This study examines labour ward culture on two British labour wards, in terms of mother-baby contact and breastfeeding, which has not been empirically researched since 1985 (Garforth & Garcia 1989). ‘Aims’: to investigate the organisational culture; examine mothers' beliefs and experiences; and midwives' knowledge, beliefs and practices. ‘Objectives’: To compare organisational cultures; identify if midwifery practice is evidence based and factors which facilitate or detract from it; identify mothers' preferences, beliefs and levels of satisfaction. ‘Study Design’: Ethnography with case study and diagnostic analysis also utilised. Methods: observation and interviews: purposive sample of mothers (n = 50) and midwives (n = 51); interviews with Heads of Midwifery (n = 2); focus groups with midwives (n = 3); and documentary analysis. ‘Results’: Despite Trust strategies and Heads of Midwifery support for evidence-based practice, clinical guidelines and midwifery beliefs about mother-baby contact and early breastfeed were not usually congruent. Mother-baby contact after birth is usually interrupted for completion of tasks and some babies have multiple contact episodes, which has not been previously described in the literature. Completion of routine tasks for transfer of mothers and babies to postnatal ward takes precedence, because of organisational demands and insufficient resources. However, most mothers expressed feeling satisfied with contact achieved and support for breastfeeding. ‘Conclusion’: Findings of the study have contributed new insights and knowledge of labour ward culture. It is not conducive to uninterrupted mother-baby contact and is not evidence-based. ‘Recommendations’: The development of a learning culture and clinical leadership to promote evidence-based practice and woman-centred care is recommended. The unique period after birth should not be disturbed, to prioritise routine tasks.

Analysis of longitudinal data is a rapidly growing field of statistical analysis, in response to the increasing availability of longitudinal datasets in many disciplines. Longitudinal studies are becoming more popular as they allow investigation of the same individuals over time, and where both within-individual and between-individual differences can be examined. Since the study of change over time is necessary in many areas, longitudinal studies and meaningful analysis of longitudinal data is essential. The health sector is one such area where longitudinal research is playing an increasingly important role. The aim of this research is to examine statistical methodologies for the analysis of longitudinal medical data, specifically General Practice (GP) records. All General Practices (GPs) in England and Wales are now computerized and routinely record detailed patient information, hence providing a rich longitudinal dataset. This research investigates new techniques and adaptations of existing methodologies to understand and explain patterns of change and the natural development and treatment of chronic diseases within routinely collected GP data. The data used here, although taken from a raw sample of 129 General Practice records, have been subjected to some cleaning and recoding in places, hence it should be considered as a secondary data source. Through out the data driven applications presented, different sub¬samples of the original dataset have been used. For the main part the full cleaned sample of 876951 patients is used where possible. Smaller samples ranging between 472 and 58675 patients are used depending on the outcome of interest and the availability of valid observations for the various applications employed. Mainly regression-based techniques, in two broad categories, were used to analyse the repeated measurements from each patient in our dataset. Firstly, linear and generalized mixed modelling approaches were used, whereas in the second phase of the project, the applications of semi-parametric and non-parametric approaches were investigated. The case study of particular interest in this research project is the incidence and progression of chronic kidney disease (CKD). There is a lack of knowledge and understanding of the natural history ofCKD and its progression over time. This project aims to address these issues. The advanced statistical models used in this research quantify how kidney function, assessed using estimated Glomerular Filtration Rate (eGFR), changes with respect to time and how other factors, including other related medical conditions (known as co-morbidities of CKD), affect kidney function and its change over time. The techniques and approaches used in this study are motivated by mixed model designs. The decline of kidney function as time progresses for typical CKD patients is observed to be non-linear. The type of nonlinear mixed models developed in this project do not assume that the decline of eGFR over time is linear, and hence are better able to model the progression of CKD than more traditional linear models. As a consequence, the proportion of the total variation in the outcome that can be explained by considering the patient level factors is tripled through the use of these non-linear models, showing they have much greater explanatory power than previous, simpler statistical models. The disease under study is Chronic Kidney Disease (CKD) but the methodologies should also be applicable other chronic, progressive diseases.

The advancements in multimedia communication technologies have enabled an increased implementation of telemedicine and e-health application for healthcare services. In parallel, advanced imaging methods have facilitated increasing reliance on medical images and videos for patient diagnosis. The high data speeds achieved by current communication technologies enables reliable transmission of medical videos for diagnosis and education purposes in telemedicine applications. The necessary process of video compression, prior to transmission, and communication channel constraints may occasionally impact the quality of the medical video received after transmission. Thus, to verify the reliability of the received video, quality evaluation is necessary. However, the present approaches used for medical video quality evaluation have limitations in addressing the contextual requirements of medical videos. The research work presented in this thesis addresses quality evaluation of medical ultrasound videos for telemedicine and e-health applications. The studies presented in the thesis include a subjective quality assessment study of medical ultrasound videos compressed via the High Efficiency Video Coding (HEVC) standard and the validation of the performance of state-of-the-art video quality metrics using the subjective cores of medical experts. Further, the rate-distortion and rate-quality performance of HEVC is analysed for the compression of medical ultrasound videos. A video quality metric, Cardiac Ultrasound Quality Index (CUQI), for cardiac ultrasound videos is proposed that considers the motion and edge features of cardiac videos for quality evaluation. The proposed metric assessment closely agrees with the subjective assessment of medical experts. Finally, a content-aware packet scheduling approach for transmission of medical ultrasound videos over Long Term Evolution (LTE) wireless network is presented. The scheduling approach employs a utility function based on the temporal complexity of the medical ultrasound videos and results in improving the received video quality. The research outcomes presented in the thesis indicate that developing quality evaluation approaches according to the contextual requirements of the medical video modality could enable overcoming the limitations of standard quality evaluation approaches.

This research examines how front line managers (FLMs) in a NHS Mental Health Trust responded when Electronic Rostering technology was introduced into their wards, with intentions of improving efficiency, transparency, fairness, skill matching, and safety, and potentially increasing control from above. The study applied a theoretical framework developed from previous research to investigate relationships between the organisational context and FLMs’ characteristics, change management processes and technology efficacy, and analyse their impact upon FLMs’ responses to E-Rostering adoption and consequent outcomes. The research questions focused upon the influences of organisational background and the change management process. The research strategy was an in-depth case study with data collection through semi-structured interviews with managers at ward, service/general, project and senior levels, observation of meetings and training, examination of system records and Trust documents. The theoretical framework was used to design interview guides to help researcher and subjects investigate perceptions of salient factors and FLMs’ responses, and help structure analysis. Cross referencing of data supported reliability and validity of interpretations. The FLMs were ward managers perceiving themselves as professional clinical leaders and operational managers, running wards semi-autonomously. Control of deployment was vital to their authority. They showed power to resist pressures to adopt technology which threatened their control and to resist changes not congruent with their priorities. They negotiated with the project team and adapted practices to produce locally acceptable rosters. Although electronic staff records helped administration, automatic rostering was not efficacious. Rosters needed considerable manual adjustment, meaning ward managers recovered control of deployment and maintained local customs. The study confirms the importance of organisational structure and culture and of political and change management processes, in explaining responses to IT innovation. Change leaders should investigate operational practices, unit cultures and contexts to prepare for technology adoption because these factors will strongly influence FLMs’ responses.

Co-infection with Hepatitis C Virus (HCV) is a common occurrence in Human Immunodeficiency Virus (HIV)-positive patients and an increasing cause of morbidity and mortality. Little is known however of the burden or the natural history of these infections or their interactions in most parts of sub-Saharan Africa, where both viruses are endemic. In this study a total of 1500 people aged 11 months to 76 years referred to the serology unit of Royal Victoria Teaching Hospital between the months of July to December 2003 were evaluated for anti-HIV, anti-HCV and CD4+ T-cell count and compared with the subjects' socio-demographic and risk factors. HIV and HIV/ HCV seropositive persons who consented to a follow-up study were age and sex matched with HIV and HCV seronegative control subjects and followed for 18 months with biannual monitoring of trends in CD4 count against a possible HIV or HCV seroconversion of the seronegative control subjects. The overall prevalence of antibodies to HIV and HCV was 6.7% (101/1500) (Cl, 5.6-8.2) and 2.1% (31/1500) (95 % CI, 1.4-2.9) respectively. HIV rates in asymptomatic adults were 3.6 %( 43/1189) (OR: 0.16; Cl: 0.13-0.28) and 1.0 %( 12/1189 (OR: 0.16; Cl: 0.08-0.34) for HCV. HIV/HCV co-infections rate was 0.6% among all the subjects sampled and 8.6% in HIV positive persons. The HIV rate in this study is twice the UNAIDS/WHO estimate for the country and twice the numbers of women than men were infected with HIV at a comparatively younger age, while males 55 years and over had higher HIV rates than those below 35. HCV and HIV/HCV coinfection was more commonly associated with males than females. This study showed that Hepatitis C serotype 2 is the most prevalent type in the country and was predominantly associated with HIV-1, and suggests that HCV serotype 2 spread earlier than serotypes 1 and 3. The mean CD4 count of apparently healthy males and females was 489/μl and 496/μl respectively, while the mean CD4 count at diagnosis (CD4dx) of HIV, and HIV/HCV persons was 310 cells/μl and 306 cells/μl respectively. Only about half of the apparently healthy population had CD4 counts of 500 cells and over (51 %), while 1.1 % (15/1377) had counts below 200 cells per microlitre for no explained reasons. HN/HCV co-infected person recorded a lower CD4 count at diagnosis than HIV alone infected persons and also a more significant decline in CD4+ than HIV infected alone persons. The study shows that high HIV rates were independent of the educational status of the individual, while history of sexually transmitted diseases, high income earning and involvements in polygamous marriages were all significant risk factors for HIV, HCV and HIV/HCV co-infection. Female circumcision, knowledge and use of condoms, blood oath, histories of blood transfusion and wife inheritance were not associated with HIV or HCV transmission. The study found an HIV incidence rate of 1.4% (4/288) during the 18 months follow-up period and identified Sexually Transmitted Diseases (STDs) as the associated risk factor. There is need for a new CD4+ staging in the country based on the population within the country and the initiation of a large scale longitudinal study to elucidate the risk factors associated with HCV in the country. The study has provided baseline data on CD4 and its trends in co-infected persons and also a baseline on the distribution and epidemiological pattern and associated risk factors of co-infection between HIV and HCV in the country. It has also determined the incidence of HIV and its associated risk factors in the country. The study has therefore contributed to our understanding of the natural history of these infections and provided an important frame work for possible intervention.

Introduction: Cancer is the second leading cause of death in the United States (U.S.), after cardiovascular disease. Although there has been a continuous decline in cancer mortality rates in the U.S. over the past two decades, the Appalachian region, which extends through 13 states and 420 counties in the southeastern part of the U.S., has seen a lower decline in cancer mortality. From 1980-2014, cancer deaths decreased by almost 45%, but cancer mortality rates in rural Appalachia was 36% higher than for urban non-Appalachian counties. In terms of cancer-specific, although breast cancer mortality rates have also decreased significantly nationally, a lesser decline was seen in Appalachian counties (17.5%), compared with non-Appalachian counties (30.5%). Similarly, in all 13 Appalachian states, lung cancer mortality rates exceed national rates. Tennessee (TN) is one of the largest and most diverse states in Appalachia in terms of race/ethnicity, income, and location compared to similar largely rural states in the region like Kentucky and West Virginia. Objective: This study explores cancer incidence trends by demographic factors in northeast Tennessee. Methods: We extracted and examined electronic medical records for 322 cancer patients diagnosed with any of the top five cancers (breast, leukemias, lung, lymphoma, and prostate) between January and June 31, 2017, in a major oncological clinic in northeast TN, which attracts low-income individuals and Medicare patients. Variables included gender, race, marital status, tobacco use, and Zip codes. Descriptive statistics was used to examine the distribution, and the Spearman’s rank-order correlation to assess the relationship between demographic factors and cancer type. Results: Preliminary results showed that among women diagnosed with the top five cancers, the proportion of breast cancer (52.1%) was relatively higher than other cancers like lung (15.5%), leukemias (13.6%), multiple myeloma (9.9%) and lung (8.9%). The percentage of cancer diagnosed among men was leukemias (29.2%), lung (27.1%), prostate (21.9%), and lymphoma (21.9%). Findings further revealed a significant positive correlation of 0.396 (p =p= <0.001). Conclusions: This exploratory study examined the trends of cancer incidence in northeast Appalachia TN. Consistent with national trends, breast cancer continued to be the leading cancer diagnosed among women. However, the positive relationship between age and smoking appears to reflect that tobacco and nicotine use is associated with the likelihood to be diagnosed with any of the top five cancers. In addition, because the region is underserved and yet understudied, it is important to continue to evaluate cancer patterns as well as behavioral risk factors to identify areas for effective intervention.

This study examines the misconception issues that influence the underutilization of hospice services by African Americans. This descriptive study was based on the premise that there is no relationship between African Americans’ knowledge of hospice and their decision to utilize hospice. The results revealed that African Americans who completed the survey indicated they understand what hospice is; however the answers provided in the survey were not congruent. The conclusions drawn from the findings suggest that African Americans have misconceptions about hospice, and not a true understanding of what hospice is or how to use the service.

Background: We evaluated geographic patterns for immediate and delayed breast reconstruction (IBR, DBR) in Ontario. The influence of plastic surgeon availability on rates and service provision was determined. Methods: We examined IBR and DBR from 2002 through 2011 across Ontario counties. Regional availability of plastic surgeons was described. Geographic patterns were examined using funnel plots, random-effects models and migration indices. Results: Over ½ Ontario counties have no plastic surgeons. IBR ranged from 0 to 21.5% across counties and differences in plastic surgeon availability explained 41% of variation (p < 0.0001). For DBR there was less variation. 5/45 counties performed ¾ of BR, however rates among local residents were not highest. Interpretation: Nearly 1/3 of the population has limited access to plastic surgeons, contributing to low rates of BR. Geographic access is a major determinant of IBR but is less important for DBR, however service provision for both was highly regionalized.

Abstract Background: Palliative radiotherapy (PRT) plays an important role in the management of patients with bone and brain metastases; however, little is known about the use of this treatment in Ontario. Objectives: The objectives of this thesis were to a)identify health system-related and patient-related factors associated with the use of PRT for bone and brain metastases , and b) describe temporal trends in the use of PRT for bone and brain metastases. Methods: The Ontario Cancer Registry was used to identify patients who died of cancer between the years 1984 and 2004. Temporal trends in the use of PRT were described by year and disease site, using the Cochran-Armitage test for trend. A multivariate logistic regression was conducted to describe the relationship between health system-related and patient-related factors, and the use of PRT, while controlling for disease-related factors. Results: Overall, 10.0% and 4.1% of patients dying of cancer received at least one course of PRT within the last two years of life for bone metastases and brain metastases, respectively. The use of PRT for bone metastases significantly decreased from 10.4% to 9.5% (p<0.0001), while the use of PRT for brain metastases more than doubled from 2.2 to 5.1% during the same period (p<0.0001). In the multivariate analysis, age was negatively associated with the use of PRT in both cases. Patients residing in the richest communities were more likely to receive treatment. A farther distance to the nearest cancer was negatively associated with the use of PRT. The level of radiotherapy (RT) services at the diagnosing hospital was positively associated with the use of PRT for bone metastases. Prevailing waiting time did not significantly influence the use of PRT in either case. Conclusions: Over the course of the study period, the use of PRT for bone metastases decreased, while the use of PRT for brain metastases increased. Access to PRT for both bone and brain metastases was influenced by factors unrelated to need. / Thesis (Master, Community Health & Epidemiology) -- Queen's University, 2009-09-24 23:02:05.662

Background. Children with autism spectrum disorders have complex needs requiring a broad range of supports. High demand for autism services has led to gaps in the provision of care, and there is little research examining whether families of school-aged children receive services reflective of their needs. Objectives. The objectives of this thesis were to describe unmet needs reported by parents of school-aged children with an autism spectrum disorder and to examine the association between the child’s level of functional independence and the parent’s reported level of unmet need. Methods. A review of the literature on needs assessments in autism was performed. A cross-sectional study was then conducted among parents of 101 children who (1) had an autism spectrum disorder, (2) were between the ages of 6 and 13 years, and (3) were living in Manitoba, South Eastern Ontario, Prince Edward Island, or Newfoundland and Labrador. Data were collected using a written questionnaire (Family Needs Questionnaire, Impact on Family Scale, demographic questions) and a telephone interview (Scales of Independent Behaviour-Revised, service use questions). Log binomial regression was used to examine the association between the child’s functional independence and the parent’s perceived unmet needs. Results. The most commonly reported unmet needs were related to social inclusion for the child, information about special programs and services, and continuity of support. Families of children with high functional independence had lower unmet need compared to families of children with moderate functional independence (RR = 0.81, 95% CI = 0.67-0.99). Families of children with high functional independence, and who perceived a high level of impact of the child’s disability on the family, had greater unmet need (RR = 1.22, 95% CI = 1.03-1.45). Conclusion. This thesis identifies family needs which have not been met by the service system. Assessments of child and family functioning may provide insight into unmet need that is not revealed simply by knowing a child’s diagnosis on the autism spectrum. Information about the unmet needs of families of children with autism spectrum disorders may help policy makers and service planners to develop resources and services that are responsive to their client group. / Thesis (Master, Community Health & Epidemiology) -- Queen's University, 2010-07-26 11:11:27.456