Background Health information exchange (HIE) may help healthcare professionals and policymakers make informed decisions to improve patient and population health outcomes. There is, however, limited uptake of HIE in many low- and middle-income countries (LMICs). While resource constraints are an obvious barrier to implementation of HIE, it is important to explore what other political, structural, technical, environmental, legal and cultural factors may be involved. In particular, it is necessary to understand associated barriers in relation to context-specific HIE processes and deployment strategies in LMICs with a view to discovering how these can be overcome. My home country Pakistan is currently struggling to implement HIE at scale and so I undertook a detailed investigation of these issues in the context of Pakistan to generate insights on how best to promote uptake of HIE in Pakistan and in LMICs more generally. Aims The concept of HIE is evolving both over time and by context. To gain a clearer understanding of this terrain, I began by identifying different definitions of HIE in the literature to understand how these had evolved and the underlying conceptual basis for these changes. Second, I sought to understand the barriers and facilitators to the implementation and adoption of HIE in LMICs. Building on this foundational work, I then sought to explore and understand in-depth stakeholders perspectives on the context of and deployment strategies for HIE in Pakistan with a view to also identifying potentially transferable lessons for LMICs. Methods I undertook a phased programme of work. Phase 1 was a scoping review of definitions, which involved systematically searching the published literature in five academic databases and grey literature using Google to identify published definitions of HIE and related terms. The searches covered the period from January 1900 to February 2014. The included definitions were thematically analysed. In Phase 2, to identify barriers and facilitators to HIE in LMICs, I conducted a systematic review and searched for published and on-going (conference papers and abstracts) qualitative, quantitative and mixed-method studies in 11 academic databases and looked for unpublished work through Google interface from January 1990 to July 2014. Eligible studies were critically appraised and then thematically analysed. Finally, in Phase 3 I conducted a case study of HIE in Pakistan. Data collection comprised of interviews of different healthcare stakeholders across Pakistan to explore attitudes to HIE, and barriers and facilitators to its deployment. I also collected evidence through observational field notes and by analysing key international, national and regional policy documents. I used a combination of deductive thematic analysis informed by the theory of Diffusion of Innovations in Health Service Organisations that highlighted attributes of the innovation, the behaviour of adopters, and the organisational and environmental influences necessary for the success of implementation; and a more inductive iterative thematic analysis approach that allowed new themes to evolve from the data. The findings from these three phases of work were then integrated to identify potentially transferable lessons for Pakistan and other LMICs. Results In Phase 1, a total of 268 unique definitions of HIE were identified and extracted: 103 from scientific databases and 165 from Google. Eleven attributes emerged from the analysis that characterised HIE into two over-riding concepts. One was the ‘process’ of electronic information transfer among various healthcare stakeholders and the other was the HIE ‘organisation’ responsible to oversee the legal and business issues of information transfer. The results of Phase 1 informed the eligibility criteria to conduct Phase 2, in which a total of 63 studies met the inclusion criteria. Low importance given to data informed decision making, corruption and insecurity, lack of training, lack of equipment and supplies, and lack of feedback were considered to be major challenges to implementing HIE in LMICs, but strong leadership and clear policy direction coupled with the financial support to acquire essential technology, provide training for staff, assessing the needs of individuals and data standardisation all promoted implementation. The results of Phases 1 and 2 informed the design and content of Phase 3, the Pakistan case study. The complete dataset comprised of 39 interviews from 43 participants (including two group interviews), field observations, and a range of local and national documents. Findings showed that HIE existed mainly in/among some hospitals in Pakistan, but in a patchy and fragmented form. The district health information system was responsible for electronically transferring statistical data of public health facilities from districts to national offices via provincial intermediaries. Many issues were attributed to the absence of effective HIE, from ‘delays in retrieving records’ to ‘the increase in antibiotic resistance’. Barriers and facilitators to HIE were similar to the findings in Phase 2, but new findings included problems perceived to be the result of devolution of health matters from the federal to provincial governments, the politicised behaviour of international organisations, healthcare providers’ resistance to recording consultations to avoid liability and poor documentation skills. Public pressure to adopt mobile technology frameworks was found to be a novel facilitator whereas sharing regional health information with international organisations was perceived by some participants as disadvantageous as there were concerns that it may have enhanced espionage activities in the region. Conclusions HIE needs to be considered in both organisational and process terms. Effective HIE is essential to the provision of high quality care and the efficient running of health systems. Structural, political and financial considerations are important barriers to promoting HIE in LMICs, however, strong leadership, vision and policy direction along with financial support can help to promote the implementation of HIE in LMICs. Similarly, the federal and provincial governments could play an important role in implementing HIE in Pakistan along with the support of international organisations by facilitating HIE processes at federal and provincial levels across Pakistan. This however seems unlikely for the foreseeable future. At a meso- and micro-level, HIE in Pakistan and other LMICs could be achieved through using leapfrog mobile technologies to facilitate care processes for local organisations and patients. Specifically, the study on Pakistan has highlighted that LMICs may achieve modest successes in HIE through use of patient held records and use of now ubiquitous mobile phone technology with some patient and organisational benefits, but scaling these benefits is dependent on the creation of national structures and strategies which are more difficult to achieve in the low advanced informatics skill and resource settings that characterise many LMICs.

This qualitative study was designed to review the history of women in leadership and to evaluate the identified facilitators of success for women in leadership positions. Participants were asked to identify the facilitators that they considered important to their success. The facilitators were then compared to determine the most commonly occurring and the most influential among those cited by the participants. The results reflected those facilitators such as mentoring programs, training programs, as well as informal opportunities. Emotional intelligence was also examined in the context of this research. The findings of this qualitative study yielded the facilitators of success as identified by successful women leaders. Facilitators identified included familial or parental support, intrinsic motivation, educational opportunities, professional growth opportunities, emotional intelligence and mentors.

Public education in the United States has changed remarkably in the last 200 years. The buildings that house students and teachers have also gone through a dramatic evolution in that same time. The buildings in use today are far more complex in design and thus require considerable expertise to operate and maintain. Although a good deal of scholarly literature has addressed the growing demand for dedicated facilities management, very little of that research is focused on that need within public education systems or the individuals who fulfill the duties associated with that need. The purpose of this research was to evaluate the perceptions of facilities directors of public school systems. A qualitative collective case study was conducted to evaluate the perceptions of six facilities directors from public school systems in Tennessee. Analysis of transcriptions from in-depth interviews as well as document review helped identify factors those individuals perceived as facilitators or barriers to performing their duties. Findings indicated participants perceive communication, autonomy, employees, and access to resources as facilitators of their success. Participants identified communication, purchasing, funding, the age of facilities, and lack of understanding as the primary barriers to their success. This research adds to the literature related to the topic, has implications for future research and practice, and could serve as a model for research among other support service areas of public education.

Translating research to practice takes 10-20 years or more and evidence-based practice (EBP) integration remains at 10%-20%, despite recommendations requiring EBP-guided decisions. EBP integration has been associated with up to 30% decreases in healthcare system spending, improved quality outcomes, and increased staff satisfaction. Nurse leaders are accountable for EBP enculturation, yet rate quality and safety as the highest priority and EBP as the lowest. This knowledge gap perpetuates low EBP integration rates and hinders EBP enculturation. Asking whether EBP facilitative interventions for nurse leaders increase scores on organizational culture and readiness, beliefs, and EBP use scales addressed the knowledge gap via this quality improvement, pre/posttest pilot project. Multiple frameworks guided the project: the nursing process, Lewin's change management model, the Johns Hopkins Nursing EBP model, and the Five Practices of Exemplary Leadership-® model. A comprehensive literature search validated the design using EBP facilitators: educational interventions, transformational leadership, strategic planning, and a systems perspective. Pre/posttest data garnered from 14 non-direct care nurse leaders on the Organizational Culture and Readiness for System-Wide Integration of EBP Scale, the EBP Beliefs Scale, and the EBP Implementation Scale was analyzed using 2-sample t tests. Individual questions on the scales revealed statistically significant differences correlating to the facilitative interventions, yet overall aggregate scores did not change significantly. The limited findings contribute to the existing body of knowledge, while positive social implications include resolving public health and safety issues, reversing fiscal irresponsibility, and overcoming resistance to change.

Falls constitute a health care safety concern, specifically among the geriatric population institutionalized in health care facilities. From the pattern of observed falls at the project site, a discrepancy between fall prevention measures and expected outcomes was noted. Knowledge deficiency, inadequate practice skills, and insufficient organizational support were found to be the major obstacles to improving fall prevention. The purpose of this systematic literature review project was to identify evidence-based actions to reduce falls. The project was guided by Taylor's personality theory and Watson's theory of care. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses method was used to evaluate and analyze 4 of the 47 screened publications. The evidence supported 5 interventions: furthering implementation facilitators, removing barriers, improving strategies, integrating personality, and using a fall risk assessment tool. The systematic review addressed practice gaps, organizational support, and barriers to curb recurrent falls. By contributing to the improvement of individual and population health, the project might lead to a positive socioeconomic change by reducing falls and their complications.

Background: As the number of older adults in Thailand continues to increase, along with increased incidence of surgical intervention that causes pain, the quality of pain care in older adults is needed. Nurses are primarily responsible for assessing and managing pain in older adults (Jose Closs, 2008; Prowse, 2007). The use of evidence-based practices (EBPs) improves quality of care and saves healthcare cost. However, in Thailand where empirical study of using EBP related to pain in older adults is limited, research to understand how Thai nurses use EBP acute pain in older adults is needed.Purpose:The purpose of this study is to describe current practices, perceived barriers and perceived facilitators of Thai nurses on using EBP for assessing and managing acute pain in postoperative older adults.Method:A descriptive exploratory survey was conducted in 8 mid and large-size hospitals in Thailand. The Acute Pain EBP Questionnaire (APEBPQ) (Suwanraj, 2009) was distributed to 240 Thai nurses. 236 questionnaires were returned with the response rate of 98.3 percent. Open-ended questions related to barriers and facilitators of using EBPs were coded to identify major themes. MANOVA was performed to explore the differences between years of nursing experience on perceived barriers and facilitatorsResultsThe majority of participants are female (96.8%) with mean age 35.5 years (range=23-54). Thai nurses reported using 51/53 recommendations from EBPG Acute Pain most of the time/always (95%). Using an equianalgesic table (1.80±1.16) and assessing MMSE in older adults with postoperative pain (1.74±1.15) were occasionally used. Research reports published in English was the greatest barriers. Nurses perceived greatest support from a Head ward than other colleagues. Nurses with 11-20 years of nursing experience had higher reported barriers than those with 1-10 years of nursing experience.Practice Implications: This study will provide important information on barriers and facilitators of using EBPs related to pain assessment and pain management in Thailand. The results of the study will be used to develop strategies to promote the use of EBPs acute pain among Thai nurses who provide nursing care for postoperative older adults.

Inadequate cancer pain management is a global problem. The problem is particularly worse in developing countries where the majority of patients present with advanced stages of the disease. Nurses play an important role in cancer pain management because they spend the majority of their time with patients. The purpose of the study was to examine role of unit cultures on cancer pain management practices among nurses in Kenya. A focused ethnography was used to explore cancer pain management practices of two different units (general and private) within the same institution. Data were collected for four months in a national referral hospital in Nairobi, Kenya. Purposive sampling was used to recruit participants. A total of twenty five nurses and fourteen secondary participants (e.g., nurse managers) participated in this study. Data were collected through semi-structured interviews, observations, and document reviews. Content analysis was used to analyze the data. The study findings show that the unit culture plays a role in cancer pain management practices. For instance, nurses on the oncology unit prioritize pain while nurses on the private unit prioritize overall patient satisfaction. Nurses in both units do not conduct a comprehensive pain assessment and they do not use validated pain assessment tools. Facilitators, such as availability of analgesics and palliative care training, were helpful in managing cancer pain especially in the oncology unit. Barriers such as, negative attitudes towards opioids and doubting patients’ report of pain continue to hinder adequate cancer pain management in the private unit. Other barriers including lack of pain management policies, assessment tools, and workload, influence cancer pain management practices negatively in both units. Understanding the role of unit culture in nursing cancer pain management practices has important implications for policy and practice. Findings in this study show a divergence of the prevailing training of nurses on pain management and practice. Findings could be used to develop pain management policies and protocols for nurses to use as a guide in cancer pain management. Also, nurse managers could use this findings to improve practice for instance, training in cancer pain management could be expanded to include nurses in the private unit. In terms of research, studies could be done to capture patients’ perspectives regarding cancer pain management, or implementation studies could be carried out to alleviate the barriers identified. Lastly, tailored strategies aimed at changing the culture in a unit to enhance change in practice are needed.

According to several studies, there have been improvements in adolescent sexual behaviour; declining adolescent pregnancies, fewer adolescents having more than one sexual partner, and an increasing numbers of adolescents using contraceptives. Notwithstanding these improvements, there are concerns regarding adolescents’ sexual health including adolescents’ limited knowledge of sexual health issues, high rates of sexually transmitted infections and the need to eliminate barriers to adolescent sexual health services. The purpose of this study was to explore adolescents’ perceptions of the facilitators and barriers to the promotion of healthy sexuality of adolescents living in PEI. A qualitative descriptive design guided by CST and a socio-ecological framework was used to explore participants’ perceptions. Six female high school students, 16-18 years of age, participated in a face-to-face semi-structured interview followed by a second face-to-face follow up interview. Seven themes emerged from the data that was analyzed through thematic analysis: The Illusion of Accessible Resources; Risky Behaviours; Peer Pressure Alive and Well in High School; Cyberbullying; Parental Influence on Adolescent Decision Making; Inefficient and Underutilized School Health Resources; and Inefficient and Underutilized Community Health Resources. While it is evident that some promotion of healthy sexuality of adolescents is occurring in PEI, more investigation and development is needed to better support adolescents with comprehensive school services including guidance and education. The results of this study can be used to guide this future development.

abstract: The problem of the study was to investigate constraints and facilitators of Mexican American parents when deciding whether or not to enroll their children in formal swim lessons as a means of drowning prevention. The information obtained by this study (1) helps create awareness about youth drowning incidents and (2) provides insight about Mexican American perspectives and behaviors toward drowning prevention through, or not through as the case may be, youth formal swim lesson participation. This study's sample was purposively selected using typical case and snowball sampling techniques. Individual interviews were conducted with Mexican American parent participants and focus group interviews were conducted with aquatic personnel. From April to August, individual and focus group interviews were conducted in the border towns Sierra Vista, Bisbee, and Douglas in the state of Arizona. There were a total of 25 Mexican American parent participants: 10 had never enrolled their children in swim lessons and 15 had experience enrolling and observing their children in swim lessons. There were 3 focus groups interviews of aquatic personnel experts: Sierra Vista had 6, Bisbee had 7 and Douglas had 9 participants. The theory used to identify and classify the types of constraints and facilitators described in the findings of this study was the Leisure Constraints Theory proposed by Crawford, Jackson and Godbey, 1991. Finding from this study suggest that despite the uncommon perception, Mexican Americans youth are actually participating more in formal swim lessons than they have in past generations. Mexican American families in this sample reported major constraints for formal swim lessons as a reliance on learning form family and friends, swimming at private pools, money, time, and transportation as barriers to participation. Facilitators for Mexican American youth to participate in formal swim lessons are youth drowning awareness, education, lack of parental swimming ability, generational social norm behavior changes, financial assistance and an attitude shift in favor of formal swim lessons. / Dissertation/Thesis / M.S. Recreation and Tourism Studies 2013

Background: Myocardial infarction is one of the biggest health issues in Sweden. Over 25000 swedes get affected every year. There is strong evidence to show physical exercise can reduce heart related diseases and death. Only about 50 % of the patients participate in physical exercise after myocardial infarction. More knowledge about which biopsychosocial barriers and facilitators that can influence initiation to physical exercise in myocardial patients is therefore demanded. Purpose: The aim of this study was to investigate experienced barriers and facilitators to initiate physical exercise after a myocardial infarction. Method: A qualitative design with semi-structured interviews was used in this study. Five informants which experienced a myocardial infarction in the last 24 months. For the process and analysis of data a qualitative content analysis was used. Results: Other priorities, fatigue, fears and lack of self awareness to exercise activity-level was found as barriers for initiating physical exercise after myocardial infarction.Social support, importance of exercise, goals and individualised activity was found to be facilitators for initiating physical exercise after myocardial infarction. Conclusion: A good relationship, trust and information about the effects of physical exercise together with individualised exercise recommendations is important for facilitating initiationof physical exercise in myocardial patients.