D.Cur. / South Africa, like many other countries, is charged with ensuring that her adolescents are mobilised to believe in the power of their own dignity in order for their life-world to change. Hundreds of thousands of adolescents were forced to experience political upheavals, violence, neglect, incarceration and family disorganisation. Many of these adolescents were forced onto the margins of society in their strive for understanding and survival. Many dropped out of school, are unskilled and therefore unemployed. They feel hopeless as they struggle for a place in society, because society has no faith in them - "they are lost to society". The purpose of this study was to generate a psychiatric nursing model to facilitate the reintegration of marginalised adolescents into the community. This study therefore has profound social, political and economic implications for the South African community. Through this model, which is a theoretical framework to be utilized by the advanced practitioner in psychiatric nursing, adolescents will be empowered to believe in themselves, to engage in meaningful relationships and activities with their families, peer groups and the broader community. The model provides a theoretical framework that attempts to rekindle and inspire the adolescents from a state of hopelessness and disillusionment, to integrated individuals who are respected, valued and accepted as integral members of their families, peer groups and communities. The model will assume a problem solving and preventative approach. Based on this discussion, the following questions were addressed in this research: What obstacles exist that hamper marginalised adolescents' reintegration into the community? What could be done to assist marginalised adolescents' reintegration into the community? A theory generative, qualitative, contextual, exploratory and descriptive design was followed. The research was conducted in four steps with a pilot-study that preceded step one of the research. In step one, focus group discussions were conducted with five groups of respondents to explore and describe obstacles that hamper the reintegration of marginalised adolescents into the community, as well as their views on how marginalised adolescents can be assisted to be reintegrated into the community. Data was analysed using Tesch's method. Based on the results of analyzed data, disempowerment, characterized by hopelessness, alienation/isolation, anger, frustration and worthlessness - related to poor socialisation, lack of support and services, family disorganisation, peer pressure and fragmented services - was identified as a main theme among stumbling blocks. Empowerment, characterized by improved self-image, feelings of worth, belief in own dignity - related to a sense of wellbeing, belonging and respect - resulting in personal growth and societal change with ultimate reintegration, was identified as major strategy to address marginalisation. In step two, the defined concepts were related to each other to show interrelationships. Classification of central and relational concepts followed to formulate relationship-statements, the result being to depict related concepts in structural form. In step three, a visual model to be utilized as a theoretical framework by the advanced psychiatric nurse practitioner to facilitate the marginalised adolescents as recipients and the advanced psychiatric nurse as agent, was designed to facilitate reintegration into the community. The model was evaluated by a panel of experts. Step four dealt with guidelines to operationalise the model in practice, education and research. Recommendations and limitations of the research were also discussed.

INTRODUÇÃO: A globalização da pesquisa clínica no mundo está fortemente ligada ao processo de internacionalização e terceirização de Pesquisa e Desenvolvimento (P&D) da indústria farmacêutica. A escolha do local de sua execução envolve considerações sobre custo, recrutamento de pacientes, infraestrutura e ambiente ético-regulatório em pesquisa científica. O Brasil tem cenário favorável para condução da pesquisa clínica por apresentar grande massa populacional, com população heterogênea, além de alta incidência de doenças, condições climáticas distintas, médicos capacitados, adequada estrutura de centros de pesquisas e, principalmente, observância dos princípios de boas práticas clínicas. Entretanto são escassos os dados de modelos de gerenciamento aplicados aos centros de pesquisa no país.Influenciada por esse contexto, esta dissertação propõe desenvolver um modelo para o gerenciamento de projetos de pesquisa no cenário público-privado e privado. MÉTODOS: Estudo transversal prospectivo com aplicação de um questionário específico para centros de pesquisa no país. Este instrumento avaliou a aplicação prática das dez áreas de conhecimento (gerenciamento da integração, do escopo, do tempo, de custos, de qualidade, de recursos humanos, de comunicações, de riscos, de aquisições e partes interessadas) do Project Management Body of Knowledge (PMBOK®) com relação à prática diária da pesquisa clínica nos centros de pesquisa do país. RESULTADOS: 55 centros responderam ao questionário completo. Em 37 deles (67,3%) o profissional com o cargo de gerente de projetos é inexistente; não há escritório de gerenciamento de projetos (EGP) em 41 centros (74,5%). O controle de despesas e receitas é realizado por 50 centros (90,9%), porém 28(50,9%) realizam avaliação da rentabilidade. Quanto ao gerenciamento da qualidade, 28 centros (50,9%) não têm parâmetros de qualidade implantados e 11 (40,7%) não realizam auditoria interna. Falhas de comunicação estão presentes em 48 centros (87,2%). A partir da avaliação da aplicação prática das dez áreas de conhecimento do Guia PMBOK® foi desenvolvido o modelo de gerenciamento de projetos com aplicabilidade dos conceitos, ferramentas e técnicas aos centros de pesquisa clínica.CONCLUSÕES: Com a aplicação deste modelo, é possível que os centros tenham uma melhor definição do escopo de cada projeto, que os custos e prazos possuam baixa margem de variabilidade, que se estabeleça uma boa comunicação entre as partes envolvidas e que o impacto econômico do gerenciamento possa ser reconhecido. / INTRODUCTION: The globalization of clinical research in the world is strongly linked to the internationalization and outsourcing process of research and development (R&D) of the pharmaceutical industry and the place of implementation choice involves considerations about cost, patient recruitment, infrastructure and ethical- regulatory framework in scientific research. Brazil has a favorable scenario for conducting clinical research because it has a large population, with a heterogeneous population, high incidence of diseases, different climatic conditions, trained physicians, adequate structure of research centers and mainly compliance with the principles of good clinical practice. However, data on management models applied to research centers in Brazil are scarce. Influenced by this context, this dissertation proposes to develop a model for the management of research projects, in the public-private and private scenarios. METHODS: This was a prospective cross - sectional study with the application of a specific questionnaire for research centers in the country. This instrument evaluated the practical application of the 10 areas of knowledge (management of integration, scope, time, costs, quality, human resources, communications, risks, acquisitions and stakeholders) of Project Management Body of Knowledge (PMBOK®) in relation to the daily practice of clinical research in the country's research centers. RESULTS: 55 centers answered the complete questionnaire. The professional with the position of project manager does not exist in more than half of the active centers in the country 37 (67.3%); there is no project management office (EGP) in 41 (74.5%) centers. The control of expenses and revenues is carried out by 50 (90.9%) centers; however, 28 (50.9%) carry out an evaluation of the profitability. Regarding quality management, 28 (50.9%) did not have quality parameters implanted and 11 (40.7%) did not perform internal audit. Communication failures are present in 48 (87.2%) centers. Based on the evaluation of the practical application of the 10 knowledge areas of the PMBOK® Guide, the project management model was developed with applicability of concepts, tools and techniques to clinical research centers. CONCLUSIONS: With the application of this model, it is possible that the centers have a better definition of the scope of each project, the costs and deadlines have a low margin of variability, a good communication between the parties is established and the economic impact of the management can be recognized.

Book summary: Appalachian Health explores major challenges and opportunities for promoting the health and well-being of the people of Appalachia, a historically underserved population. It considers health's intersection with social, political, and economic factors to shed light on the trends affecting mortality and morbidity among the region's residents.

<p><strong>Background </strong></p> <p>Integrated care programs are collaborations to improve health services delivery for patients with multiple conditions.</p> <p><strong>Objectives</strong></p> <p>This thesis investigated three issues in evaluation of integrated care programs: (1) quantifying integration for integrated care programs, (2) analyzing integrated care programs with substantial non-compliance, and (3) assessing bias when evaluating integrated care programs under different non-compliant scenarios.</p> <p><strong>Methods</strong></p> <p>Project 1: We developed a method to quantity integration through service providers’ perception and expectation. For each provider, four integration scores were calculated. The properties of the scores were assessed.</p> <p>Project 2: A randomized controlled trial (RCT) compared the Children’s Treatment Network (CTN) with usual care on managing the children with complex conditions. To handle non-compliance, we employed the intention-to-treat (ITT), as-treated (AT), per-protocol (PP), and instrumental variable (IV) analyses. We also investigated propensity score (PS) methods to control for potential confounding.</p> <p>Project 3: Based on the CTN study, we simulated trials of different non-compliant scenarios. We then compared the ITT, AT, PP, IV, and complier average casual effect methods in analyzing the data. The results were compared by the bias of the estimate, mean square error, and 95% coverage.</p> <p><strong>Results and conclusions</strong></p> <p>Project 1: We demonstrated the proposed method in measuring integration and some of its properties. By bootstrapping analyses, we showed that the global integration score was robust. Our method has extended existing measures of integration and possesses a good extent of validity.</p> <p>Project 2: The CTN intervention was not significantly different from usual care on improving patients’ outcomes. The study highlighted some methodological challenges in evaluating integrated care programs in a RCT setting.</p> <p>Project 3: When an intervention had a moderate or large effect, the ITT analysis was considerably biased under non-compliance and alternative analyses could provide unbiased results. To minimize the bias, we make some recommendations for the choice of analyses under different scenarios.</p> / Doctor of Philosophy (PhD)

Medical researchers utilize data sharing agreements (DSA) to communicate privacy policies that govern the treatment of data in their collaboration. Expression of privacy policies in DSAs have been achieved through the use of natural and policy languages. However, ambiguity in natural language and rigidness in policy languages make them unsuitable for use in collaborative medical research. Our goal is to develop an unambiguous and flexible form of expression of privacy policies for collaborative medical research. In this thesis, we developed a DSA Privacy Ontology to express privacy policies in medical research. Our ontology was designed with hierarchy structure, lightweight in expressivity, closed world assumption in interpretation, and the reuse of other ontologies. The design allows our ontology to be flexible and extensible. Being flexible allows our ontology to express different types of privacy policies. Being extensible allows our ontology to be mapped to other linkable ontologies without the need to change our existing ontology. We demonstrate that our ontology is capable of supporting the DSA in a collaborative research data sharing scenario through providing the appropriate vocabulary and structure to log privacy events in a linked data based audit log. Furthermore, through querying the audit log, we can answer privacy competency questions relevant to medical researchers. / Thesis / Master of Science (MSc)

Introduction: There are no economic evaluations to determine the value of PRSs. The objective of this study was to determine if the addition of a PRS to traditional risk factors to guide statin therapy is a cost-effective intervention for the prevention of primary MI cases in the Ontario healthcare payer perspective. Methods: A PRS cost-effectiveness model was constructed to produce various statin prescription strategies in conjunction with the FRS. Upper PRS thresholds (between 25% to 70%) were set such that individuals falling into them would be eligible for statins while those in lower PRS thresholds (between 1% to 25%) were deemed protected and removed from consideration. The model determined number of incident MIs saved or not saved by statins, costs, quality of life, and the effect of statins on preventing MIs over a 10-year time horizon, discounted at 1.5% annually. One-way sensitivity analysis and a PSA were performed by varying all model parameters. Non-related participants of white British descent from 96,736 participants in the UK Biobank at intermediate risk for cardiovascular disease, determined using the Canadian Cardiovascular Society dyslipidemia guidelines of 2016, were used for the study. Results: The optimal clinical and economic strategy was one whereby the top 70% PRS individuals are eligible for statins, with the lower 5% PRS excluded. A base-case analysis at a PRS cost of $70 produced an ICER of $747,184.10/QALY, ranging from $525,678.90/QALY to $930,144.40/QALY in a one-way sensitivity analysis. In the PSA, the intervention has approximately a 50% probability of being cost-effective at $750,000/QALY. At a genotyping cost of $0, statin strategies guided by PRS dominated standard care when at least 12% of the lower PRS individuals were withheld from statins. When the predictive performance of the PRS is increased, the ICER drops drastically depending on the cost of genotyping and statin strategy. Conclusion: The cost-effectiveness model considers MI cases exclusively and a short, 10-year time horizon which likely overestimate the ICER. However, this study elucidates that the PRS has the potential to be extremely cost-effective in the future. / Thesis / Master of Science (MSc) / Approximately 1 in 3 Canadians live with at least one genetically linked chronic disease. Together, these diseases constitute a large economic burden on the healthcare system and well-being of individuals. Recent advancements in genetics allow risk prediction of developing complex, but common chronic diseases such as cardiovascular disease. Termed as polygenic risk scores, they have the potential to carry beneficial clinical outcomes such as an improved quality of life. However, the economics is not yet understood. This study determined that when targeting heart attacks, approximately $750,000 is required to gain an additional life-year for an adult. Although this may seem high, the result is closer to an upper-limit estimate than the true cost since polygenic risk scores have more benefits than solely for heart attacks. In the future, when accounting for their entire potential, the cost per life-year is likely to be lower, and perhaps even a money-returning investment.

Despite the availability of numerous models for knowledge translation into practice and policy, research uptake remains low in resource-limited countries. This study was aimed at developing a model to facilitate research uptake in healthcare practice and policy development. The study used a two-phase exploratory sequential approach (QUAL→QUAN). Qualitative data were collected through semi-structured interviews with a total of 21 participants, categorised as researchers (6), frontline workers/practitioners (7), programme/policy managers (4), and directors/senior managers (4) from government, private sector and academic institutions of higher learning (universities and colleges). Quantitative data were collected through an online cross-sectional survey, administered to 212 respondents who conducted research studies in the Mpumalanga Province between 2014 to 2019. The most significant findings seem to be lack of awareness of research findings and champions to lead engagements among research stakeholders on research uptake. In addition, the research has established a failure by researchers to align public health research projects to existing local contexts and available resources. Conversely, there is a growing propensity of using informal research without consideration of data quality issues. It was further observed that establishing and sustaining beneficial collaboration between all research stakeholders is required to promote effective research uptake for practice and policy development. The survey results established a total of 13 components: four individual factors (support, experience, motivation & time factor); four organisational factors (research agenda, funding, resources & partnerships), and five research characteristics factors (gatekeeping, local research committees, accessibility of evidence, quality of evidence & critical appraisal skills). However, the Spearman’s correlation coefficient revealed that of the 13 factors, only six factors had a significant positive correlation with research uptake, namely: support, experience, motivation, time factor, resources, and critical appraisal skills. Consequently, a model for institutionalising research uptake is proposed. The roles of local research committees have been clarified, and a logical framework has been incorporated with pathways and channels of engagements to enable successful implementation of the research uptake model. / Health Studies / Ph. D. (Public Health)

Over the past two decades there has been an upsurge in interest in structural equation modelling (SEM). Applications abound in the social sciences and econometrics, but the use of this multivariate technique is not so common in public health research. This dissertation discusses the methodology, the criticisms and practical problems of SEM. We examine actual applications of SEM in public health research. Comparisons are made between multiple regression and SEM and between factor analysis and SEM. A complex model investigating the utilization of antenatal care services (ANC) by migrant women in Belgium is analysed using SEM. The dissertation concludes with a discussion of the results found and on the use of SEM in public health research. Structural equation modelling is recommended as a tool for public health researchers with a warning against using the technique too casually. / Mathematical Sciences / M. Sc. (Statistics)

The research has worked towards the general aim of generating a synthesis of burnout in the nursing profession, and also towards coming to a synthesis of burnout in nursing from the perspective of the salutogenic paradigm. Existing knowledge from the literature has been consolidated and integrated, and 'new knowledge' of the phenomenological experience of the causes and symptoms of burnout and how nurses stay healthy, were presented. Firstly was discovered that burnout, over time is caused by various factors that are individual and personal and therefore not easily discovered by other than the phenomenological method, where the life world of each individual is described. Secondly, the study ofthe strengths that nurses exhibit in order to manage the tension and stress in their lives and not to succumb to illness, proved to be a sound and descriptive paradigm with great utilisation possibilities. Three answers to the salutogenic question, namely sense of coherence, hardiness and learned resourcefulness were presented in great detail. Thirdly, it was stated that the individual nurses and the nursing practice in general be made aware of: (1) the existence of burnout, (2) the contributing factors to burnout, (3) the various manifestations ofburnout at work and in the organisation, and (4) the coping strategies available to counter this problem in a positive and salutogenic manner. The phenomenological results of this research revealed a number of issues that have implications for both the prevention and treatment of burnout in nurses. The results especially established how nurses can operationalise their inherent salutogenic qualities. Specific salutogenic coping strategies emerged via the respondents. The research took a broad view of personality in health research. It studied the psychological processes underlying the observed connections between psychological variables and health outcomes. In order to study the operationalisation of these processes, a phenomenological, person-based approach was followed. They study focussed on health phenomena and the individual nurse was retained as the unit of analysis. This approach represented a movement away from a fragmented science, infatuated with technology and linked to a singular epistemology, towards a focus on the process and dynamics of personal experience. / Psychology / D. Litt. et Phil. (Psychology)

BACKGROUND: Ethiopia adopted a new strategy called integrated community case management to address common childhood illness (ICCM). This strategy has been introduced in some rural districts of Bale zone. It has multiple functions, involving assessment of sick children at community health post levels. Despite this, the efficacy of this strategy has not been investigated. Aim: This study aimed to assess the level of ICCM service utilisation and factors influencing this at health posts in Agarfa district. METHODS: Cross sectional and phenomenological methodologies were employed in this study. Data were collected from 401 mothers using questionnaires and 29 participants using in-depth interviews. Quantitative data were analysed using both descriptive and inferential statistical approaches. Thematic analysis was used for the qualitative data. RESULT: The utilsation of ICCM services is limited among caregivers in rural communities. There is a range of factors responsible for the limited utilisation. Examples of these include absence of health extension workers at health posts, caregivers’ negative perception of ICCM service, socio-cultural factors, level of education and household finance. The most common childhood illnesses noted were diarrhoea, followed by fever and cough. Caregivers seek help from HEWs at health posts two or more days after idenfying signs and symptoms of these illnesses. CONCLUSION: Behavioural messages to address prevailing negative attitudes and socio-economic barriers to accessing health care would help improve uptake of ICCM services / Health Studies / M.A. (Public Health)