Patient-reported outcome measures (PROMs) are becoming an integral part of healthcare decision making. Clinical trials, systematic reviews, and clinical practice guidelines incorporate them to learn about the effect of medical interventions in patients’ health status, without interference or mediation from clinicians or proxies. The use of these types of measures, however, is not without challenges. In particular, the complexity of the PROMs makes it difficult for patients, clinicians, and researchers to fully grasp the extent to which a treatment effect is negligible or trivial, small but important, moderate, or large. One of the most documented ways to address this issue is the use of the minimal important difference (MID), the smallest change in a PROM, either beneficial or harmful, that patients would perceive as important. A patient-oriented way to determine this threshold is the estimation of an anchor-based MID, where PROM results are compared against an external independent criterion the anchor that is in itself understandable and relevant for patients. This dissertation is an effort to facilitate the identification, evaluation, and utilization of MID estimates for PROMs. First, this thesis describes the development and reliability assessment of a new instrument to determine the credibility of primary studies ascertaining MID estimates, Second, it describes the conduct of a systematic survey to inform the creation of an inventory of all available anchor-based MIDs in the medical literature until 2015. Third, it reports an analysis of the state of the art of current MID estimates from a reporting and credibility perspective. Finally, this work concludes with a summary of the main results, presentation of strengths and limitations, and insights related to the implications for future research. / Dissertation / Doctor of Philosophy (PhD)

Background: Patient experience has become an essential quality indicator in healthcare. Purpose: The purpose of this thesis was to conduct a concept analysis of the patient experience. Methods: Walker and Avant’s methodology served as the framework for this concept analysis. Data were retrieved from seven databases and one search engine. The literature search used keywords related to "patient experience" and included articles published at any time up until March 2018. A total of 257 articles and organizational websites were included in the analysis after meeting the inclusion criteria. Results: Twenty attributes were found to define the patient experience: communication, respect for patients, information/education, patient-centered care, comfort/pain, discharge from hospital, hospital environment, professionalism/trust, clinical care/staff competency, access to care, global ratings, medication, transitions/continuity, emotional dimension, outcomes, hospital processes, safety/security, interdisciplinary team, social dimension, and patient dependent features. Conclusion: The results of this study will guide and clarify the critical concepts towards an explicit definition of the patient experience.

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As the learning outcomes movement gains strength, the need to effectively measure learning outcomes becomes more important. This study looked at the effectiveness of self-reported mastery in measuring learning outcomes by examining the correlations between (a) self-reported mastery, (b) self-reported gains, and (c) objective measures of learning outcomes. The objective measures of learning outcomes were final exams for two classes, Calculus (consisting of two forms) and Statistics. The self-reported mastery and self-reported gains items were taken from the pilot student ratings form and the old student ratings form. A total of 848 undergraduate students completed the final exam and the two student ratings forms. The summed total of the self-reported mastery items correlated at a medium strength with objective measures of learning outcomes (Calculus Form A: r = .436; Calculus Form B: r = .361; Statistics: r = .416). The relationship between self-reported gains and objective measures of learning outcomes was weaker than that of self-reported mastery and objective measures of learning outcomes (a difference of .276 for Calculus Form A, .138 for Calculus Form B, .110 for Statistics). The relationship between self-reported gains and self-reported mastery was stronger than the other two relationships (Calculus Form A: r = .473, Calculus Form B: r = .500, Statistics: r = .628). A confirmatory factor analysis produced even stronger relationships between the three latent variables, including differences between the two forms of the Calculus exam. Self-reported mastery may be more effective at measuring objective measures of learning outcomes than self-reported gains, but self-reported mastery cannot completely serve as a proxy for objective measures of learning outcomes. Administrators or researchers measuring learning outcomes on a large scale may benefit by administering self-reported mastery items instead of self-reported gains items.

BACKGROUND. The study of patient reported outcomes (PROs) has seen an exponential increase in recent years. In order to be useful in practice, PRO questionnaires should be evaluated for validity, reliability, and responsiveness. Responsiveness, which assesses a questionnaire’s ability to capture changes in quality of life (QOL) when they occur, has not formally been evaluated in hemophilia-specific questionnaires. PRIMARY OBJECTIVE. To evaluate the responsiveness of the Patient Reported Outcomes, Burdens, and Experiences (PROBE) questionnaire in individuals living with hemophilia A or B following events of interest. SECONDARY OBJECTIVES. To evaluate the responsiveness of PROBE over periods in which no events occur. To explore the use of regression analysis in aiding interpretability. To assess the presence of response shift in the study population. METHODS. Participants will be asked to complete PROBE, as well as questions indicating changes in QOL, following a bleed or surgical intervention, and every 6 months. Responses will be evaluated using anchor-based and distribution-based approaches. OUTCOMES. Minimally important differences (MIDs) and minimally detectable changes (MDCs) will be calculated, graphically represented, and compared to determine a single or small range of MID values. STUDY IMPLICATIONS. Understanding responsiveness will provide increased interpretability of PROBE scores. Using an MID value, one can be confident that a change in PROBE score greater than the MID is beyond measurement error and indicates a change in QOL. This will allow for the use of PROBE in future research trials of drug effectiveness and can offer patients’ perspectives on their changes in QOL when switching to novel therapies. In addition, physicians may be able to use PROBE as a method of tracking and better understanding changes in their patients’ health statuses in the clinical setting. / Thesis / Master of Science (MSc) / This project hopes to identify the responsiveness of the Patient Reported Outcomes, Burdens, and Experiences (PROBE) Questionnaire. The responsiveness of a questionnaire is its ability to detect a change in health status when one has occurred. In order to measure whether PROBE can detect these changes, participants living with hemophilia A or B will be asked to fill out the questionnaire, as well as a few questions aimed at determining if their quality of life has changed, after they have a bleed or a surgery, as well as after 6 months. Collecting this information will help us understand how much the PROBE score needs to change in order for patients to consider a small but important change in health to have occurred. This will help with interpreting the PROBE score, which could then be used in research or in hemophilia clinics across Canada.

Background: The degree of health variation among social groups is an important indicator of population health and the efficiency of economic and social systems. Previous studies revealed existence of health inequalities across Europe, however recent studies on the contribution of income to such inequalities are scarce. Aim: To investigate differences in self-reported health between the lowest and the highest income groups across Europe. Method: Data from the European Social Survey for 29 countries were examined. The absolute inequalities were calculated as differences in age-adjusted prevalence of poor self-reported health between the lowest and the highest income quintiles. The relative inequalities were measured by odds ratios for reporting poor health in the lowest income group compared to the highest one. Results: Income-related health inequalities were found in all countries. Larger relative inequalities among men were observed in Greece, Kosovo, Ireland, Israel, Iceland, and Slovenia; among women – in Lithuania, Denmark, Norway, Portugal, Cyprus, and Czech Republic. Conslusions: In Europe, income-related health inequalities persist, however, their degree varies across countries. Gender differences in income-related inequalities were observed within certain countries. For a comprehensive description of health situation in a country assessing both the prevalence of poor health and the inequality level is crucial.

Empirically based methods of detecting retrospective malingering (i.e., the false assertion or exaggeration of physical or psychological symptoms reportedly experienced during a prior time period) are needed given that retrospective evaluations are commonplace in forensic assessments. This study's main objective was to develop and validate a focused, standardized measure of retrospective malingering. This objective was addressed by revising the Structured Interview of Reported Symptoms (SIRS), an established measure of current feigning. The SIRS' strategies were retained and its items modified to produce two new SIRS versions: The Retrospective Structured Interview of Reported Symptoms (R-SIRS) and The Concurrent-Time Structured Interview of Reported Symptoms (CT-SIRS). Forensic inpatients were used to test the R-SIRS (n = 25) and CT-SIRS (n = 26) which both showed good internal consistency and interrater reliability. The overall effectiveness of the R-SIRS and the CT-SIRS in the classification of malingerers and genuine patients was established in this initial validation study. Moreover, their classification rates were similar to those obtained by the SIRS. Pending additional validation, these measures are expected to increase the quality of forensic evaluations by providing the first standardized methods of assessing retrospective malingering.

Osteoarthritis (OA) is one of the leading causes of global disability. Surgical intervention in the form of Total Knee Arthroplasty (TKA) has been established as an excellent treatment modality for people with OA who experience joint symptoms that have a substantial impact on their quality of life and are refractory to non-surgical treatment. In the 1970s the concept of implanting TKAs in mechanical alignment (MA) was developed as a compromise to confer mechanical advantage to the prosthesis, ignoring the patient's natural anatomy, to prevent early failure of the implant. Until now, this compromise has not been revisited. Satisfaction following TKA remains inferior to total hip arthroplasty. The cause of this dissatisfaction is not clear. Implant survival is no longer comparable to that of the early designs of TKA, and recent studies have suggested that deviation from neutral alignment does not have the detrimental effect on survivorship as previously thought. In an attempt to improve patient satisfaction following TKA a new technique has been developed whereby the prostheses are implanted in such a way as to recreate the alignment of the knee in the patient's pre-arthritic state. This has been termed natural or kinematic alignment (KA). This thesis examines the impact of KA in TKA with the primary hypothesis that TKA performed utilising KA would lead to improved functional outcome following surgery compared to that of MA. An initial single surgeon proof of concept case series of 25 patients was performed to look at the precision of new patient specific cutting blocks. The results suggested that the cutting blocks were accurate in producing the desired cuts. Following the proof of concept case series, a feasibility study was then performed comparing the new KA technique with the standard MA technique. The feasibility study familiarised the operating surgeons with the new technology in preparation for a Randomised Control Trial (RCT). A prospective blinded RCT was performed to compare the functional outcome of patients implanted with TKA in MA with that of KA. A total of 71 patients undergoing TKA were randomised to either MA (n=35) or KA (n=36). Preand post-operative hip knee ankle (HKA) radiographs were analysed. A number of patient reported outcome measures and functional tests were assessed pre-operatively, 6 weeks, 3 months, 6 months, and at 1 year post-operation. The cutting guides were accurate. There were no statistically significant differences between the MA and KA groups at 1 year. A cohort of post-menopausal women with unilateral osteoarthritis treated with TKA utilising the KA philosophy had dual energy x-ray absorptiometry scans 1.5 years post-operatively using a modified validated densitometric analysis protocol, to assess peri-prosthetic Bone Mineral Density (BMD). The contralateral knee was scanned so that relative bone mineral density could be calculated. Statistical analysis revealed no significant difference in relative peri-prosthetic bone mineral density due to variation in implant position with respect to the Lateral Distal Femoral Angle (LDFA) and the Medial Proximal Tibial Angle (MPTA). There was a significant correlation with overall HKA angle and the relative BMD under the medial side of the tibial tray. KA TKAs appear to have comparable short-term results to MA TKAs with no significant differences in function 1 year post-operatively. Overall HKA angle rather than the individual component position caused change in relative BMD under the tibial tray, therefore aiming for an anatomical joint line may improve kinematics without a detrimental effect on the implant. Further research is required to see if any theoretical long-term functional benefits of KA are realised or if there are any potential effects on implant survival.

L'objectif de la thèse est de mettre au jour les différents modes de représentation du discours autre et de déterminer leur fonctionnement dans la construction du dessin de presse en tant que commentaire de l'événement médiatique. En tant que genre hybride et humoristique, le dessin de presse emprunte ses caractéristiques rhétoriques, thématiques, discursives et formelles à la caricature, au dessin d'humour, à la bande dessinée et au commentaire journalistique. Quant aux différentes formes d'humour dans le dessin, elles sont liées étroitement à la ligne éditoriale du périodique de publication et elles sont censées créer une connivence avec le lecteur. Le cadre théorique repose sur les recherches d'Authier-Revuz. Elle détermine le lien d'un acte d'énonciation avec les différents modes de représentation du discours autre en s'appuyant sur leurs caractéristiques sémiotiques, syntaxiques et sémantiques spécifiques. Également, la représentation du discours autre relève du dialogisme bakhtinien et le lecteur doit parfois faire appel à sa mémoire discursive, sémantique, historique et collective ainsi qu'à l'implicite pour reconnaître certains énoncés comme relevant de la représentation du discours autre. Le cadre théorique ainsi posé est appliqué à un corpus de 150 dessins de presse publiés dans le quotidien Le Monde, dans l'hebdomadaire Courrier international et exposés au Mémorial de Caen entre 2010 et 2014. Les conclusions des analyses sont les suivantes : premièrement, le discours direct, le discours indirect, la modalisation en assertion seconde et la modalisation autonymique d'emprunt sont les modes de représentation du discours autre présents dans le dessin de presse. Deuxièmement, il apparaît que, malgré le repérage systématique des caractéristiques spécifiques de chaque mode, il est parfois impossible de trancher définitivement sur une forme. Seules les connaissances du lecteur peuvent l'inciter à trancher en faveur d'un mode ou d'un autre. Troisièmement, les modes de représentation du discours autre ainsi déterminés participent de la construction d'un commentaire critique, parfois humoristique, de l'événement médiatique. / The aim of the dissertation is to identify different forms of reported speech and to highlight their importance in the construction of cartoons functioning as news comments in the press. The "cartoon" is a hybrid and humorous genre, which owes its rhetorical, thematic, discursive and formal characteristics to the caricature, the humorous drawing, the comic strip and the press comment. The different types of humor in the cartoon are closely connected to the editorial line of the periodical and are supposed to create a certain complicity between the cartoonist and his reader. The theoretical framework of the dissertation is based on Authier-Revuz's work. She identifies different types of reported speech by their specific semiotic, syntactic and semantic characteristics. Reported speech also falls within dialogism as Bakhtin defined it. Readers need their discursive, semantic, historic and collective memory as well as a certain proficiency in detecting implicit messages in order to understand some occurrences of reported speech. The theoretical framework is put into practice on a corpus of 150 cartoons published in the French daily newspaper Le Monde, in the French weekly review of international press Courrier international or exposed at the "Mémorial de Caen" from 2010 to 2014. One can conclude that firstly, indirect speech, direct speech, "modalisation en assertion seconde" and "modalisation autonymique d'emprunt" are found in the cartoons. Secondly, it can be difficult to attribute a type to an utterance of reported speech even when the analyst systematically checks all utterances for specific characteristics. Only the reader's former knowledge can help him choose one of the forms. Thirdly, the cartoonist uses reported speech to create a critical and sometimes humorous comment on events and their treatment in the media.

Jenny Isberg (2009): Viljan till fysisk aktivitet – en intervention avsedd att stimulera ungdomar att bli fysiskt aktiva. Örebro Studies in Sport Sciences 6, 141 pp. Physical education (PE) at school may play an important role in the process of becoming physically active in the adolescence and in developing a physically active lifestyle. The opportunities for teachers to provide positive physical activity experiences to the student population extend regularly over the school terms. For some students, PE can be the only opportunity they have to be physically active. Therefore it is important that the students become motivated to practice physical activity and know the purpose with physical activity. The overall purpose of this dissertation was to investigate the possibilities to motivate youth, 12-16 years old, to practice physical activity and hopefully to stimulate them to continue to be physically active in young adulthood. The sample consisted of 122 Swedish compulsory school students (12-16 years old), 51 girls and 71 boys, who were either physically inactive, physically active but not formal members of sport clubs, or physically active and members of a sport club. They used a self-monitoring instrument to describe their physical activity and we compared their self-reported physical activity with their actual VO2 capacity and physical status. The self-monitoring instrument was further validated against an activity monitor, RT3. The intervention lasted one and a half years, and four to five years later a follow-up study was done. Using a quasi-experimental design, the three groups of participants were compared with youths who did not use the self-monitoring instrument. The main findings were that the associations between the accelerometer counts and the activities the students recorded in the self-monitoring instrument were high. The participants  in Group 1 (physically inactive) continued exercising nearly to the same extent as during the intervention while youths in a matched control group did not develop regular physical activity habits. Concerning Group 2 (exercisers), participants in the intervention group were more physically active both during the intervention and at follow-up, compared with a matched control group of exercisers who did not use the self-monitoring instrument. In Group 3 (sport team members), there was no difference between the intervention group and a matched control group after the intervention or at follow-up.  The conclusion of these main findings was that when someone motivates students to continue being physically active and to change their physical activity patterns in a positive direction, the self-monitoring instrument can be a door-opener for youths who are physically inactive or regularly active outside sports clubs.