitative study was to examine the relationship between employer-sponsored wellness-program participation and job satisfaction among for-profit college and university leaders. Data collection involved an online survey of 400 faculty members' from for-profit universities in the United States contacted using the Job Satisfaction Survey; 103 participants completed the survey. The theoretical framework was the need-satisfaction theory, which includes the factors that promote job satisfaction and job dissatisfaction. The results came from a multiple regression analysis that indicated a significant negative relationship between job satisfaction and participation in the employer-sponsored wellness program (β = -.22, t = -2.24, p = .027), where faculty who were not participating in the wellness program had higher levels of job satisfaction (M = 3.62) in comparison to those who did participate (M = 3.80). Interaction analyses indicated a relationship between gender and job satisfaction (β = -.26, t = -2.70, p = .008). Females were more likely than were males to have higher levels of job satisfaction, as well as years of experience and job satisfaction. Faculty who had been employed for between 11 and 15 years were more likely to have higher levels of job satisfaction. Job satisfaction appear lower for those who participate in employer-sponsored wellness programs because of the personal gratification employees' experience. The findings may contribute to social change with information that leaders could use to reduce absenteeism, increase productivity, and profitability.

Research has shown that being in a romantic relationship has related negatively with work-family conflict. Using social exchange theory, the investment model, and role theory, this study examined the relationships among the dimensions of perceived partner support, romantic relationship interdependence, and work-family conflict. A sample of 192 adults in paid employment, currently involved in a romantic relationship, were recruited from SurveyMonkey Contribute. Study participants completed online a demographic survey, the revised Support in Intimate Relationships Rating Scale (SIRRS), the Investment Model Scale, and work-family conflict scales. Correlation analyses showed that work-to-family conflict and family-to-work conflict correlated negatively with commitment and positively with quality of alternatives as hypothesized. As hypothesized, regression analyses showed that quality of alternatives and informational support explained unique variance in work-to-family conflict and family-to-work conflict and that commitment explained unique variance in family-to-work conflict. PROCESS mediation analyses showed partial support for the hypothesis of mediation. Quality of alternatives and commitment mediated the relationships between esteem/emotional support and family-to-work conflict and instrumental/tangible support and family-to-work conflict. Quality of alternatives mediated the relationships between informational support and work-to-family conflict, informational support and family-to-work conflict, and instrumental/tangible support and work-to-family conflict. The findings contribute to positive social change by offering added knowledge about the occurrence of work-family issues in the lives of employees representing a large percentage of the workforce.

The teen pregnancy rate in Henry County, Tennessee has increased over the years. The purpose of this project was to develop an evidence-based family life education policy for possible adoption by the board of education to address the persistent high teen pregnancy rate for girls aged 15-17 in the county. This present study resulted in a revised policy that was based on a comprehensive policy termed Abstinence-Centered Plus Contraception. An 18-member collaborative, organizational, and community project team, made up of community leaders, nurses, counselors, teachers, and students, assisted in the development and adoption of the policy, practice guidelines, and the development of implementation and evaluation plans for the newly adopted policy. The theoretical framework was based on the social, cognitive, and behavior change theories. The program logic model served as a framework to monitor its progress. Existing peer-reviewed literature, including research studies, state and national teen pregnancy prevention projects and curriculum, and publicly available statistics, were gathered and reviewed by the project team as background to be used for developing and changing policy at the institutional level. Project monitoring involved tracking processes surrounding policy and practice guideline development and adoption, as well as implementation and evaluation plan development for the adopted policy and whether these processes progressed as the empirically-derived teen pregnancy prevention projects should when changing sex education policy at the organizational level. This project resulted in policy adoption and developing a policy implementation and evaluation plan to be disseminated within a county school system that could decrease teen pregnancy rates and demonstrate positive outcomes.

Employer’s assistance to employees experiencing personal problems originated in the 19th century. The term Employee Assistance Programme (EAP) was however formulated in the 1970’s in the United States and, initially, only focused on alcohol dependence rehabilitation. EAPs have since seen a paradigm shift in their focus as they now deal with the full range of problems experienced by employees such as family life or relationship issues, work related stresses, financial pressures, depression or anxiety, alcohol and drug abuse. The researcher observed that some employees in the psychiatric institution, where they are employed as both professionals and non-professionals, were experiencing personal problems and very little if anything was done to provide assistance to them. It also seemed as if very few of them made use of the voluntary EAP service made available by the institution. The fact that a number of employees have problems can have serious negative consequences in that it causes a high rate of absenteeism and the institution’s core business, which is to provide care to its users, is compromised. The researcher undertook this study because EAP services fall within the realm of institutional development. This study could therefore make an invaluable contribution to the transformation discourse which has been taking place in the South African health systems in general and psychiatric institutions in particular. The purpose of this research is to determine employees’ experience of utilizing an EAP in a psychiatric hospital. The researcher is personally interested in employees’ experiences of utilizing the EAP in order to provide recommendations that will assist and strengthen the policy/guidelines for the Eastern Cape Department of Health on the use of EAPs. The workplace has an obligation to provide EAP services to employees so as to help them meet their contractual obligations in a holistic and healthy manner. The research goals are to explore the experiences of employees who have utilized an EAP. The findings will be used to make recommendations regarding the utilization of the EAP policy/guidelines that are currently used to assist the employees. The research methodology will be qualitative, descriptive, exploratory and contextual. The research population and sampling for this study will consist of the employees who have made use of an EAP. Participants will be selected using a purposive sampling approach. Data gathering will be done using semi-structured interviews, at a venue convenient to the participants. Open-ended questions will be asked to enable participants to express their perceptions on the topic. The data will be analyzed using Tesch’s method of data analysis. The identified themes will be used to describe employees’ experience of utilizing an EAP. Trustworthiness will be ensured by using Guba’s model of trustworthiness. The ethical principles of beneficence, self-determination and justice will be ensured by asking for each participant’s consent, by not coercing individuals to participate in the study and by ensuring permission from the Department of Health and from the University’s research committee to conduct the study.

The 2011 East Japan Earthquake and Tsunami suddenly took the homes, family members, friends, and familiar neighborhoods away from the children of Iwate. In the midst of this difficult situation, early childhood development (ECD) programs provided protective environments for the young children to access continuous care and development opportunities. This case study examines how these daycare centers in Iwate prepared for, responded to, and coped with the severe natural disaster, providing physical, cognitive, and psychosocial protections to these children.

The study re-affirmed that daycare centers in Iwate had integrated the national standards for disaster risk reduction (DRR). On the day of the disaster, personnel safely evacuated the children while practicing monthly drills. Despite the challenges, the daycare programs quickly re-established normalcy in children’s lives, ensuring continuous access to care. Not only did daycare personnel act in loco parentis for these children, but also re-installed daycare programs during the recovery.

The study revealed that local governments also faced serious challenges in their leadership and coordination roles. Their response capacities had been severely affected by the disaster. Governments’ appropriate and timely guidance was most beneficial for the daycare providers. Among other recommendations, I assert that in the future, local governments could take more active roles in coordinating the massive influx of humanitarian organizations.

This interpretivist research was based on my one-year fieldwork in Iwate immediately after the disaster, and employed a series of survey instruments (questionnaires and interviews). This case study contributes to the field of education and ECD in emergencies through the use of qualitative, ethnographic research. It also recognizes significant and complimentary contribution of qualitative inquiry methods, including on-site fieldwork, ethnographic analyses, and follow-up interviews, for better understanding of crisis situations.

While pre-school programs are not compulsory in Japan, the study calls attention to the valuable protection that they provide for both young children and their childhoods in emergencies. A recovery strategy that focuses on protective environments for children has great potential as a harmonizing approach, rather than as a parallel one, in the complex nature of humanitarian assistance.

The purpose of this quantitative study was to examine an under-researched topic: the relationship between psychological resilience and personal growth with spousal caregivers of patients diagnosed with Multiple Sclerosis (MS). Chronic illnesses contribute to potentially stressful changes (i.e., lifestyle, quality of life, financial wellbeing, and interpersonal relationships) for the caregiver. The theoretical foundation for this study was Walsh's family resilience theory, which contends that resilience is vital for coping with stressful life experiences and leading a more successful life. Three separate analyses were conducted to examine the relationship between the total scores of the RS and the PGIS, the SWLS, and the EMS along with the background variables to see if the covariates contributed information about the relationship between these variables while controlling for gender, marital satisfaction, time since partner diagnosis, age of caregiver, whether the participant had previous interventions, whether the couple had children, current health status, duration of marriage, and life satisfaction. Based on the findings of the multiple-regression analysis, a significant relationship was found between resilience and personal growth of 115 caregivers of MS spouses. Further analysis showed a significant relationship between resilience and satisfaction with life, with marital satisfaction being the only other variable that was significant in the model. The information gathered in this study could contribute to social change for program planners and policy makers by revealing a need for innovative support services.

Major depression disorder (MDD), also known as clinical depression, is classified as a type of affective disorder (also called mood disorder) that goes beyond the day's ordinary ups and downs. It is a serious medical condition and important health concern. In the US there is an estimated 16.1 million people living and suffering from major depressive disorder in a given year, the majority of whom may not adequately respond to initial antidepressant treatment and psychotherapy. OC Ketamine Therapy will introduce a new form of treatment for individuals suffering from major depression to the Orange County (OC) region. Ketamine infusion therapy is known to be effective and efficient in dramatically reducing symptoms of major depression. Our OC Ketamine Therapy practice will provide ketamine infusion along with nutritional guidance and psychotherapy (“talk” therapy) to care for our patients. Our an innovative approach to treatment for depression will empower individuals to make informed healthcare decision while offering a unique treatment option. Our goal will be to care for the whole individual throughout their journey with us in receiving treatment. Our dedicated staff of nurses, receptionist, marriage family therapist or psychologist, nutritionist and anesthesiologist will work together to serve our patients and their families.

The Safe and Drug-Free Schools and Communities Act of 2002, which operates under the No Child Left Behind Act of 2001, requires school districts to implement substance abuse and violence prevention programs to prevent or reduce substance use/abuse and violence and to decrease risk factors and increase protective factors that contribute to healthy child development without providing adequate funding to implement the mandate. The inadequacy of funding does not support the most effective strand of programs: community and family-based or environmental programs. An on-line survey of 43 elementary school principals was conducted to establish their knowledge and perceptions of the implementation of science-based substance abuse and violence prevention programs. The responses produced mixed results. The participants reported generally positive experiences with the implementation process of research-base prevention programs, but they admitted a lack of skill regarding implementation of community and family-focused research-based prevention programs due to their inexperience with the environmental programs. The participating principals also stated that they experienced frustration with the lack of time and the lack of funds to properly implement the research-based prevention programs. The administrators indicated they were knowledgeable about these research-based substance abuse and violence prevention programs; however, some of their responses revealed their lack of knowledge in distinguishing the difference between actual research-based programs that are on the State Board of Education's approved list and other prevention programs that are marketed. The elementary school principals in this study generally reported positive perceptions of the implementation of research-based substance abuse and violence prevention programs, including the following advantages that were supported by the literature: science-based substance abuse and violence prevention programs prevent or reduce substance use/abuse and violence and student discipline problems, and these programs increase protective factors and decrease risk factors in the lives of students and/or their families. Stated disadvantages about the amount of time required to implement the research-based prevention programs, the lack of training, and the inadequacy of funding yielded some negative perceptions. Recommendations for educational administrators include providing extensive training for site principals and teachers in prevention science and in identifying at-risk students and their needs for prevention services. In addition, administrators were encouraged to collaborate more with their communities in an effort to provide the more meaningful and effective environmental strand: community and family-oriented research-based substance abuse and violence prevention programs.

Accurate Evaluation and Management (E&M) billing and coding is an essential skill for medical clinicians. Consequences of incorrect E&M billing and coding include delayed patient treatment, delayed reimbursements from third party payers, and even charges of insurance fraud. The accuracy of billing and coding is especially salient in practices whose patient population is covered primarily by Medicare/Medicaid, as is the case in many Northeast Tennessee clinics. Despite the importance of accurate E&M billing and coding, recently graduated physicians moving into their first year of residency are often under-informed regarding proper billing and coding. Much of their knowledge about the process is picked up piecemeal over the course of their residency. The purpose of this study is to educate incoming post-graduate year one (PGY1) medical residents on the E&M billing and coding system for a rural Family Medicine clinic. During their first month as PGY1 resident physicians, participants were given a survey to assess their knowledge of E&M billing and coding for outpatient encounters. Participants then attended an educational session on this topic and received handouts that they could reference in the future. The participants were then surveyed again. Data analysis is currently underway. A repeated measure t-test will be utilized to determine if the educational session and informational handouts led to a statistically significant increase in PGY1 resident knowledge of E&M billing and coding. It is expected that participants will show significant knowledge gains as a result of the educational training. This research has important implications for medical resident training, particularly in rural practices that treat large populations covered by Medicare/Medicaid.