Multiple Sclerosis (MS) is a chronic neurological condition, which affects around 2.5 million people worldwide. At a time when there is yet no recognised cure, it is imperative that MS patients learn to cope and adjust well to living with the illness. However, research has found high rates of psychological distress associated with MS (Minden & Schiffer, 1991). This highlights the need for research to investigate the psychological factors, which make MS patients vulnerable to psychological distress. One popular social cognition model called the Self-Regulation Model (Leventhal et al., 1980) has been found to successfully predict adjustment in a range of chronic illnesses. However, previous research applying the SRM to understand adjustment to MS has been limited. The current research therefore represented the first attempt to successfully apply the full SRM to an MS population prospectively. The present thesis is comprised of three studies and employed a mixed quantitative and qualitative research design method. Studies 1 (N=103) and 3 (N=150) were both quantitative studies, which applied an extended SRM model to clinical samples of MS patients and assessed indices of psychological distress over time. Study 2 (N=15) however was a qualitative study, designed to investigate MS patients experiences of living with the condition. By combining both quantitative and qualitative methods, the findings provided a fuller understanding of the psychological factors underlying successful adjustment to MS. Overall the findings provided some support for the utility of the extended SRM in predicting adjustment to MS and highlighted the importance of positive mind states and acceptance for successful adjustment to the condition. The findings also had a number of clinical implications, which are also discussed.

Background: Antibiotics are prescribed frequently for upper respiratory tract infections (URTIs) despite the fact that most of them do not require antibiotics. This over-prescription contributes to antibiotic resistance which is a major health problem. Physicians perceive that patients’ expectations influence their antibiotic prescribing practice. Methods: As the first phase of the thesis, we conducted a systematic review to determine the effectiveness of patient-oriented interventions to reduce unnecessary use of antibiotics for URTIs. As the second phase, we conducted a qualitative descriptive study to explore patients’ views about URTIs and identify ways they manage them by using semi-structured interviews based on Common Sense-Self-Regulation Model (CS-SRM). Results: Our systematic review included 14 studies which based on their interventions were classified into two major categories: delayed prescriptions and patient/public information and education interventions. Our meta-analysis revealed that almost all studies with delayed prescription significantly reduced use of antibiotics for URTIs. Our subgroup analysis showed that prescriptions that were given at a later time and prescriptions that were given at the index consultation had similar effects regarding antibiotic use. The small number of included studies in the patient/public information and education group did not allow us to make a definite conclusion on their effectiveness. For the qualitative study, 15 individuals were interviewed. almost all participants mentioned that they only visited their doctor if their symptoms got progressively worse and they could no longer self-manage URTI symptoms. When visiting a doctor, most participants reported that they expected to receive an examination and an explanation for their symptoms. Discussion: Patient-oriented interventions (especially delayed prescriptions) may be effective in reducing antibiotic use or prescription for URTIs in patients. Further research is needed to investigate the costs and feasibilities of implementing these interventions as part of routine clinical practice. Our participants reported good knowledge regarding the likely lack of benefit from antibiotics for URTIs. The results suggest a discrepancy between our participants’ reported reasons for visiting doctors and doctors’ perceptions about patients’ reason for their visit identified in previous studies. Focusing on interventions that facilitate the communication between patients and doctors, instead of providing more education to public may help in reducing the use of unnecessary antibiotics.

Em março de 2004, o governo brasileiro aprovou as leis 10.847 e 10.848, que alteram as bases da regulação do Setor Elétrico Brasileiro. As leis instituíram novas regras para a outorga de concessões para aproveitamentos hidrelétricos e para comercialização de energia entre agentes de geração, distribuidores e comercializadores de energia elétrica. Diante da contínua demanda por investimentos na expansão da capacidade de geração, este trabalho foi desenvolvido com o objetivo de inferir sobre a capacidade do modelo institucional vigente de atrair capital privado para investimentos em geração de energia hidrelétrica. A inferência é realizada a partir da análise dos resultados dos leilões de energia nova realizados em 2005 e 2006 e da simulação do investimento em um protótipo de empreendimento de geração de energia hidrelétrica. De forma geral, as mudanças regulatórias favorecem o fluxo de investimentos para empreendimentos de geração hidrelétrica. Contudo, mais do que a um modelo institucional sólido, a derivação de investimentos para este segmento estará condicionada à ação do Estado sobre o equilíbrio entre consumo, oferta e preços de energia, enquanto principal artífice da política energética nacional. / In March 2004, the Brazilian Government passed the laws 10.847 and 10.848, which changed the regulatory guidelines of electric market. The laws established new rules for granting hydroelectric exploitation rights and for energy purchasing, among distributors, new generators and free consumers. In front of the new regulatory basis and the Brazilian demand for installed capacity increase, this research aims to infer the capacity of regulatory basis to attract private recourses for investments on hydroelectric power projects. The inference will be developed based on the results of auctions of electricity from new power plants, occurred in 2005 and 2006, and on the simulation of the investment on a prototype of a hydroelectric project in Brazil. The final remarks show that the new electric model favor the investment flow to hydroelectric power plants. However, more than to a solid institutional model, the investments on this segment will be conditioned to the Government action on the equilibrium between energy consuming, offering and prices, as the main agent of the national energy politics.

Em março de 2004, o governo brasileiro aprovou as leis 10.847 e 10.848, que alteram as bases da regulação do Setor Elétrico Brasileiro. As leis instituíram novas regras para a outorga de concessões para aproveitamentos hidrelétricos e para comercialização de energia entre agentes de geração, distribuidores e comercializadores de energia elétrica. Diante da contínua demanda por investimentos na expansão da capacidade de geração, este trabalho foi desenvolvido com o objetivo de inferir sobre a capacidade do modelo institucional vigente de atrair capital privado para investimentos em geração de energia hidrelétrica. A inferência é realizada a partir da análise dos resultados dos leilões de energia nova realizados em 2005 e 2006 e da simulação do investimento em um protótipo de empreendimento de geração de energia hidrelétrica. De forma geral, as mudanças regulatórias favorecem o fluxo de investimentos para empreendimentos de geração hidrelétrica. Contudo, mais do que a um modelo institucional sólido, a derivação de investimentos para este segmento estará condicionada à ação do Estado sobre o equilíbrio entre consumo, oferta e preços de energia, enquanto principal artífice da política energética nacional. / In March 2004, the Brazilian Government passed the laws 10.847 and 10.848, which changed the regulatory guidelines of electric market. The laws established new rules for granting hydroelectric exploitation rights and for energy purchasing, among distributors, new generators and free consumers. In front of the new regulatory basis and the Brazilian demand for installed capacity increase, this research aims to infer the capacity of regulatory basis to attract private recourses for investments on hydroelectric power projects. The inference will be developed based on the results of auctions of electricity from new power plants, occurred in 2005 and 2006, and on the simulation of the investment on a prototype of a hydroelectric project in Brazil. The final remarks show that the new electric model favor the investment flow to hydroelectric power plants. However, more than to a solid institutional model, the investments on this segment will be conditioned to the Government action on the equilibrium between energy consuming, offering and prices, as the main agent of the national energy politics.

Rheumatoid arthritis (RA) is a chronic, progressive autoimmune disease causing inflammation of the synovium resulting in severe pain, joint disfigurement and disability as well as malaise, fatigue and a depressed immune system. Treatment consists of three broad phases; firstly, following diagnosis treatment is focussed on rapid reduction of pain and inflammation. Secondly, maintenance of quiescence is sought through medication. Finally, if disease activity remains high despite medication, escalation to anti-TNF α therapy is required to prevent permanent joint damage and disability. The primary course of treatment is prescription of disease modifying anti-rheumatic drugs (DMARDs) within 3 months of onset of symptoms. However, DMARDs can take 8-12 weeks to exhibit a noticeable benefit whereas unpleasant side effects can occur shortly after initiation. Also, DMARDs do not alleviate pain; therefore it is difficult for patients to attribute recovery to this medication. For these reasons, although it is imperative for future health and functioning to take DMARDs as prescribed, non-adherence is common at 30-50%. Non-adherence to treatment can be intentional, where a decision is made not to conform to the prescription, or unintentional which is often due to forgetting. To measure intentional non-adherence, a validated measure of adherence for rheumatoid arthritis was reduced through exploratory factor analysis from 19 items to 5 items by removing items that did not add to the explained variance of adherence. The CQR5 explained 53% of the variance in adherence and was shown to have a good fit to the data through confirmatory factor analysis. A discriminant function equation was generated that correctly identifies 88.5% of patients as high or low adherers and has high clinical utility due to the brevity for patients and unidimensionality for easy interpretation. The CQR5 was used throughout the programme of research to measure intentional non-adherence along with a separate measure of unintentional non-adherence. Four commonly used social cognition models of illness were measured in 227 RA patients to determine which had the best utility for predicting non-adherence to DMARDs. Patients were recruited to represent the three stages of illness including newly diagnosed, established on DMARD therapy and established with concurrent anti-TNF α therapy. Logistic regression analysis showed that the Self Regulatory Model best predicted intentional non-adherence as patients with perceptions of worse consequences of RA and longer disease duration were more likely to be highly adherent to DMARDs in cross-sectional analysis. In contrast, the Theory of Planned Behaviour better predicted patients who self-reported forgetting their DMARDs with patients with more confidence in being able to take their medications (Perceived Behavioural Control) being less likely to forget. 171 patients were successfully followed-up six months after baseline recruitment. The longitudinal results showed that the social cognition models differed for patients at different stages of the illness suggesting that their experience of living with rheumatoid arthritis influenced perceptions of their illness and medications. Newly diagnosed patients scored lower on factors measuring perceptions of disease chronicity and seriousness whereas patients that had escalated to anti-TNF α therapy scored higher on these factors. The newly diagnosed patients also showed more variability in the social cognition scores whereas the more established patients demonstrated stable models of illness. This supports Leventhal’s (1992) theory that illness representations will be regulated through integration of knowledge and experience of an illness. Structural equation modelling was used to establish the best predictors of intentional non-adherence at six month follow-up. In support of research in other chronic illnesses (Horne & Weinman, 2002; Niklas, Dunbar & Wild, 2010), the effect of perceptions of the consequences and chronicity of the illness on adherence are mediated by perceptions of the necessity of the medication. In addition, the impact of the emotional reaction to the illness on adherence to DMARDs is mediated by concerns about the medication. In addition, this study incorporated factors from the Theory of Planned Behaviour to explain medication adherence and found that the influence of friends and family impacts on the patient’s confidence to follow the prescription accurately which in turn as an effect on adherence to DMARDs. This large longitudinal study found that by combining factors from a number of social cognition models, it is possible to explain and predict intentional non-adherence and provides some evidence for best ways to intervene to improve adherence and prognosis. To provide a more comprehensive and clinically useful picture of non-adherence, a Cost of Illness study was carried which found that patients self-reporting low adherence to DMARDs also had significantly higher costs for this medication. This was caused by an increased incidence of Leflunamide prescribing for patients who often forget their medication and was maintained longitudinally. This association has not been previously reported in the literature and provides some evidence that non-adherence to DMARDs is having a concrete effect on the clinical management of patients. Finally, an SMS text message based reminder service designed to remind patients who self-report forgetting their medications was tested through a simulation study for the cost and likely benefit in health related quality of life using the health economic analysis of the longitudinal study and the results of a survey establishing the feasibility of implementing such a service in the rheumatology clinic. A sensitivity analysis testing the number of messages sent and the cost per message found that a reminder service for the sample of patients in this programme of research would cost between £1387.00 and £142.27 per year. This would equate to a cost per Quality Adjusted Life Year (QALY) gain of between £2889.58 and £296.40 by enabling patients to adhere more rigorously to their DMARD regimen. This programme of research is the first to test four commonly used social cognition models to predict adherence to DMARDs in a large, multi-centre longitudinal study of rheumatoid arthritis patients. Perceptions of the likely duration and consequences of the illness, as measured by the Illness Perceptions Questionnaire and the necessity of medications (measured by the Beliefs about Medications Questionnaire) along with self-efficacy (measured by the Theory of Planned Behaviour) explained 24% of the variance in intentional adherence over six months. The results show the importance of considering intentional and unintentional non-adherence separately as they appear to have different underlying mechanisms as well as patients in different phases of the illness as their experience influences their social cognition models of illness. A simple SMS based reminder service could act as a cue to action to reduce unintentional non-adherence whereas addressing issues surrounding maladaptive perceptions about the illness and the treatment could improve intentional non-adherence which has the potential to improve the prognosis and quality of life for patients as well as safe costs for the NHS.

The use of renewable energy has proven to be essential for the decarbonisation of the energy system, bringing changes on both the production and consumption side, with an increase of renewable energy in the mix and a change in the role of consumers. From passive actors, Consumers are becoming Prosumers (producers and consumers) of self-generated energy, with the potential of becoming the pillar of the energy sector transition. The European Union set ambitious goals for the realization of a low carbon society by 2050, giving birth to several energy related initiatives. From a regulatory perspective, Europe is indeed paving the way for an internal energy market revolution, that sees the introduction of new actors among which, Local Energy Communities (LEC). In the progressive transition from a centralized to a decentralized system with intelligent and interconnected production sources, consumers are allowed to produce, store, share or resell their energy directly or as energy cooperatives, and can manage demand either independently or through aggregators. In this context Energy Communities take shape. In accordance with the definition given in the European RED directive "Renewable Energy Directive", this study refers to energy communities as a set of energy users who, through cooperatives, non-profit associations, or other legal forms, make common decisions for the satisfaction of their energy needs, with the aim of providing environmental, social and economic benefits. The overall objective of the study is to gain a better understanding of the environmental, grid and social impacts of local energy communities, as well as of the factors that can potentially enable or inhibit the deployment of such communities. The emergence of prosumers and energy communities raise new challenges in terms of technologies and technical requirements for the interaction with the electricity grid, in terms of the need for new business models and new energy policies and regulatory framework, to encourage these new configurations and unlock their benefits as effectively as possible. In the context of this work, a model for the assessment of LECs viability has been built; it examines the consumption and renewable generation loads, with the possibility to measure the effects of adding a battery storage system in the community configuration. The profitability of residential customers participating in a LEC is investigated for four different technological community scenario: (i) solely stand-alone PV plant (ii) stand-alone PV plant with the addition of a solar battery for self-consumption maximization (iii) stand-alone PV plant with the addition of a battery storage system for Demand Side Management behind-the-meter and (iv) stand-alone PV plant with the addition of a battery storage system for Demand Side Management front-of-the-meter. The economic impact of storage on LEC energy usage has been studied while considering the technical aspects of the proposed system. The simulation analysis – based on real residential demand profiles, renewable generation curves, battery energy storage functioning, market pricing and incentives scheme, showed that energy sharing and collective investment in residential scale renewable assets and batteries can be economically feasible, but the economics can significantly fluctuate with changes in parameters such as technology cost, LECs incentives, electricity prices, and that therefore the convenience of one scenario over the others should be verified each time the conditions change. Also, the type of services for which the battery can get revenues may disrupt the conclusions reached. The aim of the work, however, was to build a model easily adaptable to the variation of these parameters, in order to calculate case by case economics and convenience of any possible community configuration. / Användningen av förnybar energi har visat sig vara avgörande för att minska koldioxidutsläppen från energisystemet, vilket medför förändringar både på produktions- och konsumtionssidan, med en ökad andel förnybar energi i mixen och en förändrad roll för konsumenterna. Från att ha varit passiva aktörer blir konsumenterna nu Prosumers, producenter och konsumenter av egenproducerad energi, med potential att bli en pelare i övergången inom energisektorn. Europeiska unionen har satt upp ambitiösa mål om att förverkliga ett samhälle med låga koldioxidutsläpp senast 2050, vilket har gett upphov till flera energirelaterade initiativ. Ur ett regleringsperspektiv banar Europa verkligen väg för en revolution på den inre energimarknaden, där nya aktörer kommer att introduceras, bland annat lokala energikommuner. I den gradvisa övergången från ett centraliserat till ett decentraliserat system med intelligenta och sammankopplade produktionskällor får konsumenterna producera, lagra, dela eller sälja sin energi direkt eller som energikooperativ, och de kan hantera efterfrågan antingen självständigt eller genom aggregatorer. I detta sammanhang tar energisamhällen form. I enlighet med definitionen i det europeiska direktivet om förnybar energi i den här studien avses med energisamhällen en grupp energianvändare som genom kooperativ, ideella föreningar eller andra juridiska former fattar gemensamma beslut för att tillgodose sina energibehov, i syfte att skapa miljömässiga, sociala och ekonomiska fördelar. Det övergripande målet med studien är att få en bättre förståelse för de miljömässiga, nätmässiga och sociala konsekvenserna av lokala energisamhällen, samt för de faktorer som kan möjliggöra eller hindra införandet av sådana samhällen. Framväxten av prosumenter och energisamhällen ger upphov till nya utmaningar när det gäller teknik och tekniska krav för samverkan med elnätet, när det gäller behovet av nya affärsmodeller och ny energipolitik och regelverk för att uppmuntra dessa nya konfigurationer och frigöra deras fördelar på ett så effektivt sätt som möjligt. Inom ramen för detta arbete har en modell för bedömning av LECs lönsamhet byggts upp. Den undersöker förbrukning och belastning från förnybar produktion, med möjlighet att mäta effekterna av att lägga till ett batterilagringssystem i samhällskonfigurationen. Lönsamheten för privatkunders deltagande i ett LEC undersöks för fyra olika tekniska samhällsscenarier: (i) enbart fristående solcellsanläggning, (ii) fristående solcellsanläggning med tillägg av ett solcellsbatteri för maximering av självförbrukningen, (iii) fristående solcellsanläggning med tillägg av ett batterilagringssystem för styrning av efterfrågan bakom mätaren och (iv) fristående solcellsanläggning med tillägg av ett batterilagringssystem för styrning av efterfrågan framför mätaren. Lagringens ekonomiska inverkan på LECs energianvändning har studerats samtidigt som de tekniska aspekterna av det föreslagna systemet har beaktats. Simuleringsanalysen - som i skrivande stund bygger på verkliga efterfrågeprofiler för bostäder, kurvor för förnybar produktion, batterilagringens funktion, marknadens prissättning och incitamentssystem - visade att energidelning och kollektiva investeringar i förnybara tillgångar och batterier i bostadsområden kan vara ekonomiskt genomförbara, men att ekonomin kan fluktuera avsevärt med förändringar i parametrar som teknikkostnader, incitament för LEC:s och elpriser, och att det därför är lämpligt att kontrollera om det är fördelaktigt att välja ett scenario framför de andra varje gång förhållandena förändras. Även den typ av tjänster som batteriet kan få intäkter för kan påverka de slutsatser som dras. Syftet med arbetet var dock att bygga en modell som lätt kan anpassas till variationen av dessa parametrar, för att från fall till fall beräkna ekonomin och bekvämligheten hos alla möjliga konfigurationer av samhället.

83 p. / Submitted by Santiago Fabio (fabio.ssantiago@hotmail.com) on 2012-12-19T19:35:24Z No. of bitstreams: 1 88.pdf: 1431314 bytes, checksum: e77a88c490348af714e77405775135f0 (MD5) / Made available in DSpace on 2012-12-19T19:35:24Z (GMT). No. of bitstreams: 1 88.pdf: 1431314 bytes, checksum: e77a88c490348af714e77405775135f0 (MD5) Previous issue date: 2011 / A relação simbiótica entre o Estado brasileiro e a Petrobras antecede a própria criação da empresa. Assim como o ano de 1997 marcou a quebra do monopólio estatal sobre as atividades da indústria em questão, o ano de 2003 representa a mudança drástica das atitudes do governo frente à maior empresa do país. Este relacionamento chegou a tal ponto que, recentemente, por ocasião das discussões sobre o novo marco regulatório da indústria do petróleo, representantes da Petrobras fizeram parte das discussões, junto com alguns ministérios e a ANP, que resultaram na proposta de alteração do modelo regulatório para o setor. Em vista do exposto, é de relevância científica conhecer a atuação da Petrobras na reforma do marco regulatório do Pré-sal, à luz das perspectivas da análise estratégica. Mais ainda, identificar se os resultados alcançados com o novo marco regulatório foram fruto de ação intencional da empresa ou apenas reações a provocações externas (atuação do Governo Federal, por exemplo). Com base nas considerações iniciais, o objetivo geral do trabalho foi analisar em que medida os fatores institucionais, os fatores internos (recursos da firma) ou os fatores ligados à indústria moldaram a participação da Petrobras no processo de elaboração da proposta de alteração do novo marco regulatório (Projetos de Lei n. 5.938 a 5.941, 2009). Pretendeu-se investigar, igualmente, quais desses fatores se sobressaíram nas mudanças e na readequação das regras do jogo. Este trabalho argumenta, fundamentado nos resultados, que a participação da Petrobras nos trabalhos de elaboração da proposta de mudança no marco regulatório do setor foi viabilizada pela confluência de fatores institucionais (IBV) e fatores internos à firma (RBV). O presente estudo mostrou-se como oportunidade de aprofundar os conhecimentos sobre o relacionamento entre a Petrobras e Governo, de identificar e melhor conhecer aspectos pontuais da experiência regulatória brasileira, assim como testar a aplicabilidade das perspectivas estratégicas na análise de situações concretas da realidade organizacional. / Salvador

Made available in DSpace on 2016-03-15T19:34:29Z (GMT). No. of bitstreams: 1 Jose Carlos Higa de Freitas.pdf: 980227 bytes, checksum: 38796f1d72c0038c186dddc6f102e13c (MD5) Previous issue date: 2016-01-29 / This dissertation aims at analysing the new regulatory framework for the port sector established with the enactment of Law nº. 12.815 of June 5th 2013, which was regulated by Decree 8.033 of June 27th 2013. This study focus on the change of functions of the main administrative bodies that are responsible for regulating the port sector, especially the concentration of powers at the federal level. Furthermore, it also discusses the changes in the forms of exploitation of ports and port facilities, contemplating a possible regulatory asymmetry that is reflected on the port work. All changes promoted by the new regulatory framework for the port sector are analyzed according to the National Transportation System, considering the role they can play in ensuring national development, which is treated from the perspective of regional integration and modification of economic and social structures. Finally, we highlighted issues which were not discussed directly by the new law of the ports but need to be considered to picture the port as a development tool. / A presente dissertação pretende discutir o novo marco regulatório do setor portuário estabelecido com a promulgação da Lei n°. 12.815 de 5 de junho de 2013, que foi regulamentada pelo Decreto nº. 8.033 de 27 de junho de 2013. O foco do estudo está voltado para as mudanças das atribuições dos principais órgãos administrativos responsáveis pela regulação do setor portuário, com destaque para a concentração de atribuições na esfera federal. Ademais, se discutem também as alterações nas formas de exploração dos portos e nas instalações portuárias, vislumbrando uma possível assimetria regulatória que se reflete sobre o trabalho portuário. Todas as mudanças promovidas pelo novo marco regulatório do setor portuário são tratadas à luz do Sistema Nacional de Viação, considerando o papel que elas podem desempenhar para garantir o desenvolvimento nacional, sendo esse conceito tratado sob a perspectiva de integração regional e de modificação das estruturas econômicas e sociais. Por fim, são apontados elementos que não foram discutidos diretamente pela nova lei dos portos, mas que precisam ser considerados para se imaginar o porto como instrumento de desenvolvimento.