The purpose of this study was to evaluate the methods currently available to measure the functional outcomes of physiotherapy treatment for low back problems. As a preliminary step, all extant questionnaires were located and evaluated against practical criteria to determine their likely utility in clinical practice. This process identified a large number of questionnaires, however, only six back-specific questionnaires fulfilled the practical criteria for clinical application. Four of these questionnaires were selected for further evaluation along with a generic health status assessment instrument, the SF-36 Health Survey. Current recommendations suggest that a low-back specific and a generic questionnaire are required for comprehensive assessment of the impact of low back problems. The four back-specific questionnaires selected were the Oswestry Disability Questionnaire, the Quebec Back Pain Disability Scale, the Roland-Morris Disability Questionnaire and the Waddell Disability Index. An evaluation of the literature on the clinimetric properties of these questionnaires revealed that little information was available for the Quebec and Waddell questionnaires and no information was available for any of the questionnaires for a clinical population of people with low back pain seeking physiotherapy treatment in an Australian setting. The primary aim of the research was identify which, if any, of the questionnaires should be recommended for measuring outcomes of physiotherapy treatment for low back pain. Consecutive ambulatory (non-admitted) patients presenting for physiotherapy treatment at three public hospital physiotherapy outpatient departments, three community health services, and four private practices were invited to enter the study. Patients were included if they were seeking treatment for a low back problem, were aged 18 or over, and could read and write English. Subjects completed the questionnaires on two occasions six-weeks apart. One hundred and forty subjects returned the first set of questionnaires, and 106 the second set. The mean age of the sample at pre-test was 51 (SD 17) and ranged from 18 to 89 years. Sixty-six percent were female, 41% were employed and 12% were receiving compensation for their back problem. Duration of the back complaint was more than six weeks for 56% of subjects, and 60% reported five or more previous episodes or continuous pain. Referred pain in the buttock thigh or leg was reported by 70% of subjects. The first aim was to compare the questionnaires for acceptability and comprehensibility. Data quality was high for all the questionnaires (less than 5% missing data). As expected, subjects found the more complex SF-36 Health Survey more difficult to complete than three of the low-back questionnaires. However, less than 10% of subjects found any of the questionnaires more than a little difficult to complete. The next aim was to explore the internal structure and inter-relationships of the low-back questionnaires and the three physical scales of the SF-36 Health Survey (Physical Functioning, Role-Physical and Bodily Pain). Analysis of item-item correlation, item-total correlation and Cronbach�s alpha confirmed that all scales were internally consistent. Factor analysis confirmed item homogeneity (unidimensionality) of all questionnaires except the Roland-Morris Disability Questionnaire. The questionnaires were significantly intercorrelated, but correlations exceeded .70 only for the Oswestry, Quebec and Waddell questionnaires. The next aim of the research was to compare test-retest reliability of the questionnaires. The Oswestry, Quebec and SF-36 Physical Functioning scale had sufficient reliability and scale width for clinical application. Despite previous reports of high reliability, the Roland-Morris scale was significantly less reliable than several of the other questionnaires. This indicates the importance of establishing the measurement properties of a test in the population or setting in which it will be used. The Waddell Disability Index, and the SF-36 Role-Physical and Bodily Pain scales had insufficient scale width to be useful in clinical practice. More than 15% of respondents had an initial score on these scales that would not allow change to be detected with 90% confidence. The next aim of the research was to compare the responsiveness of the questionnaires. None of the questionnaires was consistently identified as more or less responsive than the others although two methods (effect size and Liang�s standardized response mean) suggested the SF-36 Bodily Pain scale was more responsive than some other questionnaires. A secondary aim of this section was to evaluate the validity of the many available responsiveness indices and a novel �reliable change� method. A �known groups� strategy was used to determine whether the responsiveness index could discriminate between the low-back relevant questionnaires and the SF-36 General Health scale, the scores of which did not change across the retest period. With the exception of the novel �reliable change� method the responsiveness indices were all found to be valid indicators of responsiveness. Guyatt�s Responsiveness Index, effect size and Liang�s standardized response mean discriminated at 95% confidence between the reference scale and all the low-back questionnaires. The standardized response mean, t-test, correlation and ROC methods discriminated between the reference scale and five or six of the seven other questionnaires. Guyatt�s index was recommended as the best of the criterion-based methods, and the effect size the best of the distribution-based methods. The three questionnaires identified as having sufficient reliability and scale width, the Oswestry, Quebec and SF-36 Physical Functioning scale, were next analysed for data fit to a Rasch model. All three questionnaires had good data fit and item function was not affected by time, age, gender or whether or not subjects reported avoiding bending. The final aim of this research was to identify by Rasch analysis items to supplement the SF-36 Physical Functioning scale. The new scale, named the Low-Back SF-36 Physical Functioning18, showed comparable reliability and responsiveness to the SF-36 Physical Functioning scale. Further research is required to establish the measurement properties of the Low-Back SF-36 Physical Functioning18 scale in an independent sample. However, it has the potential to improve the clinical measurement of function by providing clinicians with a single measurement tool for comprehensive assessment of patients with low back pain.

Thesis--Copenhagen. / Summary in Danish. Bibliography: p. 210-219.

Thesis--Copenhagen. / Summary in Danish. Bibliography: p. 210-219.

Submitted by Hiolanda Rêgo (hiolandarego@gmail.com) on 2017-03-08T13:45:51Z No. of bitstreams: 1 Dissertação_Med_Tassiana Mendel.pdf: 3604205 bytes, checksum: 5040aa6a6f49598f42f815210b97ad41 (MD5) / Approved for entry into archive by Delba Rosa (delba@ufba.br) on 2017-05-02T12:17:29Z (GMT) No. of bitstreams: 1 Dissertação_Med_Tassiana Mendel.pdf: 3604205 bytes, checksum: 5040aa6a6f49598f42f815210b97ad41 (MD5) / Made available in DSpace on 2017-05-02T12:17:29Z (GMT). No. of bitstreams: 1 Dissertação_Med_Tassiana Mendel.pdf: 3604205 bytes, checksum: 5040aa6a6f49598f42f815210b97ad41 (MD5) / CAPES / Introdução: Após um acidente vascular cerebral (AVC), os pacientes podem apresentar alterações motoras, sensoriais e cognitivas, que consequentemente podem vir a comprometer o controle postural, predispor à ocorrência de quedas, limitar a capacidade funcional e a participação social. Desse modo, instrumentos de avaliação específicos e adequados para a avaliação do equilíbrio durante a marcha dessa população são fundamentais. Objetivo: Analisar as propriedades psicométricas do Índice Dinâmico da Marcha (IDM) em pacientes após AVC, residentes na comunidade e acompanhados em um ambulatório de doenças cerebrovasculares. Desenho: Estudo de corte transversal para análise de propriedades psicométricas através do modelo Rasch. Casuística e métodos: Os participantes haviam sofrido um AVC isquêmico, tinham até dois anos de lesão e marcha independente. Para avaliação das propriedades psicométricas do IDM foi realizada a análise Rasch, por meio do programa Ministeps versão 3.90.0. Resultados: Foram avaliados 70 pacientes, com média de idade de 54,53 (±14,29) anos, sendo que 42 (60%) eram do sexo feminino. A mediana da gravidade do AVC, avaliada através da National Institutes of Health Stroke Scale (NIHSS) foi de 1 (0-9) e a capacidade funcional, de acordo com o Índice de Barthel modificado (IBm) apresentou mediana de 50 (32-50). De acordo com a análise Rasch, modificações na ordem de aplicação dos itens do IDM podem ser realizadas, pois os itens difíceis foram realizar a marcha com movimentos horizontais da cabeça, ultrapassar obstáculos e realizar a marcha com movimentos verticais da cabeça. Os itens mais fáceis foram realizar a marcha e contornar obstáculos, em superfície plana e subir e descer degraus. O IDM foi considerado um constructo unidimensional, embora o item 6 tenha apresentado escores erráticos. Conclusões: Os resultados demonstram que o IDM representa um constructo unidimensional, mas que o avaliador tenha cautela ao aplicar o item 6 (ultrapassar obstáculos). No entanto, sugere-se uma revisão da ordem hierárquica dos itens do IDM para avaliação do equilíbrio durante a marcha de pacientes após AVC.

Introduction: The Antimicrobial Self-assessment Toolkit for Acute NHS Trusts (ASAT) was developed by a pharmacist reference group of an Advisory Non-Departmental Public Body on Antimicrobial Resistance and Healthcare Associated Infections (ARHAI). It was developed in conjunction with the Department of Health. The primary purpose of the ASAT is to identify and to measure the methods of implementation of antimicrobial stewardship programmes in acute NHS trusts. The face validity was previously tested by ARHAI. The overall aims of this programme of work were to investigate the validity of the ASAT and to make iterative changes to improve its validity. Ethical approval was not required for this PhD project because it was categorised as service evaluation by the LREC. Also, ethical approval from the University of Manchester Research Ethics Committee was deemed unnecessary at the time of the PhD project due to the nature of the data collected. Methods: A mixed methodology approach utilising a sequential exploratory strategy was used to investigate the validity of the ASAT. This PhD project was composed of four sequential studies which resulted in iterative changes to the ASAT, that is, from ASAT v15a to ASAT v18. In Study 1, cognitive interviews were conducted with eight antimicrobial pharmacists in order to investigate the content validity of ASAT v15a. In Study 2, both cognitive interviews and semi-structured interviews were conducted with 10 clinical microbiologists in order to investigate the content validity of ASAT v16. In Study 3, Rasch modelling and analyses using the Partial Credit Model (PCM) were conducted on the responses to ASAT v17 from 33 NHS trusts across England. In Study 4, simple OLS regression analyses were conducted using the NHS trust ‘ability’ estimates or calibrations and Clostridium difficile (CDI) rates of participating NHS trusts in order to investigate model fit and the predictive validity of the ASAT. Results: The cognitive interviews conducted in study 1 indicated that AMPs encountered cognitive difficulties along the cognitive processing pathway in response to ASAT v15a. These difficulties included comprehension in 27 (32.5%) questions and response generation/formatting in 13 (15.7%) questions. Also respondents indicated that the role of clinical microbiologists in ASPs was underrepresented in ASAT v15a. The interviews conducted in Study 2 were confirmatory in nature as they reflected the findings of Study 1. For example terms such as ‘formulary’ and ‘policy’ were misinterpreted by respondents. Rasch modelling and analysis showed that there were items within ASAT v17 which were underfitting and overfitting the Partial Credit Model. Item fit was investigated after removal of these items which resulted in improved fit for domains 2 and 5. ASAT v18 was developed after these analyses and was included items that were productive for measurement. On examination of the OLS regression analyses conducted in Study 4, it was seen that there was poor model fit and very limited predictive validity of the model. Conclusion: The iterative methodology utilised to investigate the validity and subsequently improve the ASAT was effective in establishing content and construct validity. However, the predictive validity of the ASAT was limited. This may be due to the outcome variable chosen for the OLS regression modelling. A more sensitive outcome measure such as compliance to treatment or prophylaxis guidelines may have been more effective at establishing predictive validity. The findings of this programme of work highlighted that there is further work required to validate the ASAT such as the determination of the appropriate weights and scores for ASAT domains and also the determination of the appropriate outcomes measures to determine the efficacy of ASPs. It is recommended that further validity testing should be conducted before a further iteration of the ASAT is used as a set of quality standards or as a hospital benchmarking tool

In this paper we consider conditional maximum likelihood (cml) estimates for item parameters in the Rasch model under random subject parameters. We give a simple approximation for the asymptotic covariance matrix of the cml-estimates. The approximation is stated as a limit theorem when the number of item parameters goes to infinity. The results contain precise mathematical information on the order of approximation. The results enable the analysis of the covariance structure of cml-estimates when the number of items is large. Let us give a rough picture. The covariance matrix has a dominating main diagonal containing the asymptotic variances of the estimators. These variances are almost equal to the efficient variances under ml-estimation when the distribution of the subject parameter is known. Apart from very small numbers n of item parameters the variances are almost not affected by the number n. The covariances are more or less negligible when the number of item parameters is large. Although this picture intuitively is not surprising it has to be established in precise mathematical terms. This has been done in the present paper. The paper is based on previous results [5] of the author concerning conditional distributions of non-identical replications of Bernoulli trials. The mathematical background are Edgeworth expansions for the central limit theorem. These previous results are the basis of approximations for the Fisher information matrices of cmlestimates. The main results of the present paper are concerned with the approximation of the covariance matrices. Numerical illustrations of the results and numerical experiments based on the results are presented in Strasser, [6].

The aim of this study was to investigate the quality of the Annual National Assessment (ANA) Grade 6 mathematics instrument including its design, with reference to a single education district. The main question that was investigated was: To what extent does the 2012 Annual National Assessment Grade 6 mathematics assessment instrument provide meaningful information for making appropriate interpretations on district level? The conceptual framework underpinning this study was drawn from the Queensland Studies Authorities Assessment Policy document. The research comprised a secondary analysis design applying mixed methods using the scripts of 546 learners in one district from 5 schools selected to represent a range of achievement. A content analysis of the instrument was undertaken, followed by a statistical item analysis applying the Rasch measurement model. These analytical methods were utilised to determine the quality of the ANA Grade 6 mathematics instrument. Content validity, construct validity and reliability was investigated in order to evaluate inferences that were made and actions that were taken based upon the mathematics performance of learners in Grade 6 in the Gauteng North District (GND) in the year 2012. The investigation revealed that construct validity and content validity were largely achieved, as items were appropriately aligned to the 2012 ANA Grade 6 mathematics curriculum. However errors in mathematics and language formulation detracted from the validity of the instrument. In the case of some items, lack of clarity may have confused learners. As far as reliability is concerned the investigation revealed that the instrument had a reasonable person separation index, a measure of both item and person reliability. However, these conclusions are based on a relatively small sample from only one district and therefore has somewhat limited applicability but is nevertheless of educational consequence. / Dissertation (MEd)--University of Pretoria, 2017. / Science, Mathematics and Technology Education / MEd / Unrestricted

Post-Apartheid South Africa has undergone an educational language policy shift from only Afrikaans and English in education to the representation of all 11 official languages: Afrikaans, English, isiZulu, isiXhosa, isiNdebele, siSwati, Sesotho, Setswana, Tshivenda and Xitsonga. The national languages policy included the Language in Education Policy (LiEP), which stipulates that learners from grades 1- 3 in all ways possible should be provided the opportunity to be taught in their home language (HL). With this change, there has been a need to increase access to African languages in education. The 2007 Status of LoLT report released by the Department of Education (DoE) revealed that since 1996 up to 65% of learners in the foundation phase are being taught in their home language. In other ways, the LiEP has been successful in bridging the gap of access to African languages in the basic education system. With that said, there has been rapid growth of interest in early childhood crosscultural literacy assessment across the globe. Internationally South Africa has participated in the Southern and Eastern Africa Consortium for Monitoring Education Quality as well as the Progress in International Reading Literacy Study studies. The design of these particular international studies meant participation in the same assessment but in different languages, calling into question the equivalence of assessments across languages. Assessing across languages should aim to encourage linguistic equivalence, functioning equivalence, cultural equivalence as well as metric equivalence. South Africa has taken part in three cycles of the Progress in International Reading Literacy (PIRLS) study. The purposes of the current study is to present secondary analysis of the prePIRLS 2011 data, to investigate any differential item functioning (DIF) of the achievement scores between English and isiXhosa. The Organisation for Economic Co-operation and Development (OECD) developed a framework of input, process and output for curriculum process. The framework shows the multiple facets that needs to be considered when implementing a curriculum in a country. The curriculum process framework was used as the theoretical framework for this study. The framework views curriculum success as a process of measuring how the intended curriculum (input) was implemented (process) and should be reflected in the attained curriculum (output). The adapted framework is LiEP as the attained curriculum, as learners in the prePIRLS 2011 are tested in the LoLT in Grades 1-3. Followed by the prePIRLS 2011 assessment, as the implemented curriculum testing the learners’ comprehension skills requires by grade 4 in their HL. Lastly, the attained curriculum refers the learners’ achievement scores in the prePIRLS 2011 study. A sample of 819 Grade 4 learners (539 English L1 speaking learners and 279 isiXhosa L1 speakign learners) that participated in the prePIRLS 2011 study were included in this study. These learners wrote a literary passage called The Lonely Giraffe, accompanied by 15 items. The study made use of the Rasch model to investigate any evidence of Differential Item Functioning (DIF) on the reading achievement of the learners. The findings showed that the items did not reflect an equal distribution. In addition, an item by item DIF analysis revealed discrimination on one subgroup over the other. A further investigation showed that these discriminations could be explained by means of inaccurate linguistic equivalence. The linguistic equivalence could be explained by means of mistranslation and/or dialectal differences. Subsequently, the complexities of dialects in African languages are presented by providing isiXhosa alternative translations to the items. The significance of the current study is in its potential contribution in further understanding language complexities in large-scale assessments. Additionally, in attempts to provide valid, reliable and fair assessment data across sub-groups. / Dissertation (MEd)--University of Pretoria, 2017. / Science, Mathematics and Technology Education / Centre for Evaluation & Assessment (CEA) / MEd / Unrestricted

La presencia de cualquier tipo de disfunción visual, refractiva, acomodativa y/o binocular, puede provocar la aparición de síntomas visuales que afecten al nivel de confort del paciente cuando se realiza una tarea visual. Aunque estos síntomas son frecuentes, la literatura científica muestra disparidad en cuanto a cuáles son los que están asociados a las disfunciones, tanto en el modo de preguntar por ellos como en la forma de calibrar su severidad. En lo que se refiere a la recogida de los síntomas, existen diversos cuestionarios que evalúan la sintomatología visual en determinadas condiciones, como el uso de las lentes de contacto, el síndrome visual informático, el disconfort visual o la insuficiencia de convergencia. Sin embargo, hasta la fecha no se ha desarrollado ningún cuestionario que analice los síntomas de cualquier disfunción visual (refractiva, acomodativa y/o binocular), a pesar de que sería interesante disponer de una herramienta validada con la que poder ayudar en el diagnóstico de estas anomalías y monitorizar su tratamiento. Es por ello que el objetivo general de esta investigación es desarrollar y validar un cuestionario sobre la sintomatología asociada a las disfunciones visuales, que pueda ser utilizado en una población clínica. Para el desarrollo y validación de un cuestionario no existen unas pautas definidas ni unos pasos estrictos a seguir, pero sí se recomiendan varios tipos de análisis a incluir para que el cuestionario tenga una buena calidad, y estos deben ser: la identificación de los ítems, la selección de los ítems, el análisis psicométrico, la exactitud diagnóstica, la validez y la repetibilidad. En esta tesis doctoral se realizaron todos los análisis reseñados. En primer lugar, para identificar los ítems, se analizó la opinión de los profesionales de la visión mediante una metodología Delphi, preguntando sobre qué síntomas estaban asociados a las disfunciones visuales y cuáles de ellos deberían utilizarse en un cuestionario sobre sintomatología visual. Para el desarrollo de la metodología Delphi, se constituyó un grupo coordinador y un grupo de 14 expertos optometristas españoles de reconocido prestigio profesional. El grupo coordinador planteó al grupo de expertos el problema en cuestión, tratándolo en tres rondas. Partiendo de los resultados obtenidos en metodología Delphi, para la selección de ítems se desarrolló un cuestionario con 47 preguntas basadas en los síntomas visuales recomendados por los expertos participantes del método Delphi. Se realizó una primera reducción cualitativa mediante un pretest cognitivo, eliminando los ítems redundantes y quedando el cuestionario reducido a 33 ítems. Este cuestionario piloto, denominado Symptom Questionnaire for Visual Dysfunctions (SQVD), se pasó a una muestra de 125 sujetos de un establecimiento sanitario de óptica. Se incluyeron a sujetos con edades entre 15 y 84 años y ausencia de cualquier patología ocular. Se realizó una reducción psicométrica de ítems mediante análisis Rasch, incluyendo en este análisis las curvas de probabilidad de respuesta, ajuste de los ítems al modelo usando los estadísticos infit y outfit, dependencia local a través del estadístico Yen-Q3, análisis del funcionamiento diferencial de los ítems (differential item functioning, DIF), fiabilidad de la separación de las medidas de las personas y de los ítems, unidimensionalidad mediante el análisis de componentes principales de los residuales y medida del alineamiento entre ítems y personas (targeting). Utilizando el análisis Rasch también se calculó la tabla de transformación de puntuación ordinal a intervalos. Tras realizar todos estos análisis, se obtuvo una versión del SQVD de 14 ítems con tres categorías de respuesta, donde los datos se ajustan adecuadamente al modelo de Rasch. Con el fin de validar el cuestionario SQVD de 14 ítems, éste se distribuyó en una muestra clínica de 306 pacientes de una consulta optométrica, con edades entre 14 y 87 años, donde 204 sujetos tenían algún tipo de disfunción visual (132 disfunciones refractivas y 72 disfunciones de la visión binocular). Se realizó un análisis Rasch para evaluar las propiedades psicométricas del cuestionario donde se evaluaron los siguientes parámetros: curvas de probabilidad de respuesta, ajuste de los ítems al modelo usando los estadísticos infit y outfit, funcionamiento diferencial de los ítems (DIF), fiabilidad de la separación de las medidas de las personas y de los ítems, medida del alineamiento entre ítems y personas (targeting), dependencia local a través del estadístico Yen-Q3 y unidimensionalidad mediante el análisis de componentes principales de los residuales. Además, se analizó la exactitud diagnóstica mediante las curvas ROC (Receiver Operator Characteristic) utilizando como Gold-estándar los síntomas descritos en la historia clínica. También se evaluó la validez del cuestionario mediante la validez concurrente, medida que representa el nivel de correlación entre la puntuación del cuestionario y la puntuación de las medidas clínicas, y la validez de grupos conocidos, análisis que mide el grado en que el instrumento puede discriminar entre grupos clínicamente diferentes. Por último, se examinó la repetibilidad del cuestionario mediante el coeficiente de correlación intraclase (ICC), distribuyéndolo de nuevo a 50 personas una semana después de la primera visita. Los resultados del análisis psicométrico mostraron que el SQVD tiene categorías de respuestas ordenadas, los 14 ítems se ajustaron al modelo, no existiendo DIF significativo para sexo, presbicia y disfunciones, la fiabilidad de la separación de las personas e ítems fue adecuada, al igual que el targeting, además de mostrar unidimensionalidad y no presentar dependencia local entre los ítems. Asimismo, el SQVD obtuvo buena exactitud diagnóstica, adecuada validez concurrente, buena validez de grupos conocidos y muy buena repetibilidad. Como conclusión, los resultados de esta tesis doctoral muestran que el SQVD tiene buenas propiedades psicométricas, presenta buena exactitud diagnóstica, siendo un cuestionario válido y repetible para detectar la presencia y frecuencia de síntomas visuales relacionados con cualquier tipo de disfunción visual, bien sea refractiva, acomodativa o binocular. Por lo tanto, esta herramienta puede usarse en la práctica clínica para identificar sujetos con síntomas asociados a las anomalías visuales, así como en estudios de investigación.

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