ABSTRACT Botanic Garden User Outcomes: A Means-End Investigation Christopher Lee Wassenberg This study explored the outcomes that Leaning Pine Arboretum users experience from visiting the botanic garden. Understanding visitor motivations and benefits has been a focus in the field of outdoor recreation, and the subject of a number of botanic garden and green space visitor studies. Previous studies have found that visiting a botanic garden can serve as a coping strategy for dealing with and reducing life stress (Holbrook, 2010; Kohlleppel, Bradley, & Jacob, 2002; Maller, Townsend, Pryor, Brown, & St Leger, 2005) and that visiting public outdoor green spaces led visitors to experience greater exposure to natural spaces and to have meaningful experiences with others (Burgess, Harrison, & Limb, 1988). This study employed means-end theory (Gutman, 1982) to investigate the link between garden attributes and user outcomes. In-person interviews were conducted with 83 garden visitors during the summer of 2011. Researchers coded the interview data to identify participants’ reported attributes, consequences, and values. Intercoder reliability was conducted to ensure validity of the results. Coded data were entered into the Laddermap (Gengler & Reynolds, 1995) computer software program to be analyzed. Implication matrixes were created to determine the number of times concepts were linked. From the implication matrixes, hierarchical value maps (HVMs) were developed to display the results graphically. HVMs show the strength of links between attributes, consequences, and values, and were used to compare results from different visitor groups within the study. These groups included males and females, students and non-students, and first time and return visitors. The findings revealed that participants felt that the botanic garden and plants were the most meaningful garden attributes. These garden attributes led participants to experience the consequences new experiences and learning stress and relief and relaxation. Having experienced these meaningful consequences allowed participants to reach the most frequently mentioned values: transference and improved quality of life. The study found important links between attributes, consequences, and values, including the consequences escape and stress relief and relaxation, and the consequence new experiences and learning, and the value transference. Important differences were also found between the attribute, consequence, and value chains of multiple visitor groups. Botanical garden and arboretum mangers may use this study to improve visitor experiences and outcomes. A better understanding of visitor benefits and outcomes can help managers understand the needs of current visitors, potential visitors, and potential garden supporters. In turn, garden visitors who have better experiences may be more inclined to provide funding or other support to conserve and preserve their local gardens. Based on the results garden managers should maintain a broad range of healthy, well-displayed plants; exert high-levels of detail to all aspects of garden operations; continue to provide opportunities for full visitor immersion; and offer unified, accessible interpretation of garden spaces and plants. Additionally, these results may be used to validate funding requests and guide allocation of funding. Keywords: Botanic garden users, outcomes, means-end theory, Leaning Pine Arboretum

Purpose: The aim of this study was to assess the outcome of treatment of teeth with open apices managed by the orthograde placement of a bioceramic apical barrier as well as to identify potential outcome factors for this type of treatment. Methods: Patient records were pooled from graduate resident cases completed at Virginia Commonwealth University between January 1, 2010 and May 31, 2018. A total of 515 patients were identified using relevant ADA codes and a key word search within the patient record database. A total of 104 patients (119 teeth) had an open apex that had NSRCT utilizing a bioceramic apical barrier, with 32 of the patients (36 teeth) returning for follow-up. Results: Of the 36 examined teeth (30.8% recall rate),72% were considered healed. 92% were considered healed or healing. No predictive variable analyzed had a significant effect on the outcome. Conclusion: Overall, these results indicate that a bioceramic apical barrier technique is a promising treatment option for obturating teeth with open apices during NSRCT.

Despite increased access to prenatal care, birth outcomes continue to be a major source of disparity among women in the United States. The focus on lifestyle choices and negative behaviors prior to a pregnancy to reduce adverse birth outcomes has become a well-documented strategy. The purpose of this study was to determine if preparing for a pregnancy in advance improves birth outcomes for African American women of childbearing age between the ages of 12 and 45 years in the State of Rhode Island (RI). The theoretical foundation for this study was based on Prochaska's model of change, which is also known as the readiness to change model. This study was conducted using secondary data from the Rhode Island Department of Health PRAMS data set. The research questions determined if African American women received preconception care education at the same rate as White women, if African American women had a higher rate of infant mortality than other races, and if African American women had a higher rate of unintended pregnancies than White women in the state of Rhode Island. Independent t tests and chi square tests were used to answer the research questions. The results indicated a difference between the infant mortality rates for African American women compared to other races as well as a difference between African American women compared to White women with regard to unintentional pregnancies in Rhode Island. However, there was no difference in African American women compared to White women receiving preconception education in the state of Rhode Island. The implications for positive social change include micro- and macro-level changes in support of how planning for a pregnancy in advance can reduce poor birth outcomes.

College environments can pose both academic and social challenges for students with disabilities. For teachers and parents of children with Asperger's syndrome (AS) and high functioning autism (HFA), these challenges include communication, behavioral, and social difficulties that can hinder their attainment of educational objectives. Limited research has been conducted regarding postsecondary outcomes of elementary and secondary public school interventions provided to these students. This case study gathered information from postsecondary students with AS and HFA regarding their experiences of public school social skills interventions and their perceived impact on current social and academic outcomes. Findings were interpreted using critical theory (CT) and critical disability theory (CDT) approaches, which suggested an advocacy perspective and provided the participants a voice to express their lived experiences, offering an opportunity for others to learn from these experiences. Participants included a sample of 12 young adults with HFA and AS currently enrolled in postsecondary educational settings who were recruited through college/university disability services offices, school districts, and support groups. Interview data were examined in order to glean descriptions of the participants' social experiences and determine emergent social and academic themes among cases. Study findings indicated a need for improved guidance and education in the area of social skills for students with autism spectrum disorders (ASD) and proposed avenues for positive social change by providing educators, parents, and advocates information to support the development of improved social supports and more effective outcomes for students with ASD.

Thesis (M.Dev.) --University of Limpopo, 2007. / This study sets out to explore the challenges faced by grade 9 educators in the implementation of Outcomes-Based Education (OBE) in Maleboho East Circuit in Limpopo Province in view of the role played by this new education approach in the government’s agenda for social transformation. The study is mainly exploratory in design and has been undertaken within a qualitative framework. Thus, the study does not purport to come with explanations of cause and effect relations. It only explores the challenges that impact on successful implementation of the OBE approach. The research results show that the OBE approach is not effectively implemented in schools, due to inadequate teacher training, limited or little support to educators in their classroom practice, overcrowded classes and poor working conditions of educators. There is a need for a multi-dimensional approach that aims to address not only deficiencies in training, but also to impact on the attitudinal changes of educators. / N/A

Urinary incontinence, one of the most prevalent conditions in elderly living in nursing homes (NH) was shown to significantly impact patient's quality of life (QOL) and health outcomes. Bladder antimuscarinics (BAM), the main drug class to treat urinary incontinence, have limited effects in managing the condition; however, given their anticholinergic properties and the characteristics of those living in NH, BAM could potentially lead to serious health consequences in this population. We conducted a retrospective cohort study with a new-users design by linking existing Veterans Affairs (VA) data (inpatient, outpatient, pharmacy administrative files, and Minimum Data Set- MDS) between fiscal years 2003 and 2009. Potential risks (i.e. fractures and negative impact on cognitive performance) and benefits (i.e. improvement in urinary incontinence, social engagement and overall QOL) associated with initiation of a BAM were assessed in elderly (65+) admitted for long-term care in the VA Community Living Centers. Descriptive statistics were used to compare BAM new-users and non-users at baseline; in addition, logistic regression was used to identify important predictors of BAM initiation. Treatment selection bias was addressed by using the propensity score matching method. After balancing the groups on baseline characteristics, the risk of fractures (hip fracture, any fracture) in relationship with BAM initiation was evaluated using Cox proportional hazard analysis. BAM impact on the cognitive status measured by the MDS-Cognitive Performance Scale (CPS) was evaluated through generalized estimated equations (GEE) method. Similarly, possible benefits measured through MDS were assessed via GEE. The final cohort included 1195 BAM new-users (with the majority being prescribed Oxybutynin immediate-release) and 22,987 non-users. Predictors of BAM initiation included demographic characteristics, bladder and bowel continence status, comorbidities, medication use, cognitive performance and functional status. Our study showed that BAM improved urinary continence (OR=1.27, 95%CI: 1.07-1.50) in those treated; social engagement as measured by MDS-Index of Social Engagement also improved in users, although at a level that is not clinically significant (difference in mean MDS-ISE=0.2074, 95%CI: 0.0550-0.3598). However, BAM initiation increased the risk of fractures (hip: HR=3.69, 95% CI: 1.46 - 9.34, p=0.0059; any fracture: HR=2.64. 95% CI: 1.37 - 5.10, p=0.0039). Our results showed no difference between new-users and non-users with regard to mean CPS and overall QOL. The purpose of the study was to clarify the proper role of medication use in the management of urinary incontinence in elderly in the VA CLC. The results raise questions about the continued use of Oxybutynin IR, the main BAM prescribed in this population. Given the increased risk for fractures in the context of potential improvement in urinary continence with no clinically significant improvement in social engagement, a wiser step might be to investigate the safety profile for newer BAM for situations when an addition to non-pharmacologic management for urinary incontinence is desired for elderly in long-term care.

Observational studies are an indispensable complement to randomized clinical trials (RCT) for comparison of treatment effectiveness. Often RCTs cannot be carried out due to the costs of the trial, ethical questions and rarity of the outcome. When noncompliance and missing data are prevalent, RCTs become more like observational studies. The main problem is to adjust for the selection bias in the observational study. One increasingly used method is propensity-score matching. Compared to traditional multi-covariate matching methods, matching on the propensity score alleviates the curse of dimensionality. It allows investigators to balance multiple covariate distributions between treatment groups by matching on a single score. This thesis focuses on the large sample properties of the matching estimators of the treatment effect. The first part of this thesis deals with problems of the analytic supports of the logit propensity score and various matching methods. The second part of this thesis focuses on the matching estimators of additive and multiplicative treatment effects. We derive the asymptotic order of the biases and asymptotic distributions of the matching estimators. We also derive the large sample variance estimators for the treatment effect estimators. The methods and theoretical results are applied and checked in a series of simulation studies. The third part of this thesis is devoted to a comparison between propensity-score matching and multiple linear regression using simulation.

Background: In response to high cost and inadequate quality, the healthcare system is in the midst of a transition from paying for volume to paying for value. Billions of dollars could be saved through more effective medication use, and evidence supports the role of the community pharmacist in lowering healthcare cost and improving healthcare quality through medication optimization. Despite this, value-based payment models for community pharmacies are rare, and those that do exist have not been critically evaluated and implementation in a commercially insured population is rare. Objective: The first objective was to design and test a conceptual model of pharmacy value. The second objective was to evaluate variation in the value community pharmacies provide a commercial insurer by assessing the relationship between attributed patients’ healthcare quality and cost. Methods: This study used prescription and medical claims data for 2012 and 2013 from a large commercial insurer in Iowa and South Dakota. Patients were attributed to the pharmacy filling the majority of their prescriptions. Pharmacies’ weekly prescription volume and Sunday prescription filling behavior were used as structural measures of healthcare quality. Percent of days covered (PDC) metrics for beta-blockers, statins, renin-angiotensin system antagonists and non-insulin diabetes agents were used as process metrics. Pharmacies were excluded if the denominator for any PDC metric was less than 15. Outcome metrics consisted of a non-trauma, non-cancer, unplanned hospitalization rate and a non-trauma ED visit rate. Cost impact was categorized into pharmaceutical, medical, and total cost of care. High quality pharmacies with typical or low associated costs or low cost pharmacies with typical to high quality were identified as high value and vice versa for low value. All metrics were risk-adjusted using mixed effect models with a random pharmacy intercept. The ratio between observed and expected quality scores was used for quality scoring. Quality outliers were identified by comparing the 95% CI around pharmacies’ risk-adjusted scores to the all-pharmacy risk-adjusted score mean. A t-test was used to assess variation in pharmacy value. Results: There were 171 pharmacies and 74,581 patients eligible for scoring on all quality metrics. Mixed effects models observed a small but significant impact of pharmacy on process and outcome healthcare quality. No relationship between structures and processes, processes and outcomes was detected. Ten pharmacies were scored as high quality and nine as low quality. Similar numbers were identified for cost outliers, and significant variation in value was detected. Implications/conclusions: Results support the hypothesis that high and low value pharmacies exist. A well-designed value-based payment model could be used to create incentives for pharmacists to enhance care for commercially insured patients, but validation is needed to ensure that incentives are aligned appropriately.

American Indians are severely disadvantaged and yet known relationships among risk and protective factors and cultural identification are limited. The current study assessed associations among measures of acculturation, ethnic identity, and psychosocial outcomes among Navajo adolescents. Adjustment of Navajo adolescents in the domains of school bonding, social functioning, self-esteem, depression, delinquent behaviors, and substance use was assessed. Navajo adolescents, between the ages of 14 and 18, also completed a self-report questionnaire containing the Revised Multigroup Ethnic Identity Measure, the Orthogonal Cultural Identification Scale, and the Native American Acculturation Scale. Measures of ethnic identity were positively associated with aspects of psychosocial functioning for Navajo adolescents, with stronger predictions of school bonding, self-esteem, and social functioning outcomes emerging for males. The students' sense of affirmation and belonging to their ethnic heritage emerged as the strongest predictor of positive outcomes.

As college classrooms increase in size, the challenge of keeping students engaged in the course becomes a greater challenge. Instructors are burdened with the task of managing larger classrooms while maintaining high levels of student participation. Research has shown that students tend to hide and are less likely to participate in larger classrooms. Research has also shown that student participation is affected by fear of judgment from their peers and the instructor. However it is unclear whether this fear is tied to students’ perceived ability or self-efficacy. In addition, it may be that students’ perception of the instructor may affect their class participation. The present study attempted to disentangle how these factors work together to influence student engagement in the classroom. The present study was conducted over the fall 2013 semester. Two hundred forty four students were recruited from three introductory psychology courses. At the beginning of the semester, students were asked to report their perception of their academic ability (academic self-efficacy; ASE) and demographic information. During the last week of instruction, students were asked to self-report their ASE, level of course engagement, and perceptions of the instructors teaching self-efficacy (PIE). After grades were posted, the final grades for each student were collected. Three predictions were explored: (a) changes in ASE would predict students’ course grade, (b) the relationship between student ASE and student grades would be mediated or moderated by student engagement, and (c) PIE would moderate the relationship between students’ ASE and student engagement. Two of the predictions were supported. Changes in ASE did predict students’ course grades such that increases in ASE predicted increases in grades as well. Student engagement partially explained the relationship between ASE and grades. Closer examination showed that performance (wanting good grades in the course) accounted for the relationship between ASE and course grades. The final prediction could not be evaluated because PIE was not related to ASE. However results show that PIE does significantly impact student engagement in the course. This adds to previous literature and shows that perceptions of an instructor’s teaching self-efficacy can influence how students engage in the course. These results also align with previous research that has shown that students with higher sense of ASE and course engagement have better academic outcomes.