Master of Philosophy (Medicine) / Health care evaluation serves the purpose of monitoring the quality of health care provided by Health Care Providers (HCP), so that health care services can be provided most effectively and efficiently. Patient satisfaction studies are widely used to assess the quality of outpatient care. A client satisfaction study was conducted at an HIV health care facility in Sydney, Australia during 2007-2008. There were three objectives: 1.) To validate a questionnaire for future determination of client satisfaction in HIV health care facilities. 2.) To identify the levels of satisfaction of clients, and investigate any dissatisfaction and unmet needs towards HIV health care. 3.) To provide recommendations for improving client satisfaction levels in HIV health care. This research used a mixed method approach and consisted of two phases. The first phase was a quantitative survey conducted with 166 clients (both HIV positive and negative) at Albion Street Centre (ASC) using a newly-devised questionnaire. Clients were asked to answer demographic questions, rate their levels of satisfaction with each aspect and each HCP category, and provide suggestions for improvement. Quantitative statistical analysis was conducted to obtain a general view of client satisfaction levels. Dissatisfaction and unmet needs of clients were then investigated in-depth in the second phase of the research through qualitative face-to-face semi-structured interviews. Twenty-two clients (both HIV positive and negative) at ASC were interviewed individually and asked about their attitudes, perceptions, and experiences towards their HCP and the HIV health care services received. Thematic analysis was used to categorise and interpret the qualitative data. More than 90% of the clients were satisfied with most of the aspects covered in the survey, with a mean overall satisfaction score of 84 out of 100. Clients were most iii satisfied with the “technical quality” and “interpersonal manner” of the HCP, and were least satisfied with “waiting time” and “availability of HCP”. The HCP category with which the clients has the highest level of satisfaction was “nurses” (86%), followed by “psychologists” (84%), then “doctors” (83%). Clients who were HIV negative, had a full time job, visited ASC less frequently, or did not possess any type of Health Care Card were more satisfied with the services overall. No common dissatisfaction or unmet needs towards HIV health care service were identified. “Technical quality of HCP” and “the relationship with HCP” were the two most important determinants of client satisfaction, which outweighed the inconvenience contributed by the poor availability of HCP and the location of ASC. The maintenance of “confidentiality/privacy” was shown to be fundamental in HIV health care facilities. The multi-disciplinary nature of ASC increased the degree of convenience and satisfaction level among clients. Suggestions for improvement in client satisfaction levels include increasing the attractiveness of the physical environment and the variety of educational reading materials in the waiting area; introducing beverages, and encouraging clients to be involved in their treatment decisions. Health care administrative staff in particular are reminded not to neglect the importance of the availability of HCP, accessibility, and physical environment when establishing a new HIV health care facility. The mixed method approach (quantitative survey and qualitative interviews) proved beneficial. It increased the validity of the findings by assessing client satisfaction levels using more than one method. This enabled clarification of ambiguities noted in the initial survey through probes used in the interviews, and also allowed investigation of the determinants of client satisfaction through understanding their experiences in HIV health care. Future client satisfaction studies would benefit from using this approach.

Introduction: Ankle injuries are among the most prevalent acute musculoskeletal injuries, and are a significant burden on any health system. The interaction of the physiotherapist with the patient and their mutual understanding of impairments, function and recovery are important to achieving a satisfactory return to work and leisure activities. To date, little attention has focused on this interaction. There is a need for further exploration of differences and associations between outcome questionnaires that investigate similar domains of pain and function, and whether scores from such outcome measures are related to the patient’s perception of function and recovery. Of further interest is whether there are relationships between impairment measures and perceived function, and how actual performance of tasks might influence the patients understanding of their capabilities. To provide a more complete picture of these relationships, a ‘mixed methods’ approach using qualitative research methods within a quantitative study was thought to be most appropriate. The overall aim of this thesis was to utilise this research approach to investigate patients’ perceptions of their recovery and elucidate factors important to both therapists and patients that ultimately might enhance their understanding of recovery from an ankle injury. Literature reviews: Three literature reviews were undertaken. Firstly a review of systematic reviews investigating ankle sprains identified a wide variety of management strategies. There was a lack of strong evidence to support any particular management strategy. Hence clinicians are likely to have difficulty setting appropriate rehabilitation plans. Secondly a critical review identified a number of different outcome questionnaires that were utilised to gauge recovery level; however, justification for their selection was often lacking. This review also identified that little emphasis was placed on understanding the patients’ perception of their injury and the rehabilitation process. A final critical review investigated impairment and performance measures and identified four specific areas that were focused upon by clinicians during the treatment of ankle sprains: joint position sense, postural control, strength and performance during function. However, only weak evidence was found for there being a deficit in joint position sense, postural control and strength in the injured limb following an ankle sprain, and inconclusive evidence of deficits in physical performance of tasks related to function. Methods: Forty participants with an acute sprained ankle were recruited along with their treating physiotherapist. The participants completed a Global questionnaire, the Lower Limb Task Questionnaire (LLTQ) and the Short Form -36 (SF-36) Questionnaire at the initial visit, at discharge and at a six week follow up visit where they also undertook impairment testing involving, joint position sense, postural control and strength along with a functional performance test and selected functional activities. Ten participants were purposefully selected to undertake semi-structured interviews. The treating physiotherapists completed global questionnaires at the initial visit and at time of discharge. An interpretive hermeneutic approach was undertaken to examine the participants’ perceptions. Results: There were equal numbers of males and female participants and the average age of participants was 30.5 years. The relationship between questionnaires for the domains of pain and function varied between low and high degrees of association. The global limitations scores between the participants and physiotherapists were similar at the initial visit, whereas on discharge the participants had a significantly lower score (p<0.05) compared to the physiotherapists. With respect to impairment testing, there was a significant difference (p<0.05) between the uninjured limb compared to the injured limb for the joint position sense and performance agility hop test. All other comparisons of impairments were not significant (p>0.05). There was no association between questionnaire scores and impairment measures (p>0.05). Additionally there were no significant associations between previous injury and questionnaire scores and impairment measures. Finally in relation to the performance of specific functional tests there was a significant difference (p<0.05) between the six week follow up LLTQ score and the score following actual performance of the test. The findings of the participants’ interviews identified three key concerns. Firstly, that participants have a limited understanding of questionnaires, and secondly, that there is a difference in understanding of ‘recovery’ between the therapist and the patient at time of discharge. Thirdly, there was dissociation between outcome measures and the patient’s perception of their own recovery. Conclusions: This study revealed a lack of understanding and effective communication concerning physiotherapy practice in relation to ankle sprains. It was apparent that questionnaires purporting to measure similar constructs are at times dissimilar in scores and are not related strongly. Care needs to be taken in selecting and interpreting outcome measures particularly in relation to questionnaires. It was also apparent that caution should be exercised when considering the influence of impairment measures upon function. Physiotherapists should be aware that patients may perceive a lack of confidence in their level of function at the time of discharge. As a result physiotherapists need to incorporate strategies to improve patient confidence in their management plan.

<p>The purpose of this thesis is to improve our knowledge of substance users in the normal population. The main concern is with how the meaning of drug use is constructed. To answer this, the thesis draws on different theoretical principles and mixed methods design.</p><p>The thesis is made up of four sub-studies, with interconnected foci. The first three papers are based on a qualitative research project in which 44 socially integrated drug users in Stockholm were interviewed. The fourth paper is a cross-national quantitative analysis of nationally representative student samples.</p><p>The first of the three qualitative papers explores the construction of the informant’s self-identity. The second paper analyses the informant’s perceptions of drug-related risk, whilst the third paper analyses the drug users’ perception of differences between men’s and women’s drug use. The fourth paper sets the detailed analyses of the first three papers in a broader comparative frame, exploring differences in the correlates of drug use, in light of the different levels of drug use in Sweden and Switzerland.</p><p>The thesis reveals that the drug users are striving to be understood as normal integrated citizens of Swedish society. They present themselves as inherently different from drug abusers and the informants’ risk perceptions are based on a modified form of core Swedish cultural ideals of conscientiousness. The informants also waver back and forth when called upon to discuss gender and drug-taking. On the one hand they were explicit about existing differences between men’s and women’s drug use; on the other hand they were quite uncomfortable having to explicitly explain them, as this meant that they needed to draw on conservative gender roles, something which in Swedish society is a strong sign of being politically incorrect. Furthermore, the thesis shows that young drug abstainers and cannabis users are quite similar in regards to conventional social bonds.</p>

Fantasy sport participation is an online activity consuming the time, energy, and devotion of many sport followers. This activity provides participants a unique way to experience sport aside from simply viewing, listening, or following a sporting contest. Fantasy sport users present marketers and advertisers with a distinct type of sport fan, segmentation strategy, and target market. These users experience sport beyond wins, losses, and championships. They view statistics as fantasy points, individual players as products, and injury reports as team-altering news. These users see sport through a different lens. The purpose of this research is to gain familiarity with the fantasy sport user by developing an understanding of the motivations behind fantasy sport participation and examining factors associated with participation in fantasy sport; specifically involving media use, message board use, sport participation, overall satisfaction, and future intentions. Data was collected through the use of mixed methods consisting of qualitative online focus groups and quantitative questionnaires. The findings of the focus groups revealed four major themes associated with the participation and experience of fantasy sport. The themes were Competition, Socializing, Surveillance, and Ownership. These findings assisted in (1) validating past and current research, (2) developing and altering scale items for the quantitative questionnaire, and (3) providing deeper understanding of the fantasy sport experience. The major results of the quantitative questionnaire indicated top fantasy sport motivating factors as Fanship, Competition, and Social Sport with the lowest factors as Fan Expression, Ownership, and Escape. The factors with the highest significant relationship with overall satisfaction in the activity were Competition, Achievement, and Surveillance. The factors with the highest significant relationship with future intentions were Competition and Camaraderie. Other findings revealed no significant difference in motivations between different levels of sport participation and message board use. Message board use did, however, produce significant differences favoring higher overall satisfaction and future intentions for those using message boards. Other results examine (1) media use and fantasy sport participation and (2) Mavenism and Schwabism and its relationship to fantasy sport motivations, overall satisfaction, and future intentions.

The purpose of this explanatory, mixed methods case study was to examine instructional leadership within the context of rural secondary schools. This investigation followed an explanatory mixed methods design of sequential quantitative and qualitative phases (QUAL→quan). For the quantitative phase, the Principal Instructional Management Rating Scale (PIMRS) was administered to eight principals and 312 teachers in eight rural secondary schools in the southeastern United States. Descriptive analysis of principal and teacher results found that principals were most engaged in the subscales of framing school goals, coordinating curriculum, and promoting professional development and least engaged in the subscales of maintaining high visibility, protecting instructional time, and providing teaching and learning incentives. Independent t-tests found statistically significant differences in the instructional leadership of principals based on four contextual factors: school size, school SES, principal administrative experience, and district funding (per pupil expenditure). Two principals and their schools were selected for participation in the qualitative phase of the study. Interviews and observations of principals and interviews with teachers added insight to the findings of the quantitative phase. Participants characterized the principalship as a multifaceted job where secondary school principals fulfilled four leadership roles: instructional leader, district/community liaison, organizational manager, and problem solver. Participants also identified important instructional leadership behaviors not measured by the PIMRS, such as hiring effective teachers, providing instructional resources, and sharing leadership responsibilities. The study concludes with suggestions for future instructional leadership research and practical advice for rural secondary school principals.

Community involvement has been promoted and studied in diverse disciplines including planning, geography, community development, and others. In the tourism field, the shift from conventional tourism toward sustainable forms of tourism which emphasizes community-based practices in planning, development, and management has been broadly encouraged, especially in the developing world. Variously labeled, but commonly identified as Community-based tourism (CBT), this form of tourism is considered essential for community development, with an ultimate goal of sustainable development. Although many destinations have attempted to translate the CBT concept into practice, its appropriateness and success has been questioned and debated among practitioners and scholars. This research explores how members of local communities evaluate the CBT success factors discussed in the tourism literature. These factors include: 1) community participation, 2) benefit sharing, 3) tourism resources conservation, 4) partnership and support from within and outside of the community, 5) local ownership, 6) management and leadership, 7) communication and interaction among stakeholders, 8) quality of life, 9) scale of tourism development, and 10) tourist satisfaction. The main objectives of this study are: 1) developing an integrative measurement scales to evaluate the success of a CBT destination, 2) identifying the determinants of success as perceived by local communities at a CBT destination, and 3) examining the differences in CBT success factors between two communities relative to the duration and scale of tourism development, and size of the community. This dissertation employed mixed methods, combining questionnaire interviews, in-depth qualitative interviews, and participant observation as data collection tools. The fieldwork was conducted in Thailand during February – June 2010. Amphawa and Bangnoi floating markets were evaluated based on the ten factors. Results show that Amphawa, a larger and longer developed destination, is more successful than Bangnoi, a smaller and newly developed destination. Findings also indicated that the ten factors are important determinants of the success of tourism development in the two communities. Additional factors that the communities identified were advertising and the use of media as well as social networks. The integration of success factors reported in this study is recommended as a guideline for improvements in CBT development and evaluation.

The purpose of this thesis is to improve our knowledge of substance users in the normal population. The main concern is with how the meaning of drug use is constructed. To answer this, the thesis draws on different theoretical principles and mixed methods design. The thesis is made up of four sub-studies, with interconnected foci. The first three papers are based on a qualitative research project in which 44 socially integrated drug users in Stockholm were interviewed. The fourth paper is a cross-national quantitative analysis of nationally representative student samples. The first of the three qualitative papers explores the construction of the informant’s self-identity. The second paper analyses the informant’s perceptions of drug-related risk, whilst the third paper analyses the drug users’ perception of differences between men’s and women’s drug use. The fourth paper sets the detailed analyses of the first three papers in a broader comparative frame, exploring differences in the correlates of drug use, in light of the different levels of drug use in Sweden and Switzerland. The thesis reveals that the drug users are striving to be understood as normal integrated citizens of Swedish society. They present themselves as inherently different from drug abusers and the informants’ risk perceptions are based on a modified form of core Swedish cultural ideals of conscientiousness. The informants also waver back and forth when called upon to discuss gender and drug-taking. On the one hand they were explicit about existing differences between men’s and women’s drug use; on the other hand they were quite uncomfortable having to explicitly explain them, as this meant that they needed to draw on conservative gender roles, something which in Swedish society is a strong sign of being politically incorrect. Furthermore, the thesis shows that young drug abstainers and cannabis users are quite similar in regards to conventional social bonds.

The impact of Internet technology on critical thinking is of growing interest among researchers. However, there still remains much to explore in terms of how critical thinking can be fostered through online environments for higher education. Ten years ago, Garrison, Anderson, and Archer (2000) published an article describing the Community of Inquiry (CoI) framework which provided an outline of three core elements that were able to describe and measure a collaborative and positive educational experience in an online learning environment, namely teaching presence (design, facilitation, and direct instruction), social presence (the ability of learners to project themselves socially and emotionally), and cognitive presence (the extent to which learners are able to construct and confirm meaning through sustained reflection and discourse). This dissertation extends the body of research surrounding the CoI framework and also the literature on developing critical thinking in online environments by examining and exploring the extent to which teaching and social presence contribute to cognitive presence. The researcher was able to do this by offering 189 learners enrolled in 10 research methods courses and educational research courses an opportunity to use an innovative online resource (Research Design Learning Resource – RDLR) to assist them in learning about educational research and developing research proposals. By exploring how participants used this resource the researcher was able to gain insight into what factors contributed to a successful online learning experience and fostered cognitive presence. Quantitative and qualitative research approaches (mixed methods) were used in this study. The quantitative results indicated that both social and teaching presence had a strong positive relationship with cognitive presence and that learners generally perceived to have a positive learning experience using the RDLR. The qualitative findings helped elaborate the significant quantitative results and were organised into the following themes: making connections, multiple perspectives, resource design, being a self-directed learner, learning strategies, learning preferences, and barriers to cognitive presence. Future directions for critical thinking in online environments are discussed.

Leadership is important to quality improvement initiatives in healthcare. However, few studies have evaluated leadership interventions to enhance nurses’ use of guideline recommendations in the field of knowledge translation. Purpose: To develop and evaluate an intervention designed to operationalize a leadership strategy composed of relations, change, and task-orientated leadership behaviours, and to examine its influence on nurses’ use of guideline recommendations in home-care nursing. Design: Sequential mixed methods pilot study with post-only cluster randomized controlled trial. Methods Phase I: Intervention Development 1. A participatory approach was used at a community healthcare organization with 23 units across the province of Ontario, Canada. The guideline selected was developed by the Registered Nurses’ Association of Ontario for the assessment and management of foot ulcers for people with diabetes. 2. Integrative literature review, qualitative interviews, and baseline chart audits were conducted. 3. Four units were randomized to control or experimental groups. 4. Clinical and management leadership teams participated in a 12-week intervention consisting of printed materials, interactive workshop, and teleconferences. Participants received summarized chart audit data, identified priority indicators for change, and created a team leadership action plan to address barriers and influence guideline use. Phase II: Evaluation 5. Chart audits compared differences in nursing process and patient outcomes. Primary outcome: eight-item nursing assessment score. 6. Qualitative interviews evaluated the intervention and leadership behaviours. Results: No significant difference was found in the primary outcome. A significant difference was observed in nurses’ documentation of five priority indicators chosen by the experimental groups (p=.02). Gaps in care included: 53%, 76%, and 94% of patients not assessed for ulcer depth, foot circulation, or neuropathy (respectively); 75% and 93% did not receive wound debridement or hydrogel dressings. Receiving data to identify priority indicators for change and developing a leadership action plan were reported as useful to guideline implementation. The experimental group described using more relations-oriented leadership behaviours conducting audit and feedback, and sending reminders. Conclusion: Findings from this pilot study suggest that leadership is a team process involving relations, change, and task-oriented behaviours enacted by managers and clinical leaders. A leadership model is proposed as a beginning taxonomy to inform future leadership intervention studies.

Self-regulation capacity allows individuals to manage their thoughts, feelings, and actions to attain personal goals (e.g., well-being and performance), as well as adjust to their changing social and physical environment (Zimmerman, 2000). Self-regulation as a positive adaptive skill and process has not been examined in relation to well-being in the context of medicine. The purpose of the current study was to examine self-regulation with 37 medical students and 25 supervising physicians to determine whether or not it may enhance well-being and performance, and reduce stress and burnout. A mixed-methods design was used to collect and analyze the data, and findings from the quantitative and qualitative phases were presented in two separate articles. Self-regulation capacity appears to be an important skill that may help both physicians and medical students to meet the demands of the medical profession and maintain an adequate level of well-being and performance in their work and daily life.