Background: Despite national guidance and empirical support for its clinical and cost-effectiveness, cardiac rehabilitation (CR) is underused. Only 44% of patients go to CR, with angioplasty (Percutaneous Coronary Intervention; PCI) patients being least likely to attend (31% of 87,000). Aim: To investigate the relationship between ‘continuity of care’ and patients’ motivation towards CR, through the lens of self-determination theory, and develop a model to inform service design to increase CR uptake and adherence. Methods: A mixed methods approach was used. In Study 1, a theoretical model of continuity of care and motivational antecedents was tested with a cross-sectional sample of 107 PCI patients. To further explore interactions between continuity of care and motivation towards cardiac rehabilitation, a Critical Interpretive Synthesis of the extant literature was used in Study 2, and focus groups were carried out with patients and service providers in Study 3. Results: In Study 1, continuity of care positively predicted patients’ autonomous motivation towards CR, and this was partially mediated by autonomy support. Autonomy support was associated with CR attendance. In Studies 2 and 3, aspects of continuity of care with positive effects on attendance were identified. These included timely, appropriate information provision, relationships bridging CR phases and settings, and continuing management strategies incorporating trusting, warm staff-patient relationships, and positive encouragement and feedback about progress. The SDT constructs of autonomy support, need satisfaction, internalisation and quality of motivation helped to explain positive and negative influences of continuity on attendance. Conclusion: Continuity of care has a positive effect on patients’ motivation towards CR. The most enduring motivation comes from delivering continuity of care in an autonomy-supportive and competence-supportive way. Longitudinal research is needed to compare how need-supportive and need-thwarting aspects of continuity of care affect CR attendance and adherence, and whether these relationships are influenced by need satisfaction and need frustration.

The thesis begins with an exploration of my experiences of caring for dying babies which considers the way in which the care given to dying babies differs according to the care environment. This sets the scene for an exploration of rituals surrounding their care. Critical Interpretive Synthesis was selected as a research design for the study because it offered the opportunity to take an interpretive approach to a range of data and allowed the creation of new arguments. Documentary data including professional literature, professional textbooks and professional guidelines were analysed and interpreted using methods which guideline analysis, critical appraisal and rhetorical analysis. The diverse range of analyses facilitated both the rigour and meaning of the data to interrogated. Performance Theory was used as the theoretical framework in the thesis to allow the rituals to be revealed and explored as dramatic performances. The thesis demonstrated that the origin of the rituals was rooted in the need for the baby to be treated with compassion and dignity and to provide parents with the opportunity to form meaningful attachments in the brief period between the previable baby’s birth and death. The rituals were devised by parents who had been bereaved and were incorporated into guidelines. The guidelines practised the rhetoric of choice but the data demonstrated that the rituals appear to have been adopted as routines which were then used indiscriminately, robbing them of their meaning.The findings reveal how care to meet the physical needs of the dying previable baby requires to be made more explicit to enable the ideology and of ‘comfort care’ to be realised in practice. The thesis also demonstrated a need for inclusiveness to represent the spectrum of parents affected by the death of a previable baby when researching perinatal loss and formulating policy.

Strong health systems are needed to implement clinical and public health interventions. Global evidence-informed health systems guidance, such as that created by the World Health Organization (WHO), has been used to help strengthen health systems. However, global guidance needs to be contextualized or adapted to fit the realities of a particular setting. A workbook for contextualizing health systems guidance was developed to accompany WHO guidance on optimizing health worker roles to increase access to and use of key interventions for improving maternal and newborn health. This dissertation investigates the development and use of the workbook, using qualitative research methods, to help in the planning of future knowledge translation tools, to provide insights for practice and research, and to improve the workbook. First, a single case study explores the development of the workbook, which helped uncover the key features of the process, barriers that arose, and facilitators that helped overcome some of these barriers (chapter 2). Second, a single embedded case study examined the use of the workbook in two real-life settings, Peru and Uganda (chapter 3). Third, a critical interpretive synthesis of the literature was used to better define contextualization and to find what and how contextual factors could be used by policymakers to adapt guidance to their setting (chapter 4). Together, the three studies presented in this dissertation offer substantive, methodological and disciplinary contributions to the field of health systems and policy through a comprehensive examination of the workbook. It presents recommendations for improving the workbook from the perspectives of global guidance developers, users at the national level, and the broader literature on guidance and guideline development, contextualization and implementation. It also supports the continued use of workbooks, or other tools, to contextualize guidance in an effort to strengthen health systems, especially in low- and middle-income countries. / Dissertation / Doctor of Philosophy (PhD) / Strong health systems are needed in order for the right mix of clinical care and public health interventions to get to those who need them. The World Health Organization writes guidance at the global level to help countries strengthen their health systems. This guidance can be used to develop health guidance or policy for the national or subnational (e.g., provincial, state) level, but it first needs to be contextualized or adapted to that particular jurisdiction. It is important to consider what the problem is and what causes it, policy options to help deal with the problem, implementation considerations, as well as factors related to both the health system and the political system that can affect whether or not the intervention will be implemented. A workbook was developed to help contextualize guidance. This dissertation explores the process of developing and evaluating its use to help in the planning of future tools, to provide insights for practice and research, and to improve the workbook.

Background: With recent emphasis on creating a stronger, more patient-centred, health system in Ontario, there remains no clear definition of a “public health” system, hindering the ability to integrate preventive public health and health care practices. This study aims to describe public health systems and initiate a research agenda for this field. Methods: A critical interpretive synthesis of the literature was conducted using six electronic databases. In addition, data extraction, coding and analysis followed a best-fit framework analysis method. Initial codes were based on two current leading health systems and policy classification schemes: health systems arrangements (based on governance, financial and delivery arrangements) and the 3I+E framework for health policy formulation (institutions, interests, ideas and external factors). New codes were developed as guided by the data. A constant comparative method was used to develop concepts and to further link these into themes. Additional documents were identified to fill conceptual gaps. Results: 5,933 unique documents were identified and 338 documents met the inclusion criteria. 81 documents were purposively sampled for full-text review and 58 of these were included in this study. Nine documents were found to help fill conceptual gaps. Generally, public health systems can be defined using traditional healthcare systems and policy frameworks. There was also a strong emphasis on identifying and standardizing the roles and functions of public health. Partnerships (community and multi-sectoral) are common features within and between components of public health systems. A public health system framework and a model of a population health system were conceptualized. Discussion: Understanding public health systems can help strengthen these systems and further integrate preventive public health and primary care services. Systems are influenced by organizational and contextual factors that need to be explored to improve population health. A research agenda is proposed to move this field forward. / Thesis / Master of Public Health (MPH)

Yes / Ensuring an informed and effective dementia workforce is of international concern; however, there remains limited understanding of how this can be achieved. This review aimed to identify features of effective dementia educational programs. Critical interpretive synthesis underpinned by Kirkpatrick’s return on investment model was applied. One hundred and fifty-two papers of variable quality were included. Common features of more efficacious educational programs included the need for educational programs to be relevant to participants’ role and experience, involve active face-to-face participation, underpin practice-based learning with theory, be delivered by an experienced facilitator, have a total duration of at least 8 hours with individual sessions of 90 minutes or more, support application of learning in practice, and provide a structured tool or guideline to guide care practice. Further robust research is required to develop the evidence base; however, the findings of this review have relevance for all working in workforce education.

Background: Within Primary Dental Care (PDC), there is variation in dentists’ views about who should be treated in general dental practices and who should be referred to community dental services (CDSs), creating confusion about where patients can access dental care. Aims: This research aimed to explore the meanings which general dental practitioners (GDPs) and community dentists in England ascribe to their roles. It focused on why they make, accept or decline patient referrals within PDC. Methods: I conducted a configurative systematic review of literature about referrals within PDC in the UK. Data were synthesised using Critical Interpretive Synthesis. I interviewed ten GDPs and twelve community dentists working in England, covering topics informed by the systematic review. Transcripts were analysed using thematic analysis. Findings: Synthesising the literature showed that referral decisions were influenced by non-clinical factors including policies, financial contracts and dentists’ perceptions and values. Authors rarely reported directly from the perspective of primary care dentists. The interview study findings showed that the business of dentistry defined GDPs’ roles. Obscure rules and complex care systems underpinned community dentists’ roles. Participants depicted vulnerable people within ‘no man’s land’, situated between GDPs and community dentists. Vulnerable people included frail, older people, anxious and socially excluded adults, and children with high levels of disease. I identified three typologies of dentists. ‘Entrepreneurs’ felt no allegiance to the NHS and no obligation to treat vulnerable patients. ‘Altruistic carers’ cared for complex, deserving patients, rather than vulnerable patients. ‘Pragmatic carers’ accommodated some vulnerable patients but felt constrained from doing so by structural barriers. Conclusions: This study adds to our understanding of why dentists make, accept or decline referrals within PDC in England. It suggests that failure to resolve structural barriers or to consider dentists’ values will hinder attempts to reduce inequalities in access to PDC in England.

This thesis aimed to explore personal definitions and experiences of recovery from psychosis for service users (SUs) and general practitioners (GPs), as well as indentify factors which might promote or hinder recovery in a primary care context, and identify interventions which might be required to enhance the promotion of recovery in primary care. A review of existing literature pertaining to the concept of 'recovery' was undertaken, and differing conceptualisations of 'recovery' were analysed and synthesised through the use of a Critical Interpretive Synthesis. Semi-structured interviews were conducted with 24 GPs and 20 SUs. Two mixed focus groups were also carried out as follow-ups with 5 GPs and 5 SUs. The data was analysed using a modified grounded theory approach. Factors reported to promote recovery in primary care included: autonomy, choice, and empowerment for SUs in treatment decisions; signposting of peer-supported groups and services by GPs; enhancement of SUs' social support networks by GPs; advocacy and independent analysis provided by GPs; a whole-person approach to recovery (social and biomedical); less stigmatising environment of primary care; and families of SUs and GPs working together in collaboration, often having built up a trusting relationship over time through continuity of care. The following potential interventions for enhancing recovery in primary care were identified: SU-led training for GPs regarding psychosis knowledge and attitudes; raising GPs' awareness of local services and groups by encouraging service managers and group organisers to visit GP practices; establishing GP peer supervision forums; improving access to GPs with a Special Interest in Mental Health (GPwSIs); shifting a greater degree of responsibility for recovery from psychosis to primary care from secondary care; reinforcing amongst GPs an awareness of the important role which primary care can play in promoting recovery; facilitating continuity of care within large practices where feasible; and encouraging GPs to alert SUs to seriousness of potential side-effects of medication before and during treatment. The implications of the findings for policy, practice, and future research were discussed.

McMaster University DOCTOR OF PHILOSOPHY (2019) Hamilton, Ontario (Health Research Methods, Evidence, and Impact) TITLE: Measuring International Health Inequalities and Socioeconomic Status Using Household Survey Data AUTHOR: Mathieu J.P. Poirier, B.Sc., M.P.H. (McMaster University) SUPERVISOR: Dr. Michel Grignon NUMBER OF PAGES: xii, 231 / The methods underlying the quantification of health inequalities have profound consequences for measuring progress in achieving health for all. In Chapter two, associations between household wealth indices, income, and consumption were systematically compiled and different methods of wealth index calculation were evaluated for appropriateness of use in a variety of settings. Researchers are presented with a synthesis of existing evidence about the appropriateness of use of wealth indices in urban and rural areas, their robustness to changes in the asset mix, future applications, and advantages and disadvantages of primary competing methods of quantifying SES using household survey data. In Chapter three, international microdata were analyzed to evaluate how magnitudes of health inequality are affected by different methods of quantifying household socioeconomic status (SES), including income, consumption, and asset wealth. In Chapter four, the need for a transnational approach to measuring health inequalities was justified and the new method was developed using an empirical example. Substantively, these chapters develop the most complete evaluation of the association between the asset wealth, consumption, and income using both critical interpretive synthesis and microdata analysis, as well as the first meta-analysis evaluating changes in health inequality magnitudes according to the SES measure used over time and across country-income levels. The transnational analysis of health inequalities uncovered previously hidden health disparities in the island of Hispaniola, and detailed instructions for all methodological aspects of the new method were presented. The distribution of disease between nations, subnational regions, and urban-rural areas in Hispaniola were analyzed from 1994 to 2013, and the first relative geospatial wealth ranking between Haiti and the Dominican Republic was presented. Global health researchers should strive to measure the equity of health between people, and this sometimes requires analyzing populations that are not neatly contained by national boundaries. / Thesis / Doctor of Philosophy (PhD) / This thesis investigates social inequalities in health and how to measure socioeconomic status (SES) using household surveys in a way that is robust across jurisdictions. It examines how wealth indices compare to income and consumption, and develops a new method to calculate transnational health inequalities. Chapter two conducts a comprehensive evaluation of evidence surrounding the use of wealth indices in urban and rural areas, robustness to changes in assets, future applications, and the advantages and disadvantages of the primary competing methods for quantifying household SES. The third chapter systematically evaluates how health inequality magnitudes evolve over time and across country-incomes according to SES measure. Finally, a transnational measurement of health inequalities was calculated for the island of Hispaniola in chapter four, uncovering the distribution of disease between nations, subnational regions, and urban-rural areas. Detailed instructions for all methodological aspects of the new transnational method are presented.

Many strategies can be used to support the use of research evidence in decision-making. However, such strategies have been understudied in crisis zones, where decision-making may be particularly complex, many factors may influence decision-makers’ use of research evidence, and professional judgements may be particularly relied upon. Using synthesis and qualitative research methods, this dissertation examines the role of research evidence in crisis zones and strategies to support its use in decision-making. First, chapter 2 describes a critical interpretive synthesis, which drew upon a broad body of literature around evidence use in crisis zones to develop a new conceptual framework that outlines strategies that leverage the facilitators and address the barriers to evidence use in crisis zones in four systems, namely the political, health, international humanitarian aid, and health research systems. Second, in chapter 3, the focus narrows, and an embedded qualitative case study design was used to gain a deeper understanding into one of the four identified systems, the political system, and specifically the factors that influenced the use of research evidence in the governmental health policy-development processes for Syrian refugees in Lebanon and Ontario. Finally, in chapter 4, a user testing study design was used to zero-in on decision-makers’ experiences with a particular strategy within the health research system, namely an evidence website focused specifically on topics relevant in crisis zones. This dissertation provides a rich understanding of research evidence use by examining knowledge translation strategies in a setting that has been largely unexplored in the broader KT map: crisis zones. The findings from this thesis point to the need for comprehensive strategies to support evidence use in decision-making that draw upon the existing literature and are adapted for crisis zones, which can occur sequentially or simultaneously within or across the four identified systems. / Thesis / Doctor of Philosophy (PhD) / In humanitarian aid, and specifically in crisis zones, there are many different types of information decision-makers can draw from when making decisions. One specific type of information is research evidence; however, the use of research evidence, and the ways it can inform decision-making in crisis zones, has been understudied. This dissertation addresses this key gap in understanding by: 1) developing a new tool that can help decisions-makers use research evidence to inform their decisions in crisis zones within the political, health, humanitarian aid and health research systems; 2) examining the factors that influence the use of research evidence in the governmental health policy-development processes for Syrian refugees in Lebanon and Ontario; and 3) examining the perspectives of decisions-makers around using one way of supporting the use of research evidence — an evidence website — to support evidence-informed decision-making in crisis zones.