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Background: Recently, health plans have initiated pay-for-performance (P4P) programs to incentivize pharmacies to focus on medication-related quality measures. Little research exists as to what attributes help a pharmacy to perform well in a P4P program. Objectives: This study aimed to: (1) propose a conceptual framework evolved from theories pertaining to economic, psychology, and organizational behavior disciplines that may contribute to a pharmacy's performance in a financial incentive program; (2) develop theoretically-derived questionnaires designed to elicit from pharmacists and pharmacy management pharmacy characteristics and pharmacy personnel factors thought to be associated with achieving quality measures specified for a pharmacy P4P program; (3) psychometrically assess these two newly developed questionnaires designed to collect information from community pharmacies eligible to participate in a pharmacy P4P program; (4) assess the magnitude of the relationship between pharmacy-related and construct redundancy of latent variables identified in objective 3; and (5) examine pharmacy factors' association with community pharmacies achieving quality measures in a pharmacy P4P program. Methods: Two survey instruments were created from a theoretically-derived conceptual framework to measure pertinent pharmacy characteristics and pharmacy personnel factors using a multi-step, mixed-methods process. Questionnaire development entailed semi-structured interviews, item generation, expert content validation, and cognitive debriefings. Developed questionnaires were evaluated in a non-experimental, cross-sectional survey of pharmacists and pharmacy management. Pharmacy personnel surveyed for this study were affiliated with pharmacies in Inland Empire Health Plan's (IEHP's) community pharmacy network. Using items measured in each questionnaire, specified groups of items were hypothesized to have a certain underlying latent variable. Latent variables hypothesized for items measured in the pharmacist questionnaire included: (1)"adherence management -services," (2)"adherence management-counseling," (3) "asthma management," (4) "pharmacist-prescriber relationship," (5) "chronic disease management," (6) "non-dispensing ability," and (7) "workload impact". For items measured in the pharmacy management questionnaire, eight latent variables were hypothesized: (1) "program understanding," (2) "program financial salience," (3) "program involvement," (4) "organization's adaptability," (5) "organization's innovativeness," (6) "organization's proactiveness," (7) "organization's risk-taking." and (8) "organization's focal emphasis." For hypothesized latent variables with four or more items, the value thresholds of three assessment indexes were employed as criteria to evaluate each measurement model's goodness-of-fit. Indexes included: (1) 2 test statistic (i.e.,>0.05), (2) root mean square error of approximation (RMSEA) (i.e., 0.05), and (3) comparative fit index (CFI) (i.e.,>0.95). The statistical significance of item factor loadings was assessed for latent variables with (1) four or more items deemed to have adequate model fit per index criteria and (2) only three items, for which goodness-of-fit may not be assessed. Structural modeling was used to explore associations between (1) pairs of latent variables with adequate model fit and/or statistically significant factor loadings; and (2) latent variables with medication-related quality measures. The strength of associations among latent variable pairs was measured with correlation coefficients. Latent variable pairs with significant correlations greater than 0.50 were evaluated for construct redundancy, for which a change in CFI was used as the comparison criteria to determine whether the latent variables are better represented as one (i.e., (CFI<-0.01) or two constructs (i.e., (CFI ≥ -0.01). Mediation-related quality measures specified as dependent variables in structural models included: diabetes medication adherence, hypertension medication adherence, hypercholesterolemia medication adherence, absence of controller therapy in patients with asthma, use of high-risk medications in elderly, and generic dispensing rate. Results: The empirically derived conceptual framework outlined four major domains proposed for consideration when evaluating pharmacy P4P programs: (1) incentive; (2) pharmacy; (3) other influencing factors; and (4) P4P program measures. From this framework, two questionnaires were developed with the aim of measuring pharmacists' and pharmacy management's pharmacy attitudes and perspectives of a community pharmacy P4P program. The pharmacist survey instrument consisted of five sections: (i) community pharmacy P4P program; (ii) pharmacy services; (iii) pharmacist workload; (iv) pharmacy practice site; and (v) pharmacist's background. The pharmacy management questionnaire consisted of four sections: (i) pharmacy P4P program; (ii) pharmacy organization's characteristics; (iii) pharmacy practice site; and (iv) respondent's background information. Among the 604 pharmacies invited to participate, pharmacists from 114 unique pharmacies (19%) and pharmacy management from 100 unique pharmacies (17%) participated in the survey. This study identified psychometrically validated measurement models for latent constructs with items measured in the pharmacist ("adherence management-counseling," "asthma management," "workload impact" ) and pharmacy management ("program involvement," "organization's innovativeness," "organization's proactiveness," "organization's risk-taking" ) questionnaires). With the exception of "program involvement," the latent constructs measured in the pharmacy management questionnaire were identified to be significantly correlated (𝛹>0.50, p<0.001) and more parsimoniously represented as one factor rather than two (∆CFI<-0.01). No significant associations were identified in exploratory analyses of validated measurement models from the pharmacist questionnaire with targeted medication-related quality measures in IEHP's community pharmacy P4P program. Conclusion: This study collected data for two questionnaires evaluating (1) pharmaceutical care services conceptualized to be associated with targeting medication-related quality measures and (2) pharmacy management's attitudes toward a pharmacy P4P program. Furthermore, psychometric assessment of each questionnaire supplied initial validity evidence for three constructs for the pharmacist questionnaire ("adherence management-counseling," "asthma management," and "workload impact" ) and four constructs for the pharmacy management questionnaire ("program involvement," "organization's innovativeness," "organization's proactiveness," and "organization's risk-taking" ). Subsequent validation of these latent constructs in larger sample sizes is required. Continued study of pharmacy factors and their association with medication-related quality measures is needed to improve our understanding of pharmacies' performance in financial incentive programs. As pharmacy organizations are increasingly integrated into more financial incentive programs aimed at targeting process- and outcomes-related quality measures, it is essential to be able to measure pharmacy and management factors in order to determine which factor(s) impact pharmacy performance.

The self-compassion conceptualization developed by Neff (2003a, b) and its corresponding 26-item inventory (SCS) has gained interest in recent years. SCS have proven good validity and reliability, but its suggested six-factor model cannot always be replicated. Recent studies have shown a more promising two-factor model for the SCS. The aim of this study was to test the structural validity of a translated Swedish SCS in university students (n = 464; 22% men). The results showed good construct validity, test-retest and internal reliability (ICC = .97; α = .86). Partial confirmatory factor analysis could not confirm the six-factor model but did support the two-factor model consisting of a positively worded (self-compassionate attitude) and a negatively worded (self-critical attitude) factor. The modified scale (SCS-Swe22) showed good reliability and construct validity (ICC = .96; α = .89). Despite promising results, additional work is required to secure the structural construct of SCS-Swe22.

To understand obesity as a global epidemic, it is essential to understand why individuals become and remain overweight or obese. Body weight, and correspondingly being overweight or obese, is a result of one’s genetics and energy balance. Food and beverages bring energy to the body. However, their intake occurs as a result of a variety of interacting factors, e.g. physiological, cultural, genetic, social, and behavioural ones. One aspect of eating behaviour research is to identify underlying psychological aspects of individuals’ daily food intake. In laboratory experiments, researchers have aimed to identify differences in eating behaviour between normal-weight and overweight subjects. A result of those experiments was the Three-Factor-Eating-Questionnaire (TFEQ), a widely used instrument looking at three primary aspects of eating behaviour: ‘cognitive restrained’, ‘disinhibition’, and ‘hunger’. However, psychometric analysis of the German version of the TFEQ was based on two convenient clinical samples from 1989 and on one representative sample of younger subjects from 1990. Hence, one aim of the empirical studies within this dissertation was to provide an updated psychometric analysis of the German version of the TFEQ for a non-clinical setting in Germany. We also aimed to conduct associated analyses between the domains of the TFEQ and the BMI as the most important risk factor for common civilisation diseases. Overall, database was a large study sample from the baseline survey of the population based cohort Leipzig LIFE-Adult study. The first study provided age- and gender-specific norms for the three TFEQ domains. Percentile ranks and T-scores for the four age groups 40-49 years, 50-59 years, 60-60 years, 70-79 years and for both men and women were published. Additionally, the study identified craving for sweets as the most common problem in eating behaviour. The published norms for the original 59-item German version of the TFEQ can be applied in clinical and non-clinical settings. Furthermore, additional information about common problems in eating behaviour might help identify general key points related to body weight modulation. The second study analysed the factor structure of the TFEQ using both confirmatory and explorative factor analysis. Importantly, the original TFEQ factor structure was not replicated. A refined 29-item version contained three domains: ‘uncontrolled eating’ (15 items), ‘restrained eating’ (11 items), and ‘emotional eating’ (three items). The identified underlying aspects of eating behaviour are consistent with those of other studies and suggest their evidence. The highest mean BMI was found in subjects scoring high in both uncontrolled eating and emotional eating. The analysis thus confirms previous findings of the direct association between the uncontrolled eating domain and the BMI and between the emotional eating domain and the BMI. Again, this information might help identifying individual’s key problems in the challenge of maintain or lose body weight. Interestingly, in our analysis, the lowest mean BMI was found in subjects who scored low in all three of the TFEQ domains. We thus suggest that lowering the values of the three aspects of eating behaviour might be a promising approach in weight reduction programmes. Regarding the impact of eating behaviour to the BMI, social disparities might play an important role. Thus, in our third study, we hypothesized that psychological aspects of eating behaviour might mediate the indirect association between the socio-economic status and BMI. However, our analysis revealed only weak evidence for this triangular association. Therefore, we suggest that psychological factors may be less involved in this association than other types of factors (such as financial resources). In sum, understanding why individuals become and remain overweight or obese is of utmost importance, as the social and economic burden of excess weight is high. Psychological aspects of eating behaviour might partly explain individuals being overweight or obese. The studies within this dissertation revealed that the widely used TFEQ helps to identify subjects with a specific pattern of eating behaviour associated with higher BMI values, but might not explain social disparities in body weight. However, eating behaviour comprises a stable, long-term pattern of daily food intake. Therefore, research into eating behaviour offers the chance to identify fundamental aspects of body weight modulation.

To develop a scale to assess infectious disease-specific health literacy (IDSHL) in China and test its initial psychometric properties. Methods: Item pooling, reduction and assessment of psychometric properties were conducted. The scale was divided into 2 subscales; subscale 1 assessed an individual's skills to prevent/treat infectious diseases and subscale 2 assessed cognitive ability. In 2014, 9000 people aged 15-69 years were randomly sampled from 3 provinces and asked to complete the IDSHL questionnaire. Cronbach's á was calculated to assess reliability. Exploratory factor analysis, t-test, correlations, receiver operating characteristic (ROC) curve and logistic regression were used to examine validity. Results: Each of the 22 items in subscale 1 had a content validity index >0.8. In total, 8858 people completed the scale. The principal components factor analysis suggested a 5-factor solution. All factor loadings were >0.40 ( p<0.05). The IDSHL score was 22.07±7.91 (mean±SD; total score=38.62). Significant differences were observed across age (r=.0.276), sex (males: 21.65±8.03; females: 22.47±7.78), education (14.16±8.19 to 26.55±6.26), 2-week morbidity (present: 20.62±8.17, absent: 22.35±7.83; p<0.001) and health literacy of the highest and lowest 27% score groups (all p<0.05). The ROC curve indicated that 76.2% of respondents were adequate in IDSHL. Binary logistic regression analysis revealed 12 predictors of IDSHL adequacy (p<0.05). Among the 22 remaining items, Corrected Item-Total Correlation ranged from 0.316 to 0.504 and Cronbach's á values ranged from 0.754 to 0.810 if the items were deleted. The overall á value was 0.839 and the difficulty coefficient ranged from 1.19 to 4.08. For subscale 2, there were statistically significant differences between the mean scores of those with a correct/incorrect answer (all p<0.001). Conclusions: The newly developed 28-item scale provides an efficient, psychometrically sound and userfriendly measure of IDSHL in the Chinese population.

Titre : EVALUATION DE LA FRAGILITE EN ONCOLOGIE GERIATRIQUE : DEVELOPPEMENT ET VALIDATION D’UNE NOUVELLE ECHELLE DE DEPISTAGE.Mots clés : fragilité, sujet âgée, cancer, dépistage, développement, validation, analyse de survie.Résumé : Une évaluation gériatrique (EG) est recommandée pour tous les patients âgés atteints de cancer pour identifier d’éventuels problèmes de santé et ainsi optimiser la stratégie thérapeutique. Néanmoins, elle est très consommatrice de temps et de moyens. Plusieurs outils de dépistage ont été développés mais a) aucun ne dispose de propriétés diagnostiques adéquates en pratique clinique, b) ils ont le plus souvent été développés sur la base d’opinions d’experts sans développement statistique spécifique, et c) peu de données sont disponibles pour apprécier leur robustesse au changement de gold standard pour définir le concept de « fragilité ». Par conséquent, notre objectif était 1) de construire et valider un outil de dépistage performant de la fragilité et de le comparer à l’outil de dépistage G8 actuellement utilisé en oncogériatrie, 2) d’en tester la robustesse vis-à-vis de 6 définitions de référence de la fragilité et 3) d’en évaluer la valeur pronostique pour la mortalité à 1 et 3 ans. Les données étaient issues de deux cohortes prospectives de patients âgés atteints de cancer : ELCAPA (2007–2012: n=729 [développement]), et ONCODAGE (2008–2010: n=1304 [validation externe]). L’outil G8 modifié final (aire sous la courbe ROC [AUROC] : 91,6% ; Sensibilité=89% ; Spécificité=79%) comprenait 6 items indépendants : perte de poids, problèmes neuropsychologiques, statut fonctionnel, état de santé perçu, poly-prescription et existence parmi les antécédents d’une insuffisance cardiaque ou coronaropathie. Les travaux accomplis dans le cadre de cette thèse ont de plus permis de confirmer ses bonnes propriétés diagnostiques en validation externe (AUROC : 84,6% ; Sensibilité=82% ; Spécificité=69%), sa robustesse au changement de gold standard et sa valeur pronostique forte vis-à-vis de la mortalité. L’utilisation du G8 et G8 modifié devrait être encouragée en oncologie gériatrique. / Title : ASSESSMENT OF FRAILTY IN GERIATRIC ONCOLOGY: DEVELOPMENT AND VALIDATION OF A NEW SCREENING TOOL Key words: frailty, older person, cancer, screening, development, validation, survival analysis.Abstract: The comprehensive geriatric assessment (GA) is recommended in older cancer patients to inventory health problems and tailor treatment decisions accordingly. However, GA is time- and resource-consuming. Several screening tools have been developed but a) their diagnostic performance is insufficient, b) most instruments have been developed exclusively on the basis of experts’ opinions without any specific statistical psychometric development, and c) a wide variability of criteria have been used to define “frailty” as the gold standard, with no investigations of their influence on the diagnostic properties of screening instruments. Therefore, our objective was 1) to develop and validate a new screening tool for frailty that achieves high diagnostic accuracy, and to compare it to the G8 screening tool, currently used in oncogeriatrics, 2) to evaluate its robustness to modifications on the gold standard, for which 6 reference definitions were tested, and 3) to assess its prognostic value for 1- and 3-years mortality. We used two prospective cohorts of older patients with cancer: ELCAPA (2007–2012: n=729 [development]), and ONCODAGE (2008–2010: n=1304 [external validation]). The final modified-G8 (area under the ROC curve [AUROC]: 91.6%; Sensitivity=89%; Specificity=79%) included 6 independent items: weight loss, cognition/mood, performance status, self-rated health status, polypharmacy and history of heart failure or coronary heart disease. The work carried out in this thesis has also confirmed its good diagnostic properties in external validation analyses (AUROC: 84.6%; Sensitivity=82%; Specificity=69%), its robustness to modifications of the gold standard definition and its strong prognostic value for overall survival. The use of the G8 and modified-G8 should be encouraged in geriatric oncology.

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Unintended consequences of electronic health records represent undesired effects on individuals or systems, which may contradict initial goals and impact patient care. The purpose of this study was to determine the extent to which a new quantitative measure called the Carrington-Gephart Unintended Consequences of Electronic Health Record Questionnaire (CG-UCE-Q) was valid and reliable. Then, it was used to describe acute care nurses' experience with unintended consequences of electronic health records and relate them to the professional practice environment. Acceptable content validity was achieved for two rounds of surveys with nursing informatics experts (n = 5). Then, acute care nurses (n = 144) were recruited locally and nationally to complete the survey and describe the frequency with which they encounter unintended consequences in daily work. Principal component analysis with oblique rotation was applied to evaluate construct validity. Correlational analysis with measures of the professional practice environment and workarounds was used to evaluate convergent validity. Test-retest reliability was measured in the local sample (N = 68). Explanation for 63% of the variance across six subscales (patient safety, system design, workload issues, workarounds, technology barriers, and sociotechnical impact) supported construct validity. Relationships were significant between subscales for electronic health record-related threats to patient safety and low autonomy/leadership (P < .01), poor communication about patients (P < .01), and low control over practice (P < .01). The most frequent sources of unintended consequences were increased workload, interruptions that shifted tasks from the computer, altered workflow, and the need to duplicate data entry. Convergent validity of the CG-UCE-Q was moderately supported with both the context and processes of workarounds with strong relationships identified for when nurses perceived a block and altered process to work around it to subscales in the CG-UCE-Q for electronic health record system design (P < .01) and technological barriers (P < .01).