Este trabalho propõe analisar a forma como se constitui a escrita de alunos de uma turma de 1º ano do ciclo II do ensino fundamental, no momento em que escrevem para atender a demandas institucionais dadas no contexto do Programa Ler e Escrever, da Secretaria Municipal de Educação de São Paulo. Os 26 textos narrativos que compõem seu corpus foram escritos durante o ano letivo de 2010, enquanto atuávamos como professor regente dessa turma, por esse grupo de estudantes, o qual se caracterizava como recém-alfabetizado, com idades entre a pré-adolescência e a adolescência e com histórico de fracasso escolar. De maneira mais específica, os objetivos de nosso trabalho se voltam para a compreensão dos modos como os alunos registram, em seus textos escritos, duas instâncias de diálogo: a) um diálogo que se estabelece com as condições escolares imediatas de produção da escrita e b) um diálogo que se constroi no processo de formulação do texto narrativo, relacionado aos modos de gestão e transmissão do discurso de outrem ou discurso citado no corpo da narrativa. Essa problemática será abordada com base na contribuição fundadora de Bakhtin (1929/2002) e de estudos do texto e do discurso conforme propostos em Jurado Filho (1993). Do ponto de vista de sua metodologia, levando em conta o modo com o qual abordamos os dados, trata-se de uma pesquisa qualitativa, voltada para a análise textual do discurso narrativo em produções escritas de alunos. Além disso, a fim de empreender uma discussão que nos ajude na compreensão da aprendizagem escrita a partir da realidade pedagógica que analisamos, buscaremos referências nos estudos sobre os conceitos de alfabetização e de letramento (SOARES 1998, 2004; MORTATTI, 2004; COLELLO e SILVA LEITE, 2010) e, também, nos autores que têm se debruçado sobre a questão da escrita na escola a partir de uma perspectiva dialógica da linguagem e da compreensão dos espaços de ensino de língua portuguesa como espaços de interação (GERALDI 1984, 1996, 2003; VAL e ROCHA, 2005). / This research proposes to examine the constitution of writing produced by elementary school students at the 1st year of the 2nd cycle, when writing to meet institutional demands as prescribed by the Programa Ler e Escrever (Reading and Writing Program) of the São Paulo City Department of Education. The 26 narrative texts that constitute our body of research were written during the 2010 school year, while we worked as a classroom teacher of these students, by a group of students characterized as newly literate preadolescents and adolescents with a history of school failure. Specifically, the objective of our work is to understand the ways in which students record, in their written texts, two dialogue instances: a) a dialogue which is established with the immediate conditions of writing production at school, and b) a dialogue built on the process of production of narrative texts, related to the modes of management and transmission of the speech of others or speech cited in the body of the narrative. This issue will be addressed based on the founding contribution of Bakhtin (1929/2002) and on text and discourse studies proposed by Jurado Filho (1993). From the point of view of its methodology, taking into account the way in which data was reviewed, we classify this research as qualitative, focused on textual analysis of narrative discourse in written production of students. Furthermore, in order to engage in a discussion which will help us understand the writing learning process in the pedagogical context we reviewed, references will be sought in the studies on the concepts of literacy and lettering (SOARES 1998, 1994; MORTATTI, 2004; COLELLO and SILVA LEITE, 2010), as well as in the work of authors who have been addressing the issue of school writing based on a dialogical perspective of language and on the understanding of the spaces for teaching Portuguese as interaction spaces (GERALDI 1985, 1996; VAL and ROCHA, 2005).

Severe perineal trauma with injury to the anal sphincter at childbirth can have a profound effect on the physical and psychological wellbeing of women. This thesis describes literature examining resulting outcomes including effects on body image. It describes patient-based outcome measures used to capture this information, and evaluation of their psychometric properties. Body Image can be defined as an individual's perceptions and feelings about their own body. There is a growing interest in how this concept can influence quality of life and psychosocial dysfunction in medical disorders. This thesis aimed to examine relationships between severity of perineal trauma, general and genital specific body image and potentially influences such as symptoms of pelvic floor dysfunction. No patient-reported outcome measure validated for use in women after anal sphincter injury exists and this thesis also aimed to psychometrically evaluate an existing electronic questionnaire, ePAQ (electronic personal assessment questionnaire), for this application. In the thesis, a retrospective review of body image and physical outcomes attending a perineal clinic shows over half of women report perceived changes in body image after anal sphincter injury, with negative effects on self-esteem. A prospective observational cohort study explored genital and general body image in primiparous women grouped according to degree of perineal trauma or caesarean delivery. Women completed the Female Genital Self Image Score, the modified Body Image Score, ePAQ and the Edinburgh Postnatal Depression Scale a mean of 15.5 weeks (standard deviation 1.6) after delivery. There were significant differences in genital body image scores between the groups, but not in general body image, with regression analysis showing the greatest influence on genital body image to be the anatomical extent of the trauma. Embedded into this study was the evaluation of reliability (internal consistency and test-retest) and validity (face, content and construct) of ePAQ in the group of women with anal sphincter tears. This thesis presents the first research to quantify issues surrounding severe perineal trauma and body image and demonstrates that more severe trauma leads to a poorer genital body image. It also reports psychometric evaluation of ePAQ in women after anal sphincter injury providing the first single instrument with validity and reliability for use in this context.

Nesta pesquisa teve-se como objetivo analisar os arranjos de vozes estabelecidos em textos jornalísticos sobre avaliações externas. De modo mais específico, a proposta foi observar em textos publicados pela Folha de S.Paulo sobre o Ideb (Índice de Desenvolvimento da Educação Básica) e o Pisa (Programa Internacional de Avaliação de Estudantes) os seguintes aspectos: a caracterização dos locutores presentes nos textos, tanto como autores, entrevistados ou fontes jornalísticas; a heterogeneidade enunciativa e formas de inserção do discurso relatado; os modos por meio dos quais as diferentes vozes presentes nos textos são articuladas a fim de sustentar determinadas posições do jornal; e as relações interdiscursivas e dialógicas estabelecidas entre os textos e os elementos materializados no jornal. Para a constituição do corpus, foram selecionados vinte e quatro textos sobre o Ideb 2009 e dezessete sobre o Pisa do mesmo ano, todos publicados pela Folha de S.Paulo em 2010, logo após a divulgação dos resultados. Optou-se pelo uso da versão impressa, disponível no acervo digital do jornal, para que fosse possível examinar, além do conteúdo escrito, a disposição do texto e das imagens no material publicado. Como referencial teórico para as análises, foram mobilizados estudos pertencentes, principalmente, à Análise do Discurso e a diferentes correntes acerca da enunciação. Os conceitos basilares foram dialogismo (BAKHTIN, 1997, 2010), heterogeneidade enunciativa e discurso relatado (AUTHIER-REVUZ, 1990, 1999, 2004), interdiscurso (PÊCHEUX, 1993) e locutor (DUCROT, 1987). Da esfera jornalística, foram abordados também os conceitos de fontes e gêneros jornalísticos com base, sobretudo em Melo (1985) e Lage (2008). Por meio das análises realizadas, concluiu-se que, com relação aos locutores, nos textos publicados pelo jornal, predominam enunciados provenientes da esfera governamental e de think tanks, sendo que a esses últimos é atribuído o papel de fontes expert, aquelas que detêm o conhecimento teórico capaz de debater os resultados divulgados e apresentar propostas de ação. Ao saber acadêmico é relegado papel secundário, tanto quantitativamente quanto pelas maneiras como os enunciados associados a representantes de universidades são dispostos nos textos. No que diz respeito ao conteúdo, há predominantemente uma tendência à polarização entre ensino público e privado, com valorização das práticas do segundo em relação ao primeiro; consideração dos dados obtidos pelas avaliações como rankings e propagação do discurso da competitividade. / This study aims to investigate the arrangement of voices established in journalistic texts on external assessments. More specifically, this study focused on how texts published in the Folha de S.Paulo newspaper on the Ideb (Basic Education Development Index) and the Pisa (Programme for International Student Assessment) addressed the following aspects: characterization of speakers present in the texts, as authors, interviewees and journalistic sources; enunciative heterogeneity and reported speech insertion; how the different voices present in the texts are articulated in order to sustain some of the newspapers positions; and interdiscursive and dialogical relations among texts and the elements materialized in the newspaper. To build the corpus, twenty-four texts on the 2009 Ideb and seventeen on the Pisa of the same year were selected from the Folha de S.Paulo newspaper in 2010. The texts came out shortly after the release of Ideb and Pisa results. The printed texts were obtained from the newspapers digital database in order for the study to address both written content as well as text and image layout. The theoretical framework of choice mobilizes Discourse Analysis and various lines of thought in Enunciation. The fundamental concepts operated with were dialogism (Bakhtin, 1997, 2010), enunciative heterogeneity and reported speech (AUTHIER-REVUZ, 1990, 1999, 2004), interdiscourse (PÊCHEUX, 1993) and enunciator (DUCROT, 1987). From journalism, the concepts of sources and journalistic genres based mainly on Melo (1985) and Lage (2008) were approached. It was found that, with respect to the enunciators present in the Folha de S.Paulo texts, statements made by government authorities and think tanks prevailed. The latter is assigned the role of expert source, one holding theoretical knowledge capable of discussing the disclosed results and making proposals for action. Academic knowledge is relegated to a secondary role, not only quantitatively but also in the way statements associated with university enunciators are arranged in the texts. With regard to content, the prevailing trend is toward polarizing public and private education, thus valuing the practices of the latter in detriment to the former; translating data obtained from assessments as ranking lists, and promoting the discourse of competition.

Introdução: A osteoporose (OP) é doença caracterizada pela fragilidade do osso e, consequentemente, pelo incremento do risco de fraturas. É considerada problema de saúde pública na maioria dos países. Evidências epidemiológicas apontam associação entre variáveis sociodemográficas, variáveis de estilo de vida (como a ingestão de alimentos e de bebidas alcoólicas e hábito de fumar), e indicadores antropométricos (como índice de massa corporal -IMC-) e risco de OP e fraturas osteoporóticas. Objetivo: Estimar a incidência de OP e a prevalência de fraturas referidas, em idosos domiciliados no Município de São Paulo e verificar associação com variáveis sociodemográficas, de estilo de vida, e IMC. Método: analisaram-se dados do Estudo SABE (Saúde, Bem-estar e Envelhecimento) 2000 - 2006, o qual é estudo epidemiológico, longitudinal, de base domiciliar, cuja amostra inicial foi composta por 2143 idosos (&#8805;60 anos), de ambos os sexos, residentes habituais de domicílios urbanos no Município de São Paulo, e selecionados por amostragem probabilística, sendo que 829 idosos (39%) constituíram a amostra de estudo, em 2000, para análise da incidência de OP referida, em 2006, e 1072 idosos (50%) foi a amostra de estudo para análise de prevalência de fraturas após 60 anos referidas, em 2006. Investigou-se a associação entre variáveis sociodemográficas (sexo, grupo etário, vida no campo por 5 anos ou mais durante a infância ou adolescência, escolaridade e etnia), de estilo de vida (ingestão referida de leite e produtos lácteos, ovos e leguminosas, carnes, peixes e aves, frutas e verduras, frequência de ingestão de bebidas alcoólicas, e hábito de fumar); e variável antropométrica (IMC), com relação à referência de OP e fraturas após 60 anos, em 2006. Para verificar associação entre as variáveis categóricas e o desfecho, utilizou-se o teste de Rao & Scott (p<0,05) e a análise de regressão logística univariada (IC95%).O programa Stata, versão 10.1 foi usado para realizar os cálculos estatísticos. Resultados: Houve 114 casos novos de OP referida em 2006, sendo que o coeficiente de incidência (CI) de OP referida foi estimado em 13,93/1000 pessoas-ano (IC95%=11,60 16,87). O CI de OP referida em mulheres foi 22,95/1000 pessoas-ano (IC95%: 19,08 27,87), e 3,34/1000 pessoas-ano (IC95%: 1,85 6,73), em homens.A prevalência de fraturas após os 60 anos referidas foi 17,16%. Sexo feminino (OR= 7,69; p=0,000) e ingestão referida de bebidas alcoólicas < 4 vezes/semana (OR= 2,26; p=0,019), foram fatores de risco para referência de OP. Sexo feminino (OR=2,38;p=0,000), idade avançada (&#8805;75 anos)(OR=1,72; p=0,012), ingestão referida de bebidas alcoólicas < 4 vezes/semana (OR=2,45; p=0,016), referência de OP em 2000 (OR=1,75; p=0,048), e referência de OP em 2006 (OR=2,29; p=0,000), foram fatores de risco para referência de fraturas após 60 anos. Conclusões: sexo feminino, idade avançada foram fatores de risco para OP e fraturas após os 60 anos. Dentre as variáveis modificáveis, a ingestão de bebida alcoólica com frequência &#8805; 4 vezes/semana, esteve negativamente associado à referência de OP e fraturas após 60 anos. / Introduction: Osteoporosis (OP) is a disease characterized by bone fragility and increased risk of fractures. It is considered a public health problem worldwide. Epidemiological studies have found association between sociodemographic, lifestyle and anthropometrical variables and increased risk of OP and osteoporotic fractures. Objetive: To estimate incidence of self-reported OP, in 2006, and prevalence of fractures after the age of 60 year-old, on a sample of elderly individuals from the Município de São Paulo, and verify association between selected variables and outcome. Method: based on data from the SABE Study (health, well-being and aging) 2000 - 2006, which is an epidemiological prospective study of a probabilistic household sample of elderly population ((&#8805; 66 y), of both sexes, from São Paulo City, Brazil. Association between sociodemographic (sex, age, life in rural area for 5 year or more during childhood or adolescence, schooling, and race) lifestyle (reported food intake (milk and dairy products, eggs and legumes, meat, fish and poultry, fruit and vegetables), reported alcoholic beverages intake) and smoking habit; and anthropometrics\' variables, such as body mass index (BMI) and self-reported OP and fractures after the age of 60 year-old, in 2006. Rao & Scott Test was used to verify association between the categorical variables and outcome (p<0,05) as well as simple logistic regression (CI95%). Stata software, version 10.1, was used for statistical calculation. Results: There were 114 new cases of self-reported OP in 2006, and an incidence rate of 13,93/1000 persons-year (IC95%=11,60 - 16,87). In women the incidence rate was 22,95/1000 persons-year (CI95%: 19,08 - 27,87), and in men it was 3,34/1000 persons-year (IC95%: 1,85 - 6,73). Prevalence of self reported fractures after de age of 60 y was estimated in 17,16%. Female sex (OR= 7,69; p=0,000) and frequency of reported alcoholic beverages intake < 4 times/week (OR= 2,26; p=0,019), were risk factors for self-reported OP. Female sex (OR=2,38;p=0,000), advanced age (&#8805;75 y) (OR=1,72; p=0,012), frequency of reported alcoholic beverages intake < 4 times/week (OR=2,45; p=0,016), self-reported OP in 2000 (OR=1,75; p=0,048), and self-reported OP in 2006 (OR=2,29; p=0,000), were risk factors for reporting fractures after the age of 60 years-old Conclusions: female sex, advanced age, were risk factors for reported OP and fractures after 60 y. Among modifiable variables, intake of alcoholic beverages as often as > 4 times/week was negatively associated with reported OP and fractures after the age of 60 y.

Introduction The use of Patient Reported Outcome Measures (PROMs) to measure the effects of care is being advocated increasingly in clinical settings. Current patient data capture involves completion of paper questionnaires which is costly and environmentally perplexing. New innovations are required to balance the challenges of introducing data capture directly from patients while considering budgets, access to Information Technology, and the capability to use technological devices. Methods Two qualitative studies were undertaken to identify the views of patients and clinicians concerning electronic PROM data capture in osteopathic practice. One qualitative study involved patient interviews to identify their views on a selection of specific PROMs. Clinician focus groups and interviews (osteopaths, chiropractors, and physiotherapists) were undertaken concerning their views and experiences of using PROMs. Scoping of PROMs in musculoskeletal practice was undertaken followed by a systematic review of one identified PROM. The review and qualitative work informed the development of content for a mobile and web app for capturing PROM data. The app was piloted to evaluate feasibility, and the clinimetric performance of the included PROMs. Feedback from the pilot informed revisions to the app prior to implementation into osteopathic practice. Results Clinicians (n=46) identified a range of barriers and facilitators to PROM use. Patients (n=22) while generally more enthusiastic than clinicians welcomed the opportunity to provide feedback and although undaunted by the use of technology highlighted the need for assurances concerning confidentiality of data, and limits on data sharing. The systematic review identified good measurement properties for the Bournemouth (BQ). Piloting of the app involved 257 participants contributing 404 data returns: it performed well requiring minimal revision prior to implementation. Conclusions The app performed well demonstrating great potential for further development to collect outcome data in a musculoskeletal clinical setting.

Efficient allocation of public resources requires identification, measurement and quantification of costs and benefits of alternative programs. Patient reported outcomes (PROs) are routinely incorporated into economic evaluations of health technologies, but patient experience is often overlooked. This thesis aims to develop a descriptive system for patient experience that can be valued and used to inform economic evaluation. The generation and selection of items is key in the development of any PRO measure. The thesis provides a contemporary overview of recommended methods and those actually used by instrument developers. Frequently a staged approach is used to establish dimensions first, using exploratory factor analysis, followed by item selection using item response theory (IRT), Rasch or structural equation modelling (SEM). I demonstrate the use of different methods for item selection and its underlying mechanics, followed by comparison of the methods. An existing patient dataset, the Inpatient survey (2014) that collected information on nearly 70 aspects of healthcare delivery from NHS users was used. Logistic regression analyses were applied with respondents' rating of overall patient experience specified as dependent variable. Advanced statistical analyses focussed mostly on patients who had an operation or procedure. Latent construct or dimensions were derived and measurement model was confirmed using confirmatory factor analysis. IRT and factor analysis were employed in each one-factor model for item selection. Regression analyses identified many significant variables but most overlapped conceptually. An 11 and 8 factor model for patients with A&E and planned admissions respectively was determined. A generalised partial credit model and a factor analysis model identified different items to include in each dimension. Broadly the items identified by different methods related to respect, comfort and clear communication to patients. This thesis presents descriptive systems for patient experience that is amenable to valuation. It also demonstrates that different patient experience instruments are generated based on patient population used and item selection technique adopted.

Thesis Title: Enhancing rehabilitation following anterior cruciate ligament reconstruction. Context: Physical training with a neuromuscular focus has been shown to reduce anterior cruciate ligament (ACL) injury. However, ACL injury remains prevalent and often leads to joint instability, which requires surgical reconstruction. Following reconstructive surgery, a minimum of 6 months supervised rehabilitation is recommended with associated with financial cost implications to the National Health Service (NHS), the patient and society. Traditionally rehabilitation is offered in a concurrent format, whereby strength and cardio-vascular endurance exercises are performed in the same session. However, accumulating evidence from healthy populations, suggests that the development of strength might be attenuated by cardio-vascular endurance conditioning performed in close temporal proximity. This thesis comprises an entirely novel investigation of potential attenuation of strength gains in rehabilitating clinical populations that is associated with temporal incompatibility of physiological conditioning stimuli. No study has previously investigated this phenomenon, whether it might compromise the efficacy of treatment or recovery, or its potential influence on objectively-measured and patients’ perception of functional, musculoskeletal and neuromuscular performance capabilities. Objectives: The purpose of this thesis was to assess the effects of reconstruction surgery and 24 weeks of non-concurrent strength and endurance rehabilitation (with 48 week post-operative follow-up) on (a) subjective (IKDC; KOOS; PP [Chapter 4]) and objective measures of function (HOP [Chapter 5]) (primary outcome measures for this thesis), and (b) objective measures of musculoskeletal (ATFD) and neuromuscular performance (PF, EMD, RFD, SMP [Chapter 5]) (secondary outcome measures), in patients with anterior cruciate ligament deficiency. The secondary aim was to evaluate the relationships amongst a subjective outcome of function (IKDC), an objective outcome of function (HOP), and the secondary objective outcomes of musculoskeletal (ATFD) and neuromuscular (PF, RFD, EMD, SMP) performance at pre-surgery and at 24 weeks post-surgery (Chapter 6). Setting: Orthopaedic Hospital NHS Foundation Trust. Design: Prospective random-allocation to group trial involving iso-volume rehabilitative intervention versus contemporary practice, using contralateral limb assessment and clinico-social approbation controls. The design compared the effects of experimental post-surgical rehabilitation comprising non-concurrent strength and endurance conditioning with two conditions of control reflecting contemporary clinical practice (matched versus minimal assessment interaction). Participants: Eighty two patients (69♂, 13♀, age: 35.4 ± 8.6 yr; time from injury to surgery 9.4 ± 6.9 months [mean ± SD]) electing to undergo unilateral ACL reconstructive surgery (semitendinosus and gracilis graft [n = 57]; central third, bone-patella tendon-bone graft [n = 25]); were allocated to groups (2:2:1 purposive sampling ratio, respectively). Nineteen patients were lost to follow-up. Intervention: A standardised traditional concurrent (CON) ACL rehabilitation programme acted as the control versus an experimental non-concurrent (NCON) ACL rehabilitation programme that involved separation of strength and cardio-vascular endurance conditioning. An additional control group (Limited testing CON) matched the CON group rehabilitation applied within contemporary clinical practice. Outcome Measures: Chapter 4: The self-perceived primary outcome measures of function IKDC, KOOS and PP were assessed on five separate occasions (pre-surgery, and at 6, 12, 24 and 48 weeks post-surgery). However, assessment occasions were purposefully reduced to pre-operative and 48 weeks post-operative for the Limited testing CON group. Chapter 5: The primary objective outcome of function was HOP; the secondary outcomes were ATFD, PF, RFD, EMD and SMP associated with the knee extensors and flexors of the injured and non-injured legs. These objective outcomes were assessed on five separate occasions (pre-surgery, and at 6, 12, 24 and 48 weeks post-surgery). However, assessment occasions were purposefully reduced to pre-operative and at 48 weeks post-operative only for the Limited testing CON group. Chapter 6 Self-perceived (IKDC) subjective knee evaluation and the objective outcome of function (HOP), and selected objective outcomes of musculoskeletal and neuromuscular performance including ATFD, PF, RFD, EMD and SMP of the knee extensors and flexors of the injured and non-injured legs where applicable; measured at pre-surgery and at 24 weeks post-surgery were analysed for association, using Pearson product-moment correlation coefficients. A priori alpha levels were set at p<0.05. Results: Chapter 4: Factorial analyses of variance (ANOVAs) with repeated-measures investigating the primary aim showed significant group (NCON; CON) by test occasion (pre-surgery, 6, 12. 24 and 48 weeks post-surgery) interactions for self-perceived outcomes of function IKDC, KOOS and PP confirmed increased clinical effectiveness of NCON conditioning (F(2.0, 82.9)GG = 4.0 p<0.05, F(2.2, 134.7)GG = 5.5 p<0.001, F(1.9, 121.4)GG = 14.6 p<0.001, respectively) and the group mean peak relative difference in improvement for NCON was ~5.9% - 12.7% superior to CON. The greatest interaction effect was found to occur between pre-surgery and the 12 weeks post-operative test occasion for IKDC and KOOS, and between pre-surgery and the 24 week test occasion for PP. Patterns of improvements in self-perceived fitness over time were represented by a relative effect size range of 0.71 to 1.92. Improvement patterns were not significantly different between control groups offering matched or minimised assessor-patient interaction (CON vs. Limited testing CON; pre-surgery vs. 48 weeks post-surgery) indicating that clinical approbation by patients had not contributed to the outcome. Chapter 5: Factorial analyses of variance (ANOVAs) with repeated-measures showed significant group (NCON; CON) by leg (injured/non-injured) by test occasion (pre-surgery, 6, 12, 24 and 48 weeks post-surgery) interactions of the objective measure of function (HOP) together with the secondary outcomes of ATFD, PF, RFD, EMD and SMP. Similar responses were noted for the knee extensors and flexors of the injured and non-injured legs (F(2.1, 248) GG = 4.5 to 6.6; p<0.01) and confirmed increased clinical effectiveness of NCON conditioning (range ~4.7% - 15.3% [10.8%]) better than CON between 12 and 48 weeks. Patterns of improvements in physical fitness capabilities over time were represented by a relative effect size range of 1.92 to 2.89. Improvement patterns were not significantly different between control groups offering matched or minimised assessor-patient interaction (CON vs. Limited testing CON; pre-surgery versus 48 weeks post-surgery) indicating that clinical approbation by patients had not contributed to the outcome. Chapter 6: Two-tailed probabilities were used due to the exploratory nature of this study. A limited number of weak to moderate statistically significant correlations were confirmed (ranging from r = 0.262 – 0.404; p<0.05; n=48 [amalgamated NCON and CON groups] ) between IKDC and most notably, the neuromuscular performance outcome of EMD. Conclusion: Overall, the patterning and extent of changes amongst self-perceived, functional, musculoskeletal and neuromuscular performance scores offer support for the efficacy of using non-concurrent strength and endurance conditioning to enhance post-surgery rehabilitation. The limited robustness of relationships amongst the validated and frequently-used self-perceived outcome of function [IKDC], and objectively-measured outcomes of function and musculoskeletal and neuromuscular performance suggested that each might properly reflect an important but separate aspect of clinical response and should be deployed to detect change.

Nesta pesquisa teve-se como objetivo analisar os arranjos de vozes estabelecidos em textos jornalísticos sobre avaliações externas. De modo mais específico, a proposta foi observar em textos publicados pela Folha de S.Paulo sobre o Ideb (Índice de Desenvolvimento da Educação Básica) e o Pisa (Programa Internacional de Avaliação de Estudantes) os seguintes aspectos: a caracterização dos locutores presentes nos textos, tanto como autores, entrevistados ou fontes jornalísticas; a heterogeneidade enunciativa e formas de inserção do discurso relatado; os modos por meio dos quais as diferentes vozes presentes nos textos são articuladas a fim de sustentar determinadas posições do jornal; e as relações interdiscursivas e dialógicas estabelecidas entre os textos e os elementos materializados no jornal. Para a constituição do corpus, foram selecionados vinte e quatro textos sobre o Ideb 2009 e dezessete sobre o Pisa do mesmo ano, todos publicados pela Folha de S.Paulo em 2010, logo após a divulgação dos resultados. Optou-se pelo uso da versão impressa, disponível no acervo digital do jornal, para que fosse possível examinar, além do conteúdo escrito, a disposição do texto e das imagens no material publicado. Como referencial teórico para as análises, foram mobilizados estudos pertencentes, principalmente, à Análise do Discurso e a diferentes correntes acerca da enunciação. Os conceitos basilares foram dialogismo (BAKHTIN, 1997, 2010), heterogeneidade enunciativa e discurso relatado (AUTHIER-REVUZ, 1990, 1999, 2004), interdiscurso (PÊCHEUX, 1993) e locutor (DUCROT, 1987). Da esfera jornalística, foram abordados também os conceitos de fontes e gêneros jornalísticos com base, sobretudo em Melo (1985) e Lage (2008). Por meio das análises realizadas, concluiu-se que, com relação aos locutores, nos textos publicados pelo jornal, predominam enunciados provenientes da esfera governamental e de think tanks, sendo que a esses últimos é atribuído o papel de fontes expert, aquelas que detêm o conhecimento teórico capaz de debater os resultados divulgados e apresentar propostas de ação. Ao saber acadêmico é relegado papel secundário, tanto quantitativamente quanto pelas maneiras como os enunciados associados a representantes de universidades são dispostos nos textos. No que diz respeito ao conteúdo, há predominantemente uma tendência à polarização entre ensino público e privado, com valorização das práticas do segundo em relação ao primeiro; consideração dos dados obtidos pelas avaliações como rankings e propagação do discurso da competitividade. / This study aims to investigate the arrangement of voices established in journalistic texts on external assessments. More specifically, this study focused on how texts published in the Folha de S.Paulo newspaper on the Ideb (Basic Education Development Index) and the Pisa (Programme for International Student Assessment) addressed the following aspects: characterization of speakers present in the texts, as authors, interviewees and journalistic sources; enunciative heterogeneity and reported speech insertion; how the different voices present in the texts are articulated in order to sustain some of the newspapers positions; and interdiscursive and dialogical relations among texts and the elements materialized in the newspaper. To build the corpus, twenty-four texts on the 2009 Ideb and seventeen on the Pisa of the same year were selected from the Folha de S.Paulo newspaper in 2010. The texts came out shortly after the release of Ideb and Pisa results. The printed texts were obtained from the newspapers digital database in order for the study to address both written content as well as text and image layout. The theoretical framework of choice mobilizes Discourse Analysis and various lines of thought in Enunciation. The fundamental concepts operated with were dialogism (Bakhtin, 1997, 2010), enunciative heterogeneity and reported speech (AUTHIER-REVUZ, 1990, 1999, 2004), interdiscourse (PÊCHEUX, 1993) and enunciator (DUCROT, 1987). From journalism, the concepts of sources and journalistic genres based mainly on Melo (1985) and Lage (2008) were approached. It was found that, with respect to the enunciators present in the Folha de S.Paulo texts, statements made by government authorities and think tanks prevailed. The latter is assigned the role of expert source, one holding theoretical knowledge capable of discussing the disclosed results and making proposals for action. Academic knowledge is relegated to a secondary role, not only quantitatively but also in the way statements associated with university enunciators are arranged in the texts. With regard to content, the prevailing trend is toward polarizing public and private education, thus valuing the practices of the latter in detriment to the former; translating data obtained from assessments as ranking lists, and promoting the discourse of competition.

Patient adherence to in-clinic rehabilitation is between 30-70% and even lower for home exercise programs (HEPs). Barriers to patient adherence have been identified and include but are not limited to anxiety, depression, lack of positive feedback, lack of social support, lack of time, low levels of physical activity at baseline, pain during exercise, and low self-efficacy. As clinicians prescribing rehabilitation may not be able to influence all of the identified barriers, they may positively influence others. Self-efficacy, or an individual’s belief in his/her ability to successfully complete a task, is a patient barrier that may be addressed by a clinician when aware of low self-efficacy and have tools to improve this barrier. Interventions to overcome this specific barrier have demonstrated an increase in not only self-efficacy but patient adherence as well. Although interventions have proven to be successful, patient adherence has yet to increase according to the literature. At this time, there is no evidence to suggest that clinicians are assessing an individual’s level of self-efficacy prior to prescribing HEPs. In addition, there is no known metric to measure self-efficacy for HEPs in patients rehabilitating musculoskeletal conditions. Assessment of patient barriers, specifically self-efficacy, needs to be a standard of care in order to increase adherence, in turn, improve patient outcomes and to reduce the cost to our healthcare system. The first purpose of this dissertation was to determine in patients with musculoskeletal conditions what scales have been developed and evaluated for assessing self-efficacy in conjunction with adherence. In addition, to determine if a tool exists specifically to assess self-efficacy for HEPs. Due to the task and situation-specific nature of self-efficacy, it is important that this construct is reflected in the assessments utilized by clinicians. The second purpose was to determine the importance and utilization of patients’ self-efficacy to physical therapists when addressing patient barriers. This included determining how physical therapists assess patient self-efficacy and barriers to assessment. The third purpose was to develop the Self-Efficacy for Home Exercise Programs Scale and determine the psychometric properties of the instrument. This also allowed for the examination of how self-efficacy relates to patient adherence in a musculoskeletal patient population. The results of the first study suggest that within the musculoskeletal literature, a number of scales are being used to assess patient self-efficacy. These scales are either task, situation, or condition specific. No scale was found to assess self-efficacy for HEPs. This finding indicates the need to develop a scale to assess self-efficacy for HEPs. In the second study, 71% (n = 329/464) of physical therapists, disclosed assessing self-efficacy prior to prescribing HEPs and rated self-efficacy as very to extremely important when it comes to their patients’ adherence. Verbal discussion is the most common method of self-efficacy assessment (50%), followed by observation of the patient (38%), then patient self-report questionnaires (10%). Commonly, physical therapists report using verbal discussion and observation in combination. Of the 29% of the physical therapists that do not assess self-efficacy, 40% report not knowing how to assess self-efficacy, 19% are not sure what to do with the information once self-efficacy is assessed, 16% claim there are other barriers to assessment, 15% claim that assessing self-efficacy will not change their practice, another 9% claim assessing self-efficacy takes too much time, and the last 1% do not know what self-efficacy is. These results further suggest the need for a scale to assess self-efficacy for HEPs. The purpose of the final study was to developed a Self-Efficacy for Home Exercise Programs Scale. The scale was found to have high internal consistency (α = 0.96), acceptable test-retest reliability (ICC = 0.8, SEM = 5, MDC = 7), and strong convergent validity with the Self-Efficacy for Exercise scale (rho(ρ) = 0.83, p < 0.01). Unique to this scale, a cutoff score was determined to be 59 points with a positive likelihood ratio of 2.0 (95% CI 1.1 – 2.5) indicating those who score below 59 points on the SEHEPS would be 2 times more likely to be non-adherent than adherent to their HEP. A weak to moderate, positive relationship was detected between the patients’ initial level of self-efficacy for their HEP and adherence (rho(ρ) = 0.38, p = 0.03). These results suggest that the Self-Efficacy for Home Exercise Programs Scale may be utilized by rehabilitation clinicians to assess self-efficacy for HEPs. Clinically, this scale may provide clinicians the ability to decipher patients who are not likely to adhere to their prescribed HEP, allowing clinicians to intervene immediately. Early intervention to improve self-efficacy may increase adherence to HEPs and eventually patient outcomes.

Femoral acetabular impingement (FAI) is a bony hip condition that often results in tears to the acetabular labrum. Patients with FAI experience pain, decreased function, and quality of life. FAI and its’ sequela are treated definitively with hip arthroscopy. Hip arthroscopy is being performed with increasing frequency, and while most patients respond favorably, a subset of 10-20% of patients have suboptimal outcomes. Previous research suggests that mental status may be a primary driver in the way patients with FAI respond to and feel pain. Measures of mental status include the presence of mood disorders and psychosocial patient reported outcomes (PROs). Psychosocial constructs that have yet to be examined in patients with FAI include self-efficacy, kinesophobia, and pain catastrophizing. The Pain Self-Efficacy Questionnaire (PSEQ) gauges an individual’s confidence, or self-efficacy, in their ability to complete tasks despite their current pain. Previous research has established that a patient’s self-efficacy is an important determinant of long-term success following orthopedic surgery. Kinesophobia, measured via the Tampa Scale for Kinesiophobia (TSK), is a measure of movement-related fear. In contrast to self-efficacy, fear of movement has been identified as a predictor of early success following orthopedic surgery. Lastly, pain catastrophizing is a set of maladaptive behaviors including ruminating on pain, feeling helpless to overcome painful situations, and magnifying the circumstances surrounding the painful experience. Catastrophizing behaviors, measured via the Pain Catastrophizing Scale (PCS), have been repeatedly linked to increased pain and decreased functionality in a variety of orthopedic populations. To date, the relationship between these psychosocial variables and pain has not been examined in patients with FAI. The primary aim of this dissertation was to evaluate the role of psychosocial factors on pre and postoperative pain in patients with FAI undergoing hip arthroscopy. To accomplish this aim we performed a series of three studies. The first study was a retrospective chart review to determine the prevalence of mental health disorders and compare preoperative clinical presentation between patients with and without mental health disorders. The second was a cross-sectional study designed to determine if any psychosocial variables could predict preoperative hip pain. The final study utilized a longitudinal, cohort design. Patients were tested preoperatively and at 12-weeks postoperative. The primary outcomes measured were self-efficacy, kinesiophobia, pain catastrophizing, and hip pain at rest and during activity measured via a visual analog scale (VAS). The purpose of this study was to determine the effect of preoperative psychosocial variables on postoperative pain, and to determine if these variables were predictive of persistent postoperative pain three months following hip arthroscopy. Based on the results from these studies we can conclude the following: 1) Mental health disorders are more common in patients with FAI than other orthopedic populations, and self-reported pain and function are worse in this subset of patients, but neither symptom chronicity nor the severity of joint deformity differs; 2) Low self-efficacy is predictive of worse preoperative pain in patients with FAI; and 3) Patients with high preoperative pain catastrophizing or low self-efficacy are more likely to have increased postoperative pain. Low preoperative self-efficacy is predictive of persistent hip pain during activity three months following hip arthroscopy, while low self-efficacy and mental health disorders are predictive of persistent hip pain at rest. Future studies are necessary to develop and implement interventions targeting low self-efficacy and elevated catastrophizing in patients undergoing hip arthroscopy to improve patient outcomes for this high-risk group.