The aim of this thesis was to explore salutogenic resources in the everyday lives of teachers, and toinvestigate how an intervention of collegial reflection influences their work-related learning and their being.The thesis includes two parts, a needs assessment and an intervention, performed between 2009 and2016. Both qualitative and quantitative approaches have been used in the process of the thesis. Methods used for data generation have been multistage focus groups interviews, individual interviews, questionnaire, open mail questions, and digital recordings of the reflection meetings. Four different methods have been used For the analyses: content analysis, hermeneutic analysis, multiple linear regression, and thematic analysis. The findings indicate that the caring relationships with pupils, but also colleagues, were important for the teachers’ finding meaning in their work. The caring relationships and the sense of meaningfulness were important resources for the teachers well-being. Collegial reflection was a health promoting resource in that it contributed with social support from colleagues, a sense of belonging, a consensus regarding shool issues, and recovery. This recovery occurred while the teachers were having their collegial reflection, indicating that they still felt recovered even though they were reflecting on work-related issues. The thesis also indicates that teachers’ experiences of time pressure at work was the variable with the strongest associaton to their experience of work-life balance. The integration of work and private lives is an important part of being a teacher. Certain aspects of work was considered as positive and salutogenic when integrated with their private lives, such as the creative aspect of teaching. However, other aspects, such as ruminating over abused pupils, were affecting their well-being in a detrimental way when integrated in their private lives. In a time when much focus is put on teachers’ increasing workload, documentation and psychosocial risks, it is important to pay more attention to the salutogenic and the enhancing aspects of  teacher's work. By doing that, teachers’ well-being may be enhanced, as well as supporting teacher retention.

abstract: Nurses are using health information technology during patient care activities in acute care at an unprecedented rate. Previous literature has presented nurses' response to technology obstacles as a work-around, a negative behavior. Using a narrative inquiry in one hospital unit, this dissertation examines nurses' interactions when they encounter technology obstacles from a complexity science perspective. In this alternative view, outcomes are understood to emerge from tensions in the environment through nonlinear and self-organizing interactions. Innovation is a process of changing interaction patterns to bring about transformation in practices or products that have the potential to contribute to social wellbeing, such as better care. Innovation was found when nurses responded to health information technology obstacles with self-organizing interactions, sensitivity to initial conditions, multidirectionality, and their actions were influenced by a plethora of sets of rules. Nurses self-organized with co-workers to find a better way to deliver care to patients when using technology. Nurses rarely told others outside their work-group of the obstacles that occurred in their everyday interactions, including hospital-wide process improvement committees. Managers were infrequently consulted when nurses encountered technology obstacles, and often nurses did not find solutions to their obstacles when they contacted the Help Desk. Opportunities exist to facilitate interactions among nurses and other members of the organization to realize better use of health information technology that improves quality and safety while decreasing cost in the patient experience. / Dissertation/Thesis / Ph.D. Nursing and Healthcare Innovation 2013

Submitted by Geandra Rodrigues (geandrar@gmail.com) on 2018-01-11T10:31:03Z No. of bitstreams: 1 mariadosocorrolinavankeulen.pdf: 2261237 bytes, checksum: 42a025939206e7e1f657e3fb828feb4a (MD5) / Approved for entry into archive by Adriana Oliveira (adriana.oliveira@ufjf.edu.br) on 2018-01-23T12:39:01Z (GMT) No. of bitstreams: 1 mariadosocorrolinavankeulen.pdf: 2261237 bytes, checksum: 42a025939206e7e1f657e3fb828feb4a (MD5) / Made available in DSpace on 2018-01-23T12:39:01Z (GMT). No. of bitstreams: 1 mariadosocorrolinavankeulen.pdf: 2261237 bytes, checksum: 42a025939206e7e1f657e3fb828feb4a (MD5) Previous issue date: 2017-09-29 / Eventos adversos são danos desnecessários à saúde de um indivíduo causados pela atividade profissionais de saúde. No Brasil e no mundo, a saúde sofre com o alto custo do cuidado em saúde vinculado à incorporação tecnológica, ao aumento da carga de trabalho dos profissionais de saúde e à mudança no perfil epidemiológico da população, que apresenta maior longevidade e múltiplas doenças crônicas e emergem preocupações voltadas para a qualidade do cuidado, capacitação técnica e profissional e eficiência das organizações de saúde. O objetivo principal foi dimensionar os custos relativos ao tratamento de danos causados por eventos adversos no período de um ano na instituição proposta, em duas unidades: Unidade de Práticas Integradas de clínica e Unidade de Estrutura Funcional clínica, além de identificar e descrever os fatores relacionados à ocorrência de evento adverso. A população do estudo foi de pacientes hospitalizados para tratamento clínico. O desenho da pesquisa é observacional, seccional, com dados individuais e abordagem quantitativa, comparando dois setores de clínica médica do hospital para testar a hipótese de que não há diferença na quantidade de eventos adversos ocorridos entre duas unidades de tratamento clínico e um estudo tipo Cost of Illness, utilizando custos diretos como categoria analítica. Os critérios de inclusão foram: pacientes maiores de 18 anos, internados para tratamento clínico pelo Sistema Único de Saúde, com permanência maior que 24h e alta hospitalar a mais de 30 dias. Os critérios de exclusão são: pacientes internados para tratamento psiquiátrico. O método detecção de eventos adversos foi a Ferramenta Global Trigger Tool para, desenvolvida pelo Institute of Health Improvement. Foram detectadas 96 internações (20,0%) com pelo menos um (1) evento adverso, 144 eventos no total, correspondendo a uma média de 1,5 eventos por pacientes afetados, dos quais 31 (21,5%) estavam presentes na admissão e 125 (86,8%) foram considerados evitáveis. As características relacionadas a processos clínicos e cirúrgicos apresentaram razões de chance mais significativas: ter sido submetido à cirurgia aumentou a chance de ocorrer evento adverso em aproximadamente 8 vezes (OR 7,93) e o tempo de internação maior ou igual a 3 dias aumentou a chance de evento adverso em 4 vezes (OR 4,03). Ter sido internado em uma Unidade de Estrutura Funcional representou uma chance duas vezes e meia maior de sofrer um evento adverso em comparação com pacientes que foram internados em Unidade de Práticas Integradas. Foi observado que pacientes com evento adverso tiveram aumento na média do custo total de 98,83%, se comparados com pacientes que não tiveram evento adverso. Na Unidade de Práticas Integradas esta diferença representou um aumento de 131,2%, enquanto na Unidade de Estrutura Funcional, o custo de internações com evento adverso excedeu em 76,4% o custo de internações sem evento adverso. Para o Sistema Único de Saúde, a incidência de evento adverso custou um incremento na média da receita paga à instituição equivalente à 55%. Este custo médio na Unidade de Práticas Integradas foi de 61,5% e na Unidade de Estrutura Funcional foi de 36,9%. O estudo pode confirmar que eventos adversos são muito frequentes nesta amostra e representam um gasto excessivo para a instituição e para o Sistema Único de Saúde. / Adverse events are unnecessary damages to an individual’s health caused by professional’s health care. Brazil and other countries suffer from the high costs of health care related to technological incorporation, the increase of health professionals’ workload and the change in the epidemiological profile of the population that provides greater longevity and multiple chronic diseases. Concerns arises regarding the quality of care, technical and professional training, and the efficiency of health organizations. The main objective was to estimate the costs related to the treatment of damages caused by adverse events within one year in the institution, comparing two units: Integrated Practices Unit of Internal Medicine and Functional Structure Unit besides in order to measure the incidence and describe the factors related to the occurrence of adverse event. The study population was patients hospitalized for clinical treatment. This was a retrospective, observational, sectional design, using individual data and quantitative approach comparing two clinical practice sectors of a hospital to test the hypothesis that there is no difference in the adverse events’ amount between these two units. Besides that a study of Cost of Illness using direct costs as analytical category was done. Inclusion criteria were: patients over 18 years of age hospitalized for clinical treatment by Brasilian Health system: Sistema Único de Saúde, with length of stay longer than 24 hours and hospital discharge over 30 days. Exclusion criteria were: inpatients for psychiatric treatment. The method of adverse events’ detection was the Global Trigger Tool developed by the Institution of Health Improvement (IHI). In 96 hospitalizations (20.0%) at least one (1) adverse event was detected and 144 adverse events representing an average of 1.5 events per affected patients. Thirty-one adverse events (21.5%) were present in Admission and 125 (86.8%) were considered preventable. The characteristics related to clinical and surgical procedures had more significant odds ratio: being submitted to surgery increased the chance of AD occurring in approximately 8-fold (OR 7.93) and the hospital’s length of stay greater than or equal to 3 days increased the chance of adverse event in 4 times (OR 4.03). The admission to a Functional Structure Unit represented a two and a half times greater chance of suffering an adverse event compared to patients who were hospitalized in Integrated Practices Unit. It was observed that hospitalizations with adverse event costs of 98.83% to the institution if compared to hospitalizations without adverse event. In the Integrated Practices Unit adverse event represented an increase of 131.2% while in the Functional Structure Unit the costs of adverse event exceeded 76.4. The incidence of adverse event increased around 55% the amount SUS should pay the health service deliver. This average cost was 61.5% in Integrated Practices Unit and 36.9% in Functional Structure Unit. The study have shown that adverse events are very frequent in this sample and represent an excessive expenditure for the institution and the Unified Health System.

Sexually transmitted infection (STI) prevalence rates are increasing in the United States and globally. Education has been found to be an important strategy for increasing STI testing and treatment rates among sexually active young adults. The goal of this project was to develop an interactive educational game suitable for young adults to decrease the social and economic burden of STIs. The health belief model informed the project. A moderated usability evaluation was conducted using the concurrent think-aloud technique. The participants (N = 5) were a purposive sample of professionals who played the interactive game and then completed Schnall, Cho, and Lie’s Health-Information Technology Usability Evaluation Scale instrument. The findings revealed the necessity of (a) an introduction screen, (b) a reward system for correct answers, and (c) avatars, while also highlighting that (d) the effect on indicator value bars is difficult to understand and (e) the timer led to a feeling of being rushed. The Cronbach’s alpha for the participant group was 0.798, the subscale “Perceived Ease of Use” achieved an alpha level of 0.815, and the subscale “Perceived Usefulness,” 0.762. Refinements to the game based on these data might help to ensure that use of the interactive game contributes to social change by increasing knowledge of STIs in the young adult population.

In recent years, there has been an enormous growth in the literature that has focussed upon assets, in other words emphasising the positive attributes of both people and communities; these include children and young people’s developmental assets, community asset mapping and public health, all of which have generated a wide range of literature. Although there has been some consideration of assets within a child health context, this is limited and no literature has previously documented the mapping of children’s assets at an individual level. It has long been recognised that wellbeing is an integral aspect of health. Children’s wellbeing has been the focus of much concern at both national and international levels; this has resulted in the publication of key documents by prominent organisations, as well as the undertaking of a range of research. Despite this, studies have not previously sought to map the assets underpinning children’s wellbeing – this research has addressed this deficit. This study was supported by a theoretical framework that was specifically developed to guide the study. An ethnographic approach and a photo elicitation method were drawn upon to facilitate the gaze through the lens of ‘Activities that I Enjoy’; this in turn enabled the mapping and emergence of assets that underpin children’s wellbeing. Two primary schools in the south-east of England were used to recruit twenty Year 5 children (aged 9-11 years of age). The participants, ten boys and ten girls, were given disposable cameras and asked to take photographs of the activities that they enjoyed. The children’s photographs were integral to subsequent individual semi-structured interviews that sought to gain insight into children’s wellbeing. ii A constant comparative analysis technique facilitated the mapping of assets that underpinned the children’s wellbeing; this process revealed one overall Stabilising Asset as well as eight internal and three external assets. Whilst some of the assets have been previously recognised, others have not; in particular, the study revealed ‘When I Have Got Nothing To Do: Resourcefulness’ as an internal asset that has not formerly been articulated. All of the assets are presented within the ‘I’m Good’: Children’s Asset Wheel [CAW], an original model that provides a new and important insight as well as being an integral component of the initial guiding theoretical framework. As its contribution to knowledge, the study offered a number of key insights including: The presentation of an innovative guiding theoretical framework that not only has the potential to inform future research, but also professionals in relation to the practicalities of asset mapping. Secondly, the study developed and documented a detailed original approach to asset mapping at an individual level; thirdly, the research facilitated the design of the CAW which encapsulates the assets underpinning children’s wellbeing. Appropriate dissemination strategies have been initiated, and will continue, in order to facilitate the study’s contribution to the existing body of knowledge.

Background: There is considerable evidence that physicians lack sufficient training in facilitating transition from pediatric to adult care systems for adolescents and young adults (A/YA). While several primary care residency programs have introduced health care transition (HCT) curricula in recent years, there are few studies that assess the effectiveness of HCT teaching models. Purpose: To assess the impact of a residency education program that uses electronic health records (EHR) and other methods to teach residents how to prepare A/YA for transition to adult care. Methods: In a mixed methods, quasi-experimental research design, quantitative methods were used to measure change in knowledge, confidence and experience among 67 Pediatrics and Med-Peds residents who participated in the program. All residents and a comparison group were invited to complete a 35-item pre/post-survey; a retrospective chart review provided documentation of age-specific HCT preparation tasks completed by residents during well visits for A/YA aged 12-21. Descriptive and correlational analyses were conducted to compare differences between resident and control test scores for 5 outcome variables, and to measure resident utilization of the HCT tool in the EHR. Using the Reach Effectiveness-Adoption Implementation Maintenance (RE-AIM) evaluation model as a guide, semi-structured interviews were conducted concurrently with residents and faculty to assess program acceptability, feasibility, and other important attributes. Interviews were transcribed and analyzed using a constant comparative, iterative process. Results: Survey results showed residents (11 matched pairs) scored significantly higher than controls (13 matched pairs) in 2 of 5 outcomes: exposure to HCT learning activities (p=.0005) and confidence in providing primary care for YSHCN (p=.0377). Overall utilization of the EHR tool among 51 residents was 52.8% (57 of 108 patient visits). In interviews conducted with 16 residents and 6 faculty, both groups said that HCT training is a highly relevant need. Residents said they had little knowledge or experience in HCT prior to the intervention but felt more confident in their abilities afterwards. The HCT tool in the EHR was the only intervention element among multiple modalities that reached all study participants, with more than 80% of residents interviewed reporting they used the HCT tool "usually" or "always." Factors that influenced program adoption included accessibility of educational materials, ease of use, time constraints, patient age and health condition, and attending physicians' enforcement of the protocol. Conclusion: This study contributes to the body of knowledge concerning HCT by increasing our understanding of ways to effectively educate residents about transition preparation. Results show a positive intervention effect on selected dimensions of resident knowledge, confidence, and practice in HCT, highlighting program strengths and weaknesses. The program is distinctive in educating residents to prepare all A/YA for HCT, as recommended by major medical associations for pediatric and adult care physicians, and in its use of the EHR as a primary teaching tool, a consideration for reducing time-intensive didactic instruction. It provides a model that can be adapted by other residency and provider training programs, and suggests a need to integrate acquisition of health care self-management skills more broadly in child and adolescent health preventive care tools and policies.

Objectif : Étudier le risque d’hémorragies intracrâniennes et d’infarctus du myocarde chez les patients vivant avec le VIH. Méthode : J’ai réalisé deux études de cohorte au sein de la banque de données de la Régie de l’assurance maladie du Québec. J’ai défini la cohorte des patients VIH-positifs, y ai étudié l’incidence d’hémorragies intracrâniennes et d’infarctus du myocarde, et l’ai comparée à une cohorte VIH-négative de même âge et de même sexe. J’ai étudié l’association entre ces évènements et l’exposition aux antirétroviraux au moyen d’études cas-témoin nichées dans la cohorte des patients VIH-positifs. Résultats : Le VIH est associé à un risque plus élevé d’hémorragies intracrâniennes, particulièrement au stade SIDA. Les patients VIH-positif sont également plus à risque de subir un infarctus du myocarde, et certains antirétroviraux sont associés à un risque plus grand. Conclusion : Les banques de données médico-administratives représentent un moyen valable d’étudier les comorbidités non-infectieuses chez les patients atteints du VIH. / Objective: To study the risk of intracranial hemorrhage, acute myocardial infarction and their determinants in HIV-infected patients. Methods: I conducted two matched cohort studies within the database of the Régie de l’assurance maladie du Québec. I identified the cohort of HIV-infected patients and compared the incidence of intracranial hemorrhage and myocardial infarction with that in an age and sex matched cohort of HIV-negative patients. To study the association between these events and exposure to antiretrovirals, I conducted two matched case-control studies nested in the HIV-positive cohort. Results: HIV-infected patients had increased risk of developing intracranial hemorrhage, particularly if they had AIDS. They were also at greater risk of suffering from myocardial infarction. Exposure to some antiretroviral drugs was associated with greater risk of myocardial infarction. Conclusion: Administrative health data can be used to study the non-infectious complications of HIV infection, but validation studies are needed to evaluate data quality.

La presente tesi descrive i risultati del programma di controllo dei pesticidi in regione Lombardia da 1996 a 2008 ed analizza i dati per calcolarne, con metodi diversi, la valutazione dell’esposizione del consumatore. 9387 campioni sono stati analizzati con un numero di campioni irregolari pari all’1%. Il numero di campioni senza residuo era pari al 69% ed il numero di campioni con i residui al di sotto del valore limite stabilito per legge era del 30%. Successivamente per capire l'esposizione dei consumatori a residui di antiparassitari si è utilizzato un metodo deterministico sviluppato da EFSA (PRIMo). È stato trovato che fra i campioni irregolari analizzati, solo 31 potrebbero causare il danno alla salute del consumatore. Un’ ulteriore analisi è stata quella di effettuare una valutazione con metodo probabilistico (Creme) calcolando l'esposizione cumulativa di antiparassitari sulla salute dei consumatori. Coem primo passo, residui di uno stesso pesticida trovato su campioni di patate sono stati inseriti nel software. Inoltre, campioni contenenti residui di pesticidi organofosfati sono stati inseriti nel software accoppiati con i dati italiani di consumo. In entrambi i casi, la valutazione cumulativa probabilistica dimostrava un adeguato livello di sicurezza per adulti e bambini. / The presented thesis describes the results of the pesticide monitoring programme in Lombardy Region from 1996 to 2008 and analyses the data gathered to calculate consumer exposure assessment with different approaches. A total of 9387 samples were analysed and the number of irregular samples was equal to 1%. The number of samples without residues was 69% and the number of samples with residues within the MRL was 30%. A further step to understand the exposure of consumers to residue of pesticides was obtained with the use of a deterministic approach developed by EFSA (PRIMo Model). It was found that among the detected irregular samples, only 31 might cause harm to the health of the consumer. An additional step was constituted by the use of one probabilistic method (Creme Software) to calculate the cumulative exposure of pesticides for the consumers. As a first step, residues of Chlorprofam were plotted in the software on samples of potato. In addition, samples containing residues of Organophosphates were also plotted along with the Italian consumption data. In both the case studies, the probabilistic acute cumulative assessment indicated that the intake, for adults and toddlers was below the set toxicological endpoint.

Objectif : Étudier le risque d’hémorragies intracrâniennes et d’infarctus du myocarde chez les patients vivant avec le VIH. Méthode : J’ai réalisé deux études de cohorte au sein de la banque de données de la Régie de l’assurance maladie du Québec. J’ai défini la cohorte des patients VIH-positifs, y ai étudié l’incidence d’hémorragies intracrâniennes et d’infarctus du myocarde, et l’ai comparée à une cohorte VIH-négative de même âge et de même sexe. J’ai étudié l’association entre ces évènements et l’exposition aux antirétroviraux au moyen d’études cas-témoin nichées dans la cohorte des patients VIH-positifs. Résultats : Le VIH est associé à un risque plus élevé d’hémorragies intracrâniennes, particulièrement au stade SIDA. Les patients VIH-positif sont également plus à risque de subir un infarctus du myocarde, et certains antirétroviraux sont associés à un risque plus grand. Conclusion : Les banques de données médico-administratives représentent un moyen valable d’étudier les comorbidités non-infectieuses chez les patients atteints du VIH. / Objective: To study the risk of intracranial hemorrhage, acute myocardial infarction and their determinants in HIV-infected patients. Methods: I conducted two matched cohort studies within the database of the Régie de l’assurance maladie du Québec. I identified the cohort of HIV-infected patients and compared the incidence of intracranial hemorrhage and myocardial infarction with that in an age and sex matched cohort of HIV-negative patients. To study the association between these events and exposure to antiretrovirals, I conducted two matched case-control studies nested in the HIV-positive cohort. Results: HIV-infected patients had increased risk of developing intracranial hemorrhage, particularly if they had AIDS. They were also at greater risk of suffering from myocardial infarction. Exposure to some antiretroviral drugs was associated with greater risk of myocardial infarction. Conclusion: Administrative health data can be used to study the non-infectious complications of HIV infection, but validation studies are needed to evaluate data quality.

Introduction: The European Union (EU) is a political and economic confederation <p>composed by 27 member states (EU-27). The EU implemented several standardizations in laws, <p>justice and home affairs and shares the consensus that health care should be regulated by the <p>state. A high level of human protection should be ensured in all its member states. European <p>health systems are funded and managed by each national government and for historical <p>reasons health policy and health expenditure are not homogeneous. <p>Whereas cancer incidence is dependent on factors such as population age, life-style and <p>genetic predisposition, cancer mortality in general is dependent on the efficacy of health <p>systems in providing cancer prevention, efficient screening methods and treatments. <p>Around 20% of the breast cancers show amplification/overexpression of HER2 that is <p>associated with a more aggressive disease and worse clinical outcome. By targeting the HER2 <p>receptor trastuzumab has significantly improved overall survival and changed the natural <p>course of this disease. <p>Objectives: This study aims to evaluate (1) the association of health expenditure with <p>breast cancer outcome, (2) to explore to which degree the differences in breast cancer survival <p>are related to the speed of uptake of trastuzumab and its determinants and (3) to evaluate the <p>real usage of trastuzumab and its relation to breast cancer survival in the EU. <p>Results: Breast cancer survival was found strongly correlated with health expenditure. A <p>clear cutoff divides Western and Eastern Europe in that regard, with western countries showing <p>higher health expenditure and higher breast cancer survival than Eastern Europe. Trastuzumab <p>reimbursement was faster in Western European countries, a factor associated with higher <p>health expenditure and better health policy performance. Trastuzumab uptake is increasing all <p>over Europe in the last 12 years, however it is still being under used in Eastern countries while <p>in Western Europe the uptake is sufficient to treat virtually all patients in need of the drug. <p>Conclusion: Important discrepancies in breast cancer survival exist in the EU. Western <p>Europe has higher breast cancer survival and higher health expenditure than Eastern Europe. <p>This can be partially explained by the faster approval and increased uptake of trastuzumab in <p>Western countries. Higher health expenditure and better health policy performance were <p>factors linked to faster reimbursement and uptake of trastuzumab. / Doctorat en sciences médicales / info:eu-repo/semantics/nonPublished