This thesis examined the evidence, policy decision-making, and implementation of HPV vaccination in Canada as a case study to explore normalization versus individualized decision making in public health programs. Mixed methods were used: a systematic review, content analyses and policy document analysis. Overall, the scientific evidence supported an effect of vaccination against HPV infection and precancerous cervical lesions, but evidence regarding cervical cancer incidence or mortality is lacking. Scientific and medical communities appeared optimistic about the vaccine, but cautious about its readiness for routine implementation. Policy decision-making was initially cautious, but shifted towards active program implementation, possibly related to the availability of federal funding. The educational materials and media coverage both sent clearly normalizing messages about HPV vaccination. The discussion suggests that HPV vaccination might be more suited to an individualized than population approach, but many factors coincided to promote its implementation, in Canada, within a traditional public health model.

This thesis examined the evidence, policy decision-making, and implementation of HPV vaccination in Canada as a case study to explore normalization versus individualized decision making in public health programs. Mixed methods were used: a systematic review, content analyses and policy document analysis. Overall, the scientific evidence supported an effect of vaccination against HPV infection and precancerous cervical lesions, but evidence regarding cervical cancer incidence or mortality is lacking. Scientific and medical communities appeared optimistic about the vaccine, but cautious about its readiness for routine implementation. Policy decision-making was initially cautious, but shifted towards active program implementation, possibly related to the availability of federal funding. The educational materials and media coverage both sent clearly normalizing messages about HPV vaccination. The discussion suggests that HPV vaccination might be more suited to an individualized than population approach, but many factors coincided to promote its implementation, in Canada, within a traditional public health model.

This thesis examined the evidence, policy decision-making, and implementation of HPV vaccination in Canada as a case study to explore normalization versus individualized decision making in public health programs. Mixed methods were used: a systematic review, content analyses and policy document analysis. Overall, the scientific evidence supported an effect of vaccination against HPV infection and precancerous cervical lesions, but evidence regarding cervical cancer incidence or mortality is lacking. Scientific and medical communities appeared optimistic about the vaccine, but cautious about its readiness for routine implementation. Policy decision-making was initially cautious, but shifted towards active program implementation, possibly related to the availability of federal funding. The educational materials and media coverage both sent clearly normalizing messages about HPV vaccination. The discussion suggests that HPV vaccination might be more suited to an individualized than population approach, but many factors coincided to promote its implementation, in Canada, within a traditional public health model.

Background: There are professional expectations for public health nurses to engage in and develop competencies in evidence-informed decision-making (EIDM). The purpose of this research study was to develop and psychometrically test a measure to assess competence in EIDM among public health nurses. Methods: Guided by the Standards for Educational and Psychological Testing (American Educational Research Association, American Psychological Association, & National Council on Measurement in Education, 2014), a three stage study was employed to develop and psychometrically evaluate the new self-report EIDM Competence Measure: 1) Stage one: a systematic review of existing measures assessing four EIDM competence attributes of knowledge, skills, attitudes/beliefs, and behaviours; 2) Stage two: item development for the EIDM Competence Measure comprised of four subscales (knowledge, skills, attitudes/beliefs, and behaviours); and 3) Stage three: psychometric testing (reliability, validity, acceptability) which included item reduction from an original 40-item to a final 27-item tool. Results: The EIDM Competence Measure consists of 27 items aligning with a four-factor model of EIDM knowledge, skills, attitudes/beliefs, and behaviours establishing internal structure validity. Cronbach’s alpha for these four factors was 0.96, 0.93, 0.80, and 0.94, respectively. Significant associations between EIDM competence subscale scores and education, EIDM training/project involvement, and organizational culture established validity based on relationships to other variables. For the original 40-item tool, missing data was minimal as 93% of participants completed all items and mean completion time was 7 minutes and 20 seconds. Conclusions: The EIDM Competence Measure is a conceptually and psychometrically robust instrument that has potential for use in public health nursing practice. / Dissertation / Doctor of Philosophy (PhD) / Nurses who work in public health have professional expectations to participate in evidence-informed decision-making (EIDM). Because of this, it is important to measure how competent they are in EIDM. The purpose of this study was to develop and test a tool that measures EIDM competence among public health nurses using a three-stage study. The first stage involved reviewing literature on existing tools that measure different components of EIDM competence including EIDM knowledge, skills, attitudes/beliefs, and behaviours among nurses. The second stage involved using existing tool items and developing new items for a new tool named the EIDM Competence Measure. In the third stage, the EIDM Competence Measure was tested to assess its validity, reliability, and acceptability among public health nurses in Ontario. The EIDM Competence Measure was found to have strong validity, reliability, and acceptability, showing that there is potential for its use in public health nursing practice.

African Americans bear a disproportionately high burden of cancer incidence and mortality in this country. The purpose of this dissertation was to investigate factors associated with African-American men, who are incarcerated, making informed health decisions about participation in prostate cancer screening, as well as exploring factors that reduce modifiable risk factors for cancer. The United States incarcerates more people per capita than any country in the world and African American men are overrepresented in the U.S. prison system This dissertation is composed of three manuscripts. The first paper reviews the current literature about the factors that influence African-American males in making informed decisions about whether to participate in prostate cancer screening. The second paper uses existing data from a sample of 129 incarcerated African American men to examine the value of an intervention aimed at reducing modifiable risks for cardiovascular disease – and by extension, cancer – in inmates. The third paper explores predictors of intent to screen (or not) for prostate cancer in incarcerated African-American males, as well as those factors that influence informed decision-making in this population. These papers provide an overview of factors that influence incarcerated African-American men’s health decisions (health literacy, having a relative with previous diagnosis). These findings can be used to guide future research that addresses African-American male decision-making about personal health outcomes.

Previous research indicates that pre- and in-service teachers are not receiving adequate training to implement data-informed instructional decision making. This is problematic given the promise this decision making process holds for improving instruction and student learning. At the same time, many educators do not see the value of different types of assessment data (e.g. accountability data), and lack the knowledge, skills, and confidence to use available data to guide instructional decisions. The purpose of this study was to conduct a formative evaluation of an online training designed to improve Iowa pre- and in-service teachers’ perceptions about data, data knowledge, skills and confidence working with data. The training along with a data literacy test was administered online to 29 pre-service teachers from two Iowa universities. A pre-post design was used to assess changes in these data constructs. Results indicated that participants’ perceptions about external accountability data improved significantly after completing the training, as did their confidence working with data. However, most participants’ data performance were relatively stable pre-post training. A content analysis of responses pre-post revealed qualitative changes in some participants’ thinking about data. Participants rated the value, effectiveness and quality of the training and complementary materials. Ratings were mostly positive, with participants signifying the training and materials as valuable and effective for enhancing their understanding of data as well as their confidence working with data. Participants also identified opportunities for improving the training. The author concludes with a discussion of the results, implications for future research, and how the study adds to the existing literature and informs practice.

This thesis focuses on expectant parents’ experiences and needs when soft makers are detected at mid-trimester ultrasound, resulting in an unexpected assessment of risk for fetal anomalies. The thesis also describes the prevalence of ultrasonographic fetal soft markers and the incidence of Down syndrome in a low-risk population of 10,535 pregnant women with a total of 10,710 fetuses, as well as the risk of invasive prenatal diagnostics in conjunction with the detection of soft markers. Finally, the thesis aims to explore the value of a web-based patient decision aid (DA) in facilitating informed decision making regarding routine fetal screening for anomalies and the fathers’ role in decision making regarding prenatal screening. A prospective observational study was conducted between 2008–2011 to investigate the prevalence of ultrasonographic fetal soft markers at second trimester screening. During this time period, 12 women and 17 men were interviewed about their experience when soft markers were detected. Based on the results of these interviews, a web-based decision aid (DA) to enhance expectant parents’ decision-making concerning fetal screening was developed and a trial initiated to test its utility. Interviews were conducted with 17 women who received access to the DA, 11 who had chosen to use the DA and six who had not used it. All interview studies were analysed using systematic text condensation (STC) developed by Malterud. Soft markers were detected in 5.9% of the fetuses at mid-trimester ultrasound, whereof 5.1% were isolated. All soft markers showed a positive likelihood ratio (LR+) for DS; however, the association was only statistically significant for the collapsed category ‘any marker’ (isolated, multiple or combined with anomaly), not for isolated markers. An almost 24-fold increase of invasive diagnostic testing was shown in all women, including those with a low estimated risk for aneuploidy, i.e. < 1/200 (paper III). The results from interviews showed that the finding of soft markers created much anxiety and indicated that both women and men lacked awareness of the potential of the ultrasound examination (papers I and II). The results also showed that the men were actively engaged in decision making not only by supporting their partners, but also considered their own values and needs regarding these issues (paper II). It was also evident that women wanted their partners to be engaged in decisions regarding fetal diagnostics (papers I and IV). The web-based patient DA was able to initiate a process of conscious decision making in pregnant women, as a result of their interaction with the tool. The DA allowed for clarification of women’s thoughts and priorities and helped them to understand the significance of the screening result and providing a basis for making informed decisions regarding fetal screening (paper IV).

abstract: Sexual assault at colleges and universities in the United States is a significant health and human rights issue that impacts somewhere between one-in-four and one-in-five students. Despite the alarmingly high burden, overall rates of disclosing to crisis, health, and victim services, and reporting to schools and law enforcement remain low. In order to buffer students from associated short- and long-term harm, and help them reestablish safety and pursue justice, empirically-supported, innovative, and trauma-informed secondary prevention strategies are needed. To address this pressing issue, the current study used a trauma-informed, feminist community research approach to develop and design a prototype of an internet-based decision aid specifically tailored to assist students at Arizona State University who experience sexual assault with making informed choices about reporting and seeking care, advocacy, and support on and off campus. Results from preliminary alpha testing of the tool showed that: 1. It is feasible to adapt decision aids for use with the target population, and 2. While aspects of the tool can be improved during the next phases of redrafting and redesign, members of the target population find it to be acceptable, comprehensible, and usable. / Dissertation/Thesis / Doctoral Dissertation Global Health 2018

Background. In order to deliver effective and efficient public health services, the best available research evidence should be considered when making public health decisions. The process of evidence-informed decision making (EIDM) involves searching for research evidence, appraising and synthesizing the high quality evidence, and adapting the evidence with consideration of local contextual factors and community preferences. For many public health departments achieving EIDM has been a challenge. Methods. This study aimed to learn how EIDM spread through interpersonal interactions within the health department of a provincial government in Canada. The health department was selected based on anecdotal evidence suggesting that ideas of EIDM had diffused within this department. Employees were invited to participate in an electronic survey about their interactions regarding EIDM. The data collected from this survey were analyzed using social network analysis methods. This helped to show how the interpersonal connections helped to spread the ideas of EIDM within the organization. Results. In this organization EIDM discussion occurred most often within the organizational divisions, whereas influence for EIDM often occurred both within and between divisions. The type of relationship that appeared most important in discussion of EIDM was colleague relationships, while supervisors were more important for encouraging use of EIDM. Furthermore, individuals in leadership positions within the organization were shown to have played an important role in the diffusion of EIDM. Limitations and Conclusions. Low participation resulted in a limited picture of the whole network of this organization. The use of social network analysis is a relatively novel approach for studying the diffusion of EIDM, and there are challenges to this approach that requires special consideration when working with organizations. / Thesis / Master of Science in Nursing (MSN)

abstract: A core reform area of President Obama’s Race to the Top (RTT) framework, the Statewide Longitudinal Data Systems (SLDS) program, offered funding to states for the development of their own data systems. As a result, Arizona received funding to build a longitudinal student data system. However the targeted audience—teachers—needed training to move from a state of ‘data rich but information poor’ to one of developing actionable knowledge. In this mixed methods action research study, six teachers from three schools participated in job-embedded data-informed decision making (DIDM) and root cause analysis (RCA) professional development to improve their abilities to employ DIDM and RCA strategies to determine root causes for student achievement gaps. This study was based on the theories of situated learning, specifically the concept of communities of practice (CoP), change theory, and the Concerns-Based Adoption Model (CBAM). Because teachers comprise most of the workforce in a district, it is important to encourage them to shift from working in isolation to effectively implement and sustain changes in practice. To address this concern, an online wiki provided an avenue for participants to interact, reflect, and share experiences across schools as they engaged in the application of new learning. The results from this ten-week study indicated an increase in participant readiness levels to: (a) use and manage data sources, (b) apply strategies, and (c) collaborate with others to solve problems of practice. Results also showed that participants engaged in collaborative conversation using the online wiki when they wanted to share concerns or gain further information to make decisions. The online collaboration results indicated higher levels of online discussion occurred when participants were attempting to solve a problem of practice during the learning process. Overall, participants (a) used collaborative strategies to seek, create, and/or utilize multiple sources of data, not just student learning data, (b) worked through implementation challenges when making changes in practice, and (c) sought further types of data collection to inform their decisions about root causes. Implications from this study warrant further investigation into the use of an online CoP as an avenue for increasing teacher collaboration across schools. / Dissertation/Thesis / Doctoral Dissertation Leadership and Innovation 2016