The main purpose of this study was to explore the influence of social support and self-efficacy on the physical activity beliefs and behaviours of participants in a peer-mentoring intervention embedded in a community-based exercise program. A second purpose was to explore social support, self-efficacy, and perceived barriers and facilitators to exercise program adherence for study participants within the community-based exercise program setting. Participants (N=10, plus 6 mentors) were adults with chronic health conditions living in a low-income neighbourhood. Intervention (n=4) and comparison (n=6) groups completed self-report measures of physical activity, social support, and barrier self-efficacy at baseline, 6-weeks, and 12-weeks. Interviews were used post-intervention to explore the impact of peer mentoring, perceived social support and self-efficacy within the exercise setting, and barriers and facilitators to physical activity for study participants. Intervention participants showed greater exercise program adherence than comparison participants at 6-weeks. Qualitative findings suggest the peer mentoring intervention increased motivation and sense of obligation to adhere to the exercise program, and provided vicarious learning opportunities that may have indirectly influenced exercise program adherence for intervention and mentor participants. Findings also suggest that the exercise program was highly influential to participants’ social support and self-efficacy beliefs. Multiple barriers and facilitators to physical activity were reported. Overall, the current study supports the use of peer mentoring as an intervention strategy in combination with additional strategies to promote exercise program adherence in the study population. Practical implications are discussed in relation to the promotion of exercise program adherence in older adults with chronic health conditions participating in a community-based exercise program in a low-income neighbourhood. / Thesis (Master, Kinesiology & Health Studies) -- Queen's University, 2011-09-29 10:44:19.343

Despite (national) strategies/frameworks for care at the end of life, many patients do not die at their preferred location or under the form of care desired. This cross-country comparison study analyzed system-level characteristics - such as legislation, regulation and financing - that might influence service delivery in the care for terminally ill adults and their implications for outcomes and costs. Drawing on triangulated data from Canada, England, Germany and the United States of America and taking a 'most similar – most different' perspective, it was hypothesized that system-level factors might impede the broader use of (integrated) models of hospice and palliative care/the system-wide adoption of best practices. An embedded case study examined resource utilization and costs of shared care and its role as a potential best practice avenue. While similar with regard to leading causes of death, patient needs and potential avenues to care, different service models were employed – including hospice and palliative care. Generally offered alongside standard care along the disease continuum and across settings - and featuring common elements like physical, psycho-social and spiritual care - outcomes (e.g., access, utilization) varied. Legislative (e.g., jurisdictional), regulatory (including education and training) and financial issues were identified as barriers, as were public knowledge and perception ('giving up hope') challenges. Advance care planning, dedicated and stable funding, population aging and standards of practice/guidelines to care were seen as facilitators. Successful policy implementation requires concerted action to align system-level characteristics – with each alone being essential but not sufficient. Policies need to be monitored and fine-tuned, with a caveat toward their transferability between jurisdictions. The analysis of the shared-care approach in the rural Niagara-West setting revealed effective and efficient home-based hospice and palliative care – on par with per diem funding for long-term care homes and lower than average alternate level of care and hospital costs in Ontario, and in line with the Medicare Hospice Benefits in the United States of America. The thesis results provide a base for further analyses across jurisdictions and settings and might assist decision makers in the allocation of resources to meet the complex needs of hospice and palliative care populations.

Despite (national) strategies/frameworks for care at the end of life, many patients do not die at their preferred location or under the form of care desired. This cross-country comparison study analyzed system-level characteristics - such as legislation, regulation and financing - that might influence service delivery in the care for terminally ill adults and their implications for outcomes and costs. Drawing on triangulated data from Canada, England, Germany and the United States of America and taking a 'most similar – most different' perspective, it was hypothesized that system-level factors might impede the broader use of (integrated) models of hospice and palliative care/the system-wide adoption of best practices. An embedded case study examined resource utilization and costs of shared care and its role as a potential best practice avenue. While similar with regard to leading causes of death, patient needs and potential avenues to care, different service models were employed – including hospice and palliative care. Generally offered alongside standard care along the disease continuum and across settings - and featuring common elements like physical, psycho-social and spiritual care - outcomes (e.g., access, utilization) varied. Legislative (e.g., jurisdictional), regulatory (including education and training) and financial issues were identified as barriers, as were public knowledge and perception ('giving up hope') challenges. Advance care planning, dedicated and stable funding, population aging and standards of practice/guidelines to care were seen as facilitators. Successful policy implementation requires concerted action to align system-level characteristics – with each alone being essential but not sufficient. Policies need to be monitored and fine-tuned, with a caveat toward their transferability between jurisdictions. The analysis of the shared-care approach in the rural Niagara-West setting revealed effective and efficient home-based hospice and palliative care – on par with per diem funding for long-term care homes and lower than average alternate level of care and hospital costs in Ontario, and in line with the Medicare Hospice Benefits in the United States of America. The thesis results provide a base for further analyses across jurisdictions and settings and might assist decision makers in the allocation of resources to meet the complex needs of hospice and palliative care populations.

Human papillomavirus (HPV) is widespread in the population and an important concern for public health. HPV-associated benign and cancerous disease is vaccine preventable yet vaccine uptake has been suboptimal. Adolescents are the primary target for vaccination yet their perspective has been inadequately examined. Ontario provides population-based preventive HPV vaccination to adolescent girls yet in the program’s first 2 years only approximately half of eligible girls received it. Effective strategies to improve vaccine uptake are needed. This thesis proposes a theory and ethics-based model to guide health promotion planning for HPV vaccination. Adopting an adolescent perspective, the model is applied and comprises: 1) a systematic review to identify barriers and facilitators to HPV vaccination from the viewpoint of young females; 2) GIS uses for communicating geospatial health information regarding vaccination; and 3) a roadmap for the future including recommendations for guiding principles, research, intervention development, and health policy.

Examining service providers’ perspectives of barriers and facilitators for immigrant women seeking employment / There are multi-faceted barriers that shape the employment trajectories and economic outcomes of immigrant women in the Canadian labour market. In response to the barriers that immigrant women experience, the Federal government, Immigration, Refugee, and Citizenship Canada (IRCC), have initiated funding towards employment programs for immigrant women. This critical ethnographic study examines the perspectives of ten service providers in the Greater Toronto Area (GTA), in order to identify the barriers and facilitators immigrant women experience within employment services when trying to obtain secure well-paid employment. The data analysis revealed three major themes: the role of funding for employment programs and settlement services, the categorization of immigrant women by skills; and the application of individualized services to meet the needs of immigrant women. Using an intersectional lens, my research highlights that immigrant women experience various challenges to finding, obtaining, and maintaining employment due to the intersection of their social location (e.g. race, gender, immigration status, language, culture, and religion). Service providers mitigate some of these barriers to secure well-paying employment by providing individualized services to meet differential needs of immigrant women. While this approach has led to success in matching some immigrant women to jobs that align with their field of expertise and career goals, service providers are restricted in their ability to meet the full needs of immigrant women due to underfunding and structural barriers. My research reveals that employment services, immigration processes, and labour market practices can (re)produce and maintain the marginalization of immigrant women in the labour market. This paper concludes with some policy recommendations for immigrant-serving employment services and social work practice. / Thesis / Master of Social Work (MSW)

Rehabilitation clinics remain until this day a greatly unexplored topic from the perspective of architectural design. Stroke is the most common condition that is treated in neurological rehabilitation clinics in Germany and it is a disease that causes the most complex disability. Since stroke numbers are expected to constantly grow in the future, there is a definite need for understanding the stroke survivors’ spatial needs and for accommodating them in the built environment in a way that supports their recovery process and their life after rehabilitation. This PhD thesis aims at contributing to this wide knowledge gap and at introducing new research directions focusing on the relationship between stroke patients’ and the rehabilitation built environments. Rehabilitation clinics were chosen as the research setting for this study as the environments that stroke survivors encounter after the hospital stay and where they undergo a challenging rehabilitation process with the goal of returning home to their normal lives. This rehabilitation process involves living in rehabilitation clinics for a certain period and attending various types of therapies led by a multidisciplinary team, with multiple therapies per day, every day of the week. This type of intensive therapy is important for stroke patients since the greatest amount of functional recovery can be expected in the first 3 to 6 months after the stroke onset. German neurological rehabilitation clinics are commonly transformed from other functions or newly built without evidence-based knowledge about the spatial needs of their patients. This practice creates barriers in the built environment for patients, likely hindering their recovery process and negatively influencing their psychological well-being. These barriers can most directly influence and hinder patients’ mobility within the clinic. Mobility, as the main goal of stroke rehabilitation, is often not well-supported in the built environment of rehabilitation clinics. This study, therefore, focuses on identifying barriers and facilitators to mobility in rehabilitation clinics and their architectural properties and the different experiences of patients with different mobility levels. Three empirical research methods were used to investigate the relationship between the stroke inpatients’ mobility and the built environment of rehabilitation clinics: patient shadowing, patient questionnaire and staff questionnaire. These three methods were the elements of Post-occupancy evaluation (POE) applied in seven German neurological rehabilitation clinics over the period between September 2016 and May 2018. The results show that the built environment of rehabilitation clinics hinders patients’ mobility in five main aspects: challenging wayfinding, long distances, insufficient dimensions of corridors, floor surfaces and physical obstacles. It was also found that mobility facilitators are greatly lacking. Stroke patients with the lower levels of mobility, and especially patients using a wheelchair, were found the most vulnerable to the identified barriers. Patients were also greatly inactive during their time in the clinic since 50% of the day was spent in patient rooms. They also expressed a wish for a greater variety of common spaces within the clinic. The absence of motivating spaces was likely to be another important reason for patients’ inactivity, besides the avoidance of various barriers. The architectural properties of the identified barriers and facilitators were used to develop a catalogue of architectural design guidelines that present a new model for rehabilitation buildings: the transitional model. The given recommendations are based on the obtained study results and the experience of living in rehabilitation clinics and observing their daily life for 14 weeks. The catalogue of guidelines is intended for architects, medical professionals and others included in the process of planning a rehabilitation clinic. The main goal is to provide directly applicable evidence-based recommendations for mobility supporting clinics and to facilitate the dialogue between different professions involved in the planning process. / Rehabilitationskliniken sind bis heute ein aus architektonischer Sicht wenig erforschtes Thema. Schlaganfall ist die häufigste Erkrankung, die in neurologischen Rehabilitationskliniken in Deutschland behandelt wird und die die komplexeste Beeinträchtigung verursacht. Da zu erwarten ist, dass die Anzahl der Schlaganfälle in Zukunft stetig zunimmt, müssen die räumlichen Bedürfnisse der Schlaganfallpatienten unbedingt begriffen und in der gebauten Umgebung so untergebracht werden, dass ihr Genesungsprozess und ihr Leben nach der Rehabilitation unterstützt werden. Diese Dissertation zielt darauf ab, zu dieser breiten Wissenslücke beizutragen und neue Forschungsrichtungen einzuführen, die sich auf die Beziehung zwischen Schlaganfallpatienten und der rehabilitierten Umgebung konzentrieren. Rehabilitationskliniken wurden als Forschungsumgebung für diese Studie ausgewählt, da sie nach dem Krankenhausaufenthalt von Schlaganfallpatienten heimgesucht werden und sich dort einem herausfordernden Rehabilitationsprozess unterziehen, um zu ihrem normalen Leben zurückzukehren. Dieser Behandlungsprozess beinhaltet das Leben in Rehabilitationskliniken für einen bestimmten Zeitraum und die Teilnahme an verschiedenen Arten von Therapien, die von einem multidisziplinären Team mit mehreren Therapien pro Tag an jedem Tag der Woche durchgeführt werden. Diese intensive Therapieform ist wichtig für Schlaganfallpatienten, da in den ersten 3 bis 6 Monaten nach dem Schlaganfall mit der größten Wiederherstellung der Funktion gerechnet werden kann. Deutsche neurologische Rehabilitationskliniken werden häufig von anderen Funktionen umgestaltet oder ohne evidenzbasiertes Wissen über die räumlichen Bedürfnisse ihrer Patienten neu errichtet. Dieses Vorgehen schafft Barrieren in der gebauten Umgebung für Patienten, die wahrscheinlich ihren Genesungsprozess behindern und ihr psychisches Wohlbefinden negativ beeinflussen. Diese Barrieren behindern auch die Mobilität der Patienten in der Klinik. Mobilität als Hauptziel der Schlaganfallrehabilitation wird in der bebauten Umgebung von Rehabilitationskliniken häufig nicht gut unterstützt. Diese Studie konzentriert sich daher auf die Identifizierung von Barrieren, die Erleichterungen für die Mobilität in Rehabilitationskliniken und deren architektonischen Eigenschaften, sowie auf die unterschiedlichen Erfahrungen von Patienten mit unterschiedlichen Mobilitätsniveaus. Drei empirische Forschungsmethoden wurden verwendet, um den Zusammenhang zwischen der Mobilität von Schlaganfallpatienten und der gebauten Umgebung von Rehabilitationskliniken zu untersuchen: Patienten-Shadowing, Patientenfragebogen und Mitarbeiterfragebogen. Diese drei Methoden waren die Elemente der Post Occupancy Evaluation (POE), die in sieben deutschen neurologischen Rehabilitationskliniken im Zeitraum von September 2016 bis Mai 2018 angewendet wurden. Die Ergebnisse zeigen, dass die bebaute Umgebung von Rehabilitationskliniken die Mobilität der Patienten in fünf Hauptaspekten behindert: Herausfordernde Orientierung, große Entfernungen, unzureichende Abmessungen der Korridore, Bodenflächen und physische Hindernisse, sowie ein Mangel an Unterstützungselemente der Mobilität. Schlaganfallpatienten mit eingeschränkter Mobilität und insbesondere Patienten, die einen Rollstuhl benutzen, waren am anfälligsten für die festgestellten Hindernisse. Die Patienten waren auch während ihrer Zeit in der Klinik sehr inaktiv, da 50% des Tages in Patientenzimmern verbracht wurden. Die Patienten wünschten sich mehr Abwechslung in den Gemeinschaftsräumen der Klinik. Das Fehlen von motivationsfördernde Bereiche ist wahrscheinlich ein weiterer wichtiger Grund für die Inaktivität der Patienten, neben der Vermeidung verschiedener Hindernisse. Die architektonischen Eigenschaften der identifizierten Barrieren und Unterstützungselemente wurden verwendet, um einen Katalog von Empfehlungen für die architektonische Gestaltung zu entwickeln, in dem ein neues Modell für Rehabilitationseinrichtungen vorgestellt wird: das Übergangsmodell. Die gegebenen Empfehlungen basieren auf den erhaltenen Studienergebnissen und der Erfahrung der Beobachtung der Abläufe in Rehabilitationskliniken für 14 Wochen. Der Empefehlungskatalog richtet sich an Architekten, Mediziner und andere Personen, die an der Planung einer Rehabilitationsklinik beteiligt sind. Hauptziel ist es, direkt anwendbare evidenzbasierte Empfehlungen für mobilitätsunterstützende Kliniken bereitzustellen und den Dialog zwischen verschiedenen am Planungsprozess beteiligten Berufen zu erleichtern.

Introduction: Au Nigeria, la couverture de la détection et du traitement de la tuberculose pharmaco-résistante (TPR) est toujours faible malgré la mise en place de services gratuits depuis 2011. Le pays se classe au sixième rang mondial avec une proportion de cas de patients résistants aux médicaments de 4,3% et de 15% dans les cas d’une réinitialisation au traitement. Le pays a aussi un fardeau élevé pour la tuberculose, la TPR, et le VIH, avec une prévalence de 219 et 11 pour 100 000 habitants pour la tuberculose et la TPR et de 1,28 pour 1 000 habitants pour le VIH. Sans traitement, la mortalité due à la tuberculose est d'environ 70% en dix ans, augmentant avec la coïnfection par le VIH, et la résistance aux médicaments; et descendant en dessous de 5% avec traitement. Les taux de survie de la tuberculose pharmaco-résistante sont plus faibles et le traitement est plus long, plus coûteux et plus toxique. Cela peut poser des défis différents à la fois pour les patients et les systèmes de santé comparativement à la tuberculose de la forme commune. Cependant, la réponse au traitement et la survie sont influencées par la détection précoce et à l'initiation rapide au traitement, idéalement dans les quatre semaines suivant le diagnostic, en particulier avec la coïnfection par le VIH. Les caractéristiques sociodémographiques interagissent souvent de manière complexe avec des facteurs systémiques, pour accroître la vulnérabilité et les désavantages - ces interactions sont particulièrement bien examinées à travers un cadre conceptuel d'équité à l'accès à la santé, et pourrait offrir des analyses et des recommandations pertinentes pour les politiques. Cette thèse explore les barrières et les facilitateurs à l’accès au diagnostic et au traitement au niveau des patients et du système de santé au Nigéria. Méthodes: Cette thèse est une étude transformative de méthodes mixtes. Nous avons d’abord réalisé une revue systématique mixte pour identifier les obstacles et les facilitateurs influençant l’accès au diagnostic et au traitement de la TPR en Afrique subsaharienne. Nous avons par la suite mené une méta-synthèse qualitative pour examiner en profondeur les obstacles aux soins de la tuberculose auxquels se heurtent les patients, la communauté, et le système de santé. Nous avons utilisé les résultats des deux revues systématiques pour affiner notre cadre conceptuel afin d'orienter la conception et l'analyse de l'étude empirique qui a suivi. Le cadre conceptuel adapté est basé sur le cadre de Levesque. Ce cadre centré sur les patients conceptualise l’accès aux soins selon des dimensions du système de santé et des patients. Cette étude comprenait également une analyse rétrospective d’une cohorte de patients diagnostiqués en 2015 (n = 996) à l'aide de données secondaires nationales et une analyse en cascade des soins de la tuberculose pharmaco-résistante entre 2013 et 2017. Nous avons mené des analyses statistiques descriptives et analytiques. Nous avons effectué une régression logistique et d'autres tests d’association pour mesurer la relation entre les variables catégorielles. L’étude qualitative était une étude de cas qui consistait à examiner la dynamique de soins du point de vue des patients (n = 86 participants, n = 7 groupes de discussions, 5 entretiens approfondis avec des patients diagnostiqués et non traités), leurs familles (n = 19 participants, n = 1 groupe de discussion, 7entretiens approfondis ), membres de la communauté (n = 23 , n=2 groupes de discussion), agents de santé (n = 5 entretiens approfondis) et gestionnaires de programme (n = 29 entretiens approfondis) dans quatre États du Nigéria. Nous avons analysé nos données qualitatives à l'aide d'une analyse thématique. Résultats: Notre revue systématique mixte et notre méta-synthèse qualitative ont indiqué des obstacles et des facilitateurs à l’accès aux soins de la tuberculose pharmaco-résistante au niveau du système de santé et des patients. Les problèmes de fonctionnement des laboratoires et des cliniques, l’absence de connaissances et les attitudes des prestataires de soins, et la gestion de l'information étaient des obstacles à l’accès aux soins de la TPR. Les facteurs facilitateurs comprenaient des outils de diagnostic plus récents, la décentralisation des services et le coût gratuit des soins. Au niveau des patients, la perte de suivi avant ou pendant les soins en raison de la perception négative des soins dans les services publics, le genre, la famille, l’engagement professionnel ou scolaire, et le recours aux soins dans le secteur privé constituaient des obstacles. Les facilitateurs étaient la séropositivité pour VIH, la multitude de symptômes, et le soutien financier des patients. Nos résultats quantitatifs ont révélé une certaine amélioration mais des progrès insuffisants dans le diagnostic et la couverture du traitement au Nigeria entre 2013 et 2017. Notre analyse en cascade a montré des abandons significatifs entre chaque étape des soins, en commençant par les tests et en terminant par l'achèvement du traitement. En moyenne, 80% des cas estimés n'ont pas eu accès au test; 75% de ceux qui ont été testé n'ont pas été diagnostiqués; 36% des personnes diagnostiquées n'ont pas commencé le traitement et 23% d'entre elles n'ont pas terminé le traitement pour la période entre 2013-2017. En 2015, les patients et les enfants atteints de la TB qui résident au nord du Nigéria avaient une probabilité de 0,3 [IC à 95% 0,1-0,7] et 0,4[0,3-0,5] de terminer le traitement une fois la maladie diagnostiquée comparativement aux patients et aux enfants qui résident au sud du pays. Les hommes avaient une probabilité de 1,34 [IC à 95% 1,0-1,7] plus élevée de terminer le traitement après le diagnostic comparativement aux femmes. La localisation géographique et les niveaux de soins étaient associés à un traitement et / ou à un traitement rapide. Notre étude qualitative a identifié des obstacles aux soins aux niveaux individuel, familial, communautaire, et du système de santé. Certains groupes sociodémographiques de patients avaient un accès inéquitable aux soins de la TPR. Alors que les patients étaient pour la plupart traités de manière égale au niveau de l'établissement, certains patients avaient plus de difficulté à accéder aux soins en fonction de leur sexe, de leur âge, de leur profession, de leur niveau d'éducation, et de leur religion. La dynamique familiale et conjugale influencent l’accès aux soins des patients, en particulier des enfants et des femmes. Elle agissait parfois comme un obstacle aux soins. D’autres facteurs qui ont probablement entravé l’accès incluaient l’absence de considérations sur les droits d’accès et la protection des patients dans les directives de traitement et les protocoles de soins. Les patients ignoraient pour la plupart les causes de la tuberculose pharmaco-résistante et la disponibilité des soins gratuits. Le nombre d'agents de santé et les problèmes de formation, la faible performance des laboratoires et des cliniques sont des obstacles aux soins de la tuberculose au niveau du système de santé. Les principaux facilitateurs à l’accès aux soins comprenaient le soutien familial, le soutien financier aux patients et le traitement gratuit. Conclusions: Malgré la gratuité des tests et des traitements de la TB pharmaco-résistante au Nigéria depuis 2011, les couvertures de diagnostic et de traitement restent constamment faibles. Les obstacles à l’accès au diagnostic et au traitement de la TB et de la TB pharmaco-résistante sont similaires. Toutefois, la TB pharmaco-résistante présente des défis particuliers en raison de la complexité des procédures de prétraitement et des toxicités résultant des médicaments eux-mêmes. Notre étude avait pour objectif de mieux comprendre les facteurs qui influencent l’accès à l'initiation au traitement de la TB pharmaco-résistante. Nos résultats montrent que les obstacles les plus importants sont l'accès aux tests et au diagnostic, malgré les progrès technologiques de diagnostic et des protocoles cliniques. Notre étude a identifié plusieurs obstacles liés aux patients et au système de santé. La plupart des patients atteints de TB pharmaco-résistante n'ont pas accès aux tests et ne sont pas diagnostiqués, souvent en raison d'un manque d'information. Les politiques et les programmes de lutte contre la tuberculose pharmaco-résistante ne sont pas toujours équitables, en particulier pour les populations vivant dans les zones rurales, les enfants, et les femmes. Les résultats de notre étude ont généré des données probantes pertinentes pour les décideurs et les partenaires internationaux pour remédier aux disparités systémiques et fournir des services plus équitables. L'élimination des obstacles à l’accès aux soins en temps opportun devrait être une priorité urgente pour améliorer le programme de lutte contre la tuberculose au Nigéria. Dans la faible détection des cas et la couverture thérapeutique, les interventions devraient viser l'équité en facilitant l’accès aux soins des populations vulnérables. / Background: Detection and treatment coverage for drug-resistant tuberculosis (DR-TB) in Nigeria are persistently low despite the implementation of free diagnostic and treatment services since 2011. Nigeria has a high burden for tuberculosis, ranking 6th globally with 4.3% drug resistance in new, and 15% in retreatment cases. The World Health Organization classifies the country as a high burden for TB, DR-TB, and HIV, with a prevalence of 219 and 11 per 100,000 population for TB and DR-TB, and 1.28 per 1,000 population HIV. Without treatment, mortality from tuberculosis is approximately 70% within ten years, increasing with HIV co-infection and drug resistance - and decreasing to below 5% with treatment. DR-TB survival rates are lower, and treatment is longer, costlier, and more toxic; this may pose different challenges to both patients and health systems than is the case for drug-sensitive (DS-) TB. However, treatment response and survival are positively impacted by early detection and treatment initiation, ideally within four weeks of diagnosis, especially with HIV co-infection. Socio-demographic characteristics often interact in complex ways with systemic factors, to increase vulnerability and disadvantage – these interactions are particularly well examined through an equity of health access framework and could offer policy-relevant analyses and recommendations. This study explores patient and health system barriers and facilitators to diagnosis and treatment for DR-TB in Nigeria. Methods: This is a sequential transformative mixed-methods study. First, a mixed-methods systematic review identified barriers and facilitators affecting diagnosis and treatment for DR-TB in sub-Saharan Africa. A subsequent qualitative meta-synthesis was used to examine in more depth the patient, community, and health system barriers to TB care. The results of the systematic reviews were used to refine our conceptual framework and to guide the design and the analysis of the subsequent empirical study. The adapted conceptual framework is based on the Levesque framework for patient-centred healthcare access, which conceptualises access to care as having health system and patient dimensions. This study also included a retrospective cohort analysis of patients diagnosed in 2015 (n= 996 ) using National secondary data, and a DR-TB care cascade analysis of the period between 2013 and 2017. We used descriptive statistics, logistic regression and other tests of association to measure the relationship between variables categorical. The qualitative phase used a case study design to examine the dynamics of care from patients' perspectives (n= 86 participants, N= 7 focus group discussions (FGD), 5 in-depth interviews (IDIs) with diagnosed and untreated patients), their relatives (n= 19 participants, N= 1 FGD, 7 IDIs ), community members (n=23 in 2 FGDs), healthcare workers (n= 5 IDIs ), and program managers (n= 29 IDIs) in four States in Nigeria. We analysed our qualitative data using thematic analysis. Results: Our mixed methods systematic review and qualitative meta-synthesis revealed barriers and facilitators to DR-TB care at the health system and patient levels. Health system laboratory and clinic operational issues, poor provider knowledge and attitudes and information management were some barriers. Facilitators included newer diagnostic tools, decentralisation of services and free cost of care. At the patient level, loss to follow-up before or during care due to negative public sector care perceptions, gender, family, work or school commitments and using private sector care were some barriers. Facilitators were HIV positivity, having more symptoms, and financial support. Our quantitative findings revealed some improvement but inadequate progress in diagnosis and treatment coverage in Nigeria between 2013 and 2017. Our cascade analysis showed significant dropouts between each stage of care, starting with testing and ending with treatment completion. On average, between 2013-2017, 80% of estimated cases did not access testing; 75% of those who test were not diagnosed; 36% of those diagnosed were not initiated on treatment and 23% of these did not finish treatment. In 2015, children and patients in Northern Nigeria had odds of 0.3 [95% CI 0.1-0.7] and 0.4 [0.3-0.5] of completing treatment once diagnosed; compared with adults and patients in Southern Nigeria; while males were shown to have a 1.34 [95% CI 1.0-1.7] times greater chance of completing treatment after diagnosis compared to females.. Geographic locations and levels of care were associated with ever receiving treatment and or timely treatment. Our qualitative data and document review identified barriers to care at individual, family, community, and health systems levels. Some patient socio-demographic groups had inequitable access. While patients were mostly treated equally at the facility level, some patients experienced more difficulty accessing care based on their gender, age, occupation, educational level and religion. Parental and spousal influences affected patients, particularly children, and women, and were sometimes barriers to care. Other factors that likely hampered access include the absence of considerations for patients’ access rights and protection in the treatment guidelines and workers manuals. Patients were mostly unaware of the causes of DR-TB disease and the availability of free care. Health worker numbers and training, clinic, and operational laboratory issues limited patients’ access at the health system level. The main facilitators to care included family support, patient financial support, and free treatment. Conclusions: Despite the provision of free DR-TB testing and treatment in Nigeria since 2011, coverage for diagnosis and treatment remain persistently low. Our literature review identified many of the same access factors affecting both DS-TB and DR-TB. However, DR-TB had peculiar challenges due to complexities in pre- treatment procedures, and in toxicities as a result of the medications themselves. This study was designed to investigate the access factors impacting DR-TB treatment initiation identified in literature. However, our findings showed that the biggest barriers to DR-TB care were essentially in access to testing and diagnosis, making any advances in diagnostic technology and treatment regimens of little benefit to DR-TB patients in Nigeria. Several patient and health system factors were shown to impede access to DR-TB care, particularly for certain groups of patients. Most DR-TB patients are not accessing testing and do not get diagnosed, often due to a lack of information. Also, DR-TB policies, structures and processes are not always equitable, especially for rural dwellers, children and women. Findings from our mixed methods study provided the additional insights needed by policymakers and implementing partners to address systemic disparities and provide more equitable services based on the population's needs. Eliminating barriers that negatively impact timely access to care should be an urgent priority for the TB program in Nigeria. In Nigeria's low case-finding and treatment coverage, interventions should target equity and ease of access, specifically for the barriers identified at the patient and health system levels.

No / Aims and objectives To (1) investigate the organisation, provision and practice of oral care in typical UK stroke units; (2) explore stroke survivors', carers' and healthcare professionals' experiences and perceptions about the barriers and facilitators to receiving and undertaking oral care in stroke units. Cerebrovascular disease and oral health are major global health concerns. Little is known about the provision, challenges and practice of oral care in the stroke unit setting, and there are currently no evidence-based practice guidelines. Design Cross-sectional survey of 11 stroke units across Greater Manchester and descriptive qualitative study using focus groups and semi-structured interviews. Methods A self-report questionnaire was used to survey 11 stroke units in Greater Manchester. Data were then collected through two focus groups (n = 10) with healthcare professionals and five semi-structured interviews with stroke survivors and carers. Focus group and interview data were recorded, transcribed verbatim and analysed using framework approach. Results Eleven stroke units in Greater Manchester responded to the survey. Stroke survivors and carers identified a lack of oral care practice and enablement by healthcare professionals. Healthcare professionals identified a lack of formal training to conduct oral care for stroke patients, inconsistency in the delivery of oral care and no set protocols or use of formal oral assessment tools. Conclusion Oral care post-stroke could be improved by increasing healthcare professionals' awareness, understanding and knowledge of the potential health benefits of oral care post-stroke. Further research is required to develop and evaluate the provision of oral care in stroke care to inform evidence-based education and practice.