Philosophiae Doctor - PhD / Background: Stroke is acknowledged globally and among Nigerian rehabilitation researchers as a public health problem that leave half of its survivors with significant neurological deficits. The attendant sequelae of stroke affects the functional ability, limits activity performance and participation of stroke survivors within the community. The inability to re-establish pre-existing roles after stroke further poses additional challenges on the society, friends and families of the stroke survivor with regards to cost and burden of care. Although stroke disrupt the career pathway of working age survivors briefly, recurrently or permanently; a systematic pathway that facilitates job placement and retention at work for stroke survivors could reduce the devastation and burden caused by unemployment following stroke. As this vocational rehabilitation pathway and programme is currently unavailable for stroke survivors, this study aimed to design a RTW intervention programme that could facilitate the work re-entry for stroke survivors in the state of Osun, Nigeria. Method: The study utilized a multi-phase mixed method research design that was guided by the Intervention Mapping (IM) framework to achieve its objectives. This consisted of three iterative phases that informed one another with the findings culminating into the developed return to work programme for stroke survivors in Osun State. Phase one used a convergent mixed method parallel approach to obtain baseline information on the RTW process, the impairments, activity limitation, and the participation restrictions experienced by stroke survivors in Osun state, Nigeria in two distinct stages that involved a cross-sectional survey and qualitative interviews. The cross sectional survey administered questionnaires that included the Work Rehabilitation Questionnaire, the International Classification of Functioning, Disability and Health (ICF) Brief Core Sets for vocational rehabilitation (VR) and the Work Impact Questionnaire (WIQ) using the face to face method. Descriptive statistics such as measure of central tendencies and frequencies as well as inferential statistics such as logistic regression analysis were performed on the questionnaire data. The qualitative study involved concept mapping using in-depth interviews with stroke survivors who have and those that have not RTW. The transcripts from the in-depth interviews were analysed using the thematic content method. Phase two entailed a scoping review of literature that reported on interventions aimed at facilitating RTW of stroke survivors. The last phase of the study involved a Delphi study with experts in the field of stroke and vocational rehabilitation. The Delphi survey was conducted over three rounds with the final draft of the RTW programme emerging at the third round. Results: Two hundred and ten stroke survivors with mean age 52.90±7.92 responded to the quantitative stage of the phase thereby yielding a response rate of 76.36%. Sixty three point eight percent of the respondents had returned to work with half of them in full time employment (32.9%) while 36.2% had not returned to work. The majority of the respondents identified that travel to and from work (43.8%) and access at work (43.3%) had an impact ranging from ‘quite a bit’ to ‘extreme’ on their ability to work on the WIQ. The results from the quantitative stage further showed that more than ten percent of the respondents experienced complete problem in four components of activity and participation domains of the ICF brief core sets for VR and these include remunerative employment (21.4%), acquiring new skills (17.1%), non-remunerative employment (16.7%), as well as acquiring, keeping and terminating jobs (14.3%). Similarly, energy and drive functions (41.9%) and higher level cognitive function (36.2%) were indicated as culminating in moderate to severe problems in more than a third of the respondents while the “performance of complex interpersonal relationship” and “exercise tolerance function” resulted in no or little difficulty for the respondents. The findings from the logistic regression analysis showed that the combination of side of body affected by stroke (left), type of vocational rehabilitation programme, symptoms of stroke, environment, body function impairments as well as activity and participation problems were the factors that predict RTW after stroke. The logistic regression model significantly explained 55.0% to 75.4% of the variance in RTW after stroke and correctly classified 89.0% of all the cases/respondents. Results from the qualitative stage of the first phase suggests the lived experience of returning to work after stroke to have entailed three themes that was represented by a concept map. The first theme revealed that “it was difficult to live with stroke” for the survivor. The second theme revealed that the stroke survivors’ environment could either worsen or lessen the difficulty experience while the third theme highlighted the various issues that directly impacted on the resumption of worker role of the participants. The scoping review phase (phase two) identified that RTW interventions for stroke survivors falls into three core components which includes 1) intervention components that interface with the stroke survivor; 2) intervention components that interfaced with the workplace and; 3) components that describe strategies of implementation. These core components are interventions that could guarantee an effective RTW for strokes survivors when included in a RTW programme. In the third phase which was the concluding phase of the study, 13 experts in the field of stroke and vocational rehabilitation unanimously agreed at the third round of Delphi that the content of RTW programme for stroke survivors should include an assessment phase, work intervention training phase, work test placement phase and clients full participation in worker role phase that will span a 12 week duration. The developed RTW programme, conceptualized as Stroke Return to Work Intervention Programme (SReTWIP) was designed to be individually tailored to meet the need of the stroke survivor and implemented by an interdisciplinary team that will include the OT and PT as key members. Equally, the stroke survivor is expected to be involved in the decision making process throughout the duration of the SReTWIP. And finally, the programme is to be coordinated by a case manager who will be a member of the interdisciplinary team. Conclusion: It can be concluded that 63.9% of stroke survivors in Osun State, Nigeria return to work. Problems pertaining to lack of energy and drive functioning; higher level cognitive functioning; acquiring new skills; handling stress and psychosocial demands; travel to and from work and access were the common body impairments and problems with activities and participation restrictions that the stroke survivors encountered. Similarly, the study concludes that a multi-faceted programme, the SReTWIP, comprising of four interconnected phases of interventions that targets multiple factors such as personal and environment factors influencing work resumption is likely to be more effective in facilitating quick RTW after stroke.

Magister Scientiae (Occupational Therapy) - MSc(OT) / Individuals diagnosed with stroke particularly in rural communities have a poor return to work rate. Vocational rehabilitation has been used as an intervention strategy with various types of clients with disability or injury in order to improve their work skills. The aim of the proposed study is to describe the experiences and perceptions of individuals diagnosed with stroke about the usefulness of the Model of Occupational Self Efficacy in assisting them in returning to their worker role particularly in a rural setting. Eight participants were purposively selected from the data base of a local hospital and semi structured interviews were conducted with the participants until saturation occurred. Furthermore, two focus groups were conducted with eight participants. A key informant was also interviewed to assist the researcher with a different perspective and to avoid bias. The data was analysed by means of thematic analysis into codes, categories and themes. Trustworthiness was ensured by means of credibility, applicability, transferability and conformability. Informed consent and confidentiality was ensured. Permission was obtained from the UWC research committee and from the Department of Health. Four themes were merged from the findings: Theme one: Obstacles which affects the return to work of CVA Participants in a rural community. Theme two: Establishing a strong belief in functional ability through occupation. Theme three: Adaptation strategies that enhances the work participation of stroke survivors in a rural community. Finally Theme four: The MOOSE enables transition to the worker role in a rural context. The findings revealed that the participants experienced a loss of their former self thus affecting their worker identity as they were no longer able to experience the gratification of fulfilling their worker role. This was due to the participants not being aware of the return to work options that they had. After the stroke the participants battled with not only overcoming their condition but also the stigma which the community and their employers had of stroke. Overcoming the stroke event and returning to work required that potential barriers and facilitators be identified by the participants and the researcher. The study also identified adaptation strategies that the participants utilised in order to overcome the barriers and assist the participants to have a smoother transition into the workplace. In conclusion the findings of the study revealed that the participants suffer a loss of their former abilities and undergo a loss of their self-esteem. As a result of the loss, participants struggled to return to work not only due to their loss of abilities but also their lack of knowledge regarding return to work and stroke. The findings indicated that there should be more education regarding the stroke that needs to be conducted in communities via media such as local newspapers, local radio stations, clinics and hospitals. The findings of the study may assist Occupational Therapy practitioners to improve services in a rural community for stroke survivors and improve the facilitation of the return to work process after stroke. The MOOSE facilitates motivation for participants to regain their self-esteem and thus move forward to resume a worker role. / 2020-08-31

Thesis advisor: Jane Flanagan / BACKGROUND: Breast cancer survivors experience a range of needs in the post-treatment phase as they transition into survivorship and beyond. The transition to survivorship requires breast cancer survivors to actively engage in self-managing their care, but little is known about patient engagement into survivorship care and what factors may contribute to this. Information is needed to further explore patient engagement into survivorship care, what factors may contribute to it and which patients are more likely to engage in their care and thus be better equipped to self-manage during survivorship. PURPOSE: The purpose of this study was to explore how demographic/personal factors and survivorship outcomes are related to and may contribute to patient engagement in early stage breast cancer survivors. METHODS: A cross-sectional, web-based self-report national survey was conducted using measures assessing personal/demographic factors, survivorship outcomes: health-related quality of life (HRQOL), fear of cancer recurrence (FCR), cancer health literacy (CHL) and two measures of patient engagement (patient activation (PA) and knowing participation in change (KPC). There was one open-ended question regarding additional survivorship concerns, not addressed in the previous survey items. Participants were recruited using Dr. Susan Love’s Army of Women Research Foundation and Craigslist. Data were analyzed via bivariate associations and backwards linear regression modeling in SPSS. RESULTS: The final sample included 303 participants (301 females and 2 males) with a mean age of 50.70 years. The sample was predominantly White, non-Hispanic and equally dispersed across the United States. Patient engagement, as represented by PA and KPC, was significantly correlated with 13 predictor variables and there were 10 predictor variables that resulted in significant ANOVA relationships with PA and KPC. In both the KPC and PA regression models, HRQOL significantly predicted for patient engagement. In the KPC regression model, social support and level of education also significantly predicted for patient engagement and receipt of a survivorship care plan contributed unique variance to the model. The open-ended question response categories included: physical concerns, mental health concerns, financial toxicity, social support, body image concerns, other concerns or no concerns/none. CONCLUSIONS: This study provides preliminary evidence that personal/demographic factors and survivorship outcomes may contribute to patient engagement in breast cancer survivors. Using assessment tools that measure factors such as HRQOL, social support, education level and patient engagement may give providers some insight as to which survivors may be ready to engage in survivorship care and those that may need more resources and/or support. Additional studies are needed to replicate and validate these results. More research is needed aimed at maximizing patient-centered care, patient engagement and ultimately improving SC. Keywords: breast cancer survivor, survivorship, patient engagement, health-related quality of life, social support. / Thesis (PhD) — Boston College, 2019. / Submitted to: Boston College. Connell School of Nursing. / Discipline: Nursing.

Bakgrund: Bröstcancer är den vanligaste dödsorsaken bland kvinnor och är den vanligaste cancersjukdomen i Sverige. Sjukdomen behandlas med kirurgi, strålning, cellgifter och hormoner. Omvårdnaden på dessa kvinnor grundar sig på att stötta, hjälpa och motivera till egenvård, självförtroende och förändra syn på livet.   Syfte: Syftet var att beskriva kvinnors upplevelser av bröstcancer efter avslutad primärbehandling.   Metod: I denna litteraturöversikt har åtta kvalitativa och två mixade forskningsrapporter inkluderats. Dessa har inhämtats från databaserna Cinahl Complete, PubMed och PsycINFO med sökorden “breast neoplasms”,”life experience” och “survivors”. Samtliga artiklar kvalitetsgranskades och analyserades enligt Fribergs (2017) metod för kvantitativa och kvalitativa studier.  Resultat: Kvinnor upplevde förändrat liv efter bröstcancerbehandling. Bröstcancer ledde till kroppsliga och mentala utmaningar som påverkade kvinnornas vardag, förändrad kroppsuppfattning och känslor samt förändrade relationer. Resultatet delades i tre huvudkategorier, upplevelse av förändrad kropp, rädsla ochrelationer. Diskussion: Resultatet diskuterades utifrån Dorothea Orems omvårdnadsteori och tidigare forskningar samt kvinnornas upplevelser. Resultatet visar att kvinnor efter avslutad primärbehandling upplevde rädsla och en förändrad syn på sin kropp. Författarna diskuterar i resultatdiskussionen sjuksköterskans roll i uppföljningsvården av kvinnor som har drabbats av bröstcancer. / Background: Breast cancer is the most common cause of death among women and it is the most common cancer disease in Sweden. The disease is treated with surgery, radiation, chemo and hormones. The nursing care of these women is focused on supporting, helping, and motivating self-care, self-confidence and life changes.  Aim: The purpose was to describe women's experiences of breast cancer after completing primary treatment. Method: In this review of literature, eight qualitative and two mixed method articles have been included. These have been obtained from the databases Cinahl Complete, PubMed and PsycINFO with the keywords "breast neoplasms", "life experience" and“survivors”. All of the articles were quality-reviewed and analyzed according to Friberg's (2017) method for quantitative and qualitative studies. Results: Women experienced a life change after breast cancer treatment. Breast cancer caused bodily and mental challenges that affected women's everyday lives, changed body image, emotions and changed relationships. The result was presented to three main categories, experience of changed body, fear andrelationships. Discussion: The result was discussed in relation to Dorothea Orem's nursing theory and previous research as well as the women's experiences. The result shows that women after primary treatment often experienced fear and a changed view of their body. The authors discuss the role of the nurse in the follow-up care of women who have suffered from breast cancer.

Rape has historically been constructed as a women’s issue and, as such, research has focused on female survivors of sexual assault. Current research on the topic indicates that the construction of female rape is structured by stereotypical gender roles and patriarchal/misogynistic structures. However, there is very little research on male rape. This exploratory thesis seeks to fill this gap by exploring how the meaning of male rape is constructed on Twitter posts that contain the hashtag “MaleRape”. Two thousand ninety-two tweets were collected. The final sample was comprised of 840 tweets and qualitative content analysis was the method used to code and organize the data. Preliminary analysis suggested that the constructions varied significantly by region; accordingly, the data were sorted into the following four regions: North America; Europe; Africa; and Asia. The analysis, rooted in critical feminism, explores how male rape is constructed in each region. The findings indicate that there is some consistency across regions, especially with respect to the ways in which patriarchal assumptions led to the denial of male rape and the silencing of survivors. However, there were interesting differences in the various regions. This thesis addresses the influence of heteronormative constructions and calls for more consideration of cultural differences when studying sexual violence.

Children who experience a parent's death by suicide are a vulnerable population at risk for emotional and mental health issues as well as suicide attempts (Cerel, Fristad, Weller, & Weller, 1999; Kuramoto et al., 2010; Wilcox et al., 2010). Yet, in spite of the knowledge that effective postvention is in reality prevention (Cerel et al. 2008), relatively little is known about these children and adolescents, particularly regarding their experiences following the suicide. The current research study investigated which resources, assistance, and actions of those around the child were perceived as most helpful and unhelpful following the parental suicide. Through semi-structured qualitative interviews using the hermeneutic approach, the researcher interviewed 17 adults who, as children or adolescents, were bereaved by parent suicide. Helpful experiences and support included assistance processing the suicide and an openness in the face of stigma. Unhelpful experiences included judgment and blame, silence regarding the suicide and deceased parent, and a heightened awareness of the surviving parent's challenges. Individuals who were perceived as helpful generally had pre-existing relationships with the children and helped meet their practical and emotional needs. It is recommended that customized and varied support be offered, along with the message that it is important to talk about suicide and memorialize the deceased parent. Additional research is needed to further explore the complex experiences of children of parent suicide; this will aid in the development of evidence-based interventions to better support them.

Commercial Sexual Exploitation of Children (CSEC) is the sexual exploitation of minors for commercial profit. The intersection between sex trafficking victimization and substance use has not yet been explored in clinical research and is not reflected in current clinical treatment of survivors when they exit their exploitation. The research question explored in this study focused on the substance use treatment considerations and challenges clinical social workers face when treating survivors of CSEC living in Massachusetts. Subquestions included understanding how cumulative trauma from CSEC impacts substance use treatment and how the coercive use of substances aimed at maintaining victim submission impacts substance use treatment. Contemporary trauma theory was the theoretical basis that informed this action research study. The sample included 5 clinical social work practitioners who had experience working with victims and survivors of CSEC. Data collected through a focus group was coded, compared, and analyzed for major and emergent themes using the constant comparison method. The key findings of the study include the lack of training and experience specific to the population, the impact of trauma, the effect of CSEC on substance use treatment, and the need for specialized treatment services. The findings of the study may create positive social change by increasing knowledge of the dynamics of substance use treatment with CSEC survivors, informing best practices for social worker professionals working with this population, and advising the development of trauma-informed substance use treatment for CSEC survivors.

Research shows that women who have been sexually assaulted once are more likely to be sexually assaulted again (revictimized). Several factors contribute to the likelihood of a woman being revictimized, including social support, personal behavior, and psychological health. This research proposes that a combination of these factors contributes to a woman’s self-perception as a victim or survivor of sexual assault. It is this self-perception that determines revictimization. Twenty women were interviewed to explore the victim or survivor mentality and its relation to revictimization. All women had negative consequences of the assault. Negative consequences lead some women to develop a victim mentality. Some women were able to find positive consequences out of their assault and developed a survivor mentality. Revictimization was linked to negative consequences of the initial victimization and the victim mentality that resulted from the negative consequences. Reasons for non-revictimization were somewhat the opposite of the reasons for revictimization and were linked to positive consequences of the assault and the survivor mentality that resulted from the positive consequences. The overall attitudes and behaviors of a sexual assault victim determines whether she views herself as a victim or survivor which significantly impacts the likelihood of her revictimization.

Chronic illnesses such as cancer continue to be among the costliest for employers who provide health insurance to their employees. Despite efforts to incorporate health improvement programs in the workplace, there are concerns about the effectiveness of these programs that do not always deliver a positive return on investment. Little is known about the specific socioeconomic status of employees for whom these workplace health improvement programs are designed for. Guided by the social-ecological model, this study sought to understand the relationship between cancer health risks about socioeconomic factors among cancer survivors in the employer-insured population. Data were extracted from the 2013 Behavioral Risk Factor Surveillance System for employer-insured individuals who identified as having been diagnosed with cancer at some point in their life (N = 7,007). A multivariate linear regression analysis was used to assess the effect of household income, level of education, race/ethnicity of respondents on cancer health risks based on the American Cancer Society Guidelines on Nutrition and Physical Activity for Cancer Prevention (ACS). The analysis of variance indicated that the overall model was significant (P < .05). College graduates had the highest level of compliance with requirement for cancer prevention; participants' adherence to the guidelines varied depending on their household income. This study may contribute to positive social change as it suggests that socioeconomic characteristics of employer-insured individuals, including health history, need to be taken into consideration in the development and implementation of worksite health improvement programs.

Physical, psychological, and social debilities are common among survivors of critical illness. Survivors of critical illness require rehabilitative services during recovery in order to return to functional independence, but the structure and access of such services remains unclear. The purpose of this qualitative study was to explore the vital issues affecting quality of life from the perspective of critical illness survivors and to understand these patients' experiences with rehabilitative services in the United States. The theoretical framework guiding this study was Weber's rational choice theory, and a phenomenological study design was employed. The research questions focused on the survivors' experiences with rehabilitative services following critical illness and post-intensive care unit quality of life. Participants were recruited using purposeful sampling. A researcher developed instrument was used to conduct 12 semistructured interviews in central North Carolina. Data from the interviews were coded for thematic analysis. The findings identified that aftercare lacked unity, was limited by disparate information, and overuses informal caregivers. In addition, survivors' recovery depended on being prepared for post-intensive care unit life, access to recovery specific support structures, and the survivors' ability to adapt to a new normalcy. Survivors experienced gratitude for being saved, which empowered them to embrace new life priorities. The implications for social change include improved understanding of urgently needed health care policies to provide essential therapies and services required to support intensive care unit survivors on their journey to recovery.