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京都大学 / 新制・課程博士 / 博士(社会健康医学) / 甲第23820号 / 社医博第120号 / 新制||社医||12(附属図書館) / 京都大学大学院医学研究科社会健康医学系専攻 / (主査)教授 中山 健夫, 教授 小杉 眞司, 教授 柳田 素子 / 学位規則第4条第1項該当 / Doctor of Public Health / Kyoto University / DFAM

Trustworthy clinical practice guidelines assist health care professionals in selecting the management options that optimize patient health outcomes. The development of trustworthy guidelines requires the consideration of many aspects and the involvement of multiple contributors, often working in groups. The guideline panel plays the key role in the development process as it is responsible for prioritizing topics that should be covered as part of the guideline effort, formulating questions, reviewing the evidence, developing and agreeing on the recommendations, and endorsing the final guideline document. Ensuring transparency throughout the process by appropriately organizing and documenting panel activities is an essential standard that is used to assess the credibility of a developed guideline and its resulting recommendations. The adoption of conceptual frameworks that systematically guides panel members in their decision-making process (e.g. the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence to Decision (EtD) frameworks) can aid in the formulation of methodologically sound recommendations. In this dissertation, I used the example of a guideline on diagnosis and treatment of autism spectrum disorders to describe how rigorous research methods can support guideline panels in the development process from early stages to the formulation of recommendations. In another prominent guideline development effort with the American Society of Hematology, I have identified two steps in the process where panel members may benefit from further support and addressed these gaps by conceptualizing and developing novel approaches. The first approach comprises modelling baseline risk estimates for patient-important outcomes when only surrogate data is available. The second approach proposes a method to estimate decision thresholds for judgments on health benefits and harms using the GRADE EtD framework. While these approaches are tailored to address specific guideline panel needs, guideline methodologists could use the underlying concepts to find solutions to aid guideline panels in other steps of the development process. / Thesis / Doctor of Philosophy (PhD) / Clinical practice guidelines assist health care professionals in selecting management options that can best improve the health outcomes of their patients. The development of trustworthy guidelines is a complex process that requires the contribution of several entities. The guideline panel, which typically comprises different experts (clinicians, patient representatives, experts in research methodologies) plays the key role in this process as it is responsible for selecting the most important questions to address in the guideline, reviewing the evidence supporting an option, agreeing on the recommendations, and endorsing the final guideline document. To ensure that the process of developing guidelines is transparent and that the recommendations are credible, it is important that panel activities are well documented and follow rigorous methods. Structured frameworks, such as the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence to Decision (EtD) approach, have been developed to systematically guide the panel members and to minimize the error that could be introduced while making decisions. In this thesis, I describe the development of an approach and its application for comprehensive guideline development by the Italian National Health Institute, to describe rigorous guideline development and propose two novel approaches to further assist panel members in enhancing their guideline development. The first of these two enhancements to guideline development describes how to derive a modelled estimate of the risk of having certain health conditions when this data is not directly available in the medical literature. The second of the two enhancements is a method to support guideline panels in judging how substantial the desirable and undesirable effects of health interventions are. Both approaches were tailored to fit specific needs but can be adapted to inform the improvement of other steps in the guideline development process.

Cooperative Extension (CE) is a nationwide system that addresses leading concerns for United States residents from agricultural production to healthy youth development. As 80% of Americans are not meeting the Physical Activity Guidelines (PAG), promoting physical activity is a recent addition to CE priority areas. To build capacity of CE to offer physical activity, training on physical activity within the system is needed. Since yoga is a public health intervention growing in popularity due to its link to flourishing and mental well-being, this is a holistic practice that may target physical and mental health in the United States. Due to the variety of yoga practices one could engage with it is important to clarify the link between physical activity and yoga. This dissertation included four studies to promote physical activity and yoga within CE. Study one established the efficacy of a virtual micro-credentialing program for CE professionals (N = 64) that increased their knowledge about physical activity programming and increased their own physical activity levels. The second study was an iterative and pragmatic investigation of wellness initiatives for CE professionals to increase flourishing and physical activity within themselves. The third study explored the degree to which temperature and tempo of yoga classes impacted measured heart rate and rate of perceived exertion. Preliminary evidence suggests that ~30% of the yoga class contributed to moderate-vigorous physical activity, regardless of the temperature and speed. The fourth study was a systematic appraisal of urban and rural yoga studio offerings. The results included that most studios offer 60-minute classes, focused on asana (movement) rather than the other limbs (components) of yoga. This work also resulted in a studio audit form for CE professionals to assess yoga studios for appropriateness to recommend to their participants. Future work includes scaling out the micro-credentialing program and determining the degree to which knowledge of physical activity leads to physical activity program adoption (study 1); ensuring CE professionals have access to wellness initiatives to avoid burn out (study 2); ongoing investigation of the physiological benefits of yoga (study 3); and testing the utility of the studio audit form (study 4). / Doctor of Philosophy / Physical activity is an important part of living a healthy life and can look different for everyone. The Physical Activity Guidelines for Americans recommend for people to get 2 days of full body strength training along with 150 minutes of moderate intensity aerobic activity each week. Aerobic activity is activity that gets your heart rate up. In the first manuscript of this dissertation, Cooperative Extension professionals were trained in how to promote physical activity and physical activity programming. Cooperative Extension is a nationwide program that helps get research knowledge from the universities to the public. The second manuscript looks at how Cooperative Extension professionals were able to incorporate more mindfulness, yoga, and self-care for themselves through employee wellness programs, and which programs worked best in a practical way. The third manuscript looks at if the physical practice of yoga can increase heart rate to moderate to vigorous intensity zones in order to determine if a typical community-based yoga flow could contribute to meeting the aerobic components of the Physical Activity Guidelines. Based on this study, yoga can help participants get into the moderate intensity aerobic activity zone. The fourth manuscript explores the research and development of a yoga studio audit tool. This tool helps assess yoga studios so that public health professionals can recommend the studio that is the right fit for their clients.

Yes / Research ethics review by ethics committees has grown in importance since the end of the Nuremberg trials in 1949. However, ethics committees have come under increasing criticisms either for been ‘toothless or too fierce’ (Fistein & Quilligan, 2012:224). This paper presents a personal account of my experience in obtaining ethical approval for my PhD study from a UK university and the ethical dilemmas encountered in the fieldwork in Ghana. In this paper I question whether strict adherence to ethical guidelines developed from western perspectives is useful in conducting research in non-western societies. As more academics are increasingly been mandated to undertake international research, the paper argues for more flexibility in the ethical approval process to accommodate cultural differences.

As large displays become more affordable, researchers investigate their productivity impacts and try to develop techniques for making the large display user experience more effective. Studies show that large displays enable users to create and manage more windows and engage in more complex multitasking behavior. Although recent work demonstrates significant productivity benefits of large shared displays, it shows numerous usability issues because current software design is not scaling well. Therefore, we took steps towards developing two user interface design guidelines for large shared displays. Specifically, empirical studies have been conducted to compare the effects of large shared display and personal display use. When each of them is used as a secondary display, large shared displays impose increased interruption and comprehension. Empirical and qualitative studies are designed to develop two user interface design guidelines for large shared displays. We designed a system called SuperTrack that uses a large shared display and the proposed guidelines to further enhance team efficiency and productivity in collaborative software development environments. Finally, an in-situ evaluation assesses the benefits of SuperTrack. Results show that exposing software development team members to a large shared display through SuperTrack leads to more communication among the members and improved group awareness — leading to increased productivity and efficiency. / Master of Science

The use of in-stream flow control structures for channel stabilization has become increasingly popular due to its potential cost-effectiveness and ecological benefits. These structures help to protect the bank from erosion and lateral migration. However, a large number of these projects fail due to inadequate design guidelines. This study aims to create authoritative design guidelines which are based on hydraulic and physical criteria attributed to the channel reach. In this report, some of the most common types of in-stream structures have been reviewed and results from a practitioner experience survey have been analyzed. This research has allowed for the selection of the most promising structures which will be studied later in the project. / Master of Science

This study retrospectively evaluated patient records from two cardiac rehabilitation (CR) service centers located in large urban hospitals using a Process Evaluation System (PES) recently developed through a collaborative project of the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR), Madison, WI, and the Center for Clinical Quality Evaluation (CCQE), Washington, DC. The major aims were to: 1) evaluate the utility of the PES as an audit instrument for assessment of adherence to the 24 quality process criteria that comprised the PES; and 2) determine whether adherence to the PES criteria resulted in different patient outcomes for those cases where intervention need was documented at patient admission. Using the data abstraction manual and audit procedures developed by AACVPR/CCQE, a trained medical technician audited 150 CR records for consecutively treated outpatients who typically received 36 sessions of treatment in either Moses H. Cone Memorial Hospital, N.C. Heart Institute, Greensboro, NC, or Carolinaà ­s Medical Center, Charlotte, NC, covering a calendar period between 1995-97. The data were pooled from both sites for analyses and included patients with one or more of the following diagnoses: MI (37%), angina (14%), coronary revascularization (76%), and other (18%). The cost of utilizing the PES was assessed by evaluating the technician time required to abstract a patient record and this was observed to improve over the course of the review period, i.e., mean abstraction time for initial versus final 20 records = 13.2 min. and 4.6 min., respectively. Experience with the PES suggested areas where instrument revision should be considered, e.g., the operational guidelines for extracting acceptable markers were not always clear enough or sufficiently flexible to allow determination of adherence of a record to the 24 quality process criteria. Adherence to the PES was determined, case by case, for each of the 24 criteria. In 129 cases (86% of the sample), complete adherence was found, i.e. 100% adherence to all 24 criteria that included indicators of key clinical steps for patient intake, treatment planning, and follow-up. The remaining 21 records (14%) showed adherence to at least 21 of the 24 criteria (87.5%). Given the uniformly high levels of adherence to the PES documented by these two program sites, the data could not resolve the question of whether patient outcome effects were different between cases of high versus low adherence to PES. Nonetheless, outcome data were examined to evaluate achievement levels in four different areas widely considered by clinicians as important to treatment success: blood cholesterol, smoking status, exercise tolerance, and body mass index (BMI). Of the study patients diagnosed with dyslipidemia 12 of 27 (44%) had levels < 200 mg/dl by exit. Seven of 14 documented smokers (50%) reported quitting at exit from treatment. Forty-nine patients of 117 (42%) who initially could only maintain treadmill walking for 10 min. at levels below 4 METs, were able to exceed this level by treatment end. Six of 104 (6%) with BMI values > 24.9 kg/m2 had a documented decrease in this indicator of overweight by treatment end. The threshold levels for outcome criteria used here to describe achievement levels in this data set are somewhat arbitrary. However, the criteria are reflective of the standards typically suggested as meaningful for effective secondary risk reduction in CR programs (Franklin et al., 1996). The PES system was developed to audit the quality of CR process in treatment centers, as standardized by a consensus panel to reflect the content of the evidenced-based CR guideline recently published by the US Agency for Health Care Policy and Research (Cardiac Rehabilitation as Secondary Prevention: #17, 1995). The findings of this study suggest that the content markers of quality process in the PES are relevant and the instrument is efficient to administer. When field tested against two urban centers in North Carolina where state statutes require program certification for CR treatment centers, these centers demonstrated uniformly high adherence to the PES and a pattern of good achievement for several patient outcome measures accepted as relevant to evaluation of treatment success for individual patients. / Master of Science

En el presente estudio se indican los resultados y la trayectoria de investigación de la autora referente al estudio de las técnicas constructivas propias de las fábricas de ladrillo en la zona de intramuros de la ciudad de Valencia (España), concretamente en los barrios de Velluters, la Seu-Xerea, el Carmen, el Mercat y San Francesc. El estudio se fundamenta en el trazado de un perfil socio, económico, cultural y técnico vinculado a la producción preindustrial del ladrillo y a su puesta en obra en Valencia. Se establecen los rasgos principales que vinculan la manufactura y el empleo de ladrillos preindustriales referidos a un entorno cronológico y geográfico determinado, desde la fundación de la ciudad hasta la llegada de producciones cerámicas industriales. En este marco, el registro pormenorizado de fábricas históricas de ladrillo refleja una serie de datos métricos y técnicos específicos. Por ello la investigación se ha concentrado en el estudio de 84 edificios históricos, tanto residenciales como monumentales. De esta manera, se han podido seleccionar 95 fábricas de ladrillo (cara a vista, agramilado, fingido, enlucido, tapia valenciana, aplantillado o vidriado). Todo ello ha generado una recopilación exhaustiva de fichas, que reflejan los aspectos técnicos, diagnósticos y analíticos de los ladrillos, con un estudio paralelo de fuentes arqueológicas, ordenadas en 19 registros de ladrillos romanos y medievales. A través de los resultados obtenidos con el estudio pormenorizado de fábricas, la recopilación de datos arqueológicos y el análisis de laboratorio de algunas muestras de ladrillo y mortero, se propone extraer una serie de datos estadísticos y reflexiones. A lo largo del estudio se describen sincronías, diacronías, pervivencia de técnicas vigentes en las fábricas que conducen a una propuesta cronotipológica para las fábricas urbanas y sus detalles (zócalos, vanos, dinteles, aleros entre los principales). / Cristini, V. (2012). El ladrillo en las fábricas del centro histórico de Valencia. Análisis cronotipológico y propuesta de conservación [Tesis doctoral]. Editorial Universitat Politècnica de València. https://doi.org/10.4995/Thesis/10251/15665