Aim To assess current methods of prediction of adverse pregnancy outcomes, develop a prediction model and assess diet and life style in preventing preeclampsia. Methods Meta-analyses performed to assess the role of abnormal 1st trimester biomarker levels in predicting PE and the predictive accuracy of 2nd trimester UAD indices for stillbirth. A prospective observational study was performed to assess the efficacy of maternal characteristics, biomarkers, arteriography and UADs for predicting adverse pregnancy outcomes. Previously published 1st trimester PE prediction models were validated using data collected from the observational study. A systematic review on the effect of diet and life style based metabolic risk modifying interventions on PE was performed. Results The review of biomarkers found that abnormal levels were particularIy associated with early onset PE. The stillbirth review demonstrated a three-four fold increased risk of still birth with abnormal UAD. 1045 women were included for analysis in the prospective observational study. Our models' detection rate (false positive rate of 15%) was 72% for PE; 48% PIH; 30 % SGA < 10th centile; 57% SGA < 5th centile and 67% stillbirth. In the validation study the observed discrimination ability in the derivation studies ranged from 0.70 to 0.954. When validated against the study cohort, the AUC varied importantly, ranging from 0.504 to 0.833. Dietary interventions were shown to reduce the risk of PE by 33%, with no reduction in risk with mixed interventions or fatty acid supplementation. Conclusion The high heterogeneity of studies in the systematic reviews makes it difficult to draw firm conclusions regarding the use of biomarkers or UADs in screening for pregnancy complications. Our prospective study showed a role for haemodynamics as part of routine 1st trimester screening for assessing the risk of hypertensive disease in pregnancy.

Aims and objectives Substance misuse is a chronic relapsing condition associated with high morbidity and mortality. Treatment attempts to reduce harms associated with drug use and to promote recovery and has developed considerably in the last 30 years. Opioid substitution therapy using methadone (OST-M) is an effective treatment for opioid dependency. Though the effectiveness of OST-M in delivering harm-reduction is well evidenced, evidence demonstrating recovery is limited as is understanding of those factors influencing progress. In this context, national policy makers and stakeholders have repeatedly questioned the value of OST-M as a substance misuse treatment and, at times, have sought to limit its use. Rigorous, long term outcome studies of UK subjects are required to improve clinical outcomes in OST-M subjects and to ensure ongoing availability of evidence-based treatments. In this context, the study had two main objectives: to demonstrate that standard clinical information systems can deliver rich, valid datasets to support outcome research; to use these data to explore the relationships between a selection of baseline variables (patient characteristics, comorbid conditions, the nature of substance misuse and the treatment received), the clinical process and long term outcomes achieved in a large cohort of OST-M patients in a standard NHS treatment setting. Methods and materials Standard clinical information, collected over 7 years, was linked with validated data from a range of databases. A large representative sample (76% of the OST-M treatment population in a region) was described in detail. Follow-up data were retrieved from clinical casenotes (4 years) and linked datasets (4-7 years) and collated to create a database for analysis. Variables for analysis were selected following a review of the published literature. Univariate analyses were undertaken to demonstrate statistically significant associations between baseline and follow-up variables. Significant variables were then entered into multiple regression analyses to develop predictive models for selected outcomes. Any predictive models were then subjected to cross-validation to determine their predictive power in novel datasets. Key results Many highly significant associations were shown. Significant personal (demographic) factors included: age, gender, having children, having conflict in personal relationships, educational level achieved and being in employment. It was notable that the area lived in (of three districts) was strongly associated with a wide variation in clinical process and outcomes achieved. Whether treated in primary care or specialist services, the medical treatments received, the level of non-NHS support and patient satisfaction showed strong associations with outcome. Baseline illicit drug use was also strongly associated with outcome. Multiple regression analyses found that despite these highly significant associations, strong predictive models of long terms outcome could not be demonstrated. Where weak models were created - predicting drug use (by self - report); drug use (positive tests); family stability - cross validation showed these had no predictive value in novel datasets. Conclusions Standard clinical information, linked with relevant NHS datasets can give rich and comprehensive data suitable for research of large representative samples over long time periods. This study represents one of the largest OST-M populations ever described in the UK with longer follow-up periods than most of the published literature. In this study strong associations were found between a range of independent and dependent variables over 4-7 years. These findings broadly reflected the evidence base. However, the associated variables could not generate strong useful predictive models of long term outcome. This could reflect issues of study design or data quality. This type of approach should be further developed in the field of substance misuse research. Issues of data quality would require to be addressed to maximize the value of these datasets. Further research is required to develop better understanding into key factors influencing long term outcomes of treatment in substance misuse.

The Hispanic Paradox is the finding that Hispanic immigrants living in the United States have better health than Anglo Americans despite being socioeconomically disadvantaged (Crespo et al., 1996; Stern et al., 1999; Sundquist et al., 1999; Dixon et al, 2000; Lariscy et al., 2015; Overton et al., 2015; Thomson et al., 2013). The literature surrounding the Hispanic Paradox has studied these effects primarily in Mexican-American Immigrant populations (Sundquist et al., 1999; Dixon et al, 2000; Lariscy et al.); however, additional research has found similar findings for various other Hispanic countries such as Cuba and Puerto Rico (Abraido-Lanza, A F. et al., 1999). It is not known if there is a Hispanic Paradox advantage during the menopausal transition. This study compared the health outcomes of 90 Mexican immigrant women between the ages of 40-60 living in the Utah to 78 Anglo American women of the same age in order to test the hypothesis that Mexican immigrant women are healthier than their Anglo-counterparts during the menopausal transition. We compared the health of the two groups of women across various health outcomes including blood pressure, C-reactive protein, BMI, fasting glucose, and cholesterol. Contrary to our hypotheses, Anglo Americans had better health across the board on all health outcome variables (BMI; F (1)= 3.63, p =.050; C-Reactive Protein; F (1)= 9.05, p =.003; Cholesterol; F (1)= 43.51, p =.000; Blood Pressure; F (1)= 43.32, p =.000; Fasting Glucose; F (1)= 12.25, p =.001). We speculate that our findings are not consistent with Hispanic Paradox theory because of the religious culture in Utah that lends itself to healthier individuals who refrain from cigarette smoke and alcohol consumption.

The following research study aimed to discover the relationships and contributions that parent partners have in the reunification process of parents and children within the child welfare system. The study utilized a quantitative secondary data analysis design and the data were obtained from a Southern California Children and Family Services agency within the CWS/CMS database, as well as the parent partner database. Data were analyzed through SPSS software and descriptive statistics and inferential statistics were conducted to describe and assess the variables of interest. A total of 296 participants were used in the study and the majority of parents (73%) had an open case due to multiple allegations. The study found that there existed a statistically significant relationship between the utilization of the parent partner service and the likelihood of reunification. Furthermore, the study also revealed that as the number of contacts between a parent and a parent partner increased, the more likely the parent was to accomplish his/her goals. The study found that, specifically, during their open case, as 60% of parents reunified when they met 11 to 20 times with their parent partner. This study suggests that it would be a beneficial resource for child welfare agencies to incorporate the parent partner program as part of their practice. Furthermore, the agencies and counties that have already implemented the parent partner program may encourage their social workers to continuously recommend a parent partner for their clients. The research study would benefit from further research to assess the types of interactions parents and parent partners have during contacts.

There is a gap between organizational commitment to professional value of the nurse and the achievement of quality outcomes. This study explored the relationship between the productivity model and the professional value (PVS) model of the hospital-based registered nurse (RN). It was essential to understand how to measure nursing's contribution to patient care as a means to promote patient care outcomes. The current professional nursing dynamic provides an unprecedented opportunity for nurses to achieve their highest professional potential through increased demonstration of advocacy and accountability for the central tenets of nursing. The intent of this project was to explore the elements of the professional nursing workforce in a modern-day hospital. This study was conducted on the medical, surgical, progressive care unit (PCU) and critical care unit (CCU) of a community-based acute care hospital Washington State. A quantitative approach was undertaken utilizing a descriptive correlational study design. RNs on the identified units received electronic invitation and survey via organizational email system, resulting in a participation rate of 47.1% (N=48). The study found that PVS model achievement explained patient outcome variable variance (fall rate 86.4%, HAPU 83.1% and CAUTI 40.9%). Further, large effect size (98%) with work unit variance was demonstrated with PVS model achievement. The innovative PVS model was found to demonstrate a statistically significant difference from existing productivity model, and alignment of RN staffing with organizational quality goals. Recognizing the professional value of the RN could promote meaningful change in the healthcare landscape and optimize patient care and quality outcomes.

acase@tulane.edu / This dissertation uses a mixed methods design to analyze how the Colombian student-centered school model Escuela Nueva affects learning outcomes, and how well the model is implemented. Primary data from 78 schools in the department Quindío show large variation in implementation across schools, both overall and with regard to the model elements. On average, schools implement only around 62% of the elements. While schools that are officially classified as Escuela Nueva tend to implement more elements than conventional schools, the difference is not large, and considerable variation exists within each group. Qualitative data confirms these heterogeneities, and suggests that differences across schools are even larger than captured by the quantitative data, given the different ways in which the program is being used or adapted in practice. Learning outcomes are measured as scores on the national standardized test Pruebas SABER. Multilevel modeling techniques are used to analyze the scores from over 810,000 students in 21,235 schools across Colombia. The results show that students in schools that are officially classified as Escuela Nueva score significantly better, the difference amounting to 10.5 to 23.2 points (0.14 to 0.30 standard deviations). This effect is comparable to the effect of the difference of one socioeconomic level. Furthermore, Escuela Nueva tends to decrease the achievement gaps between socioeconomic levels and genders. The analysis also reveals large differences in the effect of the school model across municipalities and departments. For the department Quindío, the effect of the school model is analyzed using an implementation index instead of the official classifier. Data is available for 1,068 students in 76 schools, representing half of the department’s rural primary schools. Multilevel estimation generally shows no effect of program implementation, but cannot take into account the large relative sample size. Survey estimation techniques reveal a large effect of Escuela Nueva implementation for grade 3 mathematics and for civic competencies, where the difference in the expected score between a school with a low and one with a high implementation index is 140 to 220 points. The department-level analysis also confirms that the Escuela Nueva model helps to close gaps between socioeconomic levels. / 1 / Katharina Hammler

This thesis validates the Science Laboratory Environment Inventory for the first time in a field based environmental setting using a water quality-monitoring program within a girls' high school and compares the cognitive achievement of students in the water quality-monitoring school with those in non-water quality-monitoring schools. The psychosocial learning dimensions of the water quality-monitoring program are assessed using a modified form of the Science Laboratory Environment Inventory.The results indicate that students involved in the water quality-monitoring school were more homogenous and ranked higher in their cognitive achievement and transferability of concepts than students in the non-water quality-monitoring schools. Pre and post testing together with anecdotal information affirmed that there was a direct association between the quantitative results and qualitative information in relation to the learning dimension scales of the Science Laboratory Environment Inventory.Comparisons were made between similar water environmental programs in different countries and the water quality-monitoring school program results. The use of skills and constructivist techniques indicates that the water quality-monitoring program together with real life problem solving work is an effective method for improving science learning.

This thesis describes a research study that investigated the relationships between school level environment and student outcomes. The study involved 620 teachers and 4645 students from 57 Australian secondary schools in all states and territories. Student outcome measures included mathematics achievement, attitudes and beliefs toward mathematics and were collected as part of the Third International Mathematics and Science Study. Teachers perceptions of their school environment were measured using the School Level Environment Questionnaire and included variables such as student support, affiliation, professional interest, mission consensus, empowerment, innovation, resource adequacy and work pressure. Previous research has shown that factors at the school level, like environment, influence education at the classroom level and to further investigate this, data regarding the instructional practices of teachers was included in the analysis. The unique methodology used to investigate influences on student mathematics achievement is also described in this thesis. A two-step approach to modelling consisted of the analysis of two conceptually distinct models. The first was an analysis of the measurement model, which specifies the relationships between the observed variables and the latent variables. The second involved a structural equation model, which specifies the relationships among the latent variables as posited by theory and previous research. In addition, a multilevel analysis was included to further partition the variance in student outcomes between the student level, the classroom level and the school level. The results of these analysis linked particular variables of interest to improved student outcomes. / For example, teachers who felt supported and empowered were more likely to employ student-centred instructional practices and that work pressure and resource adequacy influenced the instructional approaches in the classrooms. The success attribution of students determined which method of instruction promoted positive outcomes. Furthermore, these results indicate relationships between student outcomes, attitudes and achievement, and the relationships between attitude and achievement were recursive with influences from student background variables. The multilevel analysis demonstrated the importance of the influence of factors at the classroom level in influencing student outcomes and highlighted factors at the school level that explained differences in achievement. The significance of this study is in the provision of evidence that demonstrates the effects on student outcomes and not only supports, but significantly adds to previous research. This thesis provides practical implications for teaching and for school policy that can be implemented to promote positive student outcomes. The thesis also provides a rationale for further research that would involve an investigation of the effects of change as suggested from the results of these analysis reported from this study.

Research in the area of caregiving has tended to focus on the impact of the caregiving experience itself without consideration of continued psychological distress for caregivers after institutionalisation or death. Seven caregivers of loved ones with Alzheimer's Dementia (mostly spousal) were interviewed about their experiences of caregiving and their emotional well-being after placement of their loved one into a residential care facility or death. The nature of the carers relationship with their loved one (e.g. highly dependent), lack of social supports, inactivity and a poor experience of transition into care seemed to be factors relating to poorer outcomes for these caregivers. Utilisation of social supports, involvement in pleasant events, adequate preparation and information relating to the disease and collaboratively planned transition into care played protective roles for the remaining carers who reported decreased levels of anxiety, guilt, depression and stress post-institutionalisation/death. The implications of the current research for practise, policy change and prevention are extensive and suggest that risk factors may be identifiable and thus poorer mental health outcomes in caregivers preventable. A need for greater support to be made available to caregivers is necessary.

Customer loyalty in services is the focus of the research. The research problem sought to determine both indirect and indirect effects of relational outcomes on customer loyalty, conceptualised as a psychological state. Relational outcomes are defined as: the thoughts, feelings, and relationships perceived by customers arising from the interaction with a service employee. This class of variable is differentiated from other relational factors such as the characteristics of the actors in the interaction and their behaviours. The effects of relational outcome antecedents were compared to service evaluation antecedents such as customer satisfaction, quality, and value. Customer loyalty was modelled as a psychological state and grounded in the unique characteristics of services. The pioneering work of Kingstrom (1983) was used as a basis for extending the literature. Customer loyalty is an important variable for both services marketing researchers and industry. Accordingly, the research was justified on both theoretical and managerial grounds. Four factors inspired the identification of the research gap: a lack of service loyalty research grounded in service characteristics, lack of studies that conceptualised loyalty as a psychological state, inadequacy of service evaluation measures to predict customer loyalty, and the perceived importance of social interaction to service outcomes. Data collection included pilot studies, re-analysis of published literature, and three major studies. In the first major study, 23 informants provided insights into the nature of three specific relational outcomes: friendship, social comfort, and social regard. The second study was a cross-sectional survey of 190 hair-dressing customers. The specific relationships between friendship, social regard, social comfort, value for money, service encounter satisfaction, perceived core service quality, and customer loyalty were established in this study. New scales were also developed for friendship, social regard, social comfort, and customer loyalty. A third study collected survey data from 406 customers of hairdressing salons, cafes, and naturopathic clinics. Hypothesised relationships were tested through three nested structural equation models. The results indicate that relational outcomes in general are important to customer loyalty. Their effects on loyalty as a psychological state are both direct and indirect. The strength of the effects of relational outcomes on loyalty compares favourably with the effects of service evaluation measures on loyalty. The construct of friendship between individual customer and service employee was found to be related significantly and positively with customer loyalty. The effect of personal friendship appears to have as strong an effect as perceptions of core quality and service encounter satisfaction. Another major finding was that the two relational outcomes of social comfort and social regard both had an indirect influence on customer loyalty. This effect was mediated through the service evaluation constructs of perceived core service quality and service encounter satisfaction. Social comfort affected both quality and satisfaction whereas social regard only influenced quality. However, the impact of social regard on core quality was substantial. Friendship was not found to have a significant relationship with either quality or satisfaction. These findings suggest that there is a temporal dimension to the influence of relational outcomes. Both social regard and social comfort appear to be more important in the early stages of customer-service provider interaction. It also appears that customers evaluate the core quality of everyday services such as hair salons, cafes, and naturopaths using social cues such as feeling well regarded. A further major finding was the lack of a significant relationship between value for money and psychological loyalty in both quantitative studies. Effects of quality, satisfaction, and friendship appear to be important to loyalty development whereas customer value is not. This finding suggests that value for money may be related directly to actual purchase behaviour or repurchase intentions rather than mediated through psychological feelings of loyalty. Hence, evaluations which reflect pricing considerations are less likely to be associated with psychological loyalty than more relationally oriented constructs. The findings indicate important implications for both marketers and researchers. Marketing strategists need to be clear about pursuing either a loyalty or a value for money strategy. The former may not result from the latter. Relational outcomes lead to psychological loyalty but their interactive effects operate differently. Friendship with a service employee provides a direct contribution to loyalty development. Whereas social regard and social comfort affect customers' evaluation of the service. Pursuing a relational strategy will have implications for the way frontline staff are selected and trained. Theoretical implications include: using the relational outcomes as a basis for middle range theory development, support for the linear-additive measurement approach, use of laddering techniques to determine relevant influencing variables, and additional explanatory power to the service recovery literature. In conclusion, a unidimensional construct of psychological loyalty, grounded in service characteristics, was developed, tested, and evaluated for wide application to service industries. Three specific relational antecedents: Friendship, social regard, and social comfort were found to be important to the development of customer loyalty. The research highlighted how these relational outcomes interacted with service evaluation measures to produce loyal customers. Accordingly, Kingstrom's (1983) work has been extended.