While many studies focus on the links between multiple risk factors and negative outcomes such as child maltreatment, less is known about the influence of protective factors in the face of risks. The theoretical base of this study was a social ecological model of interactive influences including individual parent, family, and neighborhood level factors to predict outcomes. Protective Factor Index (PFI) and Risk Factor Index (RFI) predictors were developed to explore potential multi-level protective factor buffering effects on key child development and parenting outcomes. Participants were first time mothers enrolled in a randomized controlled study of the Healthy Start/ Healthy Families Oregon (HS/HFO) home visitation program (treatment group) who completed a follow-up phone survey at the child’s 12 month birthday (n = 405). Families were offered HS/HFO services prenatally after meeting risk screening eligibility criteria on the New Baby Questionnaire (NBQ). Program mothers having received at least one home visit (n = 248) were included in the final analyses. Families had an average of 3.1 (SD = 1.2) NBQ risk factors at enrollment and 83% reported having trouble paying for basic needs. Families received an average of 16 home visits in the first 6 months of the program. Thirty-one percent of mothers were aged 19 or younger, 60% were White and Non-Hispanic, 31% were Hispanic, and 9% were another race/ethnicity. Hierarchical regression models with main effects (RFI, PFI, race) and an interaction term (RFI X PFI) were developed to predict eight outcomes. Interaction effects models were not significant. Five RFI main effects were significant: higher RFI scores were associated with greater likelihood of child welfare involvement, greater parenting stress, less favorable scores on child health and well-being, lower parent responsiveness and ii acceptance, and less supportive learning environments. One PFI main effect was significant: higher PFI scores predicted lower parenting stress. A trend level result showed higher PFI scores were associated with less child welfare involvement. Race was significant in two models: White/Non-Hispanic families were more likely to have a home visitor report child welfare involvement and had more frequent parent-child activities compared to other race/ethnicity families. Unpacking the results with separate single risk factor (12 items) and protective factor (10 items) regression models followed. Results showed parent’s prior family history of maltreatment and younger maternal age predicted child welfare involvement (home visitor report), while protection was seen for those with access to housing support. Social support and family functioning protectors were linked to lower parenting stress, while maternal depression showed the opposite finding. Better scores on a child health and well-being measure were seen with higher neighborhood cohesion and greater participation in HS/HFO; in contrast, neighborhood violence and frequent mobility were linked to worse scores. Developmentally supportive home environments were seen for families participating in additional parent support programs, in which the mother had greater knowledge of infant milestones and behavior, and if the family had access to housing supports. Unemployment proved to be associated with less enriched home environments. In summary, there was no support for the cumulative PFI in buffering risk for negative outcomes in this model. The RFI was also a more robust predictor of outcomes compared to the PFI in the main effects models. Overall, study findings provide some evidence for the utility of specific protective factors, as well as cumulative and specific single risk factors, for screening families for effectively targeting services and guiding the conceptual development of program and evaluation formats.

No description available.

Animal assisted interventions are becoming more prevalent in our society. Animal interventions have become a popular therapy technique that exist to aid a variety of disabilities. Equine therapeutic riding has become one of the most popular forms of animal assisted therapy for both children and adults. While research shows the importance and benefits of animal assisted therapy for children, there is a lack of research concerning parental satisfaction within therapeutic riding programs. This study tested a newly developed instrument for measuring parental satisfaction for therapeutic riding programs. The Parent/Caregiver Evaluation Tool (Kerr, 2021) was administered to parents/caregivers whose children participated at the North Dakota State University Bison Strides Riding Program to determine the instrument’s reliability. Secondly, the instrument was administered the parents/caregivers of the MSU Equine Assisted Therapeutic Riding Program. It was found that parents/caregivers were satisfied with the program, but there were some recommendations given.

No description available.

Introduction Transition care clinics (TCCs) have proven to be effective in meeting the time-sensitive needs of patients in the post-discharge period and ensuring smooth transitions of patients from hospital to home. These clinics have led to lower readmissions, lower emergency department visits, cost savings, and lower rates of other adverse events following discharge. However, TCCs, including the East Tennessee State University Family Medicine (ETSU-FM) TCC have been facing high rates of patient no-shows. Aim The aim of this dissertation is to identify the different components and outcomes of TCC based on the literature. We further aim to analyze the TCC implementation process at the ETSU-FM clinic, identify gaps, and provide recommendations to address those gaps. Methods A scoping review was conducted using three databases (PubMed, Web of Science, and PsycINFO) searches while following the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews Checklist to identify different components of TCCs and the associated outcomes. Additionally, a mixed-methods study was conducted using patients and providers from the ETSU-FM clinic to identify different factors associated with patients’ no-shows to scheduled TCC appointments. Results Eighteen studies were analyzed and TCC components and patients’ outcomes were assessed. Predischarge communication with patients and caregivers, early post-discharge contacts, etc. were identified as some of the effective components of TCC. Our review also highlighted that TCC resulted in lower readmissions, lower ED visits, and cost-effectiveness. For the mixed-methods study, we included 520 patients in our quantitative analysis and interviewed 10 providers for the qualitative analysis. Several patient-level and system-level factors were found to be associated with TCC no-shows. A few of the factors that were deemed modifiable by the clinic have been identified and recommendations provided accordingly. Conclusion TCCs play a vital role in ensuring smooth care transitions of patients following discharge. It is crucial to conduct context-level studies to identify factors that are associated with TCC no-shows and design interventions accordingly. Doing so could lead to pursuit of the triple aim of healthcare: improving patients’ experience of care, improving the health of populations, and reducing the per capita cost of health care.

<p><strong>Introduction:</strong> In Ontario alone, an estimated 6,700 people (3,000 women; 3,700 men) will die of lung cancer in 2011 (Canadian Cancer Society, 2011). A diagnosis of cancer is associated with complex decisions; the array of choices of cancer treatments brings about hope, but also anxiety over which treatment is best suited for the individual patient (Blank, Graves, Sepucha et al., 2006). The overall cancer experience depends on the quality of this decision (Blank et al., 2006). Clinical practice guidelines are knowledge translation tools to facilitate treatment decision-making. In Ontario, guidelines have been developed and disseminated with the purpose to inform clinical decisions, improve evidence based practice, and to reduce unwanted practice variation in the province. But has this been achieved? To study this issue, the purpose of the current study was to gain an in-depth understanding and develop a theoretical framework of how Ontario physicians are making treatment decisions with their non-small cell lung cancer patients. The following research questions guided the study: (a) How do physicians make treatment decisions with their stage II, stage IIIA and stage IIIB non-small cell lung cancer patients in Ontario? (b) How do knowledge translation tools, such as Cancer Care Ontario guidelines, influence the decision-making process?</p> <p><strong>Methods:</strong> A qualitative approach of grounded theory, following a social constructivist paradigm outlined by Kathy Charmaz (2006), was used in this study. 21 semi-structured interviews were conducted; 16 interviews with physicians and 5 with health care administrators. The method of analysis integrated grounded theory philosophy to identify the treatment decision-making process in non-small cell lung cancer, from the physician perspective.</p> <p><strong>Findings:</strong> The theory depicts the treatment decision-making process to involve five key “guides” (or factors) to inform the treatment-decision making process: the unique patient, the unique physician, the family, the clinical team, and the clinical evidence.</p> <p><strong>Conclusion:</strong> Decision-making roles in lung cancer are complex and nuanced. The use of evidence, such as, clinical practice guidelines, is one of many considerations. Information from a large number of sources and a wide array of factors, people, emotions, preferences, clinical expertise, experiences, and clinical evidence informs the dynamic process of treatment decision-making. This theory of the treatment decision-making process (from the physician perspective) has implications relevant to treatment decision-making research, theory development, and guideline development for non-small cell lung cancer.</p> / Master of Science (MSc)

<p>The thesis presents three papers discussing some of the methodological issues regarding studies investigating complex community-based cardiovascular health interventions. All three studies involved the Cardiovascular Health Awareness Program (CHAP), a standardised blood pressure and risk factor assessment and educational sessions held in pharmacies or other locally accessible areas in small to mid-sized communities in Ontario, Canada.</p> <p>The first paper reviews the literature and proposes a guide on how to develop a theoretical framework for complex community-based interventions using CHAP as an example. The paper describes a stepwise process of developing a theoretical framework including challenges encountered and strategies employed to overcome them.</p> <p>The second paper presents how recently published randomized controlled trials evaluating complex community-based cardiovascular health interventions monitored and reported implementation fidelity based on a structured review of the published articles and a survey of their primary authors. The results showed that fidelity reporting of included studies was better than those described in previous reviews. Fidelity was verified through self-reports by implementers and supervision by researchers. Strategies described to standardize intervention delivery were through training of implementers and use of implementation guides. The authors’ survey results were consistent with the review results though there were some gaps which could be improved to strengthen fidelity reporting.</p> <p>A data analysis issue with studies investigating complex community-based interventions is that outcomes can be affected by factors from multiple levels. The third paper explores the association of individual, partnership, and community-related factors with CHAP participants’ use of health-related community resources and cardiovascular risk behaviours. This was a cross-sectional analysis of an on-going cohort study. The results showed that individual factors (age and self-efficacy) had the most consistent association with the outcomes. Community and partnership level variables showed less consistent association with the outcome. Methodological and analytical challenges were presented.</p> / Doctor of Philosophy (PhD)

<p>Community participation has been identified as a key facilitator of community health among marginalized populations in international health statements. However, knowledge gaps in the community participation literature regarding marginalized populations has been attributed to the lack of consistent definitions of community participation, ambiguity about the features of community participation initiatives (e.g., methods and strategies) that are appropriate for marginalized populations, and limitations of existing community participation frameworks in specifying the ways and means in which different marginalized populations might effectively participate, as well as in recognizing that community participation is highly contextual and situational. All of these factors have made it difficult to draw broader conclusions about the impact of participation methods and strategies for marginalized populations from evaluations of participation initiatives.</p> <p>The overall purpose of this thesis is to better understand how to involve marginalized populations in the planning and decision-making for local health services. First, a critical interpretive synthesis (CIS) was conducted to better understand the role of community development principles used in community participation initiatives with marginalized populations and the factors contributing to the influence of the principles in enabling the participation of these populations. Second, an in-depth comparative case study of four community participation initiatives in Ontario Community Health Centres (CHCs)—which are primary health care organizations serving 74 high-risk communities throughout the Province of Ontario—was conducted to identify the core features of participation initiatives with marginalized populations, and reflect on the particular challenges of engaging marginalized populations. Third, four focus groups were held at four Ontario CHCs to examine the role of frameworks as mechanisms for translating knowledge about community participation practice with marginalized populations. Overall, this thesis broadens our understanding of community participation with marginalized populations in the context of local health services planning and decision making. Specifically, this thesis contributes a theoretical basis for future research and provides practical knowledge for planning and evaluating community participation initiatives with marginalized populations.</p> / Doctor of Philosophy (PhD)

In the United States (US), substance use, misuse, and substance use disorders are significant public health problems. Additionally, the difference between needing substance use treatment (SUT) and receiving treatment is becoming more pronounced. Therefore, the aims of this dissertation include, 1) to synthesize evidence of barriers and facilitators to integrating SUT into mainstream health care (MHC) after the Affordable Care Act was nationally implemented in 2014, 2) to examine the rate of treatment completion and dropout, along with its associated factors, among youth who received Medication-Assisted Opioid Therapy (MAT), 3) to determine the relationship between prior treatment episodes and length of stay (LOS) among adults in residential rehabilitation facilities (RRF) and explore other predictors of LOS and, 4) to determine whether experiencing multiple treatment episodes and being in certain age groups was associated with longer wait period to enter SUT. The literature synthesis involved data from five databases and was informed by PRISMA. Quantitative analysis (aims 2-4) included log-binomial, Poisson, and logistic regression models using the Treatment Episode Data Set-Admissions and Discharges. Andersen’s Behavioral Model for Health Services was the conceptual framework used to inform aims 2-4. For aim 1, several patient, provider, and program/system-level barriers and facilitators were identified, which highlights the need to use a comprehensive approach to improve SUT adoption in MHC. For aim 2, among youth who received MAT, 43.9% completed treatment and 56.1% dropped out. Factors positively associated with treatment completion included MAT use, males, self-help group participation, admission to detoxification and residential/rehabilitation settings, and being in the Midwest/Western US; while minority races (excluding Blacks/African Americans) and being in the South resulted in lower likelihood. For aim 3, the average LOS in RRF was 16.4 days, and having ≥ 1 prior SUT episode (PSUTE) was associated with slightly higher LOS. Some predictors associated with lower LOS included age (18-34 years), males, being employed, private insurance, and being in the Northeast. For aim 4, a longer wait period was identified among clients 25-49 years and those with ≥5 PSUTEs. These factors should be considered to improve SUT use, and future studies should corroborate these findings.

Introduction: Quality improvement (QI) encompasses a wide range of healthcare studies and activities with the common goal of improving patient outcomes, healthcare system performance, and professional development. QI is characterized by a diversity of definitions, stakeholders, clinical fields and study designs, which creates challenges for rigorous reporting and evaluation of these studies. Understanding and addressing the methodological issues that arise from conducting QI studies from multiple clinical disciplines is critical for generating good evidence for healthcare improvement to tackle health system challenges. Objectives: This thesis addressed three independent objectives: (i) Determine the quality of reporting of QI studies in neonatology. (ii) Compare different statistical methods that can be used to analyze data from a cluster randomized controlled trial with repeated measures data and examine how the estimate of intervention effects varies between these approaches. (iii) Determine the cost-effectiveness of providing timely surgery or timely rehabilitation for patients with hip fracture. Methods: Objective 1: We conducted a systematic survey of quality improvement studies in neonatology to examine the extent to which these publications adhered to SQUIRE 2.0, the guidelines for reporting studies that sought to improve the quality, safety, and value of healthcare. Using the same set of articles, we examined how various methodological attributes, such as stakeholder engagement, outcome measures, and statistical process controls, are reported in these studies. Objective 2: To compare the differences in the statistical estimates of intervention effects between linear mixed models and Generalized Estimating Equations, for the CP@Clinic Program cluster randomized RCT, which contains routinely collected monthly outcome data aggregated at the cluster level. Objective 3: We constructed a Markov cohort model to estimate the cost-effectiveness of receiving timely surgery within 24 hours of admission to the emergency department, receiving immediate admission to inpatient rehabilitation following acute care discharge, receiving both, or none. Results: Objective 1: In our assessment of reporting quality, we found that adherence to SQUIRE 2.0 guidelines was inadequate and that journals should endorse the SQUIRE 2.0 guideline for improvement publications to alleviate this issue. We found that process measures was the most frequently reported methodological attribute (89%), while stakeholder engagement with leadership (32%) or caregivers (10%) were infrequently reported or conducted. Objective 2: In comparing statistical methods for analyzing a cluster randomized controlled trial with correlated data, we found that it was critical to apply a correction to the variance estimator of generalized estimating equations to produce robust estimates of the intervention effects. Objective 3: In our economic evaluation, both timely surgery alone and the combination of timely surgery and timely rehabilitation yielded cost-effective improvements in the quality-adjusted life-years of patients with hip fracture. However, the combination of receiving timely surgery and timely rehabilitation requires a high willingness-to-pay threshold, above $128,000 per quality-adjusted life-years, to be considered cost-effective. Conclusions: Overall, understanding the state of reporting and the broad spectrum of methods and methodologic issues for evaluating quality improvement initiatives will advance its rigorous research, evaluation, reporting, and contribution towards informed decision-making for tackling pressing healthcare issues. / Thesis / Doctor of Philosophy (PhD) / Quality improvement (QI) is a field of healthcare research that can be defined in many ways, and research in this field is conducted by researchers from various medical disciplines. Consequently, challenges may arise in reporting and evaluating QI interventions. Thus, it is important to examine how QI interventions are reported in academic literature and the methods used to evaluate their effectiveness in improving health. The current thesis aims to address these issues through three independent objectives: (1) examine the details reported in QI studies in neonatology, (2) compare different statistical methods that can be used to analyze data from a community paramedicine cluster randomized controlled trial, and (3) investigate whether providing timely surgery and timely hospital-based rehabilitation is a cost-effective way to improve the quality of life of patients who have experienced hip fracture. The findings of these studies will provide insights into the challenges of reporting and evaluating QI interventions, and suggest ways to improve them.