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.

Les migrations internationales augmentent et l'Europe ne fait pas exception avec plus de 10% de la population de l'Union Européenne en 2014. Une question importante est le tabagisme des immigrés qui pourrait entraîner des risques de maladies liées au tabac différents de ceux des natifs des pays hôtes. Pourtant, on ne connait que très peu l'usage du tabac, qui est une cause évitable de cancer, et les maladies liées au tabac chez les immigrés en Europe. L'objectif général de cette thèse était d'étudier l'usage du tabac et le risque de cancers liés au tabac chez les immigrés. Les objectifs spécifiques étaient de : enquêter sur le tabagisme et ses déterminants chez les immigrés en France (étude pilote TOBAMIG), comparer l'incidence des cancers liés au tabac entre les immigrés et les natifs au Danemark, mettre ces résultats en contexte avec les connaissances actuelles, et suggérer un design d'étude sur le tabagisme et le risque de cancer lié chez les immigrés en France. L'étude pilote TOBAMIG a collecté des informations sur l'usage du tabac dans un échantillon d'immigrés, représentatif pour la plupart des caractéristiques démographiques. Avec des modifications, les résultats indiquent la faisabilité d'une étude à grande échelle en France. Au Danemark, le taux d'incidence des cancers liés au tabac chez les immigrés était inférieur à celui des natifs ; cependant, de grandes disparités ont été observées par site cancéreux et pays d'origine, suggérant en outre un rôle du tabagisme dans les pays d'origine des immigrés. Enfin, deux designs d'étude sont proposés, qui varient en fonction de la quantité d'information recherchée, afin de mieux comprendre le tabagisme des immigrés / International migration is increasing and Europe is no exception with immigrants accounting for more than 10% of the total European Union population in 2014. One pressing issue is tobacco use in immigrants as they may use tobacco differently from the natives of the hostcountry and this could result in differing tobacco‐related cancers (TRC) risks compared to those in the natives. However very little is known about tobacco use, a major avoidable cancer cause, and TRC in immigrants in Europe. The overall objective of this thesis was to investigate tobacco use and risk of TRC in immigrants. The aims were to: explore tobacco use and its determinants in immigrants in France (TOBAMIG pilot study), compare the burden of TRC between immigrants and natives in Denmark, put these results into context with current knowledge, and give guidance on how to set up a study on tobacco use and cancer risk in immigrants in France using the experience from the TOBAMIG pilot study. In the TOBAMIG pilot study information on tobacco use and its determinants was collected from a mixed sample of immigrants, suggesting a large‐scale study was in principle feasible, but modifications from the TOBAMiG approach were to be made. In Denmark, the overall TRC rate in immigrants was lower than that of the natives; however, large differences were observed by cancer‐site and by country of origin, suggesting that among other factors the smoking patterns from the immigrant’s country of origin have a primary role in the burden of TRC. Finally, with regard to a large‐scale study in France, two study designs are proposed, depending on the quantity of information sought, to better understand tobacco use in immigrants and risk of TRC

This diploma thesis is used as a pilot study, which requires sensitive and private information. Data necessary for research have been hardly accessible. The own qualitative research has been done in form of half-standardized interviews, secondary analysis and case studies. There have been delimitated areas and specified main guideline questions, which were, if necessary, closely specified in the course of interview. The maximum length of an interview was 45 min. Respondents answered questions in anonymous way. 14 case studies have been developed based on obtained data.

This research evaluates two different Biological Nitrogen Removal (BNR) systems for enhanced nitrogen removal in decentralized wastewater treatment. The first study evaluated the performance of Hybrid Adsorption and Biological Treatment Systems (HABiTS) at the pilot scale with and without stage 1 effluent recirculation. HABiTS is a system developed at the bench scale in our laboratory and was designed for enhanced BNR under transient loading conditions. It consists of two stages; an ion exchange (IX) onto clinoptilolite media coupled with biological nitrification in the aerobic nitrification stage 1 and a Tire-Sulfur Adsorption Denitrification (T-SHAD) system in the anoxic denitrification stage 2. The T-SHAD process incorporates NO3- adsorption onto tire chips and Sulfur Oxidizing Denitrification (SOD) using elemental sulfur as the electron donor for NO3- reduction. Previous bench scale studies evaluated HABiTS performance under transient loadings and found significantly higher removal of nitrogen with the incorporation of adsorptive media in stage 1 and 2 compared with controls (80% compared to 73%) under transient loading conditions. In this study, we hypothesize that a HABiTS system with effluent recirculation in nitrification stage 1 may enhance nitrogen removal performance compared to that without recirculation. The following were the expected advantages of Stage 1 effluent recirculation for enhanced nitrogen removal: 1) Pre-denitrification driven by the mixture of nitrified effluent from stage 1 with high concentrations of biochemical oxygen demand (BOD) septic tank effluent. 2) Moisture maintenance in stage 1 for enhanced biofilm growth. 3) Increased mass transfer of substrates to the biofilm in stage 1. 4) Decreased ratio of BOD to Total Kjeldahl Nitrogen (TKN) in the influent of stage 1. Two side-by-side systems were run with the same media composition and fed by the same septic tank. One had a nitrification stage 1 effluent recirculation component (R-system), which operated at a 7:1 stage 1 effluent recirculation ratio for the first 49 days of the study and at 3:1 beginning on day 50 and one was operated under forward flow only conditions (FF-system). The R system removed a higher percentage of TIN (35.4%) in nitrification stage 1 compared to FF (28.8%) and had an overall TIN removal efficiency of 88.8% compared to 54.6% in FF system. As complete denitrification was observed in stage 2 throughout the study, overall removal was dependent on nitrification efficiency, and R-1 had a significantly higher NH4+ removal (87%) compared to FF-1 (70%). Alkalinity concentrations remained constant from stage 1 to stage 2, indicating that some heterotrophic denitrification was occurring along with SOD, as high amounts of sCOD leached from the tire chips in the beginning of the study, reaching sCOD concentrations of 120-160 mg L-1 then decreasing after day 10 of operation of stage 2. Sulfate concentrations from stage 2 for each side were low until the last 10 days of the study, with an average of 16.43 ± 11.36 mg L-1 SO42--S from R-2 and an average of 16.80 ± 7.98 SO42--S for FF-2 for the duration of the study, however at the end of the study when forward flow rates increased, SO42--S concentrations increased to 32 mg L-1 for R-2 and 40 mg L-1 for FF-2. Similar performance was observed in the FF system as the bench scale reactor tests. The second part of the research focused on the findings from a study of a Particulate Pyrite Autotrophic Denitrification (PPAD) process that uses pyrite as the electron donor and nitrate as the terminal electron acceptor in upflow packed bed bioreactors. The advantages of using pyrite as an electron donor for denitrification include less sulfate production and lower alkalinity requirements compared with SOD. The low alkalinity consumption of the PPAD process led to comparison of PPAD performance with and without oyster shell addition. Two columns were operated side-by-side, one packed with pyrite and sand only (P+S), while another one was packed with pyrite, sand and oyster shell (P+S+OS). Sand was used as a nonreactive biofilm carrier in the columns. My contribution to this research was to carry out Scanning Electron Microscopy-Energy-Dispersive X-Ray Spectroscopy (SEM-EDS) analysis to support the hypothesis that oyster shell contributes to nitrogen removal because it has a high capacity for biofilm attachment. SEM analysis showed that oyster shell has a rough surface, supported by its high specific surface area, and that there was more biofilm attached to oyster shell than pyrite or sand in the influent to the column. EDS results showed a decrease in atomic percentages for pyrite sulfur in the effluent of both columns (59.91% ± 0.10% to 53.94% ± 0.37% in P+S+OS column and to 57.61% ± 4.21% in P+S column). This finding indicated that sulfur was oxidized more than iron and/or the accumulation of iron species on the pyrite surface and supports the coupling of NO3- reduction with pyrite oxidation.

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.

Fear of cancer recurrence (FCR) is defined as “fear, worry, or concern relating to the possibility that cancer will come back or progress (Lebel et al., 2016, p. 3266). FCR is the most frequently reported concern identified among cancer survivors (Baker, Denniston, Smith, & West, 2005; Lebel, Rosberger, Edgar, & Devins, 2007). Although approximately 50% of cancer survivors experience moderate-to-high levels of FCR (Simard et al., 2013), few psychosocial interventions exist that directly target this construct. The overarching study objectives were: (a) to adapt a manualized, 6-week, cognitive-existential group therapy intervention for FCR to an individual format; (b) to pilot-test the feasibility, acceptability, and satisfaction of this individual intervention on n=3 participants; and (c) to further pilot-test the efficacy of the individual intervention on n=25 participants, via a randomized controlled trial (RCT). In study 1, n=3 cancer survivors (1 male, 2 females) completed the one-on-one therapy intervention for the psychological treatment of FCR. Sessions were 60-90 minutes long, and included cognitive restructuring exercises, behavioural experiments, relaxation techniques, existential processing of the here-and-now, and finding meaning in life post-diagnosis. Participants completed questionnaire packages throughout the intervention and an exit interview to determine their overall feedback on the intervention. Quantitative analyses revealed downwards trends in fear of cancer recurrence and cancer-specific distress across participants. Qualitative analyses of the exit interviews revealed that all participants found the intervention useful, and that the sessions had favourable pacing and length. In study 2, the FCR intervention was further pilot-tested via an RCT. Twenty-five female cancer survivors were randomized to an experimental group or a wait-list control group. Sessions included cognitive restructuring techniques, behavioural experiments, confronting existential distress, and relaxation exercises. Nineteen women (n=9 intervention, n=10 control) completed the 6-week therapy intervention, and completed questionnaire packages at pre-, post- and 3-month follow-up. Between-within ANOVAs revealed significant interactions in the primary outcome measure of FCR, and secondary outcome measures of cancer-specific distress and uncertainty in illness for participants in the experimental group. Repeated measures ANOVAs revealed reductions in FCR, cancer-specific distress, uncertainty in illness, reassurance-seeking, cognitive avoidance, and intolerance of uncertainty, and revealed improvements in positive reinterpretation and growth, use of emotional support and mental health (improved quality of life) for participants in the experimental group, as compared to the wait-list control group. The variables that changed either maintained or improved at follow-up. Results from this study demonstrate promising results in addressing FCR in cancer survivors via a cognitive-existential intervention. Future research should continue investigating the specific therapeutic ingredients that are most effective for the psychological treatment of FCR.

The aim of the study was to explore non-compliance with T.B. treatment amongst T.B. patients at Moreteletsi Hospital. Due to the nature of the data that was needed the phenomenological strategy as a research strategy / design was used. Interviewing was used as a method of data collection and 20 T.B. patients at Moreteletsi Hospital were interviewed. The medical aspects of T.B. were discussed with emphasis on: what T.B. is, how it is diagnosed, T.B. treatment as well as social work intervention with patients. The patients indicated that members of the community are not supporting them. They further mentioned that western medicines have side effects on them and that the health centres are far from them. It was established that it is difficult for many T.B. patients to understand the causes of T.B. as they are explained from the western medical orientation because they associate T.B. with witchcraft. There are several factors that cause patients not to comply with medical treatment with the dominant one being the strong belief in traditional medicine. The community should be educated to emotionally support the patients. A holistic approach in the form of bio-psychosocial model can be of great benefit when used so that all the needs of the patients can be given attention. The research report was concluded by the conclusions and recommendations. / Dissertation (MA (SW) Health Care)--University of Pretoria, 2007. / Social Work and Criminology / unrestricted

Magister Scientiae (Occupational Therapy) - MSc(OT) / Occupation-based hand therapy (OBHT) is an approach to practice that integrates multiple frames of reference while remaining rooted in an occupational therapy perspective. Hand function is important for participation in daily occupations. The current focus in assessment and treatment of clients in occupational therapy remains on body structure and function which is also true in South Africa. The gap in the literature about the effects of OBHT indicates that there is a need for a study in a South African context. This research was conducted to examine the influences of an OBHT among clients with hand injuries within occupational therapy practice in a South African context.

Background: Many patients discharged from the hospital do not appropriately fill their discharge medications. At Boston Medical Center, an urban safety net facility, a bedside discharge medication delivery service was pilot tested in 2012 to ensure pediatric patients with asthma left in possession of their new medications. The service was expanded to all pediatric discharges in 2013. It is unknown whether beside delivery increases the proportion of written prescriptions captured by the hospital-owned pharmacy or if the service achieves a positive return on investment. Whether such a service improves patients’ satisfaction, medication adherence, or clinical outcomes is also unknown. Methods: Two primary methodologies were used to evaluate the impact of this novel service. The first evaluated the relative risk of filling a prescription in the hospital- owned pharmacy after the expansion of delivery eligibility criteria using two years of discharge prescription information, corresponding pharmacy fill data, and a hierarchical model with generalized estimating equations (GEE) to account for non-independent events. Initial patient-level impacts of the delivery service were evaluated through a pilot randomized controlled trial to test logistics and obtain empiric estimates of study parameters. Results: Patients were 1.44 times more likely to fill a medication at the hospital- owned pharmacy providing the delivery service after the intervention (95%CI 1.3-1.59). The increased profit generated by prescriptions captured as a result of offering the delivery service is estimated to be equivalent to 8-15% of a pharmacist full-time- equivalent (FTE), whereas only 3% of an FTE was required to provide the service, indicating a positive return on investment. Pilot study data suggest families did not differ significantly with regards to perceived satisfaction or reported outcomes whether randomized to usual care or delivery. Conclusion: A service to deliver discharge medications can yield a positive return on investment, allowing an institution to offset uncompensated care. To further study the intervention, a trial with randomization at the level of the ward or institution is needed. / 2017-10-02T00:00:00Z

Sexual mindfulness has been shown to improve couple's relationship and sexual satisfaction. Mindfulness research has mostly been conducted with White participants, largely leaving out the perspectives of diverse participants. This study piloted an online culturally-adapted version of the Sexual Mindfulness Project with Black and interracial couples (N=26 heterosexual individuals in a committed relationship from three different continents; age range 23€“44) to understand the program's acceptability and impacts. Qualitative interviews and quantitative surveys showed that couples enjoyed the program and experienced positive relational and sexual impacts post-intervention, including improved relationship satisfaction, sexual satisfaction, communication, and sexual mindfulness. Implications to improve the program curriculum and delivery are discussed.