Strong health systems are needed to implement clinical and public health interventions. Global evidence-informed health systems guidance, such as that created by the World Health Organization (WHO), has been used to help strengthen health systems. However, global guidance needs to be contextualized or adapted to fit the realities of a particular setting. A workbook for contextualizing health systems guidance was developed to accompany WHO guidance on optimizing health worker roles to increase access to and use of key interventions for improving maternal and newborn health. This dissertation investigates the development and use of the workbook, using qualitative research methods, to help in the planning of future knowledge translation tools, to provide insights for practice and research, and to improve the workbook. First, a single case study explores the development of the workbook, which helped uncover the key features of the process, barriers that arose, and facilitators that helped overcome some of these barriers (chapter 2). Second, a single embedded case study examined the use of the workbook in two real-life settings, Peru and Uganda (chapter 3). Third, a critical interpretive synthesis of the literature was used to better define contextualization and to find what and how contextual factors could be used by policymakers to adapt guidance to their setting (chapter 4). Together, the three studies presented in this dissertation offer substantive, methodological and disciplinary contributions to the field of health systems and policy through a comprehensive examination of the workbook. It presents recommendations for improving the workbook from the perspectives of global guidance developers, users at the national level, and the broader literature on guidance and guideline development, contextualization and implementation. It also supports the continued use of workbooks, or other tools, to contextualize guidance in an effort to strengthen health systems, especially in low- and middle-income countries. / Dissertation / Doctor of Philosophy (PhD) / Strong health systems are needed in order for the right mix of clinical care and public health interventions to get to those who need them. The World Health Organization writes guidance at the global level to help countries strengthen their health systems. This guidance can be used to develop health guidance or policy for the national or subnational (e.g., provincial, state) level, but it first needs to be contextualized or adapted to that particular jurisdiction. It is important to consider what the problem is and what causes it, policy options to help deal with the problem, implementation considerations, as well as factors related to both the health system and the political system that can affect whether or not the intervention will be implemented. A workbook was developed to help contextualize guidance. This dissertation explores the process of developing and evaluating its use to help in the planning of future tools, to provide insights for practice and research, and to improve the workbook.

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Background: With recent emphasis on creating a stronger, more patient-centred, health system in Ontario, there remains no clear definition of a “public health” system, hindering the ability to integrate preventive public health and health care practices. This study aims to describe public health systems and initiate a research agenda for this field. Methods: A critical interpretive synthesis of the literature was conducted using six electronic databases. In addition, data extraction, coding and analysis followed a best-fit framework analysis method. Initial codes were based on two current leading health systems and policy classification schemes: health systems arrangements (based on governance, financial and delivery arrangements) and the 3I+E framework for health policy formulation (institutions, interests, ideas and external factors). New codes were developed as guided by the data. A constant comparative method was used to develop concepts and to further link these into themes. Additional documents were identified to fill conceptual gaps. Results: 5,933 unique documents were identified and 338 documents met the inclusion criteria. 81 documents were purposively sampled for full-text review and 58 of these were included in this study. Nine documents were found to help fill conceptual gaps. Generally, public health systems can be defined using traditional healthcare systems and policy frameworks. There was also a strong emphasis on identifying and standardizing the roles and functions of public health. Partnerships (community and multi-sectoral) are common features within and between components of public health systems. A public health system framework and a model of a population health system were conceptualized. Discussion: Understanding public health systems can help strengthen these systems and further integrate preventive public health and primary care services. Systems are influenced by organizational and contextual factors that need to be explored to improve population health. A research agenda is proposed to move this field forward. / Thesis / Master of Public Health (MPH)

Children and adolescents with cerebral palsy (CP) often receive botulinum toxin (BoNT-A) to manage spasticity. Our 2014 study developed an inventory of parents’ goals for BoNT-A treatment, but reasons for selecting these goals were unclear. The current study aimed to describe and categorize the effects of BoNT-A that parents observed according to WHO’s International Classification of Functioning, Disability and Health (ICF) framework. This qualitative study used interpretive description. Fifteen parents of non-ambulatory young people with CP (mean age 10.2 years, SD 3.9, 7 males) who received BoNT-A were recruited through McMaster Children’s Hospital’s Spasticity Management Clinic. Interviews were conducted in-person or by telephone for 20-60 minutes. The research team read the initial transcript, identified codes, and finalized the coding framework. Member checking was conducted to enhance trustworthiness. The key theme was that parents needed to find the right path to do what is best for their child. Parents described how they learned about both positive and negative effects of BoNT-A treatment: some parents emphasized the child’s pain during BoNT-A injections (negative), but also felt that BoNT-A was helpful for their child (positive). Most effects of BoNT-A were coded at the ICF activity level, such as dressing These observations helped inform parents’ decision to continue with BoNT-A and identify future goals. This study provides insight into parents’ journey of learning about BoNT-A and goal-setting for their child. Parents’ perspectives will be used to refine the 2014 inventory of goals to facilitate collaborative goal-setting for BoNT-A treatment. / Thesis / Master of Science (MSc) / Children diagnosed with cerebral palsy (CP) receive botulinum toxin (BoNT-A) as a treatment to reduce muscle tone. Current research on the use of BoNT-A injections in non-ambulatory children with CP is scarce and may not incorporate the perspectives of the family about their goals for treatment. This study interviewed parents to ask about the effects that they observed in their child after BoNT-A treatment. Fifteen parents were interviewed and all parents spoke about their journey of “finding the right path to do what is best for my child” as they learned about the possible effects of BoNT-A treatment for their child. By learning about parents’ journey, informational resources can be developed and shared with other parents about the effects of BoNT-A treatment. It is important to help parents understand these effects, which would allow them to discuss and identify appropriate goals with healthcare professionals in future BoNT-A treatment sessions.