序破急 Jo-Ha-Kyu: enticement - crux - consolidation. From study to learning: Process drama projects in the Japanese English language university classroom

This dissertation investigates how social issues can be explored through process drama projects in the Japanese university English as a Foreign Language classroom context. The trajectory of this dissertation moves along a traditional Noh three part macro-continuum, called Jo-Ha-Kyu, interpreted as enticement, crux and consolidation. Within these three parts, there are six further divisions. Part I consists of three sections: Section I, the introduction, sets the backdrop for the entire dissertation, that of Japan, and aims to draw the reader into its culturally unique and specific world. This section outlines the rationale for placing the ethnographer at the centre of the research, and presents Japan through the eyes of the writer. Section II outlines relevant Japanese cultural norms, mores and values, the English educational landscape of Japan and an overview of theatre in Japan and its possible influences on the Japanese university student today. Section III provides three literature reviews: second language acquisition, drama in education to process drama, and Content Language Integrated Learning. In Part 2, Sections IV and V respectively consist of the research methodology and the action research at the core of this dissertation. Section IV describes the case of Kwansei Gakuin University, then explains the design of the process drama curricula. Section V details the three-process drama projects based around the three social issues at the centre of this dissertation. There is also a description of an extra project that of the guest lecturer project. The ultimate goals of all four projects were to change motivation through English in a CLIL context, to develop linguistic spontaneity and to deepen emotional engagement with the themes. Part 3 serves to reflect upon the viability of using process drama in the Japanese university curriculum, and to critically self-reflect on the project as a whole.

Time use, daily activities, and health-related quality of life of school-going late adolescents in Cork city and county: A cross-sectional study

Aim: This thesis examines a question posed by founding occupational scientist Dr. Elizabeth Yerxa (1993) – “what is the relationship between human engagement in a daily round of activity (such as work, play, rest and sleep) and the quality of life people experience including their healthfulness” (p. 3). Specifically, I consider Yerxa’s question in relation to the quotidian activities and health-related quality of life (HRQoL) of late adolescents (aged 15 - 19 years) in Ireland. This research enquiry was informed by an occupational perspective of health and by population health, ecological, and positive youth development perspectives. Methods: This thesis is comprised of five studies. Two scoping literature reviews informed the direction of three empirical studies. In the latter, cross-sectional time use and HRQoL data were collected from a representative sample of 731 school-going late adolescents (response rate 52%) across 28 schools across Cork city and county (response rate 76%). In addition to socio-demographic data, time use data were collected using a standard time diary instrument while a nationally and internationally validated instrument, the KIDSCREEN-52, was used to measure HRQoL. Variable-centred and person-centred analyses were used. Results: The scoping reviews identified the lack of research on well populations or an adolescent age range within occupational therapy and occupational science; limited research testing the popular assumption that time use is related to overall well-being and quality of life; and the absence of studies that examined adolescent 24-hour time use and quality of life. Established international trends were mirrored in the findings of the examination of weekday and weekend time use. Aggregate-level, variable-centred analyses yielded some significant associations between HRQoL and individual activities, independent of school year, school location, family context, social class, nationality or diary day. The person-centred analysis of overall time use identified three male profiles (productive, high leisure and all-rounder) and two female profiles (higher study/lower leisure and moderate study/higher leisure). There was tentative support for the association between higher HRQoL and more balanced time use profiles. Conclusion: The findings of this thesis highlight the gendered nature of adolescent time use and HRQoL. Participation in daily activities, singly and in combination, appears to be associated with HRQoL. However, the nature of this relationship is complex. Individually and collectively, adolescents need to be educated and supported to create health through their everyday patterns of doing.

Assessment in primary education in Ireland

This doctoral study examines assessment in primary education in the Republic of Ireland. The nature and purpose of assessment offer an insight into the values which are prioritised by an education system. In 2011, in the Republic of Ireland, the Department of Education and Skills (DES) published a strategy aiming to improve standards of literacy and numeracy. The document, entitled, Literacy and numeracy for learning and life: the national strategy to improve literacy and numeracy for children and young people 2011-2020, contains improvement targets as measured by standardised tests. It also mandates the increased use of standardised tests in primary education, and directs that aggregated scores should be reported to both Boards of Management and the DES. The study is framed by the theoretical perspectives of Michel Foucault and Pierre Bourdieu. Both of these commentators examine social policy and practice in an effort to provide insight into the history and operation of social institutions. This study is especially influenced by Foucault’s archaeology and genealogy of knowledge, and his notion of governmentality. It is also particularly cognisant of Bourdieu’s thoughts on habitus, doxa and capital. The study contains reviews of literature in the areas of assessment, assessment policy, and assessment policy in Ireland. These reviews highlight current debate in each of these areas while also grounding this debate in an historical context. The dissertation contains four empirical sections. 1) It analyses policy documents prepared in the development of the published strategy as well as investigating the strategy itself. In so doing it is aware of the burgeoning influence of pan-national bodies on policy development. 2) A number of high profile policy makers were interviewed as part of the study and their views are interpreted in light of the findings of the literature reviews. 3) The perspective of teachers was sought through a questionnaire survey. This gathered data on these teachers’ views on the purpose of assessment as well as their actual practice. 4) Finally, children were also included as participants in this study. They were interviewed in focus groups and encouraged to contribute drawings as well on their views of assessment in primary school. Literacy and numeracy for learning and life is seen as a seminal document in Irish education. This study is significant in its analysis of original data from high profile policy makers, including two Ministers for Education and Skills. It is also significant in its inclusion of the perspectives of primary school pupils. Finally, the study considers the nature and role of assessment in a holistic manner by including the views of policy makers, teachers and pupils. The study notes that policy development in Ireland underwent a change in the preparation of Literacy and numeracy for learning and life and that international influences, while present, are also mediated to suit the local context. It also highlights a lack of clarity in the definition of assessment in primary education and argues that there is a lack of balance in the approaches that are prioritised. The study demonstrates that teachers are impacted by the strategy but that they also change it by focusing on their own concerns while using assessment tools. The children provide compelling evidence of the impact of assessment on the learner. The study shows how assessment tools (and school subjects) are valued with differing levels of importance by a variety of stakeholders.

The framework for REVIEWS: an exploration into design principles for an electronic medical early warning system observation chart

The observation chart is for many health professionals (HPs) the primary source of objective information relating to the health of a patient. Information Systems (IS) research has demonstrated the positive impact of good interface design on decision making and it is logical that good observation chart design can positively impact healthcare decision making. Despite the potential for good observation chart design, there is a paucity of observation chart design literature, with the primary source of literature leveraging Human Computer Interaction (HCI) literature to design better charts. While this approach has been successful, this design approach introduces a gap between understanding of the tasks performed by HPs when using charts and the design features implemented in the chart. Good IS allow for the collection and manipulation of data so that it can be presented in a timely manner that support specific tasks. Good interface design should therefore consider the specific tasks being performed prior to designing the interface. This research adopts a Design Science Research (DSR) approach to formalise a framework of design principles that incorporates knowledge of the tasks performed by HPs when using observation charts and knowledge pertaining to visual representations of data and semiology of graphics. This research is presented in three phases, the initial two phases seek to discover and formalise design knowledge embedded in two situated observation charts: the paper-based NEWS chart developed by the Health Service Executive in Ireland and the electronically generated eNEWS chart developed by the Health Information Systems Research Centre in University College Cork. A comparative evaluation of each chart is also presented in the respective phases. Throughout each of these phases, tentative versions of a design framework for electronic vital sign observation charts are presented, with each subsequent iteration of the framework (versions Alpha, Beta, V0.1 and V1.0) representing a refinement of the design knowledge. The design framework will be named the framework for the Retrospective Evaluation of Vital Sign Information from Early Warning Systems (REVIEWS). Phase 3 of the research presents the deductive process for designing and implementing V0.1 of the framework, with evaluation of the instantiation allowing for the final iteration V1.0 of the framework. This study makes a number of contributions to academic research. First the research demonstrates that the cognitive tasks performed by nurses during clinical reasoning can be supported through good observation chart design. Secondly the research establishes the utility of electronic vital sign observation charts in terms of supporting the cognitive tasks performed by nurses during clinical reasoning. Third the framework for REVIEWS represents a comprehensive set of design principles which if applied to chart design will improve the usefulness of the chart in terms of supporting clinical reasoning. Fourth the electronic observation chart that emerges from this research is demonstrated to be significantly more useful than previously designed charts and represents a significant contribution to practice. Finally the research presents a research design that employs a combination of inductive and deductive design activities to iterate on the design of situated artefacts.

The knowledge, attitudes and beliefs of patients and their healthcare professionals around oral dosage form modification: a systematic review of the qualitative literature

Objectives: The objective of this systematic review was to synthesize the available qualitative evidence on the knowledge, attitudes and beliefs of adult patients, healthcare professionals and carers about oral dosage form modification. Design: A systematic review and synthesis of qualitative studies was undertaken, utilising the thematic synthesis approach. Data sources: The following databases were searched from inception to September 2015: PubMed, Medline (EBSCO), EMBASE, CINAHL, PsycINFO, Web of Science, ProQuest Databases, Scopus, Turning Research Into Practice (TRIP), Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Database of Systematic Reviews (CDSR). Citation tracking and searching the references lists of included studies was also undertaken. Grey literature was searched using the OpenGrey database, internet searching and personal knowledge. An updated search was undertaken in June 2016. Review methods: Studies meeting the following criteria were eligible for inclusion; (i) used qualitative data collection and analysis methods; (ii) full-text was available in English; (iii) included adult patients who require oral dosage forms to be modified to meet their needs or; (iv) carers or healthcare professionals of patients who require oral dosage forms to be modified. Two reviewers independently appraised the quality of the included studies using the Critical Appraisal Skills Programme Checklist. A thematic synthesis was conducted and analytical themes were generated. Results: Of 5455 records screened, seven studies were eligible for inclusion; three involved healthcare professionals and the remaining four studies involved patients. Four analytical themes emerged from the thematic synthesis: (i) patient-centred individuality and variability; (ii) communication; (iii) knowledge and uncertainty and; (iv) complexity. The variability of individual patient’s requirements, poor communication practices and lack of knowledge about oral dosage form modification, when combined with the complex and multi-faceted healthcare environment complicate decision making regarding oral dosage form modification and administration. Conclusions: This systematic review has highlighted the key factors influencing the knowledge, attitudes and beliefs of patients and healthcare professionals about oral dosage form modifications. The findings suggest that in order to optimise oral medicine modification practices the needs of individual patients should be routinely and systematically assessed and decision-making should be supported by evidence based recommendations with multidisciplinary input. Further research is needed to optimise oral dosage form modification practices and the factors identified in this review should be considered in the development of future interventions.

Learning to Teach and its Implications for the Continuum of Teacher Education: A Nine Country Cross-national Study.

The purpose of this Report is to inform discussions, policy formulation, and strategic planning on teacher education in Ireland. The research gives priority to initial teacher education (ITE) and induction, their interface, and implications for the continuum of teacher education, including continuing professional development (CPD). The study involved a two-pronged approach: a narrative review of recent and relevant literature and a cross-national review of teacher education policies in nine countries, namely, Ireland, Northern Ireland, Scotland, England, Finland, USA, Poland, Singapore and New Zealand. Adopting a broad, balanced and comprehensive understanding of the role of the contemporary teacher, it provides a framework for developing quality teacher education in Ireland. The Report incorporates exemplars of good practice and notes their implementation challenges for the Irish context.  Chapter One provides a framework for conceptualising quality teacher education and the continuum. Key features that emerge from the literature are discussed: teachers¿ practice, quality teaching, the professional life-cycle, teacher learning and relationships. With more specific reference to the continuum, Chapter Two overviews initial teacher education, induction, learning outcomes and accreditation in the selected countries, including Ireland. Key features of policy in the various countries are summarised. Individual country profiles, incorporating descriptions of socio-political, teaching and teacher education contexts, are further detailed in Appendix A. Chapter Three analyses relevant literature on initial teacher education, induction, learning outcomes/professional standards and accreditation. Along with previous chapters it provides the basis for recommendations for teacher education that are presented in Chapter Four. Chapter Four draws together the findings emerging from the cross-national review in terms of the contemporary context of teacher education in Ireland and identifies key challenges and possible lines of policy development as well as recommendations for the Teaching Council and other teacher education stakeholders. Each generation has an opportunity to provide the vision and resources for renewing teacher education in light of ambitious social, economic and educational aspirations to meet perceived societal and education challenges (as occurred in the 1970s). Despite the publication of two key reviews of initial teacher education a number of years ago, there is considerable scope for further reform of teacher education. However, significant changes have occurred to teacher education course provision and content over the last 100 years. In this report, we have stressed the need for, and called for investment in, greater system and programme coherence, mentoring to support assisted practice, knowledge integration, critical reflective practice, inquiry and the development of vibrant partnerships between higher education institutions and schools as the basis for teacher education reform across the continuum. This Executive Summary presents the Report¿s context, key findings and recommendations emerging from the analysis.  

Preparation and characterisation of ceria particles

Cerium dioxide (ceria) nanoparticles have been the subject of intense academic and industrial interest. Ceria has a host of applications but academic interest largely stems from their use in the modern automotive catalyst but it is also of interest because of many other application areas notably as the abrasive in chemical-mechanical planarisation of silicon substrates. Recently, ceria has been the focus of research investigating health effects of nanoparticles. Importantly, the role of non-stoichiometry in ceria nanoparticles is implicated in their biochemistry. Ceria has well understood non-stoichiometry based around the ease of formation of anion vacancies and these can form ordered superstructures based around the fluorite lattice structure exhibited by ceria. The anion vacancies are associated with localised or small polaron states formed by the electrons that remain after oxygen desorption. In simple terms these electrons combine with Ce4+ states to form Ce3+ states whose larger ionic radii is associated with a lattice expansion compared to stoichiometric CeO2. This is a very simplistic explanation and greater defect chemistry complexity is suggested by more recent work. Various authors have shown that vacancies are mobile and may result in vacancy clustering. Ceria nanoparticles are of particular interest because of the high activity and surface area of small particulates. The sensitivity of the cerium electronic band structure to environment would suggest that changes in the properties of ceria particles at nanoscale dimensions might be expected. Notably many authors report a lattice expansion with reducing particle size (largely confined to sub-10 nm particles). Most authors assign increased lattice dimensions to the presence of a surface stable Ce2O3 type layer at low nanoparticle dimensions. However, our understanding of oxide nanoparticles is limited and their full and quantitative characterisation offers serious challenges. In a series of chemical preparations by ourselves we see little evidence of a consistent model emerging to explain lattice parameter changes with nanoparticle size. Based on these results and a review of the literature it is worthwhile asking if a model of surface enhanced defect concentration is consistent with known cerium/cerium oxide chemistries, whether this is applicable to a range of different synthesis methods and if a more consistent description is possible. In Chapter one the science of cerium oxide is outlined including the crystal structure, defect chemistry and different oxidation states available. The uses and applications of cerium oxide are also discussed as well as modelling of the lattice parameter and the doping of the ceria lattice. Chapter two describes both the synthesis techniques and the analytical methods employed to execute this research. Chapter three focuses on high surface area ceria nano-particles and how these have been prepared using a citrate sol-gel precipitation method. Changes to the particle size have been made by calcining the ceria powders at different temperatures. X-ray diffraction methods were used to determine their lattice parameters. The particles sizes were also assessed using transmission electron microscopy (TEM), scanning electron microscopy (SEM), and BET, and, the lattice parameter was found to decrease with decreasing particle size. The results are discussed in light of the role played by surface tension effects. Chapter four describes the morphological and structural characterization of crystalline CeO2 nanoparticles prepared by forward and reverse precipitation techniques and compares these by powder x-ray diffraction (PXRD), nitrogen adsorption (BET) and high resolution transmission electron microscopy (HRTEM) analysis. The two routes give quite different materials although in both cases the products are essentially highly crystalline, dense particulates. It was found that the reverse precipitation technique gave the smallest crystallites with the narrowest size dispersion. This route also gave as-synthesised materials with higher surface areas. HRTEM confirmed the observations made from PXRD data and showed that the two methods resulted in quite different morphologies and surface chemistries. The forward route gives products with significantly greater densities of Ce3+ species compared to the reverse route. Data are explained using known precipitation chemistry and kinetic effects. Chapter five centres on the addition of terbia to ceria and has been investigated using XRD, XRF, XPS and TEM. Good solid solutions were formed across the entire composition range and there was no evidence for the formation of mixed phases or surface segregation over either the composition or temperature range investigated. Both Tb3+ and Tb4+ ions exist within the solution and the ratios of these cations are consistent with the addition of Tb8O15 to the fluorite ceria structure across a wide range of compositions. Local regions of anion vacancy ordering may be visible for small crystallites. There is no evidence of significant Ce3+ ion concentrations formed at the surface or in the bulk by the addition of terbia. The lattice parameter of these materials was seen to decrease with decreasing crystallite size. This is consistent with increased surface tension effects at small dimension. Chapter six reviews size related lattice parameter changes and surface defects in ceria nanocrystals. Ceria (CeO2) has many important applications, notably in catalysis. Many of its uses rely on generating nanodimensioned particles. Ceria has important redox chemistry where Ce4+ cations can be reversibly reduced to Ce3+ cations and associated anion vacancies. The significantly larger size of Ce3+ (compared with Ce4+) has been shown to result in lattice expansion. Many authors have observed lattice expansion in nanodimensioned crystals (nanocrystals), and these have been attributed to the presence of stabilized Ce3+ -anion vacancy combinations in these systems. Experimental results presented here show (i) that significant, but complex changes in the lattice parameter with size can occur in 2-500 nm crystallites, (ii) that there is a definitive relationship between defect chemistry and the lattice parameter in ceria nanocrystals, and (iii) that the stabilizing mechanism for the Ce3+ -anion vacancy defects at the surface of ceria nanocrystals is determined by the size, the surface status, and the analysis conditions. In this work, both lattice expansion and a more unusual lattice contraction in ultrafine nanocrystals are observed. The lattice deformations seen can be defined as a function of both the anion vacancy (hydroxyl) concentration in the nanocrystal and the intensity of the additional pressure imposed by the surface tension on the crystal. The expansion of lattice parameters in ceria nanocrystals is attributed to a number of factors, most notably, the presence of any hydroxyl moieties in the materials. Thus, a very careful understanding of the synthesis combined with characterization is required to understand the surface chemistry of ceria nanocrystals.

Synthesis and reactivity of alpha-thio-beta-chloroacrylamides and alpha-thio-beta-chloroenones

Development of novel synthetic methodology for selective transformation of organic compounds is a central element underpinning organic synthesis with control of chemo-, regio- and stereoselectivity a very high priority. Reactions which can be conducted under mild reaction conditions and, ideally in an environmentally attractive manner, are particularly advantageous. The principal objective of this thesis was to explore the synthesis, reactivity and synthetic utility of a series of α,β-thio-β-chloroenones. The stereochemical features of these transformations and the potential of this novel series of compounds in the synthesis of bioactive compounds were of particular interest. In exploring the reactivity of these compounds, the key transformations included nucleophilic additions and Stille cross-coupling at the β-carbon. Chapter 1 reviews the literature relevant to the research conducted, and focuses in particular on the synthesis of β-chloroenones and related unsaturated carbonyl compounds. The synthesis of chalcone compounds from various precursors is also discussed, with particular emphasis on the use of palladium cross-coupling reactions in the preparation of these compounds. The biological activity of chalcones is also summarised in this chapter. The second chapter delineates the stereoselective synthesis of the novel α-thio-β-chloroenones from the corresponding α-thioketones in a multistep reaction cascade initiated by a NCS-mediated chlorination. A range of both alkyl and aryl β-chloroenones were prepared in this work and the oxidation of these compounds to the corresponding sulfoxides and sulfones is also outlined. The electrophilicity of the β-carbon of the enones was examined in nucleophilic addition/substitution reactions with successful access to a variety of synthetically useful novel adducts including acetals and enaminoketones. Investigation of the synthetic potential of the Stille cross-coupling reaction with the novel α-thio-β-chloroenones was explored and provided an efficient route for the synthesis of a novel series of chalcones. Most importantly this new methodology provided a new and synthetically powerful approach for carbon-carbon bond formation at the β-carbon under mild neutral conditions. A preliminary investigation into the use of these β-chloroenones as dienophiles in Diels-Alder cycloaddition reactions is also discussed in this chapter. Chapter 2 also reports the nucleophilic addition of N, O, S and C nucleophiles to previously described β-chloroacrylamides and their corresponding sulfoxide derivatives. This work builds on previous research carried out in this programme and the reactivity of these β-chloroacrylamides at the sulfide and sulfoxide level is compared. Comparison of the reactivity of the β-chloroacrylamides, in nucleophilic substitution and Stille-coupling, with that of the novel β-chloroenones is of interest. Finally, the biological activity of both the β-chloroenones and the β-chloroacrylamides in terms of cytotoxicity is summarised in Chapter 2. The final chapter, Chapter 3, details the full experimental procedures, including spectroscopic and analytical data for the compounds prepared during this research.

Between the worlds: otherworld women as intermediaries in early Irish literature

This thesis examines the ways in which Otherworldly women acted as intermediaries between the Otherworld and mortal world in early Irish literature. First it establishes the position of women in early Ireland so that appropriate comparisons can be made between mortal and Otherworld women throughout the thesis. Also, it defines what is meant by the ‘Otherworld’ and its relevence to the early Irish. It then goes on to discuss the differing goals of various intermediaries in early Irish texts, and in what manner they interact with mortals. It briefly looks at how Otherworld male intermediaries are treated differently in the literature, and why early authors might have used women in these roles as often as they did.

Literatur verstehen und inszenieren: Foreign language literature through drama, a research project

Based on the experience that today's students find it more difficult than students of previous decades to relate to literature and appreciate its high cultural value, this paper argues that too little is known about the actual teaching and learning processes which take place in literature courses and that, in order to ensure the survival of literary studies in German curricula, future research needs to elucidate for students, the wider public and, most importantly, educational policy makers, why the study of literature should continue to have an important place in modern language curricula. Contending that students' willingness to engage with literature will, in the future, depend to a great extent on the use of imaginative methodology on the part of the teacher, we give a detailed account of an action research project carried out at University College Cork from October to December 2002 which set out to explore the potential of a drama in education approach to the teaching and learning of foreign language literature. We give concrete examples of how this approach works in practice, situate our approach within the subject debate surrounding Drama and the Language Arts and evaluate in detail the learning processes which are typical of performance-based literature learning. Based on converging evidence from different data sources and overall very positive feedback from students, we conclude by recommending that modern language departments introduce courses which offer a hands-on experience of literature that is different from that encountered in lectures and teacher-directed seminars.

Medieval Irish vision literature: a genre study

This dissertation examines medieval literary accounts of visions of the afterlife with an origin or provenance in Ireland from the perspective of genre, analysing their structural and literary characteristics both synchronically and diachronically. To this end, I have developed a new typology of medieval vision literature. I address the question in what manner the internationally attested genre of vision literature is adapted and developed in an Irish literary milieu. I explore this central research question through an interrogation of the typological unity of the key texts, both in formal arrangement and in the eschatological themes they express. My analysis of the structure and rhetoric of these narratives reveals the primary role of identity strategies, question-and-answer patterns and exhortation for their narrative cohesion and didactic function. In addition, I was able to make a formal distinction at text-level between the adaptation of the genre as an autonomous unit and the adaptation of thematic motifs as topoi. This further enabled me to nuance the distribution of characteristic features in the genre. My analysis of the spatial and temporal aspects of the eschatological journey confirms a preoccupation with personal eschatology. It reveals a close connection between the development of the aspects of graded access and trial in the genre and a growing awareness of an interim state of the soul after death. Finally, my dissertation provides new editions, translations and analyses of primary sources. My research breaks new ground in the hitherto underexplored area of genre adaptation in Ireland. In addition, it contributes significantly to our understanding of the nature of vision literature both in an Irish and a European context, and to our knowledge of the transmission of eschatological thought in the Latin West. Discusses the visions of: Laisrén, Fursa, Adomnán, Lóchán, Tnugdal, Owein and Visio Sancti Pauli Redactions VI and XI.

The effectiveness of using patient-reported outcome measures as quality improvement tools

Aim: To investigate the value of using PROMs as quality improvement tools. Methods: Two systematic reviews were undertaken. The first reviewed the quantitative literature on the impact of PROMs feedback and the second reviewed the qualitative literature on the use of PROMs in practice. These reviews informed the focus of the primary research. A cluster randomised controlled trial (PROFILE) examined the impact of providing peer benchmarked PROMs feedback to consultant orthopaedic surgeons on improving outcomes for hip replacement surgery. Qualitative interviews with surgeons in the intervention arm of the trial examined the view of and reactions to the feedback. Results: The quantitative review of 17 studies found weak evidence to suggest that providing PROMs feedback to professionals improves patient outcomes. The qualitative review of 16 studies identified the barriers and facilitators to the use of PROMs based on four themes: practical considerations, attitudes towards the data, methodological concerns and the impact of feedback on care. The PROFILE trial included 11 surgeons and 215 patients in the intervention arm, and 10 surgeons and 217 patients in the control arm. The trial found no significant difference in the Oxford Hip Score between the arms (-0.7, 95% CI -1.9-0.5, p=0.2). Interviews with surgeons revealed mixed opinions about the value of the PROMs feedback and the information did not promote explicit changes to their practice. Conclusion: It is important to use PROMs which have been validated for the specific purpose of performance measurement, consult with professionals when developing a PROMs feedback intervention, communicate with professionals about the objectives of the data collection, educate professionals on the properties and interpretation of the data, and support professionals in using the information to improve care. It is also imperative that the burden of data collection and dissemination of the information is minimised.

The effects of copayment policies on adherence to prescription medicines in publicly insured populations

Introduction: Copayments for prescriptions are associated with decreased adherence to medicines resulting in increased health service utilisation, morbidity and mortality. In October 2010 a 50c copayment per prescription item was introduced on the General Medical Services (GMS) scheme in Ireland, the national public health insurance programme for low-income and older people. The copayment was increased to €1.50 per prescription item in January 2013. To date, the impact of these copayments on adherence to prescription medicines on the GMS scheme has not been assessed. Given that the GMS population comprises more than 40% of the Irish population, this presents an important public health problem. The aim of this thesis was to assess the impact of two prescription copayments, 50c and €1.50, on adherence to medicines.Methods: In Chapter 2 the published literature was systematically reviewed with meta-analysis to a) develop evidence on cost-sharing for prescriptions and adherence to medicines and b) develop evidence for an alternative policy option; removal of copayments. The core research question of this thesis was addressed by a large before and after longitudinal study, with comparator group, using the national pharmacy claims database. New users of essential and less-essential medicines were included in the study with sample sizes ranging from 7,007 to 136,111 individuals in different medication groups. Segmented regression was used with generalised estimating equations to allow for correlations between repeated monthly measurements of adherence. A qualitative study involving 24 individuals was conducted to assess patient attitudes towards the 50c copayment policy. The qualitative and quantitative findings were integrated in the discussion chapter of the thesis. The vast majority of the literature on this topic area is generated in North America, therefore a test of generalisability was carried out in Chapter 5 by comparing the impact of two similar copayment interventions on adherence, one in the U.S. and one in Ireland. The method used to measure adherence in Chapters 3 and 5 was validated in Chapter 6. Results: The systematic review with meta-analysis demonstrated an 11% (95% CI 1.09 to 1.14) increased odds of non-adherence when publicly insured populations were exposed to copayments. The second systematic review found moderate but variable improvements in adherence after removal/reduction of copayments in a general population. The core paper of this thesis found that both the 50c and €1.50 copayments on the GMS scheme were associated with larger reductions in adherence to less-essential medicines than essential medicines directly after the implementation of policies. An important exception to this pattern was observed; adherence to anti-depressant medications declined by a larger extent than adherence to other essential medicines after both copayments. The cross country comparison indicated that North American evidence on cost-sharing for prescriptions is not automatically generalisable to the Irish setting. Irish patients had greater immediate decreases of -5.3% (95% CI -6.9 to -3.7) and -2.8% (95% CI -4.9 to -0.7) in adherence to anti-hypertensives and anti-hyperlipidaemic medicines, respectively, directly after the policy changes, relative to their U.S. counterparts. In the long term, however, the U.S. and Irish populations had similar behaviours. The concordance study highlighted the possibility of a measurement bias occurring for the measurement of adherence to non-steroidal anti-inflammatory drugs in Chapter 3. Conclusions: This thesis has presented two reviews of international cost-sharing policies, an assessment of the generalisability of international evidence and both qualitative and quantitative examinations of cost-sharing policies for prescription medicines on the GMS scheme in Ireland. It was found that the introduction of a 50c copayment and its subsequent increase to €1.50 on the GMS scheme had a larger impact on adherence to less-essential medicines relative to essential medicines, with the exception of anti-depressant medications. This is in line with policy objectives to reduce moral hazard and is therefore demonstrative of the value of such policies. There are however some caveats. The copayment now stands at €2.50 per prescription item. The impact of this increase in copayment has yet to be assessed which is an obvious point for future research. Careful monitoring for adverse effects in socio-economically disadvantaged groups within the GMS population is also warranted. International evidence can be applied to the Irish setting to aid in future decision making in this area, but not without placing it in the local context first. Patients accepted the introduction of the 50c charge, however did voice concerns over a rising price. The challenge for policymakers is to find the ‘optimal copayment’ – whereby moral hazard is decreased, but access to essential chronic disease medicines that provide advantages at the population level is not deterred. This evidence presented in this thesis will be utilisable for future policy-making in Ireland.