만성콩팥병 환자의 투석 적응경험에 관한 질적 사례연구

박혜연 연세대학교 행정대학원 2021 국내석사

The purpose of this study is to identify changes and new issues in common in life before and after dialysis of patients with chronic kidney disease, and to identify the needs for social welfare services for each period before and after dialysis. A qualitative case study was conducted to identify difficulties in the adaptation process and changes in life through in-depth consideration of dialysis adaptation experience of patients with chronic kidney disease. Six adults over the age of 55 who were diagnosed with chronic kidney disease were selected as patients who are currently receiving dialysis treatment. In order to check the dialysis adaptation experience of patients with chronic kidney disease, efforts were made to select participants in the research with a balance in the use experience in accordance with social welfare service standards. Patients who perform peritoneal dialysis or hemodialysis were selected for depth interviews, and patients who performed dialysis after kidney transplantation or transplantation were excluded. The research method was analyzed by applying 'Within case analysis' and 'between case analysis' within the qualitative case study method to identify differences and meaningful features that fit not only common issues but also individual characteristics. The within case analysis summarized the study in a storytelling manner on dialysis adaptation processes experienced in chronological order, and the between case analysis identified common recurring issues as top 15 categories and bottom 31 categories in chronological order. This stark difference in the experience before and after dialysis allowed patients to distinguish the difficulties of each time. The following points are derived to discuss social welfare services required by period. Social welfare services needed before dialysis are : First, strengthening support for treatment cost, second, encouraging maintenance of patient treatment through multidisciplinary team communication, third, supporting decision on treatment methods through mentoring and group program participation, and establishing a community economic safety net. The contents of social welfare services, which are based on the needs of research participants after the start of dialysis, are first, expanding support for transportation services for the disabled, second, living and financial support after dialysis, third, recovery of interpersonal relationships and social activities through programs, fourth, job activities and rehabilitation to the society. This study specifically observed psychosocial and economic difficulties experienced before and after dialysis, and identified the experience of overcoming difficulties and the desire for social welfare services needed during continuous treatment. Therefore, it is significant in that it has sought ways to support medical social welfare services in hospitals and social welfare services in terms of communities outside the hospital in the pre and post dialysis period in the experience of adapting dialysis of patients with chronic kidney disease. The limitations are as follows. First, it is necessary to secure a population that can be representative of the disease and to research that reflects the number of different cases. Second, a study on adaptive experiences that distinguish dialysis treatment methods is needed. Third, research on the effectiveness of medical social worker intervention in various hospitals that provide disease education should provide a basis for expanding multi-disciplinary team access and participation as essential educators. Fourth, research is needed to analyze the effectiveness of financial expenditure as well as service needs to expand the application of calculation specials from the time of the procedure. Since this study is based on subjective experience, it should reflect the resources needed for objective surveys and policy development of chronic disease management in the items. Thus, we look forward to overcoming the limitations of this study and proceeding with subsequent studies in the future. 본 연구는 만성콩팥병 환자의 투석 전·후 삶의 변화와 공통의 새로운 이슈들을 확인하고 투석 전·후 시기별로 필요로 하는 사회복지서비스에 대한 욕구를 파악하는 것에 목표를 두고 있다. 만성콩팥병 환자의 투석 적응경험에 대한 심층적 고찰을 통해 적응 과정에서의 어려움과 삶의 변화를 확인하고자 하였으며, 치료 시기별로 필요한 의료사회복지서비스에 대한 탐색을 위해 질적 사례연구를 실시하였다. 연구 대상자는 만성콩팥병으로 진단받은 만 55세 이상의 성인 6명이며 현재 투석치료를 실시하고 있는 환자로 선정하였다. 만성콩팥병 환자들의 투석 적응경험을 확인하고자 사회복지서비스 기준에 따른 이용 경험에 있어 균형을 가지고 연구 참여자를 선정하고자 노력하였다. 복막투석 또는 혈액투석을 실시하고 있는 대상자를 선정하여 심층면접을 실시하였으며 신장이식 또는 이식 후 투석을 시행하는 환자는 제외하였다. 연구방법은 공통의 이슈뿐만 아니라 개별 특성에 맞는 차이점을 확인하고 의미 있는 특징들을 파악하고자 질적 사례연구 방법 내‘사례 내 분석(Within case analysis)’과‘사례 간 분석(between case analysis)’을 적용하여 결과를 도출하였다. 사례 내 분석에서는 시간 순으로 경험했던 투석 적응과정에 대해 스토리텔링 방식으로 연구를 정리하였으며, 사례 간 분석은 공통의 반복되는 이슈들은 시간 순서에 따라 상위 범주 15개, 하위 범주 31개로 확인되었다. 시기별로 필요로 하는 사회복지서비스에 대한 논의점을 도출하면 다음과 같다. 투석 전 필요로 하는 사회복지서비스는 첫째, 시술비 지원 강화 둘째, 다 학제간 팀 소통을 통한 환자 치료유지 독려 셋째, 멘토링 및 집단프로그램 참여를 통한 치료방법 결정 지원 넷째, 지역사회 경제적 안전망 구축이다. 투석 시작 후 연구 참여자들이 필요로 하는 내용을 토대로 정리한 사회복지서비스 내용은 첫째, 신장 장애인 이동서비스 지원 확대 둘째, 투석 후 생계 및 경제적 지원 셋째, 프로그램을 통한 대인관계 회복 및 사회적 활동 넷째, 직업 활동 및 사회복귀 지원이다. 본 연구는 투석 전·후에 겪는 심리사회적, 경제적 어려움을 구체적으로 관찰하였으며 어려움을 극복 할 수 있었던 경험과 지속적인 치료 과정에서 필요로 하는 사회복지서비스에 대한 욕구를 파악할 수 있었다. 이에 만성콩팥병 환자의 투석 적응경험에서 투석 전·후 시기에 맞는 병원 내 의료사회복지서비스와 병원 밖 지역사회 측면에서의 사회복지서비스에 대한 지원 방안을 모색했다는 점에서 큰 의의를 가진다. 한계점은 다음과 같다. 첫째, 질환의 대표성을 지닐 수 있는 모집단을 확보와 다양한 사례 수를 반영한 연구가 필요하다. 둘째, 투석 치료 방법의 구분과 직업복귀 경험에 관한 연구가 진행되어야 한다. 셋째, 질환교육을 실시하는 다양한 병원의 의료사회복지사 개입의 효과성에 관한 연구를 통해 다학제 팀 접근의 확대와 필수교육자로의 참여를 확대할 수 있는 근거를 마련해야 한다. 넷째, 시술시기부터 산정특례 적용을 확대하기 위해서 서비스 욕구뿐만 아니라 재정지출의 효과성을 분석하는 연구가 필요하다. 본 연구는 주관적인 경험에 의한 판단이므로 객관적인 설문조사 및 만성질환관리의 정책개발에 필요한 자원을 항목에 반영해야한다. 이와 같이 본 연구의 한계점을 극복하여 향후 진행 될 후속 연구가 마련되기를 기대한다.

의료사회사업에서 척수손상자를 위한 사례관리 실천모형 연구

민현순 경성대학교 정책정보대학원 1997 국내석사

The purpose of this study is to develop an appropriate case management practice model for the spinal cord injured in medical social work setting, and to test it for the practiccal purposes. This study is evolved through literature review, which is related to spinal cord injury and case management, and the researcher's experience with the spinal cord injured in medical social work setting. The contents of the intended model are as follow: The goals of this model are related to help the spinal cord injured to perform appropriately their daily living tasks in community. Continued rehabilitation treatment and care after being discharged from the hospital are highly emphasized in this model, which is intended to achieve an effective rehabilitation management. Therefore, compared to the other traditional social work practices, this model focuses more on monitoring, follow-ups, and re-assesments. The model uses teamwork approach which is composed of rehabilitation doctors, nurses, physical therapists, volunteers, and social workers. In this case, the role of case manager is a professional manager. In order to solve various problems of the spinal cord injured, public and personal resource systems are composed and used. Tn modifying case management process, Rothman's experiential model for social work practice is referred. In order to test this model empirically, it has been applied to an existing medical social work practice setting. The study sample is consisted of 3 clients, who were diagnosed as spinal cord injury, hospitalized at rehabilitation medicine unit in Pusan ** hospital, and who were given services more than one years by this researcher. This study subjects had various problems, for instance, economical, psycho-social and family problems, so they could not carry out daily living tasks properly by then. In assessment phase, re-assessment phase, and evaluation phase, measured were the Escrow (Environment, Social support, Cluster of family member. Resources, Outlook, Work or school status) profile that can evaluate home care assessment, and the modified Barthel index that can evaluate ADL(Activities of Daily Living) score. After being applied, the tests showed positive trends being occurred to the study subjects (clients), And all of the subjects were found to be strengthened by social network also. Therefore, this researcher was able to conclude that the proposed model could contribute positively welfare of the spinal cord injured. Even in a situation where community resources are limited and the service delivery system is not well established, this study could show that this model can contribute for the spinal cord injured to integration of the their community. In this case, the social worker as a case manger should be effective as following. First, social workers should strengthen their function as an educator and as a continuous monitoring person. Social worker should have sensibility to social welfare policy and community resources. And they have to develop the resource systems of the base of relationship with the spinal cord injured. Particularly, in a situation of the deficit of service facilities and resource systems as in the case of Korea, they must intervene the contexts of social network. Second, it is needed that social workers put their efforts in community resource development. Third, social workers should intervene to the situations in need of strengthening functions of extended families by activating family conference and developing family education programs. Based on the findings in this study, a few of suggestions are as follows. First, it is needed that assessment tools be provided before practicing case management, so that the effectiveness of applying life-task centered case management model can be more empirically tested Second, the availability of this model might need ta be tested on extending to the other areas like the brain-injured and the other clonic diseased. Third, in testing the effectiveness of case management method like this, it is required to have control groups in the phase of study design. Fourth, applying the case management model, which is developed in the context of western countries, to the situation in Korea, the efforts of developing other contexts like half-way care facilities are needed.

과부담의료비지출이 미충족의료경험에 미치는 영향 : 사회복지서비스이용 조절효과 분석

유지혜 연세대학교 사회복지대학원 2018 국내석사

In Korea, the health insurance system allows the people to receive medical services regardless of their income and ability to pay. However, the health insurance coverage is very low that it is possible for people to pay a substantial amount of copayment. High copayments and excessive medical costs cause a heavy burden on households and can lead to an economic risk. In particular, excessive medical expenditure may cause patients to waver or abandon medical services. Although the national and private foundations are providing various social welfare services to reduce the expenditure for patients' households and receive continuous treatment, there is a significant lack of research on the effectiveness of these services. The purpose of this study is to examine the effect of catastrophic health expenditure on unmet healthcare needs and to verify the moderating effect of social welfare service as social support. This study utilized 10,072 data from the Korea Welfare Panel 11th Wave (2016). The catastrophic health expenditure was measured using two threshold approach. The unmet healthcare needs have been identified through unmet medical experience because of economic reasons. The use of social welfare services is examined through cost of living, medical support, and product support. Logistic regression analysis was used to examine the effect of catastrophic health expenditure on unmet healthcare needs and the moderating effect of social welfare service use. The results of this study are as follows. First, catastrophic health expenditure has a statistically significant effect on unmet healthcare needs. This indicates that the greater the catastrophic health expenditure, the higher the probability of experiencing unmet healthcare needs. Second, the moderating effect of social welfare service utilization has a negative effect on the relationship between catastrophic health expenditure and unmet healthcare needs. This means that the greater the catastrophic health expenditure, the greater the possibility of experiencing unmet healthcare needs. However, when using social welfare services, it is improbable to experience unmet healthcare needs. Based on the results of the study, the social and welfare implications of policy and practice are suggested. First, there is a need to expand the public medical expense subsidy to reduce catastrophic health expenditure. Second, there is a need to offer Integrated Health and Social Welfare Services of Experts for those with the unmet healthcare needs due to the catastrophic health expenditure. Third, there is a need to provide social welfare services to help those with socioeconomic conditions when catastrophic health expenditure is spent thus the social welfare service decreases the unmet healthcare needs. 우리나라는 건강보험제도를 통해 전 국민이 소득과 지불능력과 관계없이 의료서비스를 제공받도록 하고 있다. 그러나 OECD 국가들과 비교하였을 때, 건강보험을 통한 보장성이 낮고 실제로 지불해야 되는 본인부담금이 높은 것으로 나타났다. 높은 본인부담금은 가구에 과중한 부담을 주며, 과도한 의료비용으로 인해 경제적 위험을 겪을 수 있다. 특히 과도한 의료비지출은 지속적인 치료가 필요한 환자의 의료서비스이용을 망설이거나 포기하게 만들 수 있다. 국가 및 민간재단 등의 기관에서 환자 가구의 과부담의료비지출을 감소시키고 지속적으로 치료를 받을 수 있도록 다양한 사회복지서비스를 제공하고 있으나, 이와 관련된 효과성 연구가 부족한 것으로 나타났다. 따라서 본 연구는 과부담의료비지출이 미충족의료경험에 미치는 영향을 분석하고 사회복지서비스이용의 조절효과를 검증하였다. 본 연구는 2016년 한국복지패널 11차 자료 가구원 10,072명의 자료를 활용하였다. 과부담의료비지출은 역치적 접근법을 활용하여 과부담의료비지출을 측정하였다. 미충족의료경험은 경제적 이유로 인한 미충족의료경험 여부를 확인하였다. 사회복지서비스의 경우 생계비 지원, 의료비 지원, 물품 지원 여부를 확인하였다. 과부담의료비지출과 미충족의료경험의 관계 및 사회복지서비스이용의 조절효과를 검증하기 위해 로지스틱회귀분석을 하였다. 본 연구의 주요 연구결과는 다음과 같다. 첫째, 과부담의료비지출이 미충족의료경험에 정적으로 유의미한 영향을 미치는 것으로 나타나, 과부담의료비지출이 클수록 미충족의료를 경험할 가능성이 높아지는 것을 확인하였다. 둘째, 과부담의료비지출과 미충족의료경험의 관계에서 사회복지서비스이용의 조절효과가 부적으로 유의미한 영향을 미치는 것으로 나타났다. 이를 통해 사회복지서비스를 이용할 경우 과부담의료비지출이 미충족의료경험에 미치는 영향을 감소시키는 것으로 검증되었다. 이와 같은 연구결과를 바탕으로 정책적, 실천적 영역의 사회복지적 함의를 제시하였다. 첫째, 과도한 의료비지출을 감소시키기 위해 정부에서 시행되는 의료비지원사업의 대상 확대가 필요하다. 둘째, 과부담의료비지출로 인해 미충족의료를 경험하는 대상에게 전문가의 보건·의료·복지의 통합적인 개입이 필요하다. 마지막으로, 사회복지서비스이용이 과부담의료비지출을 완화시켜 미충족의료를 경험할 가능성을 낮춤에 따라 사회경제적 상황에 도움이 되는 사회복지서비스의 제공이 필요하다는 것을 제안하였다.

The Impact of Mindfulness on Communication with Health Care Providers for Older Adult Quilters

Gill, Mary Peyton Cauthorn Walden University ProQuest Dissertations & Theses 2022 해외박사(DDOD)

Active aging plays a pivotal role in countering the effects of multimorbidities and enhancing mental and physical well-being of individuals. Prior research supports the benefits of mindfulness, a key component of active aging, in enhancing older adults’ physical and mental health, but the effect of mindfulness on older adults’ communication with medical social workers and other health care providers has not been studied. The purpose of this phenomenological qualitative study was to gain a better understanding of how older quiltmakers experienced mindfulness and how this affected their communication with their health care providers. The study, which drew from empowerment theory, included eight women and one man in East Central Kansas who were 65 and older, lived independently, and quilted. The participants engaged in interviews that were transcribed and coded to identify key themes. One of the themes that emerged was connection to others. Although all of the participants reported that quilting enhances communication with others, only half of the respondents perceived that quilt making increased communication with their healthcare providers. The other themes that emerged were creating and mental health. Through this research, older adults can gain an understanding of the importance that hobbies or engaging in other interests can potentially provide a means to practice mindfulness and communicate with others. This can possibly improve mental and physical health. This study affirmed the importance of connection with others, productivity, and the feeling of well-being that can be generated through quiltmaking.

재난적의료비 지출이 노인 우울에 미치는 영향 : 빈곤화의 매개효과분석

이한기 연세대학교 사회복지대학원 2017 국내석사

With the reality of super-aged society ever expanding, health expenditure on the elderly is increasing each year. Increase in the health expenditure not just poses economic crisis, but also causes serious impact to the mental health of households with elderly. Thus, it is critical to identify the contributing factors and problems; and avert the progression and find the solution. Against this backdrop, this study clarifies the effect of catastrophic health expenditure on depression of the elderly, and investigates the mediating effect of impoverishment. Using three-year data from the Korea Welfare Panel Study, the multiple regression analysis was conducted on 5,315 elderly 65 and above. The major results of this study are as follows. First, experience in catastrophic health expenditure has a noticeable effect as it reaches this study’s threshold criteria of 10 percent. Moreover, other threshold criteria of 20, 30 and 40 percent also had a noticeable effect on depression. Second, there were noticeable connections between catastrophic health expenditure and poverty. Similar to depression, there was a noticeable impact on poverty at all threshold criteria. In addition, at 10 percent threshold criteria, catastrophic health expenditure of the households with elderly was the major factor contributing to poverty and the direct cause. Third, according to the analysis for the relationship between catastrophic health expenditure and depression, the mediating effect of impoverishment and poverty had the full mediating effect on the relationship between catastrophic health expenditure and depression. This indicates that experiences in health expenditure do not immediately impact the elderly’s depression. Rather, catastrophic health expenditure causes households with the elderly to lead a financially difficult life, and in turn they are forced into poverty, leading to more severe depression. Definition of Social welfare in this research is described below. First, excessive health expenditure negatively affects the finance of the households with the elderly; therefore, they are forced into poverty and develop a higher risks of depression. To avert this trend, it is expected to further expand the coverage of the existing health care system. Second, poverty and mental health are not separate issues. It is necessary to expand the economic support for the elderly with poverty issue. Poverty and mental health should be recognized as one issue while strategies should be developed to provide comprehensive intervention and to cater to the needs of the elderly. Third, there should be various experts in the field to manage the crisis caused by excessive health expenditure. Notably, general hospitals and health institutions are recommended to institutionalize legal basis for medical social workers to provide social welfare service associated with social counseling and various resources. 현재 초고령화 사회를 앞두고 있는 상황에서 노인 보건의료비 지출 역시 매년 증가하고 있다. 이러한 의료비 증가는 단순히 경제적 위기만이 아닌 노인 가구의 정신건강문제에 심각한 문제를 줄 수 있음을 인식하고, 이와 관련한 영향요인들과 문제경로를 파악하여 이를 예방하고 해결하기 위한 개입방안을 마련해야 할 것이다. 본 연구는 이러한 문제의식 하에 재난적의료비 지출이 노인 우울에 미치는 영향을 파악하고, 빈곤화의 매개효과를 검증한다. 한국복지패널 3개년도 데이터를 활용하여, 65세 이상 노인 5315명을 최종 분석대상으로 다중회귀분석을 실시하였다. 본 연구의 주요결과는 다음과 같다. 첫째, 재난적의료비 지출 경험은 본 연구의 역치 기준인 10%일 경우 우울에 정적 영향을 미치는 것으로 나타났다. 이와 더불어 다른 역치 수준들(20%, 30%, 40%)에서도 우울에 정적 영향을 미치는 것이 확인되었다. 둘째, 재난적의료비 지출 경험과 빈곤화와의 관계에서 정적 영향을 확인할 수 있었다. 우울과 마찬가지로 빈곤화에서도 기준 역치 10% 뿐만 아니라 모든 역치 수준들에서 빈곤화에 정적 영향을 미치는 것이 확인되었으며, 이는 노인가구의 재난적의료비 지출이 빈곤화 원인으로 직접적인 영향을 주고 있다는 점을 말해준다. 셋째, 재난적의료비 지출과 우울의 관계에서 빈곤화의 매개효과를 분석한 결과, 빈곤화는 재난적의료비와 우울의 관계에서 완전매개효과를 가졌다. 이러한 결과는 재난적의료비 지출 경험이 즉시 노인 우울감을 높인다기보다 재난적의료비 지출로 노인 가구가 빈곤 이행이 되고, 빈곤층으로의 전락한 노인의 우울을 높일 수 있음을 말해준다. 본 연구의 사회복지적 함의는 다음과 같다. 첫째, 과도한 의료비 지출이 노인가구경제에 부정적인 영향을 미쳐 빈곤층으로 전락하는 위기상황과 이로 인한 우울 증가의 위험을 막기 위해서 현 보건의료제도의 보장성을 더욱 확대하는 노력이 필요하다. 둘째, 빈곤문제와 정신건강 문제를 별개의 문제로 인식해서는 안 되며, 빈곤 노인을 위한 경제적 지원을 확대해야 하는 것뿐만 아니라 빈곤문제와 정신건강의 문제를 하나의 문제로 파악하여 이를 해결할 수 있는 통합적인 개입 또는 노인 특성에 맞는 정책이 필요하다. 셋째, 과도한 의료비 지출로 인한 위기상황 발생 시 이를 대처하기 위한 다양한 일선 현장 전문가들의 개입이 필요하다. 특히 현재 종합병원 및 보건의료기관에서 심리․ 사회적 상담과 다양한 자원연계를 통한 사회복지서비스 제공 및 개입을 시행하고 있는 의료사회복지사의 법적 제도화와 활동수가 신설 및 개편이 필요하다.

저소득 남성 독거노인 암환자의 암 투병 경험에 대한 질적 사례연구

김다은 연세대학교 사회복지대학원 2023 국내석사

The purpose of this study is to learn more about the fighting cancer experience of low-income, older male cancer patients who live alone and to suggest social welfare services they need for them during their struggle against cancer. Through an in-depth psychosocial review of cancer treatment experiences of low-income male older adults living alone, I attemted to identify the challenges in the cancer treatment process, and a qualitative case study was conducted to confirm the need for social welfare services. The study participants were recruited through a purposive sampling of six low-income older males 65 years or older who had been diagnosed with solid cancer and were undergoing treatment or follow-up care. Data were collected through one-on-one in-depth interviews with six study participants. In this study, in-case analysis and inter-case analysis, one of the analysis methods of qualitative case studies, were conducted. In Within Case Analysis, specific accounts of the participants' experiences throughout the struggle against cancer were provided. In Between Case Analysis, thematic analysis method was used to identify common themes in the cancer fighting experience of low-income older male cancer patients who lives aloneliving alone that transcend beyond specific instances. As a result of the study, 7 upper categories and 25 subcategories were derived. The top 7 categories are <the pain of cancer added to the accumulated weight of life> and <kindness. And growth> was divided into a large theme. It was divided into "sadness and calmness of being a cancer patient," "Vacancy in a family, absence of guardians," "social relationships that have to be cut off by themselves," "Cancer in a situation where it is difficult to make a living ", "environments that make it difficult to overcome cancer alone," and "people and institutions that helped me in struggling against cancer.“ Through this study, it was confirmed that low-income older male cancer patients who live alone experience several challenges as a result of their disease’s diagnosed in the context of precarious economic and psychosocial support systems. The weak socioeconomic environment, which is not suitable for cancer treatment, further aggravated the hardships they experience. After that, it was confirmed that cancer patients with low-income male older adults living alone experienced post-traumatic growth through the economic and psychosocial support from an official and informal system. Suggestions for improving the better environment and quality of life for low-income older male cancer patients who lives alone are as follows. First, expanding psychosocial support provided by medical social workers and other medical staff, second, supporting medical expenses and indirect medical expenses, third, improving the socio-economic environment for cancer treatment, and fourth, forming a new community. This study did not widely reflect the experiences of cancer patients diagnosed with Hematologic Malignancy, terminal stage, recurrence, and metastasis. Also, it has a limitation that the regional characteristics of the countery were not taken into account. Through this study, which examined the experience of fighting cancer in depth, it confirmed the complex difficulties experienced by cancer patients with demographic and sociological characteristics of poverty, men living alone, and the older male. This study is meaningful that policy and practical measures were proposed to improve the quality of life of older cancer patients who are low-income males living alone. Through this study, it is anticipated to provide fundamental information that may be used to develop policies and services that would enhance the quality of life for low-income older cancer patients who lives alone. 본 연구의 목적은 저소득 남성 독거노인 암환자의 암 투병 경험에 대해 알아보고, 암 투병 중 이들에게 필요한 사회복지 서비스를 제언하는 데 있다. 저소득 남성 독거노인 암환자의 암 투병 경험에 대한 심리사회적 측면에서의 심층적 고찰을 통해 암 투병 과정에서의 어려움을 확인하고자 하였으며, 필요한 사회복지서비스 확인을 위해 질적 사례연구를 진행하였다. 연구 참여자는 고형암을 진단받고 치료 중이거나 추후 관리 중인 만 65세 이상의 저소득 독거노인 남성 총 6명을 의도적 표집을 통해 모집하였다. 연구 참여자 6명과 개별 심층 면담을 통해 자료를 수집하였다. 본 연구에서는 질적 사례연구의 분석 방법 중 하나인 사례 내 분석과 사례 간 분석을 실시하였다. 사례 내 분석에서는 연구 참여자들의 암 투병 과정에서의 경험에 대한 세부적인 기술을 하였다. 사례 간 분석에서는 주제분석 방법을 활용하여 개별 사례를 초월하는 저소득 남성 독거노인 암환자의 암 투병 경험의 공통적인 주제를 확인하였다. 연구 결과, 7개의 상위범주와 25개의 하위범주가 도출되었다. 7개의 상위범주는 <누적된 삶의 무게에 더해진 암의 고통>과 <다정한 손길. 그리고 성장>이라는 큰 주제로 구분하였다. 이는 다시 ‘암환자가 된 슬픔. 그리고 담담함’, ‘가족의 빈자리, 보호자의 부재’, ‘스스로 단절할 수밖에 없는 사회적 관계’, ‘생계를 유지하기도 버거운 상황에 부닥쳐버린 암’, ‘암을 홀로 이겨내기에 버거운 환경들’, 그리고 ‘암 투병 과정에서 힘이 되어 준 사람들과 제도’, ‘어려움을 넘어선 성장’으로 구분되었다. 본 연구를 통해 저소득 남성 독거노인 암환자는 경제적, 심리사회적 지지체계가 미약한 가운데 암을 진단받고 치료하게 되어 복합적인 어려움을 경험하는 것을 확인하였다. 암 투병에 적합하지 않은 취약한 사회경제적 환경은 이들이 경험하는 고난을 더욱 가중시키고 있음을 발견하였다. 이후, 저소득 남성 독거노인 암환자는 공식적, 비공식적 체계의 경제적, 심리사회적 지지를 통해 외상 후 성장을 경험하게 되는 것을 확인하였다. 저소득 남성 독거노인 암환자의 더 나은 투병 환경과 삶의 질 향상을 위한 제언을 도출하면 다음과 같다. 첫째, 의료사회복지사와 의료진의 심리사회적지지 확대, 둘째, 의료비 및 간접의료비 지원, 셋째, 암 치료에 관한 사회경제적 환경 개선, 넷째, 새로운 공동체 형성이다. 본 연구는 혈액암, 말기, 재발과 전이를 진단받은 암환자의 경험을 폭넓게 반영하지 못했으며, 연구 대상자 중 상당수가 수도권에 거주하고 있어 전국의 지역적 특성을 고려하지 못했다는 한계가 있다. 본 연구는 빈곤, 남성, 독거, 노인이라는 인구사회학적 특성을 지닌 암환자의 암 투병 경험을 심층적 고찰을 통해 이들이 겪는 복합적인 어려움을 확인하였다. 이를 통해 저소득 남성 독거노인 암환자의 삶의 질을 향상시킬 수 있는 정책적, 실천적 방안을 제언하였다는 데 의의가 있다. 본 연구를 통하여 저소득 남성 독거노인 암환자의 안정된 투병 환경 조성과 삶의 질 향상을 위한 정책과 서비스 마련에 기초자료로 활용될 수 있을 것으로 기대한다.

Utilization of Medications for Opioid Use Disorder Among Pregnant Individuals in the U.S

Curran, Laura ProQuest Dissertations & Theses New York Universit 2022 해외박사(DDOD)

Background. Despite the effectiveness of medication for opioid use disorder (MOUD), the rates of utilization remain low among pregnant individuals entering substance use treatment. MOUD use varies by state, and remains particularly low among certain populations and among those linked to treatment from the criminal justice system. Estimates of MOUD are needed by state in order to better understand how state-level policy or political contexts influence access to MOUD for pregnant patients. Both individual and structural level barriers exist for this population, including both emotional and systems level challenges which compound the problem of access. This dissertation examines national and state-level estimates of MOUD use among this population, individual and state-level characteristics influencing MOUD use, and explores the experiences of pregnant individuals entering treatment and navigating a system of care that is often complex and stigmatizing.Research Aims. The three research aims align with the three manuscripts that comprise this mixed-methods dissertation. Aim 1 (Manuscript 1) seeks to estimate annual rates of MOUD use among pregnant admissions to substance use treatment programs, both nationally and by state and examines the trends in MOUD and various referral sources to treatment. Aim 2 (Manuscript 2) examines individual and state-level determinants of MOUD among pregnant individuals, looking at the associations between sociodemographic factors, mental health status, and criminal justice referrals to treatment, and state-level factors like the presence of a prenatal substance use policy and political climate of a state. Aim 3 (Manuscript 3) seeks to contextualize these variations in MOUD use and access, and explores the experiences of women as they seek and navigate MOUD during pregnancy.Design and Analysis. This three-paper dissertation employs a sequential-explanatory mixed methods design to investigate MOUD use both quantitatively using national, state, and admissions-level data and qualitative data to explore the experiences of patients receiving MOUD during pregnancy. For Aims 1 and 2, secondary data from the Treatment Episode Dataset- Admissions (TEDS-A) from were examined, which includes nationally representative data for admissions to publicly funded substance use treatment programs in the U.S. For Aim 1, trends in MOUD use were examined by region and by state for the years 2010 to 2018. Descriptive statistics explored trends and disparities in MOUD use for this 9-year period. For Aim 2, policy data from the Guttmacher Institute and political data from Gallup Tracking were examined in addition to TEDS-A data, and descriptive statistics, t tests of proportions, Chi-square tests, and multilevel binary logistic regression analyses were conducted to understand the effects of state-level factors on individual MOUD use in substance use treatment programs. For Aim 3, women who received MOUD during their pregnancy in two states were interviewed to explore the experiences of seeking and receiving MOUD during pregnancy.Results. Findings for Aim 1 identified a nationwide average annual rate of MOUD use among pregnant individuals in U.S. treatment programs from 2010 to 2018 of 50-55%. MOUD use was consistently highest in the Northeast region, and consistently lowest in the South over the nine-year period. The largest proportion of pregnant individuals admitted to treatment were self-referred, and this was the largest proportion who received MOUD across all nine years. The lowest rates of MOUD occurred among those referred by the criminal justice system in all regions and in every year (approximately 18-30%). Aim 2 analyses included a total of 8,970 pregnant admissions with an opioid use disorder (OUD) in 2018. Of all admissions, about 15% were referred by the criminal justice system (n= 1,318), and only 30.8% of these referrals received MOUD once entering treatment. More pregnant admissions who were self-referred to treatment received MOUD than any other referral source. Of those admissions who received MOUD, 47.21% had a co-occurring mental health disorder. Multilevel logistic regression analyses showed that neither the presence of a punitive or priority access policy were significant predictors of MOUD, but having a co-occurring disorder, a criminal justice referral, and the political affiliation of a state where the admission happened were all significant predictors of MOUD receipt for pregnant women. Aim 3 included qualitative data from 24 postpartum women who were mostly Black (91.7%), married (62.5%), and primarily received methadone to treat OUD (70.8%) while others used buprenorphine or naltrexone. Over half of the participants were referred to treatment by their primary care physician or prenatal doctor (54.2%), and seven participants had contact with child welfare professionals at the time of delivery of their babies. Ten major qualitative themes were identified as either barriers or facilitators of MOUD during pregnancy, and included: mental health problems, emotional challenges, coercion by providers, cost/financial strain, transportation, health concerns, stigma/discrimination, supportive relationships with providers, social support, and COVID-19 related facilitators.Conclusion. Findings from this dissertation highlight the varied rates of MOUD by region and by state. And while it was hypothesized that these differences would be attributable to state-level policies surrounding prenatal substance use, the findings point more toward referrals from the criminal justice system and the presence of co-occurring mental health disorders as predictors of MOUD. It also found that individual level barriers, like mental health and the uncertainty and fears that often surround treatment-seeking during pregnancy can be alleviated by supportive and empowering substance use treatment providers that create a sense of trust and safety when pregnant women enter treatment. Overall, this dissertation can lead to a better understanding of trends in MOUD use and the factors that contribute to its receipt among those entering treatment programs. It can inform state policies at the intersection of criminal justice systems and substance use services, furthering solutions and best practices among medical providers caring for pregnant patients with OUD.

소아청소년 1형 당뇨병 환자의 심리사회적 적응에 관한 연구

안상민 연세대학교 사회복지대학원 2016 국내석사

소아청소년 1형 당뇨병 환자들은 평생 혈당 관리를 목표로 하기에 질병 관리의 부담감 등의 질병관리의 문제 뿐 아니라 여러 심리사회적 적응 및 발달에도 문제를 야기할 수 있다. 본 연구는 소아청소년 1형 당뇨병 환자의 심리사회적 적응에 영향을 미치는 요인을 살펴보고자 하였다. 이를 위해 만 19세 미만의 소아청소년 1형 당뇨병 환자들을 유의적 표집을 실시하였다. 2015년 9월부터~12월까지 서울 내 대학병원 2곳, 한국소아당뇨인협회, 소아당뇨 자조모임 등을 통해 서울, 경기 지역 및 지방에서 70명의 연구대상자를 모집하여 설문조사지를 제공하였고 그 중 58명이 연구에 자발적으로 참여하였다. 조사된 설문내용은 인구사회학적 차원(성별, 연령, 거주지, 가족의 경제적 상황 등), 의료적 차원(유병기간, 주관적 건강 상태, 입원 치료 경험), 심리사회적 차원(캠프 참여 경험, 가족지지, 또래 관계), 심리사회적 적응으로 구성되어 있고 위계적 회귀분석을 사용하여 데이터를 분석하였다. 본 연구의 주요한 결과는 다음과 같다. 첫째, 가족 지지가 높을수록 소아 청소년 1형 당뇨병 환자의 심리사회적 적응이 높아지는 것으로 확인하였다(t=2.834, p<.01). 둘째, 또래 관계가 좋을수록 소아청소년 1형 당뇨병 환자의 심리사회적 적응도 높아지는 것으로 나타났다. (t=2.648, p<.01). 셋째, 주관적 건강상태가 좋을수록 소아청소년 1형 당뇨병 환자의 심리사회적 적응이 높아지는 것으로 확인되었다.(t=-2.389, p<.05). 이렇듯이 소아청소년 1형 당뇨병 환자의 심리사회적 적응에 영향을 미치는 변수는 가족지지, 또래 관계, 주관적 건강 상태임을 확인할 수 있다. 이러한 연구결과를 바탕으로 본 연구에서는 소아청소년 1형 당뇨병 환자의 심리사회적 적응을 향상시킬 수 있는 방안으로 가족 기능 강화 캠프, 세미나 등의 가족지지 프로그램, 자조집단 운영, 학교 내 또래 관계 개입 등의 또래 관계 증진 프로그램, 건강 관리 교육 및 상담, 사례관리 등의 건강증진 프로그램의 개발을 제안하였다. Child and adolescent patients of type 1 diabetes mellitus experience not only the burden of maintaining health but also psychosocial adjustment and development issues while controlling their blood sugar as their life goals. This study examined the factors affecting psychosocial adjustment of child and adolescent patients of type 1 diabetes mellitus. Child and adolescent patients of type 1 diabetes mellitus under age of 19 years old were selected by using purposive sampling. The subjects were incruited from September to December of 2015 among 2 university hospitals in Seoul, Korea Insulin Dependent Diabetes Association, and self-help group of diabetes mellitus in child and adolescent, where about 70 subjects were sampled from Seoul, Kyung-gi, and country area, and 58 were voluntarily participated among 70. The survey constituted of socio-demographic information(sex, age, residential area, economic status of family, etc), medical dimension(duration of type 1 diabetes mellitus, subjective health status, inpatient treatment experience), psychosocial dimension(camp experience, family support, peer relationship), and psychosocial adjustment. The data were analyzed by using hierarchial regression analysis. The results are as followed. First, strong family support increased the psychosocial adjustment of type 1 diabetes mellitus in child and adolescent patients(t=2.834, p<.01). Second, better peer relationship increased the psychosocial adjustment of type 1 diabetes mellitus in child and adolescent patients(t=2.648, p<.01). Third, better subjective health status showed the improvement in psychosocial adjustment of type 1 diabetes mellitus in child and adolescent patients(t=-2.389, p<.05). Therefore, family support, peer relationship, and subjective health significantly proved to be the factors affecting the psychosocial adjustment of type 1 diabetes mellitus in child and adolescent patients. Based on the result, family function strengthening camps, seminars, family support programs, self-help group, peer relationship improving programs such as interventions within the schools, health managing education and counseling, and health promoting program development such as case managements were suggested to improve the psychosocial adjustment of type 1 diabetes mellitus in child and adolescent patients.

Influences on social workers' approach to informed consent regarding antidepressant medications

Acker, Janet K State University of New York at Albany 2013 해외박사(DDOD)

Psychotropic medications have become an increasingly frequent aspect of mental health treatment, and social workers are uniquely poised to have insight to a client's experience of medication treatment as well as to observe and process with the client the way that medications are working or not working. They are also obligated to support clients with a meaningful informed consent process. This study adopts the Theory of Planned Behavior (Ajzen, 1988) as a lens through which to better understand the factors related to clinical behavior around informed consent when social workers are working with those who are using or considering antidepressant medications. Using quantitative cross sectional survey data collected from 77 practicing Master of Social Work clinicians in New York State, the study asked the following questions: Are attitudes, subjective norms and self-efficacy associated with changes in quality of informed consent? Which of the domains theorized to influence practitioner behavior (attitudes, subjective norms, self-efficacy, personal experience, professional norms, and contextual influences of pharmaceutical marketing and the biomedical model) are significantly associated with informed consent related to antidepressants? Are personal experience, professional norms, and contextual influences of pharmaceutical marketing and the biomedical model associated with antidepressant attitudes, subjective norms and self-efficacy? The outcome variable "Quality of informed consent" was found to be significantly associated to a professional norm "regarding randomized control trials as useful": all respondents who regarded randomized control trials as useful and all respondents who were neutral about randomized control trials fell into the "not best practice" category describing quality of informed consent. The study also found significant associations between the independent variables: pharmaceutical marketing has a significant impact on social workers' attitudes and subjective norms; the bio-medical model is significantly associated with social workers self-efficacy and subjective norms. A social workers' satisfaction with their personal experience taking antidepressants were associated with all three Ajzen domains, subjective norms, attitude and self-efficacy. Professional norms, including the importance of evidence based practice and regarding randomized controlled trials as useful were also significantly associated with all three Ajzen domains. Implications for social work practice, policy and research are discussed.

Underrepresented Minority Medical (URiM) Students: A Social Work Approach to Identifying Factors Affecting Their Experience

Richards, Regina D ProQuest Dissertations & Theses Colorado State Uni 2020 해외박사(DDOD)

A major injustice in the United States is the wide disparity in health care across racial/ethnic, gender and economic lines. The lack of URiM (underrepresented in medicine) physicians is a major cause of health care disparities: health care is enhanced when the physician is race-concordant with the patient. Many URiM students have negative experiences that can impact their motivation, performance, well-being and future careers. The major goal of this research is to gain an understanding of URiM student experience as a basis for changes within the student’s Ecosystem. Using a social work approach and thematic analysis to gain a better understanding of the URiM experience at the University of Colorado School of Medicine (CU SOM), four themes emerged: (a) Overall Experience: URiM experience is multifactorial, reflecting positive, negative and ambivalent experiences and can change through time. (b) Impacts of Explicit Racism, Microaggressions and Low/Insufficient Diversity. (c) Negative Impact of Incongruence: URiM students expressed dissatisfaction at the incongruence between the medical school messaging about valuing diversity and the reality experienced by the students. (d) Sense of Belonging: multifactorial and dynamic: It is a significant factor in student experience, has multiple meanings for the students, and can change through time. In addition to the above four themes, one key result is a new definition of Sense of Belonging. Student recommendations combined with the researcher’s experience were used to generate implications for programs and student support services. These results can be used to inform program development, coaching, advising and system level improvements. This will achieve the research goal of improving the experiences of URiM students and thus potentially their motivation, performance, well-being and future careers.