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Given the rising prevalence of children diagnosed with autism and the emergence of evidence-based autism interventions, schools are now faced with the challenge of delivering high quality instruction to this unique population. Comprehensive packaged curricula have been developed to address this growing need and to allow educators to transport research-based instruction into their classroom settings. However, there is a dearth of research examining the factors associated with intervention effectiveness with children with autism in public schools. The purpose of this study is to examine the associations between school level factors, the fidelity of interventions, and student outcomes within autism support classrooms. Data were gathered from 171 students with autism spectrum disorders in kindergarten-through-second grade classrooms across 40 schools in the Philadelphia School District. Correlational analyses and linear regression with random effects analyses indicated that school level factors were not associated with and were not moderators of intervention fidelity and student outcomes. The findings suggest that autism support classrooms are like islands within the school building, such that the practices and outcomes within these classrooms were unrelated to the school context. This study indicates that when transporting an evidence-based practice into a public school classroom, it may be more necessary to focus on the classroom context rather than the school building. Future research is needed to fully delineate these relationships between school building level factors and the dissemination and implementation of evidence-based practices for children with autism within a classroom setting. / School Psychology

This dissertation explored new ways of evaluating outcomes for preschoolers with communication disorders. It identified a need to evaluate outcomes as they relate to a child’s communicative participation and provided initial models for doing this. Chapter 1 provides the context for the dissertation, discussing the theoretical framework used, the literature on communicative participation outcomes, and Ontario’s Preschool Speech and Language Program (PSLP) and its program evaluation project (the setting for the studies presented in Chapters 4 & 5). Chapter 2 is a scoping review of the literature exploring the ways in which outcomes for preschoolers with communication disorders have been evaluated. It identifies a gap in the literature related to participation-based outcomes, and thus the need for the work presented in Chapters 4 and 5. Chapter 3 presents further evidence of both construct and predictive validity of the Communication Function Classification System (CFCS), the classification tool used for PSLP program evaluation. This tool was previously validated for use with children with Cerebral Palsy, and this study provides evidence of its validity with other groups of children. Chapter 4 explored communicative participation outcomes for preschoolers accessing PSLP services by developing growth curves that predict development of preschoolers’ communicative participation skills. The models provide a first look at the growth of those skills, and show that all children make meaningful change regardless of their communicative function. Chapter 5 added meaningful predictor variables (based on available data) to the previously defined growth curves (Chapter 4) and identified both demographic and intervention-specific variables that were predictive of growth. Predictors varied by level of communicative function, a new insight in the field. This work has clinical implications both within and beyond the PSLP. Chapter 6 discusses the clinical and research implications of this dissertation work as well as ideas for future directions of my research. / Thesis / Doctor of Philosophy (PhD) / The work presented in this dissertation explored participation-based outcomes for preschoolers with communication disorders. First, by completing a scoping review, I identified the need to explore participation-based outcomes for preschoolers with communication disorders. Participation-based outcomes are important and meaningful for families, but are not typically used in speech-language research or practice. I next modelled the development of communicative participation skills (how a child uses his/her communication to engage) for preschoolers with speech and language delays who were accessing services in Ontario’s Preschool Speech and Language Program (PSLP). Following this I identified both demographic and intervention-based predictors of that communicative ‘growth’. Development was modelled separately for children in five levels of communicative function using a reliable classification tool that I validated for use with this general community-based population. This work addresses a major gap in the speech-language literature and has important implications for clinicians, administrators and policy makers in the PSLP and beyond.

Objective: Delay in diagnosis and treatment of endometrial cancer may be associated with disease progression and impact management and outcomes. Social and cultural barriers influence recognition of symptoms and self-advocacy in seeking and complying with care. Associations between social determinants of health (SDH) and disease presentation, treatment and outcomes has been shown in some healthcare systems. Our objective was to investigate these in Ontario’s universal access system. Methods: Endometrial cancer patients in Ontario diagnosed 2009-2017 were identified, and clinical, social and demographic information extracted from administrative databases. SDH were quantified using previously validated marginalization quintiles (material deprivation, residential instability and ethnic concentration). Associations between SDH, disease stage, treatment and outcome were explored using chi-square, log-rank and logistic regression. Results: 19530 patients were identified. 73% of cancers were confined to the uterus. Stage distribution differed across marginalization quintiles (p<0.001) with advanced disease found more frequently in highly marginalized patients (highest vs lowest quintile): OR=1.28 (95% CI 1.14-1.45) for deprivation, OR=1.2 (95% CI 1.06-1.35) for residential instability and OR=1.3 (95% CI 1.15-1.46) for ethnic concentration (<0.0001)). Highly marginalized patients also had less timely surgery (p<0.0001). Overall survival was shorter in patients in high deprivation and residential instability quintiles (log rank p-value<0.0001) but not in high ethnic concentration quintiles, with HR=1.4 for deprivation (p<0.0001) and HR=1.53 for instability (p<0.0001) for the highest marginalization quintile. Survival differences persisted in more uniform cohorts of early (stage I) disease and endometrioid tumors and on multivariable analysis. Conclusions: Marginalized populations diagnosed with uterine cancer present at more advanced stages, wait longer for surgery and have shorter overall survival. Associations of SDH with uterine cancer presentation and management in Ontario could shed light on the impact of these factors on disease trajectory, drive policies for patient advocacy and redistribution of resources and promote health equity in this population. / Thesis / Master of Public Health (MPH) / Conditions in the social environment in which people are born, live and work are powerful influencers of health and well-being. In fact, these circumstances have also been called Social Determinants of Health (SDH). Cancer outcomes are one of the domains impacted by SDH. In this study, we set out to investigate the association between SDH and uterine cancer outcomes in Ontario, Canada. We guessed that SDH may influence how soon patients with symptoms seek help from their doctors, how quickly their problem is investigated and how well they are able to undergo treatment. We used a tool called the Ontario Marginalization Index to break down Ontario’s uterine cancer patient population into groups according to degree of social, financial and ethnic marginalization. We found that more marginalized patients tended to present to care with more advanced cancers, that they took longer to have surgery for their cancer and that their survival was worse. These findings suggest there is more work to be done to promote health equity in cancer care.

The patient-important outcomes of cardiac and non-cardiac surgery are well-recognized but poorly understood. The causes of major morbidity and mortality in patients undergoing non-cardiac are not known. This is not the case in cardiac surgery, which is provided to a homogenous patient population that has been well-described through clinical registries. Recent improvements to the care of cardiac surgical patients have led to dramatic decreases in major morbidity and mortality. However, neurocognitive and functional impairments after cardiac surgery remain the most feared by patients and least understood by clinicians. This thesis comprises 6 chapters that inform these knowledge gaps and establish the basis upon which future research will be based. Chapter 1 is an introduction providing the rationale for conducting each of the included studies. Chapter 2 reports the VISION Mortality study, which explores the relationship between major complications and death within 30-days of undergoing inpatient, noncardiac surgery. Chapter 3 reports a study validating the use of the Standardized Assessment of Global activities in the Elderly (SAGE) scale in patients undergoing cardiac surgery. Chapter 4 presents a pilot observational study that establishes the feasibility of conducting a large, prospective cohort study to determine the relationship between decreases in cerebral saturation during cardiac surgery and postoperative functional decline. Chapter 5 presents a pilot study conducted to inform the feasibility of a large, randomized cluster crossover trial examining whether an institutional policy of restricted benzodiazepine administration during cardiac surgery (compared to liberal administration) would reduce delirium after cardiac surgery. Chapter 6 discusses the conclusions, limitations, and implications of the research presented in this PhD thesis. / Thesis / Candidate in Philosophy

Researchers and clinicians report that they think the client is the most influential component in determining the outcome of therapy. Although a variety of studies have examined the impact of various client factors on the outcome of couple therapy, this research is not cohesive and produces inconsistent results. The purpose of this multi-method study is to present a sense of the range and depth of client factors that influence the outcome of couple therapy. The use of qualitative and quantitative methods allowed the data to build on existing research while expanding the range of client factors considered. Data were gathered using a dynamic, web-based survey which assigned participants to discuss a case of successful or unsuccessful couple therapy. Participants provided their own descriptions of influential client characteristics. Participants also rated how important they thought several literature-based client factors were. Quantitative data analysis utilized descriptive statistics, principal components analysis, and logistic regression. Qualitative data were analyzed in two stages, using content analysis. Results indicated that couples can be conceptualized by five arenas of couple focus; these arenas accurately predicted whether participants were discussing a successful or unsuccessful case of couple therapy 85.9% of the time. Regarding individual client characteristics, in general, clients whose couple therapy was successful tended to be open to each other and committed to the relationship and to therapy. Unsuccessful couple therapy tended to focus on a greater number of individual issues. Couple dynamics characteristics differed according to outcome groups; participants described four types of couple dynamics that influenced couple therapy to be unsuccessful. Data showed that many client factors influenced the outcome of couple therapy, and that uncommon client characteristics could be vital to the outcome of some cases. Participants described a client's life events as impacting the outcome of couple therapy by increasing one person's vulnerability to his or her partner. If the partner acted in a way that created a sense of connection or support, this contributed to successful couple therapy. The results are presented in connection to previous research, when possible. Finally, implications for theory, research, and clinical work with couples are discussed. / Ph. D.

In order to ensure clean drinking water for all, it is crucial to understand potential upland stressors that compromise the quality of source waters treated by local community water systems (CWSs). Contamination associated with specific types of land cover can result in downstream water quality degradation, which may reduce the effectiveness of treatment by CWSs. Surface mining has been hypothesized as a source of drinking water degradation within the Central Appalachian region, which may result in adverse exposures and health disparities. The purpose of this study was to identify potential correlations between land cover and adverse birth outcomes (ABOs) through the application of watershed epidemiology, an emerging environmental health paradigm. Birth records for the Central Appalachian region were acquired from their respective state health departments from 2001 to 2015: each record contained the mother's street address, outcome variables, and covariates. Records were included in later analyses if they fell within an approximated CWS service area. Contributing land cover to each CWS was determined via previously delineated watersheds that relied on CWS intake points. A binomial generalized linear model was used to compare low birth weight (LBW), term low birth rate (tLBW), and preterm birth (PTB) incidence to CWS source watershed land cover, Safe Drinking Water Act (SDWA) violations, CWS size, and covariates related to the birth records. Source watershed mining and SDWA health based (HB) violations were significantly associated with greater risks for preterm birth (PTB) and low birth weight (LBW). Future work should be conducted to explore upstream flow impacts, address missing data in the birth records, and to more accurately represent CWS service areas to better characterize exposure. / Master of Science / Millions of individuals throughout the world are sickened by waterborne exposures every year. To ensure clean drinking water long-term, it is crucial to understand how human land cover might change the water quality of source watersheds, as this may impact the effectiveness of water treatment and increase adverse human health exposures. The goal of this effort is to understand whether land cover is linked to downstream adverse birth outcomes (ABOs) in Central Appalachia, a region of the United States previously associated with high disease incidence suspected to be partially linked to environmental exposure. Birth records were acquired for the years of 2001 to 2015 from four (VA, WV, TN, KY) respective state health departments. Each record contained the mother's address, outcome variables, and covariates (e.g., race, ethnicity). Births were located within approximate service areas for 140 surface water dependent community water systems (CWS) within the region. Data from each CWS, including weighted land cover proportions for their source watershed, were merged with the birth records according to approximate service areas. Statistical analysis suggested that higher source watershed levels of mining and urban development were associated with higher risks of preterm birth (PTB) and low birth weight (LBW). The number of health based (HB) violations associated with each CWS was also associated with both of these outcomes. Major limitations of this work include birth record data gaps and the lack of publicly available CWS service areas and/or water consumption rates, which does increase the risk of exposure misclassification.

One purpose of higher education is to graduate students who will become productive citizens. An integral aspect of being a productive citizen is employment. Finding a job requires the acquisition of skills that employers report they seek in college graduates. There are various ways that students can learn these skills. They can be learned in the classroom, and through extracurricular activities. They can also be learned from students' part time employment. Part-time employment is a significant part of the college experience for many undergraduate students. Students are employed in a variety of different jobs while in college. These jobs can be grouped into three categories: cooperative education experiences, leadership positions, and wage positions. Scholars have explored the impact of cooperative and leadership positions on students. However, an extensive search of the literature revealed no studies which investigated the kinds of skills students in wage positions learn. Yet, the number of students employed in wage positions may exceed the number of students employed in the other two types of student jobs. The purpose of this study was to examine the skills learned by undergraduate students who were employed in on-campus wage positions. The study was designed to measure whether the skills student employees learn are skills that employers seek in college graduates. To seek answers to these research questions a list of skills was developed from the literature available on job skills employers seek in college graduates. After determining the eight most common skills employers seek in college graduates they hire, the researcher operationalized the skills by assigning typical job-related activities to each of the eight skills identified in the literature as being sought by employers of college graduates. Then, the researcher recruited 32 undergraduate students (16 male and 16 female) in wage positions to report data about what they learned while working. These data were collected through logs that detailed activities in which student employees engaged while on the job. The study found that students in on-campus wage positions engaged in certain activities more than others. The activities in which they engaged indicated that they were learning some skills which employers seek in college graduates. Results showed that participants reported a high number of activities which related to Analytical Skills, Adaptability/Flexibility, and Communication Skills. Participants reported activities which related to Interpersonal Skills and Teamwork Skills to a moderate degree. Activities related to Initiative, Self Confidence, and Leadership Skills were reported least often. Differences were found in the reporting patterns of men and women. Some of these differences were found to be significant. / Master of Arts

The main purpose of this study was to conduct a meta-analysis with data collected from seven schools in Southwest Virginia school district. Data was collected for students who were referred to the Student Assistance Programs at each school. Tracking forms were used to record data for each student. Each tracking form was completed by the Student Assistance Program coordinators for their respective schools. This research was conducted in order to evaluate measurable performance outcomes of Student Assistance Programs. The results highlight the positive effects that Student Assistance Programs, SAP members, and other individuals associated with Student Assistance Programs have on students in need. The positive effect from participation in Student Assistance Programs is encouraging. However, recommendations are made for future research and implications of the current research are discussed. The need for additional research on this topic is prominent throughout this document. / Ph. D.