Master of Science / Civil Engineering / Sunanda Dissanayake / The percentage of gravel roads in rural areas in Kansas is higher than most states. A wide variation of traffic volumes across different regions and variations of local conditions and scenarios present a great challenge for local agencies to determine suitable roadway surface types for local rural roads, especially considering constraints on transportation budgets. The primary objective of this research was developing specific guidelines to identify the most suitable roadway surface for a particular roadway section with given conditions. Surveys were carried out to determine the importance of factors affecting the selection of a roadway surface type, where were later used for guideline development. General guidelines were developed using the multi-criteria assessment method in order to fulfill the main objective. The main important factors in decision-making were identified as agency cost, safety, Vehicle Operating Cost (VOC), traffic volume, purpose of road usage, and public preference. Multi-criteria assessment method involves calculating the weights for the factors important in decision-making, the respective scaled values for each factor for paved surface and gravel surface, and eventually calculating the final score for paved and gravel surface type. Equations were formulated to carry out life cycle cost (LCC) analysis along with the present worth evaluation. The formulas provided flexibility to calculate agency cost by considering local variation. VOC was calculated for paved and gravel roads considering variations in speed of different classes of vehicles, gradient and horizontal curve of the road, and the conversion factor for cost on paved surface versus gravel surface. Safety analysis was carried out for local rural roads in Kansas for five years, from 2010 to 2014, using the Kansas Department of Transportation’s KCARS database. After calculating the EPDO crash rates on paved and gravel roads in Kansas, results showed that paved surfaces were in general safer than gravel surfaces, which was taken into consideration while calculating the scaled values for safety. The final score was calculated by multiplying the weights of each factor and their respective scaled values. Roadway surface type with higher score is the preferred alternative for a road section under consideration. A computer-based program was created as a user interface, using Visual Studio, to carry out all complex calculations for determining LCC and VOC considering local variations. The program also helped determine final total scores for paved and gravel roads by considering scaled values of all-important factors considered for conversion. Another approach using cost versus traffic volume showed that the break-even point for traffic volume decreased with an increased percentage of trucks and increased vehicle speeds. Thus, the developed guideline helps determine the best roadway surface type for any set of local conditions.

Guideline development processes influence the quality of clinical guidelines. The aim of this study was to use the AGREE II instrument to evaluate the variability of the quality of selected guidelines, to determine a baseline for the quality of current guidelines and determine whether guidelines demonstrated good standard practice during their development. The AGREE II instrument was used to assess a selection of guidelines published between January 2012 and June 2013. Eleven guidelines were selected for review. Overall, guidelines scored highest in domain 1 (Scope and purpose) and 4 (Clarity of presentation); and lowest in domain 3 (Rigour of development) and 6 (Editorial independence) with the overall assessment score of three out of seven. The study demonstrated that the quality of guidelines was variable and that there are deficiencies in the guideline development process. The results from this study provide a baseline to measure the quality of future guidelines. / Dissertation (MSc)--University of Pretoria, 2014. / tm2015 / School of Health Systems and Public Health (SHSPH) / MSc / Unrestricted

The field of guideline development has made considerable progress in the past twenty years, particularly after the introduction of GRADE in 2004. However, there are many shortcomings in current guideline development including failure to use GRADE, low quality systematic reviews, and excessive delays from the publication of practice changing evidence to new recommendations. The objective of this thesis is to describe the development of evidence-based recommendations, to document methodological issues that arose and describe how the research team addressed the questions, and to document how the ultimate guidelines contributed to optimization of treatment in clinical practice. The relevant guidelines address the issues of gastrointestinal bleeding prophylaxis and coronavirus disease 2019 (COVID-19). The thesis begins by presenting three methodological issues that arose during the planning and implementation of the guideline process and the initial process of how the research team addressed the challenges. The thesis subsequently presents a published paper that documents recommendations regarding gastrointestinal bleeding prophylaxis in critically ill patients. Then, this thesis presents a published systematic review and meta-analysis addressing efficacy and safety of corticosteroids in COVID-19 based on direct evidence from patients with COVID-19, and indirect evidence from acute respiratory distress syndrome, community-acquired pneumonia, severe acute respiratory syndrome, middle east respiratory syndrome and influenza. Further, the thesis includes a published paper describing recommendations regarding corticosteroids, convalescent plasma and antiviral drugs in COVID-19 on the basis of evidence available very early during the pandemic. This thesis ends by presenting how the methodological issues were ultimately addressed in the relevant guidelines, the importance of the guidelines themselves, and presents perspectives on future research and opportunities in guideline development. / Thesis / Candidate in Philosophy

Rare diseases currently impact over 250 million people worldwide, accounting for over 3.5% of the global population. Clinicians caring for individuals living with rare diseases face difficulties providing accurate diagnosis and effective treatments. The low prevalence of individual rare diseases, and limited data and constrained resources available for research, makes it challenging to develop useful clinical guidelines. The objective of this thesis is to share our experience in conducting evidence synthesis for the guideline development of a rare disease—chronic hypoparathyroidism, and show how we addressed the challenges encountered during the review process. The thesis begins by describing the challenges of evidence synthesis for guideline development in the context of rare diseases. I then present our strategies to overcome these challenges in three systematic reviews prepared for a chronic hypoparathyroidism guideline. The thesis ends by summarizing the challenges and solutions, highlighting strengths and limitations, and describing opportunities and challenges for future research in evidence synthesis for rare diseases. / Thesis / Candidate in Philosophy

Background and objectives: Incorporating patient values and preferences as an essential input for decision-making has its potential merits in respecting the autonomy of patients, improving adherence and clinical outcomes. The Grading of Recommendations Assessment, Development and Evaluation (short GRADE) working group conceptualizes patient values and preferences as “the relative importance patient place on the main outcomes”. The objectives of this thesis include: 1) to provide an overview of a process for systematically incorporating values and preferences in guideline development; 2) to conduct a systematic review on outcome importance studies, using chronic obstructive pulmonary disease (COPD) as an example; 3) to provide guidance on how to assess certainty of evidence describing outcome importance using the GRADE criteria. Methods: We performed systematic reviews, asked clinical experts to provide feedback according to their clinical experience, and consulted patient representatives to obtain information about relative importance of outcomes in a new national guideline program. We conducted a systematic review to summarize the COPD related relative importance of outcome studies. We used a multi-pronged approach to develop the guidance for assessing certainty of evidence about relative importance of outcome and values and preferences. We applied the developed GRADE approach to relative importance of outcome systematic review examples and consulted the stakeholders in the GRADE working group for feedback. Results and conclusion: We provided an empirical strategy to find and incorporate values and preferences in guidelines by performing systematic reviews and eliciting information from guideline panel members and patient representatives. However, we identified the need for researches on how to assess the certainty of this evidence, and best summarize and present the findings. In our comprehensive systematic review project on COPD patient values and preferences we demonstrated the utility of rating evidence in systematic reviews of outcome importance. We describe the rationale for considering GRADE domains for the evidence about the importance of outcomes. We propose the assessment of the body of evidence starts at “high certainty”, and rate down for serious problems in GRADE domains including risk of bias, indirectness, inconsistency, imprecision and publication bias. Specific to risk of bias domain, we propose a preliminary consideration for risk of bias. The sources of indirectness for relative importance of outcome evidence include indirectness from PICO (population, intervention, comparison, and outcome) elements, and methodological indirectness. As meta-analyses are uncommon when summarizing the evidence about relative importance of outcome, inconsistency and imprecision assessments are challenging. Inconsistency arises from PICO and methodological elements that should be explored. The width of the confidence interval and sample size should inform judgments about imprecision. We also provide suggestions on how to detect publication bias based on empirical information. Finally, we also discuss the applicability of domains to rate up the certainty. We develop the GRADE approach for rating risk of bias, indirectness, inconsistency, imprecision and other domains when evaluating a body of evidence describing the relative importance of outcomes. Our examples should guide users and provide a basis for discussion and further development of the GRADE system. / Thesis / Doctor of Philosophy (PhD)

Philosophiae Doctor - PhD / Literature on post-operative pain indicates that post-operative pain is inadequately managed in many countries including Ghana. Little was also known about post-operative pain (POP) response and management in Ghana. This study sought to describe post-operative pain response and management among Ghanaian surgical nurses and post-operative patients within the medico-socio-cultural context. It also explored factors that influenced POP response and management and subsequently aimed to develop clinical guidelines within which post-operative pain could be managed in the medico-socio-cultural context. Research questions answered included: „what are the factors influencing post-operative pain responses among surgical patients and nurses; what clinical guidelines would be appropriate to guide post-operative pain management within the medico-socio-cultural context of Ghana?‟The study was designed as a multi-step focused ethnography which allowed the exploration of a specific sub-culture such as the surgical environment. The philosophical underpinnings of ethnography permit the investigator to use different data collection methods to fully understand the phenomenon investigated. Data collection during the ethnographic exploration phase involved individual interviews, clinical observations, and review of patients‟ clinical charts. At the stage of guideline development, data was collected through participant/expert review, systematic literature review, and consensus forum. Participants were sampled purposively and included 53 interview participants, 27 expert reviewers, and 29 consensus panel members. Also, there were 16 sections of clinical observation and review of 44 charts. The participants included nurses, patients and their relatives, the multidisciplinary team, key informants, experts, and stakeholders. The study was conducted at the Korle-Bu Teaching Hospital (KBTH) and Ridge Hospital, in Accra, Ghana. Appropriate ethical clearance was sought and individual informed consent was obtained.Concurrent analysis of data was done applying the principles of thematic content analysis and data was managed with NVivo 9. Themes that emerged from the patients‟ data were subjectivism which described pain dimensions and expressions and factors that influenced patients‟ pain experience were psycho-socio-cultural factors such as personal inclinations and socio-cultural background; and health system factors such as personnel attitude and health financing.The study also found that nurses perceived POP as an individual phenomenon and responded to pain by administering analgesics and by employing non-pharmacologic measures such as positioning and reassurance. Factors that influenced the nurses‟ pain response were individual factors such as commitment, discretion, and fear of addiction; and organizational factors such as organizational laxity and challenges of teamwork. Patients‟ relatives were also influenced by empathy, faith, and commitment to care for their post-operative patients. The multidisciplinary team and key informants were influenced by knowledge and experience in their respective specialty areas. Subsequently, the clinical guideline developed had four dimensions which highlighted patient and family education,effective teamwork, effective leadership and monitoring, and use of contemporary evidence for POP management.The study recommended that health professionals should be conscious of the subjectivenature of pain and they should educate and involve the patient on pain management decisions. Also, hospital leadership and the multidisciplinary team should be actively involved in pain management.

The use of information and communication technologies and computerised training tools in nursing education has gained traction globally and locally. Nursing campuses in KwaZulu-Natal are yet to explore this avenue despite the existence of numerous challenges with conventional methods of teaching and learning, and Integrated Management of Childhood Illness (IMCI) pre-service training. Integrated Management of Childhood Illness Computerised Adaptation and Training Tool (ICATT), an e-learning tool has been identified as an innovative technology that has the potential to strengthen IMCI pre-service training and increase training coverage at nursing campuses. The aim of this study is to investigate the nursing campuses’ readiness for the use of ICATT, and to develop guidelines and a model for improving the use of ICATT at the nursing campuses. This study adopted a sequential exploratory mixed methods design and was conducted in three phases at ten nursing campuses in KwaZulu-Natal. In phases one and two, data was collected sequentially using a semi-structured interview schedule and self-administered questionnaires. The qualitative component involved seven individual administered questionnaires. The qualitative component involved seven individual interviews with campus principals, eight focus groups of nurse educators and eight focus groups of learners. The Interpretative Phenomenological Analysis framework was used to identify themes. In the quantitative component, data was collected from nine campus principals, 35 nurse educators and 235 learners and analysed using SPSS 23. Findings from phases one and two revealed that campus principals, nurse educators and learners had positive attitudes and identified enabling factors regarding ICATT use. Additional findings revealed that pre-existing barriers related to human, material, infrastructural and financial resources could impact on the nursing campuses, nurse educators and learners’ readiness to implement and use ICATT. Findings from phases one and two led to the development of guidelines and a model for ICATT implementation at nursing campuses. Phase three employed the Delphi method to obtain consensus opinion from 11 experts for the refinement of the guidelines. The readiness for ICATT use model and the guidelines can facilitate the successful implementation and use of ICATT. / Health Studies / Ph. D. (Health Studies)

Technological advancement has significantly impacted people and organizations during the last decade. Society is exposed to an increasing rate of cyber-attacks utilizing sophisticated tools to accomplish their objectives. Previously attackers’ primary focus was exploiting technological vulnerabilities to access organizations’ information; however, attackers have shifted their focus to exploiting the vulnerabilities in people’s human nature instead. This has resulted in organizations acknowledging that technical security measures alone are insufficient in providing adequate protection for organizations and need to invest in mitigating the risk people pose to an organization’s cybersecurity. Thus realizing the need to address cybersecurity’s social-technical nature. Organizations have begun implementing cybersecurity awareness-raising initiatives to increase people’s cybersecurity awareness to reduce human-instigated breaches. This is especially crucial for organizations in the public sector to achieve because they tend to produce more destructive and widespread repercussions to society. To provide organizations in the public sector with the means to achieve good cybersecurity awareness, this thesis aims to develop a guideline for managers in large Swedish public organizations to assist them in their complex cybersecurity awareness-raising endeavors. The thesis employs a design science research strategy to develop, evaluate, and validate the guideline with the assistance of cybersecurity awareness experts. The results show six principal factors have been established as significant for raising cybersecurity awareness in large Swedish public organizations. These factors range from user-oriented, managerial, and technical, supporting the assertion that cybersecurity is a complex socio-technical matter. The key contribution of this thesis is to introduce a highly abstract guideline to enhance large Swedish public organizations’ cybersecurity awareness efforts.

Background: Lifestyle habits like tobacco use, hazardous use of alcohol, unhealthy eating habits and insufficient physical activity are risk factors for developing non-communicable diseases, which are the leading, global causes of death. Furthermore, ill health and chronic diseases are costly and put an increased burden on societies and health systems.  In order to address this situation, governmental bodies and organizations’ have encouraged healthcare providers to reorient the focus of healthcare and undertake effective interventions that support patients to engage in healthy lifestyle habits. In Sweden, national clinical practice guidelines (CPGs) on lifestyle interventions were released in 2011. However, the challenges of changing clinical practice and introducing guidelines are well documented, and health interventions face particular difficulties. The overall purpose of this thesis is to contribute towards a better understanding of the complexities of shifting primary health care to become more health oriented, and to explore the implementation environment and its effect on lifestyle intervention CPGs. The specific aims are to investigate how implementation challenges were addressed during the guideline development process (Study I), to investigate several dimensions of readiness for implementing lifestyle intervention guidelines, including aspects of the intervention and the intervention context (Study II), to explore the extent to which health care professionals are working with lifestyle interventions in primary health care, and to describe and develop a baseline measure of professional knowledge, attitudes and perceived organizational support for lifestyle interventions (Study III), and to assess the progress of implementing lifestyle interventions in primary care settings, as  well as investigate the uptake and usage of the CPGs in clinical practice (Study IV).   Methods and results: Interviews were conducted with national guideline-developers (n=7). They were aware of numerous implementation challenges, and applied strategies and ways to address them during the guideline development process. The strategies adhered to four themes: (a) broad agreements and consensus about scope and purpose, (b) systematic and active involvement of stakeholders, (c) formalized and structured development procedures, and (d) openness and transparent development procedures. At the same time, the CPGs for lifestyle interventions challenged the development-model at the National Board of Health and Welfare (NBHW) because of their preventive and non-disease specific focus (I). A multiple case study was also conducted, using a mixed methods approach to gather data from key organizational individuals that were accountable for planning the implementation of CPGs (n=10), as well as health professionals and managers (n=340). Analysis of this data revealed that conditions for change were favorable in the two organizations that served as case studies, especially concerning change focus (health orientation) and the specific intervention (national guidelines on lifestyle interventions). Somewhat limited support was found for change and learning, and change format (national guidelines in general). Furthermore, factors in the outer context were found to influence the priority and timing of the intervention, as well as considerable inconsistencies across the professional groups (II). A cross-sectional study among physicians and nurses (n=315) in Swedish primary healthcare showed that healthcare professionals have a largely positive attitude and thorough overall knowledge of lifestyle intervention methods. However, both the level of knowledge and the involvement in patients’ lifestyle change, differed between professional groups. Organizational support like CPGs and the development of primary health care (PHC) collaborations with other stakeholders were identified as potential strategies for enhancing the implementation of lifestyle interventions in PHC (III). In addition to interviews and case studies, a longitudinal survey among health professionals (n=150; n=73) demonstrated that their use of methods to encourage patients to reduce or eliminate tobacco or alcohol use, had increased. The survey also indicated that nurses had increased the extent to which they addressed all four lifestyle habits. The progress of the implementation of CPGs on lifestyle interventions in PHC was somewhat limited, and important differences in physicians and nurses’ attitudes, as well as their use of the guidelines, were found (IV). Conclusions: Health orientation differs in many ways from more traditional fields in medicine. To strengthen the implementation of this very important (but not “urgent”) field in health care, it needs, first of all, to be prioritized at all levels! The results of the studies demonstrate relatively slow adoption of lifestyle intervention CPGs in clinical practice, and indicate room for improvement. The findings of this thesis can inform healthcare policy and research on further development of the health orientation perspective, as well as on the challenges of implementing CPGs on lifestyle interventions in primary care. In summary, this thesis presents important lessons learned regarding health orientation - from the development of CPGs in the field, via assessing healthcare organizations’ readiness to change and health professionals’ attitudes to methods to support patients with lifestyle changes. / Bakgrund: Levnadsvanor som tobaksbruk, riskbruk av alkohol, ohälsosamma matvanor och otillräcklig fysisk aktivitet är riskfaktorer för att utveckla kroniska sjukdomar, vilka orsakar de flesta dödsfallen i världen. Ohälsa och dess följdsjukdomar utmanar också samhällen och hälsosystem världen över p.g.a. de höga kostnader som de medför. För att förbättra situationen så försöker regeringar och organisationer förändra hälso- och sjukvårdens perspektiv till att fokusera mer på hälsa och att arbeta med effektiva interventioner för att förebygga och att förändra människors ohälsosamma vanor. År 2011 i Sverige, publicerades nationella kliniska riktlinjer för vårdens arbete med att förebygga sjukdom genom att stödja förändring av patienters ohälsosamma levnadsvanor. Det är dock välkänt hur svårt det är att förändra klinisk praxis och att introducera riktlinjer, och interventioner på området hälsa i sjukvården brottas med specifika utmaningar. Det övergripande syftet med den här avhandlingen har varit att bidra till en bättre förståelse av komplexiteten i att hälsoorientera primärvården, och att utforska förutsättningarna till att implementera kliniska riktlinjer för att stödja förändring av patienters levnadsvanor. De mer specifika syftena var: att (I) utforska hur implementeringsutmaningarna behandlades i utvecklingsprocessen av riktlinjerna ; att (II) undersöka dimensioner av beredskapen för förändring i primärvården för att implementera riktlinjerna om levnadsvanor inkluderande aspekter av interventionen själv samt kontexten ; att (III) utforska i vilken utsträckning hälsoprofessionerna arbetar med levnadsvanor i primärvården, och att beskriva deras kunskap, attityder och uppfattat organisatoriskt stöd för livsstilsinterventioner ; att (IV) i en två-årig uppföljning utvärdera utvecklingen av arbetet med levnadsvanor i primärvården, och användningen av de specifika nationella riktlinjerna för levnadsvanor. Metod och resultat: En intervjustudie med riktlinjeutvecklare på nationell nivå (n = 7) visade att många utmaningar för implementeringen av riktlinjerna identifierades och bemöttes under utvecklingsprocessen i fyra teman av strategier: breda överenskommelser och konsensus om inriktning och syfte, systematiskt och aktivt inkluderande av stakeholders, formaliserad och strukturerad utvecklingsprocess, öppenhet och insyn utvecklingsprocess. Samtidigt utmanade dock riktlinjerna om livsstilsinterventioner Socialstyrelsens utvecklingmodell p.g.a. deras förebyggande och icke sjukdomsspecifika fokus (I). En multipel fallstudie med nyckelpersoner ansvariga för implementeringen av riktlinjerna i sjukvårdsorganisationerna (n = 10) samt vårdpersonal och chefer (n = 340), visade på gynnsamma villkor för förändring i båda organisationerna rörande förändringsfokus (d.v.s. hälsoorientering) och den specifika interventionen (d.v.s. riktlinjer om metoder för att stödja förändring av ohälsosamma levnadsvanor). Stödet för förändring och lärande visade på något svagare resultat, likaså formen för förändringen d.v.s. nationella riktlinjer i allmänhet. Faktorer i den yttre kontexten visade sig kunna påverka prioritering av och optimalt val av tidpunkt för interventionen, likaså betydande skillnader i uppfattningar mellan yrkesgrupperna (II). En tvärsnittsstudie bland läkare och sjuksköterskor (n = 315) i primärvården visade att de har en positiv attityd och en god kunskapsnivå om metoder för livsstilsförändring. Både kunskapsnivå och i vilken utsträckning man arbetar med patienters livsstil skiljer sig mellan yrkesgrupper. Organisatoriskt stöd som nationella riktlinjer och utvecklandet av primärvårdens samarbete med intressenter i närområdet identifierades som viktigt för att förbättra arbetet med livsstil interventioner (III). En longitudinell undersökning bland vårdpersonal visade att användning av metoder för att förändra patientens vanor beträffande tobaksbruk och riskbruk av alkohol har ökat över tid, och att sjuksköterskorna arbetar i högre utsträckning med alla fyra levnadsvanorna än i tidigare. Implementeringen av de nationella riktlinjerna för levnadsvanor hade inte kommit så långt vid det andra mättillfället, och stora skillnader visade sig i hur läkare och sköterskor ser på riktlinjer och i vilken utsträckning de använder dem (IV). Slutsats: Hälsofrämjande och prevention skiljer sig på många sätt från mer traditionella fält inom medicinen. För att stärka implementeringen av det här viktiga (men ej akuta) fältet i hälso- och sjukvården, så måste det först av allt prioriteras på alla nivåer! Resultatet visar på ett svagt upptag av riktlinjerna för livsstilsinterventioner i klinisk praxis, och lämnar utrymme till förbättring. Aspekter av resultatet som presenteras i avhandlingen kan vägleda fortsatt utveckling och implementering av hälsoorientering och riktlinjer för livsstilsinterventioner inom primärvården, samt användas för att påverka policy, praxis och framtida forskning. Det gäller framför allt aspekter av utveckling av nationella riktlinjer på området; hälso- och sjukvårdsorganisationernas beredskap till förändring; hälsoprofessionernas attityder, kunskap och i vilken utsträckning de arbetar med livsstilsinterventioner och riktlinjer.