Background: Cleft lip and/or palate (CL/P) is a complex, heterogeneous disorder which occurs due to the interplay between environmental and biological risk factors. Individuals in lower-middle-income countries (LMICs) are exposed to a multitude of risk factors resulting in a greater occurrence of CL/P. Research and knowledge of which risk factors are associated with CL/P in LMICs may aid health care professionals such as speech-language therapists in low-income countries in the early identification of at-risk infants. Objective: To identify and review published data on the risks associated with CL/P in LMICs. Design: A systematic review of literature was performed on electronic databases using the PRISMA-P. Literature on risks associated with CL/P in LMICs, from 2010 to 2020 was included. Results: Seventeen studies met the inclusion criteria. All studies adopted an observational study design. Biological and environmental risks were identified. Maternal and paternal age (n=7) and low socioeconomic status (n=5) were the most prominently associated environmental risk factors. Regarding biological risk factors, a strong association was identified between family history of cleft (n=7) and CL/P occurrence. Conclusion: Environmental risk factors are now being investigated more than biological risk factors in LMICs, hindering health care workers in the early identification (EI) of the possible cumulative effects of risks in CL/P. Contextually-relevant tools are recommended to promote the EI of at-risk infants. / Dissertation (MA (Speech-Language Pathology))--University of Pretoria, 2021. / Speech-Language Pathology and Audiology / MA (Speech-Language Pathology) / Unrestricted

The period of health care transition (HCT) for adolescents and emerging adults with special health care needs and disabilities involves a complex realignment of the parent–child relationship, including alterations in role responsibilities and decision making. The purpose of this systematic review was to analyze the research designs, methodology, and findings reported in studies of parents during this transition period to provide new insights for research and clinical practice. Results showed that parents were unable to clearly envision what the future held for their children and were not well prepared by the service system to anticipate future prospects. These parents have a myriad of needs that are not yet fully understood, as HCT research is in the early stages of development.

Despite efforts towards the management and prevention of Tuberculosis (TB) having shown some success, Multidrug-Resistant Tuberculosis (MDR-TB) may potentially compromise these endeavours. MDR-TB has the potential to become the most dominant form of TB in low- and middle-income countries (LMICs). The impact of environmental health factors on the optimization of health of MDR-TB infected individuals, as well as on the prevention of transmission to household contacts, is not well documented. Current Sustainable Development Goals (SDGs) aim to achieve inclusivity, sustainability and resilience, not only through economic and social changes, but also through environmental targets in order to achieve optimal health and well-being for all. However, without appropriate acknowledgment of the environment's influence on outcomes during TB treatment, these targets are potentially unattainable. Establishing the recommendations of environmental health risk factors for individuals living at home with MDR-TB will have important policy implications as well as assist in decision making for those affected with MDR-TB in LMICs, such as South Africa. This systematic review, therefore, sought to identify the environmental health factors in LMICs that affect treatment outcomes for individuals living at home with MDR-TB, to optimize their health during completion of their treatment regimen and prevent transmission to household contacts. Part A outlines the current literature available for such a topic as well as methodology used within the systematic search and analysis of included articles. Prominent environmental health exposure variables of interest that have previously been identified as having a significant role in TB transmission or influencing the well-being of infected individuals, were identified within the literature. These included air pollution, nutrition, migration, urbanization, smoking, alcohol, other substance use and housing. Outcomes of interest included optimization of health and prevention of MDR-TB transmission to household contacts. The article (part B) represents the results from the systematic search as well as the application to current policy recommendations. After screening and reviewing the full text of potential articles for inclusion (N = 87), only thirteen articles were eligible for inclusion into the final sample. All included studies were primary observational studies, examining the relationship between MDRTB and the pre-defined exposures and outcomes in populations ≥13 years of age. Environmental risk factors for household transmission of MDR-TB potentially included malnutrition but showed no significant relationship with overcrowding. There was disagreement as to whether smoking was as a significant predictor of mortality but findings did indicate that smoking did have a negative impact on sputum culture conversion among patients receiving treatment. Other substance use was found to have a significant role in the default of treatment. The use of alcohol was associated with poor treatment outcomes, default of treatment and lack of sputum culture conversion. In terms of household conditions, an association was found between substandard housing conditions and treatment default. Formal housing was associated with a decline in treatment default but a residential address change was associated with defaulting treatment. The results of the review presented contradictory results regarding the risk of mortality and underweight/overweight BMI estimates. The review potentially highlighted vulnerable population groups including gender groups, children and HIV positive individuals. Therefore, this systematic review highlighted the potential relationship between environmental risk factors and optimising the health of individuals on treatment for MDR-TB, as well as the role that promoting environmental health may play in preventing the transmission to household contacts. In conclusion, environmental risk factors should be incorporated into local health system strategies and global policy. This includes WHO targets in TB prevention efforts, as well as in action areas for the attainment of relevant SDGs (e.g. SDG 3 and SDG 5), to address the burden of MDR-TB and decrease MDR-TB transmission in LMICs, effectively and sustainably.

Introduction: Medicines are an important component of any health system. Even though the importance of medicines in the health system is indisputable, one of the major concerns remains the risk of adverse drug reactions when used by consumers. Adverse drug reactions place a burden on the healthcare system, usually as a result of complications requiring hospital admission or extended hospital admissions. In Africa, about 28.6% of adverse drug reactions reported in Africa were due to antiretroviral therapy. Recently, the adoption of the “test and treat” policy by the World Health Organisation increased the number of people receiving antiretroviral therapy. Therefore, this systematic review was conducted to explore the magnitude of antiretroviral therapy-related adverse drug reactions hospitalisations, and mortalities in the region, following the increase in people initiating therapy, and the implications to the service delivery component of the healthcare system. Methods: In March 2021, PubMed, EBSCOHost, and SCOPUS, databases were systematically searched for appropriate articles. The selection of articles was based on predefined inclusion and exclusion criteria. Data from included articles were extracted as per a set of defined criteria into a data extraction form. A meta-analysis was done using Stata package software 15.0 using Stata “metaprop” command. Results: The pooled prevalence of adverse drug reactions hospitalisations in all studies was 26.5% (95% confidence interval:18.4,35.4) and that of mortality was 6.1% (95% confidence interval:2.1,11.7). The most prevalent adverse reactions reported include hepatotoxicity, kidney injury, lactic acidosis, skin, neurologic, and hematologic reactions. The antiviral implicated, are non-nucleoside reverse transcriptase inhibitors, nucleoside/tide reverse transcriptase inhibitors, and protease inhibitors. The pediatric population was underrepresented as only two studies included pediatric patients. The economic impact of adverse reactions was impossible to estimate, as only one study reported on financial implications. Conclusion: Antiretroviral therapy-related adverse reactions hospitalisations and mortalities have a high prevalence in Africa. There are concerns about age-related morbidities and lifestyle diseases as risk factors related to adverse reactions. To adequately combat adverse reactions associated with antiretrovirals, African country health systems need multidisciplinary actions to strengthen strategies for prediction, identification, reporting, and prevention of adverse reaction occurrence.

Background: Low back pain is very common and has a tremendous economic impact. With the prevalence and incidence of low back pain on the rise, individuals are turning to alternative treatments. Yoga is the most widely used complementary and alternative medicine treatment for low back pain and it is not fully certain how effective this method is for resolving the symptoms. Objectives: The purpose of this manuscript is to systematically review the current literature for randomized controlled trials that assess the outcomes of yoga intervention in individuals with low back pain. Methods: An electronic database search was performed to analyze studies. To be included in the review, the studies were required to be a randomized controlled trial, published in English, present in a peer reviewed journal, identify yoga as the primary treatment focus for low back pain in at least one group, and included participants with at least a 12 week history of low back pain. Results: A search of the databases revealed 177 articles, of which, 8 met the inclusion criteria. Conclusions: Yoga intervention appears to be effective in alleviating symptoms brought on by low back pain. Yoga was either demonstrated to significantly improve quality of life and reduce disability, stress, depression, and medication usage associated with low back pain in 6 of the 8 analyzed trials. More research is necessary to account for the lack of between-group differences in two trials.

Environmental educators work to create an environmentally literate citizenry that is willing and able to tackle complex environmental problems such as climate change, potable water availability, and biodiversity loss. Environmental education (EE) research is a robust field that links practice and research, but lacks a comprehensive model connecting practices and outcomes. The goal of this grounded theory systematic review (GT-SR) was to create a model that identifies the context, strategies, outcomes, and core category associated with EE for secondary students in the United States (U.S.). Systematic review methods were used to locate and screen relevant, peer-reviewed research indexed in academic databases. The first search term, "environmental education," identified studies about EE. To narrow results to those focused on secondary education (grades 6–12), twelve search terms related to middle school and high school were used. After limiting the search to studies published between 2011 and 2018 and in English, 1,009 unique citation records were identified. A screening process for relevancy and quality excluded 982 records leaving 27 studies in the initial final sample. Theoretical sampling identified an additional 12 studies through a second database search and ancestry searching. Data from the 39 studies were analyzed through initial, focused, and theoretical coding using the constant comparative method. During initial coding, descriptive and In Vivo codes were used to organize the data into meaningful chunks. Focused and theoretical coding were used to further abstraction and identify categories. "Authenticity" emerged as the core category suggesting that, in order to be effective, EE for secondary students in the U.S. must be viewed as authentic in the eyes of the participants. The coding process informed the development of the Implementation of Authentic Environmental Education Programs (IAEEP) model. Although not designed to be applicable to all contexts, the model will aid EE practitioners in developing and implementing EE programs for secondary students in the U.S. and guide researchers as they evaluate EE programs. The development of the model also supports the use of a GT-SR as an appropriate and useful method for identifying, screening, and analyzing existing research to create a theoretical model. / Doctor of Philosophy / Environmental educators work to create an environmentally literate citizenry that is willing and able to tackle complex environmental problems such as climate change, lack of potable water, and loss of biodiversity. Environmental education research is a robust field that links practice and research, but lacks a comprehensive model that connects practices with agreed-upon outcomes. This systematic review used a grounded theory approach to create a grounded theory model that identifies the strategies, context, conditions, core category, and outcomes associated with environmental education for secondary students in the United States. Systematic review methods and theoretical sampling were used to locate and screen relevant, peer-reviewed environmental education research. Data from the primary studies were analyzed using initial, focused, and theoretical coding using the constant comparison method. Integration of data from the systematic review and theoretical sampling informed the development of the Implementation of Authentic Environmental Education Programs (IAEEP) model. This model will aid practitioners in developing and implementing environmental education programs for secondary students and guide researchers as they further evaluate environmental education programs.

In the development of a BMJ Rapid recommendation – an international practice guideline initiative led by the MAGIC Evidence Ecosystem Foundation, and aiming to produce trustworthy, accessible and timely guidance – of plasma exchange and dosage of corticosteroids for patients with ANCA-associated vasculitis (AAV) (Chapter 2) two methodological issues arose. The first issue is related to the rating of the certainty of evidence supporting the recommendations. Reviewers experienced challenges in making an explicit statement about what it was in which they were rating their certainty (i.e., the target of the rating of certainty of evidence). Through iterative discussions and presentations at GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) Working Group meetings, the research team developed new GRADE guidance (Chapter 3 and 4) to help systematic reviewers be aware of the importance of determining the target of their rating of certainty of evidence and provided practical principles to help systematic reviewers specify this target. The second issue arose from the process of moving from evidence to decisions. To help the BMJ Rapid recommendation panel interpret the magnitude of benefit and harm associated with plasma exchange, which required understanding patient values and preferences, the research team created a panel survey for eliciting the panelists’ view regarding patient values and preferences. The research team then applied the panel survey approach in some other guidelines. Based on the experience of developing panel surveys, and through iterative discussions and consensus, the research team developed a framework for using surveys to guide guideline panels in making inferences regarding patient values and preferences (Chapter 5). Using interpretive description, the team conducted a qualitative evaluation regarding the influence of the panel surveys on the panels’ understanding of patient values and preferences, interpretation of magnitude of benefits and harms, and on panels’ decision on guideline recommendations (Chapter 6). The panel surveys proved to help guideline panels explicitly consider and incorporate patient values and preferences in making recommendations. / Thesis / Candidate in Philosophy

Informal caregiving is growing in demand and is far from a uniform experience. Some caregivers report burdensome effects, while others attest to a wide range of benefits associated with their role. In the context of informal caregivers of persons affected by chronic neurological conditions (CNCs), psychological resilience is increasingly being explored as a protective factor that may account for variability in the caregiver experience; however, multiple sclerosis (MS) caregivers are noticeably absent from this body of work. To synthesize current evidence concerning resilience conceptualizations, assessments, and health correlates within this population, this thesis included a systematic review of resilience in CNC informal caregivers in which MS caregivers were unrepresented. Following this review, a qualitative study was conducted in informal MS caregivers to ascertain MS caregivers’ conceptualizations and unique lived experiences of resilience. Twenty-four semi-structured interviews of Canadian MS informal caregivers were conducted. Informed by the socioecological model of resilience in caring relationships, transcripts were analyzed using flexible thematic analysis. In support of the conceptual ambiguity of resilience, caregivers did not concur on a single resilience conceptualization. Emergent themes contributed to the creation of a cyclical model of resilience that incorporates adversity in the form of continuous loss and obstructed health-related self-care, individual and community resources, and multilevel adaptive pathways. We use our model to prompt future research directions and inform the development of effective resilience-enhancing interventions for MS caregivers.

The broad purpose of this dissertation is to enhance the quality of managerial decisions through evidence-based management. Specifically, it raises three key questions: What is evidence? What are the attributes of knowledge that can facilitate informed decision making? How can such knowledge be generated? To answer these questions this thesis proposes a theory of evidence, suggesting that the strength of evidence is contingent upon its methodological fit, contextuality, transparency, replicability, and consensus. A model of evidence-based decision making is offered that explores how managers’ judgment, experience, and personal values along with the values of other stakeholders, contextual factors, and ethical constraints, may affect the decision process. Moreover, this thesis argues that in order to foster evidence-based management practice we need knowledge that is rigorous, relevant and actionable. To this end, a theory of actionability is proposed, and an empirical study is conducted to determine the attributes of actionable management knowledge. Based on the study, an actionability index is suggested. Evidence that is actionable requires sustainable collaborative effort to produce, curate and communicate. To accomplish that a theory of evidence-based collaboration is proposed. This theory conceives the collaboration as an independent organization that oversees the process of bringing rigour, relevance, and actionability together, and provides an interactive platform for producers, arbiters and users of management knowledge to communicate and collaborate. A template, guided by the theory of collaboration, is designed to produce systematic reviews that are useful for management practice. / Dissertation / Doctor of Philosophy (PhD)

Background: Suicide is a worldwide concern, claiming nearly one million lives each year. The causes of suicidal behaviour are unclear, but a variety of biological, psychological, social, and environmental factors are thought to contribute to suicide risk. Many cases of suicidal behaviour cannot be explained by conventional risk proposed by clinical and research observations. Recent research has focused on biomarkers of suicidal behaviour, including brain-derived neurotrophic factor (BDNF). This thesis aims to determine the association between BDNF and suicidal behaviour by reviewing the literature and by analyzing clinical data. An additional aim of this thesis is to explore the associations between social factors and suicidal behaviour, with a particular focus on sex differences within these factors. Methods: We explored the associations between biological and social risk factors and suicidal behaviour in several ways. We conducted a systematic review to summarize and evaluate the literature regarding BDNF levels and suicidal behaviour. The protocol for this systematic review was designed and published a priori. We performed a qualitative review of the literature and a meta-analysis of studies of serum BDNF and attempted suicide. Then, we assessed the association between serum BDNF and attempted suicide using a case-control study design. We analyzed data collected from the Study of Determinants of Suicide Conventional and Emergent Risk (DISCOVER), and age- and sex-matched study of attempted suicide. In a sample of 250 participants (84 cases of attempted suicide, 104 psychiatric controls, and 93 community controls), we used linear regression analysis to determine the association between BDNF level and attempted suicide, adjusting for age, sex, body mass index, current smoking status, and antidepressant use. Finally, using the same dataset, we explored the associations of a number of social factors with attempted suicide. In a sample of 343 participants (146 cases, 104 psychiatric controls, and 93 community controls), we used logistic regression analyses to determine the associations between social risk factors and attempted suicide in men and women separately. These included age, education level, employment status, marital status, religious practice, stressful life events, and childhood abuse. Results: Our systematic review included 14 studies. The meta-analysis of three studies of serum BDNF and attempted suicide showed no significant association. The qualitative review of all studies revealed inconsistent findings regarding associations between BDNF and suicidal behaviour. In our study of serum BDNF and attempted suicide in the DISCOVER dataset, attempted suicide was not significantly associated with BDNF level. In our study of social factors for attempted suicide, some sex differences were found: Completion of post-secondary education and religious practice were found to be significant protective factors against attempted suicide only in women, and unemployment and stressful life events were significant risk factors only in men. Conclusion: This thesis provides important findings about the biological and social risk factors for suicidal behaviour. Understanding the determinants of suicidal behaviour can aid clinicians in identifying and treating vulnerable individuals. / Thesis / Master of Science (MSc)