Increasing symptom awareness, encouraging help-seeking, and facilitating timely referral are key for improving cancer outcomes, particularly for cancers such as oesophageal and gastric (stomach), where five-year survival is less than 20%. In this research, I used multiple methods to explore factors that influence timely diagnosis of these cancers from a patient's perspective, with a particular focus on health literacy (accessing, understanding and using health information, and navigating healthcare systems). I started by exploring current knowledge in this field before conducting a systematic review investigating health literacy in the timely diagnosis of symptomatic cancer. Literature was searched from January 1990-May 2017 using six bibliographic databases. I screened 2304 titles/abstracts, assessed 26 full-text papers and included three, although they were methodologically weak, therefore limiting the conclusions. To examine pathways to diagnosis for oesophageal and gastric cancer, I conducted a questionnaire study of newly diagnosed patients across two hospitals in the East and North East of England. 127 participants were recruited (39.6% recruitment rate), aged 44-96 (median 71); 102 male (80%). Most had oesophageal cancer (n=102, 80%); 64 (50%) of the total cohort were late-stage at diagnosis. Common pre-diagnostic symptoms varied between cancers (oesophageal: difficulty swallowing (n=66, 65%), painful swallowing (n=55, 54%); gastric: fatigue/tiredness (n=20, 80%), weight loss (n=13, 52%)). The questionnaire included two domains (engagement, understanding) of the Health Literacy Questionnaire with participants demonstrating high health literacy (mean 4.18 and 4.28, score 1-5). The median time from noticing the trigger symptom (prompting help-seeking) to diagnosis was 81 days (IQR 45-137.5, n=107). Twenty-six participants were purposively sampled, from questionnaire respondents, for face-to-face interviews (aged 55-88, 18 male, 15 with oesophageal cancer). I undertook thematic analysis to explore participant accounts of their pathways to diagnosis, identifying that the symptom nature was important for appraisal, while health literacy ability influenced the health system interval. Descriptions of 'heartburn', 'reflux' and 'indigestion' differed between participants, suggesting these terms may introduce uncertainty in relation to symptom experience. This is the first study to explore the role of health literacy in the timely diagnosis of symptomatic cancer, and pathways to diagnosis for oesophageal and gastric cancers, from a patient's perspective. Findings provide important insights for the development of targeted awareness campaigns and strategies enhancing GP symptom exploration.

Made available in DSpace on 2016-04-27T18:12:01Z (GMT). No. of bitstreams: 1 Treyce Rosemary Christina Vicente De Lucca.pdf: 621082 bytes, checksum: 976547f43ddfde8be8502364209a9de4 (MD5) Previous issue date: 2013-07-30 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / This Project is part in the line of research in Language and Subjectivity Of Postgraduate Program In Speech Pathology Of Pontifícia Universidade Católica de São Paulo (PUC-SP). It is a deployment of The Literacy Project and their Avatars, associated to the Observatory Education Program (OBEDUC). The writing acquisition by the child is beyond the age, since the subject, to be regarded as reader and writer, goes through a process that includes findings, successes and failures. Are the effects of these errors and successes that the child submit or not the rules of language and assume a tongue. Objective: Evaluate the therapeutic speech permissive intervention when compared with the prescriptive, optional and interdictive models of the use of reading and writing in learners with learning difficulties. Methodology: Type of study: A systematic review of randomized clinical trials and quasirandomized clinical trials. Search strategy: the following databases were searched: MEDLINE, CENTRAL, EMBASE LILACS, PSYCINFO e ERIC. Discernment for selection studies: clinical trials that evaluated any speech therapy techniques for learners with learning difficulties. Data collection and analysis: the extraction and evaluation of methodological quality of included studies performed by two independent reviewers. Results: 637 references were identified by the mean databases, resulting in 12 studies selected. In these studies was possible evidence a diversity regarding the efficacy of interventions. It is possible notice one or more means of intervention at the same search. In the selected studies there is not a significative differences concerning the sex of the research subjects. Most of the subjects analyzed were children or teenagers between 0 to 15 years of old. This is an expected factor, once this is the chronological age for the formation of a reader and a writer. Conclusion: It is possible note that the interventions practices are used by audiologists are not described of the way that are proposed by organizational model of the language symptoms in Speech. It was observed that all interventions are improvements related to learning, but we highlight the need for further studies to prove the efficacy, since research was found improvements by itself, beyond the same research suggest the need for future studies to validation of the results obtained / Este projeto insere-se na linha de pesquisa Linguagem e Subjetividade do Programa de Estudos Pós-Graduados em Fonoaudiologia da Pontifícia Universidade Católica de São Paulo (PUC-SP). Trata-se de um desdobramento do projeto A Alfabetização e seus Avatares, vinculado ao programa Observatório de Educação (OBEDUC). A aquisição da escrita pela criança está para além da faixa etária, dado que o sujeito, para ser considerado leitor e escritor, passa por um processo que inclui descobertas, erros e acertos. São pelos efeitos desses erros e acertos que a criança se submete ou não às regras da linguagem e assume uma língua. Objetivo: Avaliar a intervenção terapêutica fonoaudiológica permissiva quando comparada aos modelos prescritivos, facultativos e interditivos do uso da leitura e da escrita em alfabetizandos com dificuldades de aprendizagem. Metodologia: Tipo de estudo: Revisão sistemática de ensaios clínicos randomizados e quase-randomizados. Estratégia de busca: Foram pesquisadas as seguintes bases de dados: MEDLINE, CENTRAL, EMBASE LILACS, PSYCINFO e ERIC. Critério para a seleção dos estudos: Os ensaios clínicos que avaliaram quaisquer técnicas fonoaudiológicas em alfabetizandos com dificuldades de aprendizagem. Análise e coleta de dados: A extração e a avaliação da qualidade metodológica dos estudos incluídos realizada por dois revisores independentes. Resultados: 637 referências foram identificadas pelas principais bases de dados, resultando em 12 estudos incluídos, nos quais se constatou provável diversidade referente às eficácias das intervenções. É possível notar um ou mais meios de intervenção em uma mesma pesquisa. Nos estudos selecionados, não houve diferenças significantes referentes ao sexo dos sujeitos analisados. A maioria deles eram crianças ou adolescentes, na faixa etária de 06 a 15 anos de idade, sendo este um fator esperado, uma vez que esta é a idade cronológica para constituição de um leitor e escritor. Conclusão: É possível notar que as práticas de intervenção utilizadas pelos fonoaudiólogos não são descritas da maneira como proposto pelo modelo de organização dos sintomas de linguagem em Fonoaudiologia. Foi observado que todas as intervenções apresentam melhoras referentes à aprendizagem, mas destacamos a necessidade da realização de outros estudos para comprovação de suas efetividades, uma vez que foram encontradas pesquisas que obtiveram esta melhora, além das mesmas apontarem a necessidade de estudos futuros para validação dos resultados obtidos

Introdução: Com o avanço das tecnologias para saúde, novas opções terapêuticas estão emergindo, incluindo aquelas direcionadas para doenças raras, e cuja eficácia e segurança são de difícil determinação quando utilizados os métodos originalmente delineados para as doenças frequentes. Nesse caso, as revisões sistemáticas sobre os tratamentos existentes para doenças raras, cujos custos são elevados, são importantes para o processo de tomada de decisões a fim de definir o perfil de pacientes que mais provavelmente responderão positivamente a cada tratamento. A mucopolissacaridose tipo I (MPS I) é uma doença autossômica recessiva causada pela ausência ou deficiência da atividade da hidrolase lisossomal alfa-L-Iduronidase, com amplo espectro clínico e envolvimento multissistêmico. A terapia de reposição enzimática (TRE) intravenosa (IV) com laronidase a 0,58 U / kg / infusão semanal está atualmente aprovada para tratar estes pacientes em diferentes cenários clínicos. O objetivo do presente estudo foi avaliar a eficácia e segurança da TRE IV com laronidase para o tratamento de pacientes com MPS I. Métodos: Revisão sistemática da literatura com buscas realizadas no Clinical Trials, MEDLINE / PubMed, EMBASE, LILACS e Cochrane Library. A pesquisa foi limitada aos ensaios clínicos publicados até 31 de dezembro de 2015. O primeiro critério de inclusão foi o de ser um ensaio clínico randomizado (ECR) comparando laronidase a placebo; se fossem identificados menos de 5 ECR, seriam incluídos também ensaios abertos e não randomizados, controlados ou não (quasi-experimentais) (≥ 5 pacientes) que avaliassem resultados relevantes definidos a priori. A revisão sistemática foi conduzida de acordo com a Colaboração Cochrane, e a meta-análise foi feita pelas diretrizes PRISMA. Em relação aos desfechos para os quais a meta-análise não pode ser realizada, aqueles com classificação GRADE igual ou superior a MODERADO foram considerados como indicadores de evidência sobre a eficácia ou segurança. Resultados: A fase de seleção encontrou 613 artigos. Durante a primeira fase de seleção, 66 artigos duplicados foram eliminados, e 547 artigos foram selecionados, dos quais 155 tiveram texto completo ou resumo avaliado para elegibilidade. Destes trabalhos, o número final de artigos incluídos chegou a nove para a síntese qualitativa (apenas dois ECR). Quatro estudos foram incluídos na meta-análise, sendo possível realizá-la para os seguintes desfechos: ocorrência de eventos adversos relacionados ao ratamento ou infusão (65%), leves na maioria dos casos (rash, urticaria e febre), desenvolvimento de anticorpos IgG para a laronidase (88%), índice de apnéia-hipopnéia [média de mudança = 0,05 (IC 95% -10,3, 10,4)], glicosaminoglicanos urinários (GAGs) [média de mudança = - 65,5 μg / mg creatinina (IC 95% -68,8, -62,3)], tamanho do fígado [média de mudança = -31.03% (IC 95% -36,1, -25,9)], índice de massa do ventrículo esquerdo [média de mudança = 0,49 (IC 95% -2,3, 3,3)], distância coberta no Teste de Caminhada de 6 minutos [média de mudança = 17,25 (IC 95% -6,64, 41,13)]. Em relação aos desfechos para os quais a meta-análise não pode ser realizada, encontramos evidência de benefício da laronidase em relação à flexão de ombros. Conclusões: Como esperado para doenças raras, encontramos poucos ensaios clínicos sobre laronidase e esses estudos eram bastante heterogêneos, especialmente na forma de avaliação dos desfechos, impedindo que a maioria das variáveis fosse meta-analisada. Os nossos resultados sugerem que a laronidase IV é eficaz em reduzir a excreção de GAGs urinários e a hepatomegalia associada à MPS I, e em aumentar o grau de flexão do ombro desses pacientes. A laronidase também parece ser segura nas populações estudadas, geralmente com eventos adversos leves. Acreditamos que esta metodologia proposta, incluindo estudos com outros delineamentos além de ECR, é capaz de avaliar de forma adequada a evidência disponível para doenças raras, como mostram os resultados obtidos. / Background: With the advancement of health technologies, new therapeutic options are emerging, including those targeted at rare diseases, and whose efficacy and safety are difficult to determine when using the methods originally designed for frequent illnesses. In this case, systematic reviews of existing high-cost rare disease treatments are important for the decision-making process in order to define the profile of patients who are most likely to respond positively to each treatment. Type I mucopolysaccharidosis (MPS I) is an autosomal recessive disease caused by the absence or deficiency of the lysosomal hydrolase alpha-L-Iduronidase activity, with broad clinical spectrum and multisystemic involvement. Intravenous (IV) enzyme replacement therapy (ERT) with 0.58 U / kg / weekly infusion laronidase is currently approved to treat these patients in different clinical settings. The objective of the present study was to evaluate the efficacy and safety of IV ERT with laronidase for the treatment of patients with MPS I. Methods: A systematic literature review was performed by searching the ClinicalTrials.gov, MEDLINE/PubMed, EMBASE, LILACS, and Cochrane Library databases. The search was limited to clinical trials published until December 31, 2015. The first inclusion criterion was being a randomized controlled trial (RCT). If fewer than five RCTs were identified, open-label and nonrandomized trials, controlled or uncontrolled (quasi-experimental), including ≥ 5 patients, and evaluating relevant outcomes defined a priori, were also included. The systematic review was conducted according to Cochrane Collaboration, while the meta-analysis followed the PRISMA guidelines. Outcomes not included in meta-analysis with a GRADE classification of moderate or better were deemed indicative of evidence of efficacy or safety. Results: The selection phase retrieved 613 articles. During the first phase of selection, 66 duplicated entries were excluded and 547 articles were screened, of which 155 had the abstract or full text read for assessment of eligibility. Of these papers, nine (only two RCTs) were ultimately included for qualitative synthesis. Four papers were included in the meta-analysis, which was performed for the following outcomes: occurrence of treatment-emergent or infusion-related adverse events (65%), mild in most cases (rash, urticaria, and fever), development of IgG antibodies to laronidase (88%), apnea-hypopnea index [mean change 0.05 (95%CI -10.3, 10.4)], urinary glycosaminoglycans (GAGs) [mean change -65.5 μg/mg creatinine (95%CI -68.8, -62.3)], liver size [mean change -31.03% (95%CI -36.1, -25.9)], left ventricular mass index [mean change 0.49 (95%CI -2.3, 3.3)], and distance covered in the 6-minute walk test [mean change 17.25 m (95%CI -6.64, 41.13)]. Among the outcomes not included in meta-analysis, we found evidence for benefit of laronidase regarding shoulder flexion. Conclusions: Our results suggest, as expected for rare disorders, that there are few studies on this issue published in the literature, and this studies are very heterogeneous, mainly concerning the way outcomes are evaluated, preventing most variables to be meta-analyzed. Our findings suggest that IV laronidase effectively reduces the urinary GAG excretion and hepatomegaly associated with MPS I and can improve shoulder flexion in these patients. Laronidase also appears to be safe in the studied population, with generally mild adverse events. We believe that this proposed methodology, including studies with other designs besides ECR, is capable of adequately assessing the available evidence for rare diseases, as shown by the results obtained.

O trabalho da odontologia no sistema público de saúde brasileiro é marcado por procedimentos puramente clínicos. Com a implantação da Estratégia Saúde da Família passou-se a exigir uma postura diferenciada, com o intuito de promover a saúde bucal por meio de atividades educativas. Na população adolescente se torna ainda mais necessária essa postura, devido ao distanciamento que o adolescente costuma ter do serviço de saúde, bem como a resistência a atividades de prevenção. Assim sendo, o objetivo geral desse estudo é identificar os estudos de intervenção sobre educação em saúde bucal para adolescentes existentes na literatura nos últimos 10 anos. Para tal, foi realizada uma revisão sistemática da literatura, considerando intervenções referentes à educação para a saúde bucal de adolescentes, em três idiomas (inglês, português e espanhol) e foi pesquisada a literatura dos últimos 10 anos. A identificação dos artigos foi feita através de busca bibliográfica na base de dados PUBMED/Medline e LILACS/Bireme utilizando como descritores adolescent; dental health education, education; oral health. Dois examinadores realizaram a estratégia de busca e, quando necessário, um terceiro examinador também foi contatado. Após a leitura dos títulos, resumos e artigos completos, os estudos foram avaliados quanto à qualidade. Foram encontradros 894 artigos na estratégia de busca, e, após a leitura dos títulos, resumos e a do estudo completo e, seguindo critérios de inclusão e exclusão previamente definidos, 24 artigos foram eleitos para análise final. Das 24 publicações analisadas, 14 eram em inglês, 06 em espanhol e 04 em português. Quanto à base de dados, 12 artigos foram do PUBMED/Medline e 12 da LILACS/Bireme. O ano de 2012 foi o que teve mais publicações referentes ao tema e o Brasil foi o país com mais estudos realizados. O tamanho da amostra e as estratégias utilizadas para a execução da intervenção foram diversos. A grande maioria dos estudos foi eficaz no desenvolvimento das atividades educativas com adolescentes. Os questionários e os exames bucais foram as medidas de desfecho mais utilizadas. Quanto à qualidade, a maioria dos estudos analisados foi de qualidade intermediária ou pobre, sendo que apenas 4 estudos foram considerados de boa qualidade. Os dados coletados são de grande relevância para a atuação dos profissionais na atenção primária em saúde e na condução de atividades educativas em saúde bucal com a população adolescente. Esse estudo tem potencial para instrumentar o trabalho educativo em saúde bucal, otimizando os resultados e promovendo uma maior efetividade das ações educativas para o público adolescente. / The work of dentistry in the Brazilian public health system is marked by purely clinical procedures. With the implementation of the Family Health Strategy, it was necessary to adopt a differentiated approach in order to promote oral health through educational activities. In adolescents, this position is even more necessary due to the adolescents' distancing from the health service, as well as resistance to prevention activities. Thus, the general objective of this study is to identify intervention studies on oral health education for adolescents, published in the literature in the past 10 years. For this, a systematic review of the literature was carried out considering interventions for oral health education of adolescents in three languages (English, Portuguese and Spanish) and the literature of the past 10 years was researched. The identification of the articles was done through bibliographic search in the database PUBMED/Medline and LILACS/Bireme using as keywords "adolescent; Dental health education; Oral health". Two examiners performed the search strategy and, when necessary, a third examiner was also contacted. After reading titles, abstracts and articles in full, the studies were evaluated for their qualities. A total of 894 articles were found in the search strategy, and after reading their titles, abstracts and the study in its entirety, 24 articles were selected for final analysis, following previously defined inclusion and exclusion criteria. Of the 24 publications analyzed, 14 were in English, 06 in Spanish and 04 in Portuguese. As for the database, 12 articles were from PUBMED/Medline and 12 were from LILACS/Bireme. The year of 2012 was the one that had more publications related to the subject and Brazil was the country with more studies realized. The size of the sample and the strategies used to carry out the intervention were diverse. The vast majority of studies were effective in the development of educational activities with adolescents. The questionnaires and oral examinations were the most used outcome measures. Regarding their qualities, the majority of studies analyzed were of intermediate or poor quality, and only 4 studies were considered of good quality. The data collected are of great relevance for the professionals' performance in the primary health care and in the conduction of educational activities in oral health with the adolescent population. This study has the potential to implement educational work in oral health, optimizing the results and promoting greater effectiveness of educational actions for the adolescent public.

A escassez de sistemas consolidados de reciclagem de veículos no Brasil e o grande volume de veículos em final de vida (VFVs) junto aos pátios do Departamento Estadual de Trânsito do Rio Grande do Sul - DETRAN/RS serviram de base para o desenvolvimento desta dissertação. Em face disso, o objetivo deste trabalho foi desenvolver um sistema de reciclagem de VFVs ambientalmente mais sustentável, a partir de exemplos globais de melhores práticas adotadas, atendendo à legislação vigente do país. Para tanto, a presente dissertação é composta por dois estudos fundamentados em revisões sistemáticas e em estudos de caso. Inicialmente, como resultado da primeira revisão sistemática, foi realizada a comparação de sistemas de gestão de reciclagem de veículos, identificados em 25 países. Essa comparação possibilitou ampliar o conhecimento de tecnologias e de procedimentos adotados em diferentes realidades, permitindo a proposição de oito políticas a serem adotadas em âmbito nacional, bem como três ações de melhoria ao atual sistema do DETRAN/RS. Em seguida, a segunda revisão sistemática permitiu a proposição de um sistema ambientalmente adequado para reciclagem de VFVs, que sirva de base para a futura padronização de processos de reciclagem, visando a potencial criação de centros especializados em reciclagem de veículos (CERVs). Diante do exposto, os resultados da pesquisa demonstraram que o tema da reciclagem de veículos está inserido num cenário mais amplo, necessitando da participação de todos os stakeholders envolvidos no processo, a exemplo: (i) das montadoras e fabricantes de peças, no desenvolvimento de tecnologias automotivas; (ii) dos entes federados, na criação de legislações mais rígidas e específicas, com foco na economia circular; e (iii) da sociedade na busca de produtos eco-amigáveis. Por fim, conclui-se que, associado às políticas e ações de melhoria sugeridas, a adoção do sistema ambientalmente adequado para reciclagem de VFVs proposto, poderá acelerar a criação de um ambiente favorável para o desenvolvimento e a consolidação da reciclagem no país. / The scarcity of consolidated vehicle recycling systems in Brazil and the huge amounts of endof- life vehicles (ELVs) at the Transit State Department of Rio Grande do Sul - DETRAN/RS courtyards served as the basis for the development of this Masters dissertation. Therefore, the objective of the work was to develop an environmentally more sustainable ELVs recycling system, based on global adopted best practices, without disregarding the country's current legislation. So, this dissertation is composed of two studies based on systematic reviews and on case studies. Initially, as a result of the first systematic review, a comparison of vehicle recycling management systems was carried out, identified in 25 countries. This comparison allowed the increasing of the knowledge about technologies and procedures adopted in different realities, making possible a proposal of educational policies to be adopted at national level, as well as three improvement actions for the current system of the DETRAN/RS. Subsequently, a second systematic review allowed a proposal for a suitable environmentally recycling system for the ELVs, which serves as the basis for a standardization of recycling processes, aiming the potential creation of specialized centers for such processes (CERVs). Considering this, the research results showed that the theme of product recycling is inserted in a broader scenario, requiring participation of all stakeholders involved in the process, such as: (i) the automakers and parts manufacturers, in the automotive technologies development; (ii) the federal entities, in the creation of more rigid and specific legislation, focusing on the circular economy; and (iii) the society in the search for eco-friendly products. Finally, it is concluded that, associated with the suggested policies and improvement actions, the adoption of the proposed environmentally appropriate system for the recycling of the ELVs, may accelerate the creation of a favorable way to the develop and consolidate the recycling in our country.

Depression is common in people with coronary heart disease (CHD) and is associated with worse physical outcomes. The nature of the causal association between CHD and depression, and the mechanism underpinning the association of depression with worse physical outcomes, remains unclear. Perseverative negative thinking may contribute to the development of depression in people with CHD. The aim of this thesis was to investigate the prospective association of perseverative negative thinking with depression, anxiety and worse physical outcomes in people with CHD, and to explore factors that may mediate this association. First, a systematic review identified 30 studies, of which the majority found an association between measures of perseverative negative thinking and subsequent depression, anxiety or emotional distress in people with long term conditions. Studies that controlled for covariates showed more mixed results, though the majority (15 / 25) still supported a significant association, with effects being small in magnitude. Findings were limited mainly to the association of rumination and/or catastrophizing with subsequent depression, and study quality was limited. Next, in an observational prospective cohort study 169 inpatients and outpatients with recent acute coronary syndrome (ACS) completed self-report assessments of rumination (Ruminative Responses Scale brooding subscale), worry (Penn State Worry Questionnaire), depression (Patient Health Questionnaire-8), anxiety (Beck Anxiety Inventory), and health-related quality of life (EuroQol-5D health-related quality of life, Seattle Angina Questionnaire) after hospitalisation, and at 2 month and 6 month follow-up. Additionally, assessments of potential mechanistic factors (social support, problem solving, instrumental behaviours and negative cognitive biases) were made. Baseline brooding was a significant independent predictor of depression at 6 months after controlling for the effects of important confounding variables, accounting for 2% of the variance. Findings suggested that the association of brooding with depression may be explained by deficits in problem solving ability. Rumination and problem solving may provide useful targets for the development of evidence-based interventions to improve depression among people with CHD, although the findings presented here fall short of proving a causal relationship. Future trials could be used to investigate the causal nature of the association of rumination and problem solving with depression in people with ACS.

Violence against Indigenous women is a major public health concern worldwide and Canada is no exception. Multiple forms of violence inform the broader context of violence against Indigenous women. Nurses are likely to encounter Indigenous women in a variety of settings, but evidence suggests that nurses may lack understandings of violence. This thesis explored the following question: How does extant qualitative research conducted in Canada, contribute to understanding the health and wellbeing of First Nations, Métis and Inuit (Indigenous) women who have experienced violence? During the development of this thesis, significant gaps were highlighted including underrepresentation of Inuit women in the literature, limited focus on health promotion, and lack of methodological approaches to systematic reviews that were participatory and inclusive of the community. Therefore, a secondary aim of this thesis was to privilege perspectives of Inuit women and their communities, by developing a study protocol for a collaborative and community centered approach to reviewing and assessing the extant literature. A configurative and inductive approach based on thematic synthesis was used to systematically search, retrieve, analyze and synthesize extant literature. Post-colonial feminist theory and intersectionality were used as theoretical lenses to emphasize intersections between multiple forms of violence and locate the problem within the broader context of colonization and oppression. Sixteen studies were included in this review, fifteen qualitative and one mixed methods study. Four themes with subthemes emerged based on analysis and synthesis of findings in the included studies: 1) ruptured connections between family and home, 2) that emptiness… my spirit being removed, 3) seeking help and feeling unheard, and 4) a core no one can touch. These themes represent interconnected pathways that influenced health among Indigenous women, and have implications for healthy public policy, clinical practice, and nursing education.

Introdução: O agrupamento de cuidados é uma estratégia que visa evitar a manipulação intermitente dos neonatos pré-termos, proporcionando um período maior de repouso, fundamental para seu adequado crescimento e desenvolvimento. Esta prática é amplamente utilizada nas Unidades de Terapia Intensiva Neonatal (UTIN). Objetivo: Estabelecer evidências acerca da efetividade do agrupamento de cuidados na organização do ciclo sono-vigília, na estabilidade das respostas fisiológicas e mímica facial em pré-termos com idade gestacional até 32 semanas. Método: Revisão sistemática que identificou estudos publicados e indexados nas bases eletrônicas Cochrane, LILACS, EMBASE, CINAHL, PubMed, Web of Science. Foram utilizados os descritores/termos livres clustered care, neonatal individualized developmental care program OR NIDCAP, kangaroo mother care OR KMC e skin to skin para identificação dos estudos. Além destas bases, foram realizadas buscas por estudos não publicados em revistas indexadas como anais de eventos científicos, teses e dissertações indexadas nas bases eletrônicas de bancos de teses disponibilizados em páginas eletrônicas de universidades e pela ferramenta Google scholar. A análise e seleção das publicações foram realizadas por dois revisores independentes, as publicações com análises discrepantes para inclusão ou não na revisão foram submetidas à avaliação de um terceiro revisor. As publicações que atenderam os critérios de inclusão foram selecionadas para a leitura e análise na íntegra. Após esta avaliação, as que preencheram os critérios de inclusão, foram incluídas na revisão sistemática. Resultados: Foram identificadas 1255 publicações nas bases de dados, das quais 18 foram selecionadas como prováveis inclusão e analisadas na íntegra. Destas, cinco ensaios clínicos randomizados do tipo cross-over foram incluídos na presente revisão. Os sujeitos que compuseram a amostra dos ensaios clínicos analisados foram os neonatos pré-termos com idade gestacional igual ou inferior a 32 semanas. O agrupamento de cuidados foi comparado com um procedimento doloroso. Os resultados mostraram que os RNs apresentam alterações na mímica facial (olhos espremidos), alterações comporamentais (extenção de braços, língua protusa, mãos abertas com adução dos dedos, bocejo) e diminuição na saturação de oxigênio mais significativamente no grupo submetido ao procedimento doloroso comparado ao grupo de cuidados agrupados (p<0,004). No entanto, valores semelhantes nas alterações faciais e fisiológicas ocorreram no grupo submetido ao agrupamento de cuidados e os sinais de estresse avaliados após o agrupamento de cuidados, persisitiu por maior tempo, comparado com a fase de recuperação do neonato no grupo do procedimento doloroso. Quanto à frequência cardíaca, os neonatos com idade gestacional inferior a 30 semanas apresentaram elevados índices quando o procedimento doloroso foi precedido pelo agrupamento de cuidados (p<0,0001). Conclusões: As evidências encontradas sugerem que o agrupamento de cuidados causa alterações na resposta comportamental (ciclos sono-vigília), instabilidade nos parâmetros fisiológicos (frequência cardíaca e saturação de oxigênio) e sinais de estresse demonstrado através da mímica facial (sobrancelhas salientes e sulco nasolabial) em recém-nascidos com idade gestacional menor ou igual a 32 semanas. A adoção da prática de agrupamento de cuidados não garante que os neonatos pré-termos submetidos a este tipo de cuidado apresentem respostas fisiológicas e comportamentais mais estáveis. / Introduction: The clustered care is a strategy to avoid the intermittent preterm infants handling, providing them a longer rest period, essential to their health growth and development. This procedure is widely used in the context of Neonatal Intensive Care Units (NICU). Objective: To establish evidence concerning the effectiveness of the clustered care in organizing the sleep-wake cycle in the physiological responses and facial expressions in gestational age up to 32 weeks preterm infants. Methods: A systematic review that identified the studies published in the Cochrane, LILACS, EMBASE, CINAHL, PubMed and Web of Science electronic databases. The descriptors used to identify the studies were: \"clustered care, neonatal individualized developmental care program OR NIDCAP, kangaroo mother care OR KMC e skin to skin. Also these database, it was identified the studies not published in indexed journals including studies presented in scientific events and thesis and dissertations available in the electronic databases hosted in the universities homepages and publications identified by the Google scholar gate. The selection of publications and analysis of them were performed by two independent reviewers. The publications with conflicting evaluation between the two reviewers were submitted to evaluation by a third reviewer. The publications that met the inclusion criteria were selected for analysis of the full text. After this analysis, those studies that met the inclusion criteria were included in the systematic review. Results: We identified 1255 publications in databases, 18 of them were selected as probable inclusion and were analyzed in its entirety. From these 18 studies, five cross-over randomized clinical trials were included in this systematic review. The subjects who comprised the samples of analyzed trials were premature infants up to 32 week gestational age. The clustered care group was compared with a painful procedure. The results showed that newborns exhibited alterations in the facial expressions (eyes squeezed), behavior changes (arms extension, protruding tongue, open hands with fingers adduction, yawn) and oxygen saturation decreasing more significant in the group undergoing painful procedure compared with the clustered care group (p <0.004). However, similar values in facial and physiological changes occurred in the clustered care group and stress signals evaluated after grouping care, persisted for a longer time compared to the recovery phase in the newborn of painful procedure group. As for heart rate, neonates with gestational age below 30 weeks showed high levels when the painful procedure was preceded by clustered care (p <0.0001). Conclusions: The evidence suggests that the clustered care causes changes in the behavioral responses (sleep-wake cycles), instability in physiological parameters (heart rate and oxygen saturation) and stress signals demonstrated through facial expressions (protruding eyebrows and nasolabial folds) in the premature infants up to 32 weeks gestational age. he grouping of care does not guarantee that the preterm group undergoing care exhibit more stability in physiological and behavioral responses. The adoption of the clustered care practice does not guarantee that the preterm infant underwent to it exhibit more stability in the physiological and behavioral responses.

High levels of personal car use have negative effects on the environment and on human health. This thesis presents four empirical studies that aimed to develop our knowledge of personal travel choices, focussing on the malleability of attitudes and their sensitivity in relation to specific contexts and goals. The first study (Chapter 2) presents a systematic review and meta-analysis of mechanisms of travel mode choice. The study provides a comprehensive overview of antecedents of car use and non-car use, including sub-group analyses of different contextual factors. Results also highlight the need for standardised measures and consideration of implicit thought processes. The second study (Chapter 3) employs a repertory grid technique to elicit perceptions of seven different transport modes from high mileage car users and non-car users. Comparisons between car users and non-car users highlight potentially effective and ineffective intervention targets. Findings show how sustainable transport might be promoted amongst a portfolio of travel choices. The third study (Chapter 4) utilises qualitative methods to explore the extent to which individuals’ attitude expressions are changeable. The study demonstrates that all participants hold ambivalent and conflicting attitudes, highlighting specific situations in which those attitudes are more likely to be unstable. Two related priming experiments are presented in the final empirical chapter (Chapter 5). Both use survey methodology to investigate whether manipulating the salience of car-use-incongruent goals can lead to more positive attitudes towards and increased willingness to use non-car travel modes. The study confirms that people who are motivated to make changes are a potentially optimal target group for interventions based on subliminal messages. Overall, the research presented in this thesis introduces context sensitivity into the transport literature and offers novel insights into perceptions of a range of travel modes. Recommendations include relevant avenues for future research, findings are discussed in light of implications for transport policy and practice.

Cognitive difficulties can persist for months and years after stroke and adversely impact confidence, mood and functional recovery. Stroke survivors, carers and healthcare professionals collectively agree that improving cognition is the number one research priority for life after stroke. Future research should include measurements of outcome that service users deem important. Patient reported outcome measures (PROMs) are a means of gaining patient perspectives that can be standardised for use in a trial. PROMs should be developed with service users to incorporate their priorities but people with cognitive difficulties are often systematically excluded from the development and use of PROMs. Study 1 used qualitative interviews (N=16) to explore stroke survivor perspectives on the important and measureable impacts of persisting cognitive problems. The results of this study generated requirements for a PROM that related to conceptual underpinning and face validity of a measurement tool. Study 2 was a systematic review of existing PROMs related to cognition. 20 Identified PROMs were critically appraised against the requirements generated in the qualitative study. No existing PROMs were identified that met all of the qualitative study review criteria. The next stage described in chapter 3, was to develop a new PROM that: utilised the strengths of existing tools; met qualitative study requirements; and was refined through consultation with different stakeholders, prioritising feedback of stroke survivors with cognitive difficulties. The result of this work was the Patient Reported Evaluation of Cognitive State (PRECiS) scale. Study 3 was a psychometric study with stroke survivors (N=164) to test PRECiS in a large sample. Quantitative and qualitative data were collected on acceptability, feasibility and other psychometric properties of validity and reliability. PRECiS demonstrated good acceptability to stroke survivors and performed well psychometrically. Future validation work required for PRECiS is described in discussion chapter 4. Subject to further validation work, PRECiS may be particularly useful for pragmatic trials of cognitive rehabilitation after stroke.