Participation and older people: Meaning, theory and practice

Increasing older people's participation in society is important in ageing policies worldwide. There is a need to understand the challenges for health professionals of transforming policy on participation into liberating social change practices on the ground. This paper explores the meaning, theory and practice of participation. It uses the example of a work in progress project that has attempted to address structural barriers to older people's participation within an Australian aged care facility, to illustrate theoretical and practice principles surrounding participation.

Behaviour of older people admitted for residential respite care

The aim of this pilot study was to determine whether residential respite care is used because of disruptive behaviour displayed by older people. The specific objectives were to 1) characterise older people being admitted for residential respite care, 2) obtain a preliminary estimate of the proportion of older people in residential respite care because of disruptive behaviour, and, 3) examine the relationship between residential respite care and disruptive behaviour. A quantitative approach using a cross-sectional survey was employed. The respite recipients were 35 older people with a mean age of 81.5 years (range 67-96 years). The respite recipients had been admitted for residential respite care to aged care hostels and nursing homes in a provincial city and its surrounding rural area. Nurses rated disruptive behaviour using the Dementia Behavior Disturbance Scale (DBDS). Additional reliability data for the DBDS are provided. The study found that the largest specific group of residential respite care users were widows (31.4%) who lived alone in their own home. The reason for over half (51.4%) of the residential respite admissions was to give a carer a 'break' from the older person. Although a large proportion (80%) of respite recipients were rated as having disruptive behaviour, the proportion of admissions because of disruptive behaviour was much less (28.6%). People with dementia (37.1%) scored significantly higher than people without dementia on the DBDS [F (1,33)=15.57, p

Health care to immigrant and Portuguese pregnant women in Portugal

This study aimed to assess the care received and the barriers faced by immigrants and Portuguese pregnant women in Portugal. This is an exploratory qualitative study, resorting to applying semi-structured interviews to 60 immigrant and 22 Portuguese women. Content analysis supported by QSR Nvivo10 program was used. The study was approved by an Ethics Committee. The results showed four categories related to affective dimensions-relational, cognitive, technical-instrumental and health care policy for pregnant women. As for the barriers in health care, these were mentioned by some of the expectant mothers, especially immigrant women. Almost all, both immigrant and Portuguese, pregnant women were satisfied with the health care.

Enseignement prégradué de la médecine ambulatoire a la PMU: quelques repères [Pregraduate training in ambulatory care: a Swiss perspective].

The current lack of general practitioners in Switzerland is the result of health care policy which aimed in the past years to reduce the number of medical students and physicians in private practice. Furthermore, during the past decades, the Swiss Medical Schools emphasized on the transmission of medical care by specialists and neglected primary care medicine. The Faculty of medicine at the University of Lausanne recently decided to renew the curriculum. The Department of ambulatory care and community medicine (Policlinique Médicale Universitaire) of Lausanne is committed to the elaboration of this move. The biomedical model, essential to the acquisition of clinical competence, is still taught to the students. Nevertheless, from the beginning to the end of the curriculum, an emphasis is now put on the clinical skills and the clinical reasoning.

Characterizing the vulnerability of frequent emergency department users by applying a conceptual framework: a controlled, cross-sectional study.

BACKGROUND: Frequent emergency department (ED) users meet several of the criteria of vulnerability, but this needs to be further examined taking into consideration all vulnerability's different dimensions. This study aimed to characterize frequent ED users and to define risk factors of frequent ED use within a universal health care coverage system, applying a conceptual framework of vulnerability. METHODS: A controlled, cross-sectional study comparing frequent ED users to a control group of non-frequent users was conducted at the Lausanne University Hospital, Switzerland. Frequent users were defined as patients with five or more visits to the ED in the previous 12 months. The two groups were compared using validated scales for each one of the five dimensions of an innovative conceptual framework: socio-demographic characteristics; somatic, mental, and risk-behavior indicators; and use of health care services. Independent t-tests, Wilcoxon rank-sum tests, Pearson's Chi-squared test and Fisher's exact test were used for the comparison. To examine the -related to vulnerability- risk factors for being a frequent ED user, univariate and multivariate logistic regression models were used. RESULTS: We compared 226 frequent users and 173 controls. Frequent users had more vulnerabilities in all five dimensions of the conceptual framework. They were younger, and more often immigrants from low/middle-income countries or unemployed, had more somatic and psychiatric comorbidities, were more often tobacco users, and had more primary care physician (PCP) visits. The most significant frequent ED use risk factors were a history of more than three hospital admissions in the previous 12 months (adj OR:23.2, 95%CI = 9.1-59.2), the absence of a PCP (adj OR:8.4, 95%CI = 2.1-32.7), living less than 5 km from an ED (adj OR:4.4, 95%CI = 2.1-9.0), and household income lower than USD 2,800/month (adj OR:4.3, 95%CI = 2.0-9.2). CONCLUSIONS: Frequent ED users within a universal health coverage system form a highly vulnerable population, when taking into account all five dimensions of a conceptual framework of vulnerability. The predictive factors identified could be useful in the early detection of future frequent users, in order to address their specific needs and decrease vulnerability, a key priority for health care policy makers. Application of the conceptual framework in future research is warranted.

Les admissions hospitalières pour les infections urinaires: tendances temporelles, fardeau économique et facteurs prédicateurs de mauvaise évolution des patients

Résumé Introduction: Les infections urinaires (IU) sont les infections bactériennes les plus fréquentes chez les patients hospitalisés. Cette étude décrit les tendances temporelles d'admission et de mortalité liées aux hospitalisations pour les IU, ainsi que le fardeau économique associé. Les prédicteurs de mauvaise évolution clinique et de mortalité sont examinés par la suite. Méthodes: Les données ont été extraites à partir de la base de données du NIS entre le 1er janvier 1998 et le 31 décembre 2010. 1,717,181 hospitalisations liées aux IU ont été retenues. L'incidence et la mortalité ont été calculées et stratifiées selon le sexe, l'âge et la présence de sepsis. Les frais médians et totaux pour les hospitalisations sont calculés et ajustés pour l'inflation. Finalement, les prédicteurs d'avoir un sepsis induit par les IU et de mortalité sont examinés avec une analyse par régression logistique multivariée. Résultats: L'incidence globale d'hospitalisation et la mortalité associées aux IU voit une croissance annuel estimé (EAPC) de +4.764 et +4.610 respectivement (p<0.0001). L'augmentation d'incidence est le plus marquée pour les patients âgés de 55 à 64 ans (EAPC = +7.805; p<0.0001). Les frais médians par hospitalisation ont augmenté de $10 313 en 1998 à $21 049 en 2010 (EAPC +9.405; p<0.0001). Les frais globaux pour les hospitalisations des IU ont augmenté de $8.9 milliard en 1998 à $33.7 milliard en 2010 (EAPC +0.251; p<0.0001). Les patients âgés, de sexe masculin, de race afro-américaine, ainsi que les patients assurés par Medicaid ou ceux sans assurance, et les patients soignés à des centres non-académiques sont à risque plus important de mortalité (p<0.0001). Conclusion: L'incidence et la mortalité associées aux IU ont augmenté au cours de la dernière décennie. Les frais médians ajustés pour l'inflation ainsi que les frais globaux ont augmenté progressivement au cours de la période d'étude. Dans la cohorte étudiée, les patients âgés, de sexe masculin, de race afro-américaine, ainsi que les patients assurés par Medicaid ou ceux sans assurance, et les patients soignés à des centres non-académiques sont à risque plus important de mortalité. Ces données représentent des indicateurs de qualité de soins qui pourraient permettre d'adapter certaines politiques de soins de santé aux besoins des sous-populations plus vulnérables.

Subnotificação de acidentes do trabalho não fatais em Botucatu, SP, 2002

Objective: The implementation of work-related injury prevention policies has been hindered by underreporting of incidents among formal workers, and substantial underreporting among informal workforce. This study aimed at estimating the underreporting of work-related injury in a median-sized city. Methods: A random survey was carried out among residences in the urban area of Brazil. Residents were interviewed about the occurrence of work-related injury to people aged more than nine years in the last 90 days. All incidents reported were double checked in the National Social Security Institute (INSS) records. Results: There were 9,626 residences visited. It was estimated 79.5% (CI 95%: 78.8%-80.3%) of underreporting of work-related injury. Conclusions: Work-related injury reporting is poor in the study location and this may be occurring in other cities. Data suggest the need to build up information systems on Brazilian workers' health. It should incorporate methods, materials and human recourses necessary to recognize, store, analyze, and spread information support injury prevention policies and promote workers' health programs.

A comparison between diuretics and angiotensin-receptor blocker agents in patients with stage I hypertension (PREVER-treatment trial): Study protocol for a randomized double-blind controlled trial

Background: Cardiovascular disease is the leading cause of death in Brazil, and hypertension is its major risk factor. The benefit of its drug treatment to prevent major cardiovascular events was consistently demonstrated. Angiotensin-receptor blockers (ARB) have been the preferential drugs in the management of hypertension worldwide, despite the absence of any consistent evidence of advantage over older agents, and the concern that they may be associated with lower renal protection and risk for cancer. Diuretics are as efficacious as other agents, are well tolerated, have longer duration of action and low cost, but have been scarcely compared with ARBs. A study comparing diuretic and ARB is therefore warranted.Methods/design: This is a randomized, double-blind, clinical trial, comparing the association of chlorthalidone and amiloride with losartan as first drug option in patients aged 30 to 70 years, with stage I hypertension. The primary outcomes will be variation of blood pressure by time, adverse events and development or worsening of microalbuminuria and of left ventricular hypertrophy in the EKG. The secondary outcomes will be fatal or non-fatal cardiovascular events: myocardial infarction, stroke, heart failure, evidence of new subclinical atherosclerosis and sudden death. The study will last 18 months. The sample size will be of 1200 participants for group in order to confer enough power to test for all primary outcomes. The project was approved by the Ethics committee of each participating institution.Discussion: The putative pleiotropic effects of ARB agents, particularly renal protection, have been disputed, and they have been scarcely compared with diuretics in large clinical trials, despite that they have been at least as efficacious as newer agents in managing hypertension. Even if the null hypothesis is not rejected, the information will be useful for health care policy to treat hypertension in Brazil. Clinical trials registration number: ClinicalTrials.gov: NCT00971165. © 2011 Fuchs et al; licensee BioMed Central Ltd.

A comparison between diuretics and angiotensin-receptor blocker agents in patients with stage I hypertension (PREVER-treatment trial): study protocol for a randomized double-blind controlled trial

Abstract Background Cardiovascular disease is the leading cause of death in Brazil, and hypertension is its major risk factor. The benefit of its drug treatment to prevent major cardiovascular events was consistently demonstrated. Angiotensin-receptor blockers (ARB) have been the preferential drugs in the management of hypertension worldwide, despite the absence of any consistent evidence of advantage over older agents, and the concern that they may be associated with lower renal protection and risk for cancer. Diuretics are as efficacious as other agents, are well tolerated, have longer duration of action and low cost, but have been scarcely compared with ARBs. A study comparing diuretic and ARB is therefore warranted. Methods/design This is a randomized, double-blind, clinical trial, comparing the association of chlorthalidone and amiloride with losartan as first drug option in patients aged 30 to 70 years, with stage I hypertension. The primary outcomes will be variation of blood pressure by time, adverse events and development or worsening of microalbuminuria and of left ventricular hypertrophy in the EKG. The secondary outcomes will be fatal or non-fatal cardiovascular events: myocardial infarction, stroke, heart failure, evidence of new subclinical atherosclerosis and sudden death. The study will last 18 months. The sample size will be of 1200 participants for group in order to confer enough power to test for all primary outcomes. The project was approved by the Ethics committee of each participating institution. Discussion The putative pleiotropic effects of ARB agents, particularly renal protection, have been disputed, and they have been scarcely compared with diuretics in large clinical trials, despite that they have been at least as efficacious as newer agents in managing hypertension. Even if the null hypothesis is not rejected, the information will be useful for health care policy to treat hypertension in Brazil. Clinical trials registration number ClinicalTrials.gov: NCT00971165

Tradition, Change and Variation : Past and Present Trends in Public Old-age Care

The general aim of this dissertation is to describe and analyse how public old-age care in Sweden has developed and changed during the last century. The study applies a provider perspective on how care has been planned and professionally carried out. A broader social policy perspective, studying old-age care at central/national as well as local/municipal level, is also developed. A special focus is directed at the large local variation in care and services for the elderly. The empirical base is comprised of official documents and other public sources, survey data from interviews with elderly recipients of public old-age care, and official statistics on publicly financed and controlled old-age care and services. Study I addresses the development of old-age care in Sweden during the twentieth century by studying an important occupation in this field – the supervisors and their professional roles, tasks and working conditions. Throughout, the roles of supervisors have followed the prevailing official policy on the proper way to provide care for elderly people in Sweden; from poor relief at the beginning of the 1900s, via a generous level of services in the 1960s and 1970s, to today’s restricted and economy-controlled mode of operation. Study II describes and compares two main forms of public old-age care in Sweden today, home help services and institutional care. The care-load found in home-based care was comparable to and sometimes even larger than in service-homes and other institutions, indicating that large care needs among elderly people in Sweden today can be met in their homes as well as in institutional settings. Studies III and IV analyse the local variation in public old-age care in Sweden. During the last decades there has been an overall decline in home help services. The coverage of home help for elderly people shows large differences between municipalities throughout this period, and the relative variation has increased. The local disparity seems to depend more on historical factors, e.g., previous coverage rates, than on the present municipal situation in levels of need or local economy and politics. In an introductory part the four papers are linked together by an outline of the demographic situation and the social policy model for old-age care in Sweden. Trends that have been apparent over time, e.g. professionalisation and market orientation, are traced and discussed. Conflicts between prevailing ideologies are analysed, in regards to for instance home-based and institution-based care, social and medical culture, and local and central levels of decision-making. ’Welfare municipality’, ‘path dependency’, and ‘decentralisation’ are suggested as a conceptual framework for describing the large and increasing local variations in old-age care. Finally, implications of the four studies with regard to old-age care policy and further research are discussed.

Welfare Lobby Groups responding to Globalisation: A Comparison of the Australian Council of Social Service (ACOSS) and the UK Child Poverty Action Group (CPAG)

The past decade has witnessed a period of intense economic globalisation. The growing significance of international trade, investment, production and financial flows appears to be curtailing the autonomy of individual nation states. In particular, globalisation appears to be encouraging, if not demanding, a decline in social spending and standards. However, many authors believe that this thesis ignores the continued impact of national political and ideological pressures and lobby groups on policy outcomes. In particular, it has been argued that national welfare consumer and provider groups remain influential defenders of the welfare state. For example, US aged care groups are considered to be particularly effective defenders of social security pensions. According to this argument, governments engaged in welfare retrenchment may experience considerable electoral backlash (Pierson 1996; Mishra 1999). Yet, it is also noted that governments can take action to reduce the impact of such groups by reducing their funding, and their access to policy-making and consultation processes. These actions are then justified on the basis of removing potential obstacles to economic competitiveness (Pierson 1994; Melville 1999).

Managing social policy under federalism: The challenges of hybrid funding and program delivery

This paper discusses generally the question of the level of government that should be used to administer different social policies. The chapter focuses on the Medicaid program, looking at recent state-level changes in health insurance for the poor and long-term care policy. Particular attention will be paid to the question of how states have used their new freedoms to outsource public insurance to the private sector and on the consequent differences in outcomes across states. Notably, this paper will be drawn from my forthcoming book “The American Myth of Markets in Social Policy” (Palgrave, MacMillan, November, 2015).

Hospital and environmental variation in Texas nonprofit hospital organizational policies regarding charity care

The 2005 Annual Statement of Community Benefits Standard (ASCBS) and the annual report of the Community Benefits Plan, Summary of Current Hospital Charity Care Policy and Community Benefits, were used to identify various environmental and policy relationships with regard to eligibility for charity care requirements, a component for meeting the nonprofit requirements established by the Texas Legislature for nonprofit tax exemption (Texas Health and Safety Code, §311.04610). ^ Charity care policies are established by the individual hospital (or systems) and are generally defined as rules concerning care provided by the institution without the expectation of payment. This study has been undertaken to provide specific information about the charity care eligibility requirement policies of nonprofit hospitals. These hospitals are the part of the safety net for those persons who are indigent, low-income and uninsured. This study examines nonprofit hospitals by physical location, bed size, religious affiliation, trauma level, disproportionate share, and teaching designations. County information includes population, percentage of residents eligible for Medicaid benefits, ethnic makeup of county residents, poverty level, designation of a hospital district or operators of a public hospital, and the number of nonprofit and for-profit hospitals located in the county. Although this information has been collected by the Texas Department of State Health Services (DSHS), no other analysis has been conducted. ^

Observations from the Balcony: Directions for Pediatric Health Disparities Research and Policy

In 2002, the Institute of Medicine released Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare, a landmark monograph documenting health disparities in the U.S. health care system. Since the publication of Unequal Treatment, the field of pediatric health disparities research has advanced significantly with a proliferation of studies examining a wide array of topics concerning inequities in child health. Advances in health care policy and legislation have also added to a heightened discourse on pediatric health disparities. While there has been substantial activity in efforts to address pediatric health disparities, questions remain regarding whether these efforts have changed the trajectory of health equity among children. The aim of this paper is to examine the practical challenges of addressing pediatric health disparities in the dynamic context of global changes in health care research, policy, and legislation relevant to children. Using the Adaptive Leadership framework, this paper outlines a conceptual model for assessing the scope of progress made in addressing pediatric health disparities, diagnoses the continued adaptive challenges of pediatric health disparities, and provides an agenda for further work and future investment.

Delivering essential health care services in rural areas : an analysis of alternative models /

"May 1991."