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    Whakawhirinakitanga ahua : exploring a Māori model of health service delivery : a thesis submitted for the degree of Doctor of Philosophy in Public Health (Māori Health) Massey University
    (Massey University, 2015) Fernandez, Carole Ann
    Maori health service delivery is underpinned by Maori tikanga, philosophies, values and processes; and Maori providers have consistently developed and delivered tikanga-based services to meet the needs of Maori and whanau. This thesis explored a Maori model of health service delivery, Whakawhirinakitanga Ahua, developed by an iwi health provider, Best Care (Whakapai Hauora) Charitable Trust. It aimed to uncover if health service delivery was reflective of the model, and if it addressed the health needs of Maori accessing services at Whakapai Hauora. This research was undertaken within the interpretivist paradigm using qualitative methods aligned to Maori-centred research. It drew upon the experiences, attitudes and beliefs of 50 key informants; health professionals (Maori and non-Maori) who delivered services and Maori who accessed services at Whakapai Hauora. The primary focus is on collaborative processes involved in the delivery of integrated health care. Findings in this research indicated how Maori and non-Maori work together in a Maori health environment, how they work with clients and whanau, and also at the interface with mainstream services. It demonstrated how Maori utilise tikanga-based service delivery in the provision of care to individuals and whanau; and how non-Maori working at Whakapai Hauora utilise significant aspects of tikanga-based and Treaty principles in service delivery, in response to Maori health interests within the context of Government health priorities and social policy. This thesis draws a distinction between client-centred care and whanau focused care. While client-centred practice has been a widely accepted philosophy in holistic approaches to care, whanau focused care places whanau central to all service delivery processes. It challenges health professionals to reconsider the way in which they engage with Maori and whanau, shifting mindsets from working with individuals to whanau as a collective. It challenges health professionals to acknowledge the wider environment and the determinants that impact on health and wellbeing. This thesis also acknowledges the expertise and strengths from both Te Ao Maori and Te Ao Pakeha, and highlights the significance of health professionals having to walk in both worlds in order to facilitate better outcomes for Maori.
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    Ageing in place : the experiences of older adults accessing health services in the Wakatipu : a thesis presented in partial fulfilment of the requirements for the degree of Master of Arts in Psychology at Massey University, Palmerston North, New Zealand
    (Massey University, 2013) Rose, Rachel Ann
    Access to health services is vital for maintaining the quality of life for older people. Older people living in rural and remote areas often have specific barriers to accessing good quality and timely health services. Poor health service access can make it difficult for older people in remote communities to ‘age in place’. This research explored the experiences of older residents accessing health services in the Wakatipu area of New Zealand, to provide the opportunity for older people in the area to have their voices heard, and to inform service provision in the area. The experiences of older people accessing health services in rural or remote areas are pivotal to formulating policies and building communities founded on wellbeing. A qualitative framework was chosen to record and analyse the rich and detailed experiences of the participants. Eight people aged over 75 years, who currently live in the Wakatipu basin, were interviewed. The interviews were analysed using Interpretative Phenomenological Analysis (IPA), which enables detailed attention to people’s lived experiences. Two superordinate themes of the places that people age, and strategies to maintain the positive ageing ideal, were identified. The results indicated that older adults view health services not in the narrow sense of provision of traditional GP and hospital services, but in the context of all the components required to age well in the location of their choice. This highlights the need to actively include older adults in the planning and decision making process for civic amenities, environmental design, transport, and health services.
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    An exploration of the role of short term medical missions in health care provision in Honduras : a thesis presented in partial fulfilment of the requirements for the degree of Master of Philosophy in Development Studies at Massey University, Turitea, Palmerston North, New Zealand
    (Massey University, 2005) McLennan, Sharon Joy; McLennan, Sharon Joy
    Short term medical missions, or medical brigades are teams of expatriate health professionals and lay people, who travel to Latin America and other parts of the world for a week or two to provide health care to the poor. While the number and popularity of these teams appears to be increasing, to date there has been little literature or critical research addressing their role. This thesis addresses the role of Short Term Medical Missions (STMMs), who they are, what they do and how they fit into health service provision in developing nations. In particular it outlines the services provided by STMMs, including clinical services, resource provision and preventative services, it discusses the motivation for using STMMs as service providers and it also begins to explore the impact they have on the populations and on local health care services in the areas they operate. This is done within the context of Honduras, a nation that has seen an influx of these teams in recent years, particularly since Hurricane Mitch in 1998. Honduras faces many challenges in health and health care and STMMs have been seen by some as a means of “filling gaps”. This study questions whether STMMs are indeed actually filling real gaps, and if they are, whether they most appropriate means of doing so, as there are many limitations to the ability of short term, outside volunteers to provide quality services. While not directly measuring the impact of STMMs on the health status of the population, this study discusses the actual and potential impact of STMMs on local health services, and argues that there are potential long-term consequences to their use. These consequences include an increasing dependency on outside assistance that may be detrimental to the long-term development of National health services.
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    Community participation in health development in Thailand : a thesis presented in fulfillment of the requirement for the degree of Doctor of Philosophy in Nursing at Massey University
    (Massey University, 1997) Tassniyom, Nit
    This thesis is a chronicle of research into the implementation of community participation in health development in Thailand. Community participation is recognised as the key concept of primary health care. Participation in this study has been conceptualised as power. Therefore, to participate is to achieve power, and participation is a process of empowerment. The research participants were health workers employed at the subdistrict health centre, and village health volunteers. These participant groups were chosen because the researcher perceived that they were groups with relatively little power in the Thai health service. The research involved the participants in a two stage process. The first stage was an examination of the concept of participation in relation to the community's experience with development projects. During this stage it became apparent to the researcher that the original concept of community participation was poorly understood by both participant groups. The second stage involved the use of participatory research to achieve community empowerment by supporting the participants in an analysis-action-reflection process. Dialogue, with equal respect between the researcher and participants, was the key method to encourage analysis of their existing situation in order to raise their awareness, the most important step of empowerment. Simultaneously, action research was also utilised to solve a selected health problem, dengue fever control. A comparison between the results of the implementation of action research processes and that of the participatory research processes utilised in this study revealed that participatory research better ensured community participation in health development. The findings provide an understanding of the theoretical concept of community participation in health development, and its enaction by the use of an empowerment process. The utilisation of a new primary health care approach, whereby the community is empowered to be self reliant and solve its own health problems, would depend on the acceptance and application of the empowerment approach by health workers. The empowerment approach would need to be pivotal in the work of all health personnel, including the implementation of policies and routine practice. Specifically, the empowerment approach has much to offer community health nursing and its adoption would support the World Health Organisation's recommendation that a problem-solving, process-oriented and community-based curriculum is necessary to adequately prepare these practitioners. The adoption of this approach would require expansion of the present curriculum to include not only public health science and nursing science concepts, but also those related to community development. The new curriculum would uniquely equip nurses to work in communities and this in turn would provide specialised knowledge for community health nursing, allowing it to be differentiated from other nursing specialties.
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    The measurement and correlates of women's health care utilization : a thesis presented in partial fulfillment of the requirements for the degree of Doctor of Philosophy in Psychology at Massey University, Palmerston North, New Zealand
    (Massey University, 1998) Madison-Smith, Gillian L.; Madison-Smith, Gillian L.
    Andersen's Behavioural Model of Health Care Utilization was used to examine New Zealand women's use of six health care services. The model conceptualises health care utilization as a function of predisposing, enabling and need variables. Predisposing variables encompass the individual's characteristics which are present prior to the onset of illness that represents their propensity to use health services, for example, age. Enabling variables represent features affecting the means to obtain services, for example, income. Need variables represent the presence of illness, either self perceived or professionally diagnosed. Of the six services investigated in the present study, two were non-medical (use of disability and bed days) and four were medical (use of General Practitioners (Gps), health professionals, hospitals and prescription items). The study examined a geographically stratified sample of 964 women between the ages of 19 and 90 drawn from a range of New Zealand households. Five hypotheses were tested for each of the six health services. Incorporating new measures to capture the model's components, the first two hypotheses replicated the model by examining use of health services in terms of 'contact' and 'volume'. Contact focused on whether or not a service had been accessed, while volume focused on the amount of consumption that occurred over a defined catchment period. Predisposing and enabling characteristics were important predictors of contact; but need became more important when predicting ongoing service use. The last three hypotheses expanded the model by examining the effects of trauma and Post-Traumatic Stress Disorder (PTSD) on health care utilization. Traumatic events were associated with ongoing use of bed days and hospitals. PTSD was associated with use of bed days, hospitals, and GPs. Suggestions are made regarding future research in terms of overcoming research limitations and expanding the field. These included improving measures to capture needs for women of all ages as opposed to focusing on measures capturing chronic conditions best suited for the elderly, examination of service use in terms of episode events and suggested developments for the model incorporating reciprocal and feedback loops to account for traumatic events, PTSD, personal health habits and satisfaction with use of health services.
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    Health and health-care use by New Zealand Vietnam War veterans and their wives : an examination of Andersen's model of health-care utilization : a thesis presented in partial fulfilment of the requirements for the degree of Doctor of Philosophy in Psychology at Massey University
    (Massey University, 2000) Withers, Rody Desmond
    Previous research has found that the debilitating physical and psychological sequelae of combat stress experienced by Vietnam War veterans extend also to their wives. The present study has broadened the focus by applying the Andersen model of health services utilization to health-care used by a community sample of 281 couples comprising New Zealand Vietnam war veterans and their wives who had each completed one postal survey. Andersen (1968) proposed that utilization was a function of three components: predisposition, enablement and physical-need. Predisposition represents sociocultural and personal variables such as ethnicity and health beliefs that increase the likelihood of utilization. Enablement represents familial and medical resources such as income and health insurance which facilitate access health-care. Physical-need represents perceived or diagnosed need for health-care. The present study modified Andersen's model to include two further components, psychological-need and multiple-need. Psychological-need represents variables such as distress and trauma, while multiple-need represents co-existing physical-need and psychological-need. The model was applied to a total of thirteen health-care measures which were categorised as either 'contact' or 'volume' measures Contact measured whether a service had been used, while volume measured the amount of contact with a service. Seven measures tapped professional care (treatment by hospitals, general practitioners (GPs) and other professionals), and six tapped self-care (treatment by prescriptions, bedrest or reduced activity). Although veterans reported greater health-need than their wives, they were less frequent in their use of a range of services, including GP services. Five hypotheses tested core propositions of the model. Results supported one hypothesis; namely, that physical-need was more important in explaining the frequency of GP-service use than the likelihood of its use. The other four hypotheses received either limited or no support. Two hypotheses tested the modified model and received limited support. Psychological-need and multiple-need enhanced the explanation of five and two services, respectively. No evidence was found that poor psychological functioning or co-existing health problems were associated with use of GP services. There was evidence that psychological-need was associated with use of hospital services. Findings suggested that veterans and their wives who did not possess specified enabling resources had impeded access to GP-care. Overall, predisposing characteristics accounted for most of the explained variance across the thirteen measures of health-care, and enabling resources accounted for the least. Discussion focused on the need for future research to refine health-care measures so that the reasons for use or non-use of specific services are explicit, to use longitudinal designs in order to examine the process of health-care, and to more clearly explicate the Andersen (1968) model in terms of theoretical relationships among predictors.
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    Provision at the interface : the Māori mental health contracting experience : a thesis presented in partial fulfilment of the requirements for the degree of Doctor of Philosophy in Māori Health at Massey University, Turitea Campus, Palmerston North, New Zealand
    (Massey University. Research Centre for Maori Health and Development, 2005) Boulton, Amohia Frances
    New Zealand's mental health performance and monitoring framework is a complex and evolving one. Its initial development occurred at a time when it was taken for granted that mainstream understandings of health and mainstream systems of service delivery would not only be appropriate for all New Zealanders, but would also service the needs of all New Zealanders. Latterly however there has been an acknowledgment that a wholly different understanding of health and health care has existed in this country; the worldview understood and shared by tangata whenua. This thesis uses a theoretical framework devised specifically for this research to investigate the experience of Maori mental health providers as they contract to provide mental health services for the Crown; to ascertain whether Maori mental health providers deliver outside of their contracts; and to examine the role multiple accountabilities play in contracting. The theoretical framework, the "Maori research paradigm net" is inclusive of both the kaupapa Maori and Maori centred approaches, moving beyond the traditional dichotomy that frames Maori health research and allowing the researcher the freedom to select and use the best and most appropriate research tools from both traditional social science research practices, and from Maori culture and tikanga, to answer the research question posed. The thesis concludes that Maori mental health providers deliver mental health services at the interface between two philosophical viewpoints or worldviews: that of the Maori community in which they are located and to whom they provide services; and that of the funder, from whom they obtain resources to enable them to deliver services. As a consequence of working at the interface, Maori providers regularly and routinely work outside the scope of their contracts to deliver mental health services which are aligned with those values and norms enshrined in Maori culture. To adequately acknowledge and validate the beneficial extra-contractual provision which occurs as a result of delivering mental health services at the interface, and prevent less desirable provision, a more responsive contracting environment and a performance measurement framework, which integrates both worldviews and which takes account of the multiple accountabilities that Maori providers manage, is required.