Background and Objectives: Understanding patient and public values and preferences is essential to healthcare and policy decision making. Discrete choice experiments (DCEs) are a common tool used to capture and quantify these preferences. Recent technological advances allow for a variety of approaches to create and analyze DCEs. However, there is no optimal DCE design, nor analysis method. Our objectives were to (i) survey DCE simulation studies to determine what design features affect statistical efficiency, and assess their reporting, (ii) further investigate these findings with a de novo simulation study, and (iii) explore the sensitivity of individuals’ preference of attributes to several methods of analysis. Methods: We conducted a systematic survey of simulation studies within the health literature, created a DCE simulation study of 3204 designs, and performed two empirical comparison studies. In one empirical comparison study, we determined addiction agency employees’ preferences on knowledge translation attributes using four models, and in the second, we determined elementary school children’s choice of bullying prevention programs using nine models. Results and Conclusions: In our evaluation of DCE designs, we identified six design features that impact the statistical efficiency of a DCE, several of which were further investigated in our simulation study. The reporting quality of these studies requires improvement to ensure that appropriate inferences can be made, and that they are reproducible. In our empirical comparison of statistical models to explore the sensitivity of individuals preferences of attributes, we found similar rankings in the relative importance measures of attributes’ mean part-worth utility estimates, which differed when using latent class models. Understanding the impact of design features on statistical efficiency are useful for designing optimal DCEs. Incorporating heterogeneity in the analysis of DCEs may be important to make appropriate inferences about individuals’ preferences of attributes within a population. / Thesis / Doctor of Philosophy (PhD) / This thesis focuses on the design and analysis of preference surveys, which are referred to as discrete choice experiments. These surveys are used to capture and quantify individuals’ preferences on various characteristics describing a product or service. They are applied in various health settings to better understand a population. For example, clinicians may want to further understand a patient population’s preferences in regards to multiple treatment alternatives. Currently, there is no optimal approach for designing or analyzing preference surveys. We investigated what factors help improve the design of a preference survey by exploring the literature and conducting our own simulation study. We also investigated how sensitive the results of a preference survey were based on the statistical model used. Overall, we found that (i) increasing the amount of information presented and reducing the number of variables to explore will maximize the statistical optimality of the survey; and (ii) analyzing the data with different statistical models will yield similar results in the ranking of individuals’ preferences of the variables explored.

BACKGROUND: The mandate to provide inclusive education in Canadian schools means that Speech-Language Pathologists (SLPs) need to be well-versed in frameworks such as Universal Design for Learning (UDL) that support learning among students with diverse backgrounds and abilities. To be responsive, professional graduate programs need resources that support teaching SLP students about UDL. PURPOSE: 1) To use an instructional design model and Knowledge Translation (KT) theory to develop educational resources about UDL for SLP graduate students; and 2) to assess feasibility of the resources and SLP students’ perceived and actual UDL knowledge change after resource implementation. METHODS: First, educational resources about UDL were created for SLP students using a process in which the first three phases of the Analysis, Design, Development, Implementation, Evaluation (ADDIE) instructional design model were combined with the Diffusion of Innovations (DOI) KT theory and supported by engagement of key SLP stakeholders. Stakeholder feedback about their involvement in the resource development process was assessed through a focus group and analyzed using conventional content analysis. Next, the last two phases of the ADDIE model were conducted in which the developed resources were implemented and evaluated with 19 SLP students over a three-hour session; resource feasibility and UDL knowledge were measured before and after the session using anonymous, web-based questionnaires. RESULTS: The novel process for developing resources was deemed suitable for creating high-quality theory-informed resources tailored to SLP students. SLP students perceived the resources to be practical and acceptable. There was a statistically significant improvement in students’ perceived UDL knowledge as well as improvements in actual UDL knowledge. CONCLUSION: Health educators could consider the described methodology when developing content-specific resources for health professional students. This thesis introduces a new set of resources that could be used to address an important gap in SLP training. / Thesis / Master of Science Rehabilitation Science (MSc) / Inclusive education in which students with diverse abilities learn together is an expectation within Canadian schools. People who work in schools, like Speech-Language Pathologists (SLPs), need to know about frameworks such as Universal Design for Learning (UDL) that identify specific strategies for supporting inclusive education. However, many SLPs do not know about UDL or how to apply this framework when they work with teachers. In this thesis, I used a new resource development process involving a rigorous resource design method with a theory that helps people use new ideas, to make educational resources about UDL for SLP graduate students. Next, I implemented and evaluated the resources with 19 SLP students at McMaster University. Students felt the resources were suitable and taught them new information about UDL. This thesis provides new teaching resources for SLP students to increase their knowledge about UDL and better prepare them for working in schools.

Hand therapy (HT) is a specialty area of occupational therapy (OT) practice that focuses on rehabilitation for individuals with hand and upper extremity related conditions with aim to return to performance of daily activities required for life. As with other health professionals, occupational therapy practitioners (OTPs) have a duty to the public to ensure that services rendered are safe and use evidence-based best practices to improve patient health-outcomes. In HT clinics, OTPs face numerous challenges implementing evidence-based practice (EBP) including a lack of time, skills, and misperceptions of EBP (Scurlock-Evans et al., 2014), as well as reimbursement and funding models which incentivize high productivity over time to evaluate the evidence and integrate into clinical practice. The cost of OTPs not implementing EBP into their clinical decisions negatively impacts health outcomes of the patients under their care. The Hand Therapy with Evidence Based Practice (HT-EBP) program aims to enhance patient care through enhancing private HT clinics adoption of up-to-date research evidence into clinical practice. The HT-EBP program is designed for use in community-based private HT clinics that typically have less than 10 OTPs employed. A commitment of two OTPs, preferably one seasoned and one entry level, coming together in a mentor-mentee relationship is needed to implement the program. This program requires the participating clinics and OTPs to actively engage in the development of clinical care plans through review of research evidence on selected clinical diagnoses. Resulting from the HT-EBP program, the HT clinic will be able to provide evidence-based quality care while the OTP participants will develop professionally in the field of HT, gaining firm knowledge in clinical topics and building clinical confidence at the same time. This program will be further enhanced through 1) access to high quality research databases from clinic affiliated universities, 2) professional organization’s focus on continuing education courses that develop research knowledge and analytic skills for OTPs, and 3) collaborating with clinic managers to facilitate more time for clinicians to engage in acquiring and creating knowledge in chosen clinical topics of interests. The HP-EBP will first be piloted at the author’s private HT clinic prior to recruiting other private HT clinics to adopt the program. The HT-EBP program will aim to address the challenges that OTPs face when implementing EBP by working with universities, professional organizations. With time, it is anticipated that a significant volume of evidence-based clinical care plans would be compiled and shared among OTPs in HT, thus enhancing care for patients with hand conditions. Successful implementation of the HT-EBP program may have the potential to serve as a template for other healthcare specialties to deploy EBP.

The theme of this project was synthesis and the thesis encompasses knowledge generation and knowledge translation. Systematic review methodology was employed. The initial two systematic reviews compared antidepressant medication and cognitive-behaviour therapy for the acute treatment of depression. A further comparison of a combination of the two interventions with each treatment on its own was also conducted, with the bulk of the evidence favouring the psychotherapy. Moving to the topic of knowledge translation, the main theme of the thesis, the barriers, facilitators, and interventions impacting on systematic review uptake were identified. The evidence from these three systematic reviews, using diverse methodologies, was then combined to identify the interventions that overcame specific obstacles and built on highlighted facilitators in order to improve the uptake of evidence from systematic reviews. Juxtaposing barriers and facilitators alongside effectiveness studies in this final, mixed-methods systematic review allowed a number of interventions to be recommended. The synthesis also allowed strategies to be highlighted that required further development. Interventions with a statistically significant effect such as educational visits, summaries of systematic reviews, and targeted messaging, addressed a wide range of the identified barriers and facilitators. These interventions were recommended. Promising uptake strategies requiring further development were also identified. Furthermore, large gaps in the evidence base regarding systematic review utilization were highlighted. Fewer of the facilitators identified as part of this project, such as the medico-legal protection provided by systematic reviews, appear to have been built on in order to increase review uptake. Finally, all the preceding evidence was drawn on in order to develop a proposal focused on improving the uptake of evidence from systematic reviews and meta-analyses. This doctoral project offers a menu or range of evidence-based factors that can be considered by organisations and researchers when planning strategies aimed at increasing the uptake of pre-appraised, synthesized evidence.

Introduction: Canadian First Nations experience a significantly higher rate of Mycobacterium tuberculosis (MTB) infection than non-Indigenous Canadians. Th17 cells are a subset of CD4+ T cells that are distinguished by their production of Interleukin-17A (IL-17A), an important cytokine for defense against mycobacteria. IL-17 is a primary contributor to the formation and stabilization of the lung granuloma, a biological containment vessel to protect the host from tuberculosis (TB). Past research with First Nations people has identified single nucleotide polymorphisms (SNPs) in the Th1 and Th2 immune pathways may affect their disease risk. However, SNPs in key Th17 related genes and the P2RX7 gene have not been explored in First Nations despite their important role against infectious diseases. Hypothesis: This research hypothesizes that distinct First Nations groups (Dene, Cree and Saulteaux) will have a different frequencies of SNPs in the key Th17 immunity related genes (IL-17A, IL-17AR, IL-23R, and IFN-γR) and the P2RX7 gene, as compared to a non-Indigenous Canadian group. Methods: SNP profiles (IL-17A rs2275913, IL-17RA rs4819554, IL-23R rs10889677, IFN-γR rs2234711 and P2RX7 rs3751143) were identified through literature research and the NCBI database was used for identifying gene motifs, primer locations and Restriction Enzyme cut sites. Polymerase Chain Reaction and Restriction Fragment Length Polymorphism analysis was performed on and visualized on agarose gel to determine specific allele frequencies. Four different Manitoba First Nations communities; the Northern Dene (Dene 1 N=69. Dene 2 N=52), Central Cree (N=46), and Southern Saulteaux (N=56), participated in this research and their SNP profiles were compared to a non-Indigenous Canadian cohort (N=99). Results: Allele frequencies for IL-17A were statistically different for every First Nation community when compared to the non-Indigenous cohort (Dene 1 p=0.0043, Dene 2 p=0.0000, Cree p=0.0001, Saulteaux p=0.0000). Allele frequencies for IL-17RA were statistically different for every First Nation community except Saulteaux when compared to the non-Indigenous cohort (Dene 1 p=0.0000, Dene 2 p=0.0028, Cree p=0.0000). Allele frequencies for IL-23R were statistically different for Dene 1 and Saulteaux community when compared to the non-Indigenous cohort (Dene 1 p=0.0002, Saulteaux p=0.0000). Allele frequencies for IFN-R were statistically different for Cree community when compared to the non-Indigenous cohort (Cree p=0.0026). Allele frequencies for P2RX7 were statistically different for both Dene communities when compared to the non-Indigenous cohort (Dene 1 p=0.0000, Dene 2 p=0.0000). Conclusions: An effective Th17 response is required to bring Th1 cells to infected tissues and to balance inflammatory responses. Functional SNPs may compromise an appropriate immune response and contribute to disease. This study demonstrate that the non-Indigenous population maintained a significantly different genetic profile when compared to the First Nations populations. / October 2016

The failure to translate evidence into clinical practice has been repeatedly highlighted. This failure is partly attributed to disregarding the context within which healthcare is delivered. The aim of this thesis was to develop and psychometrically evaluate the Context Assessment for Community Health (COACH) tool, and, through that process, provide opportunities to measure aspects of context perceived to be important for Knowledge Translation (KT) interventions in low- and middle-income countries (LMIC). All four studies in this thesis were mainly undertaken in Quang Ninh province, Vietnam during 2008–2014. Study II, however, was also conducted in four other LMICs (Bangladesh, Nicaragua, South Africa, and Uganda). Study I employed inductive content analysis of 16 focus group discussions to explore the influence of context in a community-based facilitation intervention in Vietnam. Studies II and III reported on the development of the COACH tool and assessment of its psychometric properties. Study IV used the COACH tool in a survey among health workers in Vietnam. To date, three sources of evidence regarding validity of the COACH tool have been provided, that is, test content, response processes, and internal instrument structure, with promising psychometric characteristics. The COACH tool could be used as means of characterizing aspects of context ahead of KT interventions, for tailoring KT strategies, and for further understanding of the results of KT interventions. / Context Assessment for Community Health

This research was undertaken to study the impact of single and multicomponent knowledge translation interventions (KTIs) on barriers to the integration of Clinical Practice Guidelines (CPG) into Clinical Decision Making (CDM) in the context of physical therapists (PTs) and find out which of the two KTIs was more effective. A literature review showed that research knowledge (e.g. CPG) in the field of PT (Physical Therapy) is not being integrated in to clinical practice (e.g. CDM), thus leading to a research-practice (R-P) gap in other words CPG-CDM gap. It is suggested in the literature that the management and behavioural aspects of PTs might be acting as barriers hindering the integration of the research knowledge into clinical practice consequently affecting the delivery of optimum patientcare. Remedial measures, namely KTIs, are suggested to address those barriers and to bridge the R-P gap. However, the phenomenon of the R-P gap, the causes of it and the possible interventions are not well understood concepts in the literature, particularly in the context of PTs. CPG for Venous Thromboembolism (VTE) in PT was chosen as the example of research knowledge. It was argued that barriers have the potential to affect CDM which in turn can affect the CPG-CDM gap. Lack of knowledge about CPG-CDM gap is a major limitation in the literature that is affecting the integration of CPG into CDM. Other gaps found in the literature that have the potential to affect CPG-CDM gap include management and behavioural variables as probable causes of CPG-CDM gap (or barriers), use of KTIs to bridge the CPG-CDM gap and, KTIs. Furthermore, lack of knowledge about relationship between barriers and CPG-CDM gap, KTIs and barriers, KTIs and CPG-CDM gap and the impact of KTIs (effectiveness) in bridging CPG-CDM gap were the other gaps found in the literature that had potential implications to CPG-CDM gap. These gaps were addressed in this research to some extent. Relationships between the independent variables (lack of knowledge of PTs in CPG, lack of favourable attitude of PTs towards CPG and lack of self-efficacy and motivation of PTs to integrate CPG into CDM) and the dependent variables (CDM and CPG-CDM gap) were defined and models were proposed. Further, it was posited that KTIs could impact barriers based on theories and models found in the literature that provided some basis to create the linkage between KTIs and management and behavioural barriers. Education material (EM) and virtual communities of practice (VCoP) were chosen as of the KTIs in this study. The models of Cabana et al. (1999) and Fischer et al. (2016), primarily, were used to ground the conceptual models represented by figures and equations. Methodologically, a positivist approach with an objective ontological stance was employed and a deductive approach and quantitative research method were used to address the research gaps. The research design included a longitudinal element and survey questionnaire. The target population was licensed PTs in the USA. Random sampling was used. Two groups of PTs were identified namely EM-group and VCoP group. Data was collected from the groups before and after administering the KTIs. The results showed that single and multicomponent KTIs impacted barriers in different ways. EM impacted lack of favourable attitude of PTs towards CPG, and lack of self-efficacy and motivation of PTs to integrate CPG into CDM as barriers and narrow the CPG-CDM gap. VCoP was found to impact the combination of four barriers and narrow CPG-CDM gap. In addition, barriers in groups of two were also impacted by VCoP and narrowed the CPG-CDM gap. Furthermore, a CPG knowledge score card and a corresponding CDM score card developed by the researcher were used to test the change behaviour of PTs in integrating CPG into CDM. This experiment showed that barriers existed and caused CPG-CDM gap and KTIs could narrow the CPG-CDM gap. The findings indicate that this research has contributed to knowledge in many ways, including unearthing the relationship between CPG-CDM gap and barriers, better understanding of KTIs, their relationship with CPG-CDM gap and barriers, gaining knowledge about the impact of single and multicomponent KTIs on single and multiple barriers and identification of methods to bridge the CPG-CDM gap.

Background: Laparoscopic surgery for colorectal cancer is a novel healthcare technology, for which much research evidence has been published. The objectives of this work were to compare the oncologic outcomes of this technology across different study types, and to define patterns of adoption on the basis of the literature. Methods: A comprehensive systematic review of the literature was conducted using 1) existing systematic reviews, 2) randomized controlled trials (RCTs), and 3) observational studies. Outcomes of interest were overall survival, and total lymph node harvest. Outcomes were compared for congruence. Adoption was evaluated by means of summary expert opinions in the literature. Results: 1) Existing systematic reviews were of low to moderate quality and displayed evidence of overlap and duplication. 2) Laparoscopy was not inferior to open surgery in terms of oncologic outcomes in any study type. 3) Oncologic outcomes from RCTs and observational studies were congruent. 4) Expert opinion in the literature has been supportive of this technology, paralleling the publication of large RCTs. Conclusions: The evaluation of laparoscopic surgery for colorectal cancer in RCTs and observational studies suggests that it is not inferior to open surgery. Adoption of this technology has paralleled RCT evidence.

Clinical decision rules improve health care fidelity, benefit patients, physicians and healthcare systems, without reducing patient safety or satisfaction, while promoting cost-effective practice standards. It is critical to appropriately and consistently apply clinical decision rules to realize these benefits. The objective of this thesis was to understand how physicians use the Ottawa Ankle Rules to guide radiography decision-making. The study employed a clinical judgment survey targeting members of the Canadian Association of Emergency Physicians. Statistical analyses were informed by the Brunswik Lens Model and Social Judgment Analysis. Physicians’ overall agreement with the ankle rule was high, but can be improved. Physicians placed greatest value on rule-based cues, while considering non-rule-based cues as moderately important. There is room to improve physician agreement with the ankle rule and use of rule-based cues through knowledge translation interventions. Further development of this Lens Modeling technique could lend itself to a valuable cognitive behavioral intervention.

Organizational learning through experience has been found to be associated with enhanced firm performance. Organizational experiments are a method of experiential learning that enable organizations to learn from experience and gain context-specific knowledge of how and why to implement new knowledge. Pilot projects, a type of organizational experiment, involve making intentional, systematic efforts to gather and analyze feedback in order to accurately assess the action-outcome relationships of adopting new knowledge prior to embarking on full-scale implementation. Despite the popularity of pilot projects used to test products, programs, and services as well as reports on the outcomes of such experiments, there is a dearth of research focusing on how organizational learning occurs during organizational experiments, and on the processes and structural mechanisms of organizational experiments that contribute to organizational learning. A qualitative, multiple-case study of eight pilot projects was carried out within nursing units across five acute health care organizations during Fall 2008. Interviews were conducted with 32 individuals, including pilot project leaders, nursing program managers and direct care nurses. An inductive approach to data analysis was applied and themes identified. Results were compared to 14 propositions that were developed based on the knowledge transfer, innovation diffusion, and organizational learning literature, and which were bracketed before data analysis to allow findings to emerge from the data. The findings advance existing organizational learning, innovation diffusion, and knowledge transfer models by illuminating the complexity of organizational learning processes. Several processes and structural mechanisms of organizational experiments were found to facilitate single-loop organizational learning, leading to incremental changes to meet existing goals and objectives. Although double-loop organizational learning, which may result in fundamental changes in an organization’s assumptions, norms, policies, goals and objectives was not observed, the study revealed a number of processes and structural mechanisms that have the potential to encourage this type of learning. Studies of organizational experiments are rare. Future directions for research and theory development are suggested to build on the findings of this study. Practical implications are offered to organizations in any industry interested in realizing the potential that organizational experiments have for double-loop learning and enhanced organizational performance.