Symptom burden in individuals with inflammatory bowel disease: a mixed methods study

To investigate the symptom burden experiences of individuals with inflammatory bowel disease (IBD). An explanatory sequential mixed methods study was conducted. A cross-sectional, correlational survey was first undertaken. Symptom burden was measured using a modified disease specific version of the Memorial Symptom Assessment Scale, which was administered to a consecutive sample of individuals with IBD (n = 247) at an IBD Outpatients department in one urban teaching hospital in Ireland. Disease activity was determined using clinical disease activity indices, which were completed by the consulting physician. A sequential qualitative, descriptive study was then conducted aimed at explaining noteworthy quantitative findings. A criterion-related purposeful sample of seven participants from the quantitative study was recruited. Semi-structured face to face interviews were conducted using an interview guide and data were analysed using content analysis. Findings revealed that participants experienced a median of 10 symptoms during the last week, however as many as 16 symptoms were experienced during active disease. The most burdensome symptoms were lack of energy, bowel urgency, diarrhoea, feeling bloated, flatulence and worry. Total symptom burden was found to be low with a mean score of 0.56 identified out of a possible range from 0 to 4. Participants with active disease (M = 0.81, SD = 0.48; n = 68) had almost double mean total symptom burden scores than participants with inactive disease (M = 0.46, SD = 0.43; n = 166) (p < 0.001). Mean total psychological symptom burden was found to be significantly greater than mean total physical symptom burden (rho = 0.73, n = 247, p < 0.001). Self-reported disease control, gender, number of flare ups in the last two years, and smoking status was found to be significant predictors of total symptom burden, with self-reported disease control identified as the strongest predictor. Qualitative data revealed tiredness, pain, bowel symptoms, worry and fear as being burdensome. Furthermore, symptom burden experiences were described in terms of its impact on restricting aspects of daily activities, which accumulated into restrictions on general life events. Psychological symptom burden was revealed as more problematic than physical symptom burden due to its constant nature, with physical and psychological symptoms described to occur in a cyclical manner. Participants revealed that disease control was evaluated not only in terms of symptoms, but also in terms of their abilities to control the impact of symptoms on their lives. This study highlights the considerable number of symptoms and the most burdensome symptoms experienced by individuals with IBD, both during active and inactive disease. This study has important implications on symptom assessment in terms of the need to encompass both physical and psychological symptoms. In addition, greater attention needs to be placed on psychological aspects of IBD care.

The quality of diabetes care in the community: practice, policy and culture

Aim: Diabetes is an important barometer of health system performance. This chronic condition is a source of significant morbidity, premature mortality and a major contributor to health care costs. There is an increasing focus internationally, and more recently nationally, on system, practice and professional-level initiatives to promote the quality of care. The aim of this thesis was to investigate the ‘quality chasm’ around the organisation and delivery of diabetes care in general practice, to explore GPs’ attitudes to engaging in quality improvement activities and to examine efforts to improve the quality of diabetes care in Ireland from practice to policy. Methods: Quantitative and qualitative methods were used. As part of a mixed methods sequential design, a postal survey of 600 GPs was conducted to assess the organization of care. This was followed by an in-depth qualitative study using semi-structured interviews with a purposive sample of 31 GPs from urban and rural areas. The qualitative methodology was also used to examine GPs’ attitudes to engaging in quality improvement. Data were analysed using a Framework approach. A 2nd observation study was used to assess the quality of care in 63 practices with a special interest in diabetes. Data on 3010 adults with Type 2 diabetes from 3 primary care initiatives were analysed and the results were benchmarked against national guidelines and standards of care in the UK. The final study was an instrumental case study of policy formulation. Semi-structured interviews were conducted with 15 members of the Expert Advisory Group (EAG) for Diabetes. Thematic analysis was applied to the data using 3 theories of the policy process as analytical tools. Results: The survey response rate was 44% (n=262). Results suggested care delivery was largely unstructured; 45% of GPs had a diabetes register (n=157), 53% reported using guidelines (n=140), 30% had formal call recall system (n=78) and 24% had none of these organizational features (n=62). Only 10% of GPs had a formal shared protocol with the local hospital specialist diabetes team (n=26). The lack of coordination between settings was identified as a major barrier to providing optimal care leading to waiting times, overburdened hospitals and avoidable duplication. The lack of remuneration for chronic disease management had a ripple effect also creating costs for patients and apathy among GPs. There was also a sense of inertia around quality improvement activities particularly at a national level. This attitude was strongly influenced by previous experiences of change in the health system. In contrast GP’s spoke positively about change at a local level which was facilitated by a practice ethos, leadership and special interest in diabetes. The 2nd quantitative study found that practices with a special interest in diabetes achieved a standard of care comparable to the UK in terms of the recording of clinical processes of care and the achievement of clinical targets; 35% of patients reached the HbA1c target of <6.5% compared to 26% in England and Wales. With regard to diabetes policy formulation, the evolving process of action and inaction was best described by the Multiple Streams Theory. Within the EAG, the formulation of recommendations was facilitated by overarching agreement on the “obvious” priorities while the details of proposals were influenced by personal preferences and local capacity. In contrast the national decision-making process was protracted and ambiguous. The lack of impetus from senior management coupled with the lack of power conferred on the EAG impeded progress. Conclusions: The findings highlight the inconsistency of diabetes care in Ireland. The main barriers to optimal diabetes management center on the organization and coordination of care at the systems level with consequences for practice, providers and patients. Quality improvement initiatives need to stimulate a sense of ownership and interest among frontline service providers to address the local sense of inertia to national change. To date quality improvement in diabetes care has been largely dependent the “special interest” of professionals. The challenge for the Irish health system is to embed this activity as part of routine practice, professional responsibility and the underlying health care culture.

Job retention and turnover: a study of child protection and welfare social workers in Ireland

Retaining social workers in child protection and welfare organisations has been identified as a problem in Ireland (McGrath, 2001; Ombudsman for Children, 2006; Houses of the Oireachtas, 2008) and internationally (Ellet et al., 2006; Mor Barak et al., 2006; Tham, 2006). While low levels of retention have been identified, there is no research that examines the factors in Ireland that influence the retention of social workers. In this thesis, data is analysed from qualitative interviews with 45 social workers in the Health Service Executive South about what influences their decisions to stay in or leave child protection and welfare social work. These social workers’ views are examined in relation to quantitative research on the levels of turnover and employment mobility of child protection and welfare social workers employed in the same organisation. Contrary to expectations, the study found that the retention rate of social workers during the period of data collection (March 2005 to December 2006) was high and that the majority of social workers remained positive about this work and their retention. The quality of social workers’ supervision, social supports from colleagues, high levels of autonomy, a commitment to child protection and welfare work, good variety in the work, and a perception that they were making a difference, emerged as important factors in social workers’ decisions to stay. Perceptions of being unsupported by the organisation, which was usually described in terms of high caseloads and demanding workloads, a lack of resources, work with involuntary clients and not being able to make a difference, were the most significant factors in social workers’ decisions to leave and/or to want to leave. Social workers felt particularly professionally unsupported when they received low quality and/or infrequent professional supervision. This thesis critiques the theories of perceived organisational support theory, social exchange theory and job characteristics theory, and uses the concept of ‘professional career’, to help analyse the retention of social workers in child protection and welfare.

A mechanistic study of anodic formation of porous InP

When porous InP is anodically formed in KOH electrolytes, a thin layer ~40 nm in thickness, close to the surface, appears to be unmodified. We have investigated the earlier stages of the anodic formation of porous InP in 5 mol dm-3 KOH. TEM clearly shows individual porous domains which appear triangular in cross-section and square in plan view. The crosssections also show that the domains are separated from the surface by a ~40 nm thick, dense InP layer. It is concluded that the porous domains have a square-based pyramidal shape and that each one develops from an individual surface pit which forms a channel through this near-surface layer. We suggest that the pyramidal structure arises as a result of preferential pore propagation along the <100> directions. AFM measurements show that the density of surface pits increases with time. Each of these pits acts as a source for a pyramidal porous domain, and these domains eventually form a continuous porous layer. This implies that the development of porous domains beneath the surface is also progressive in nature. Evidence for this was seen in plan view TEM images. Merging of domains continues to occur at potentials more anodic than the peak potential, where the current is observed to decrease. When the domains grow, the current density increases correspondingly. Eventually, domains meet, the interface between the porous and bulk InP becomes relatively flat and its total effective surface area decreases resulting in a decrease in the current density. Quantitative models of this process are being developed.

Issues in the prescribing of psychotropic and psychoactive medication for persons with learning disability: quantitative and qualitative perspectives

The administration of psychotropic and psychoactive medication for persons with learning disability and accompanying mental illness and/or challenging behaviour has undergone much critical review over the past two decades. Assessment and diagnosis of mental illness in this population continues to be psychopharmacological treatment include polypharmacy, irrational prescription procedures and frequent over-prescription. It is clear that all forms of treatment including non-pharmacological interventions need to be driven by accurate and appropriate diagnoses. Where a psychiatric diagnosis has been identified, it greatly aides the selection of appropriate medication, although a specific medication for each diagnosis, as was once hoped, is simply no longer a reality in practice. Part one of the present thesis seeks to address many of the current issues in mental health problems and pharmacological treatment to date. The author undertook a drug prevalence study within both residential and community facilities for persons with learning disability within the Mid-West region of Ireland in order to ascertain the current level of prescribing of psychotropic and psychoactive medications for this population. While many attempts have been made to account for the variation in prescribing, little systematic and empirical research has been undertaken to investigate the factors thought to influence such prescribing. While studies investigating the prescribing behaviours of General Practitioners (GP's) have illustrated the complex nature of the decision making process in the context of general practice, no similar efforts have yet been directed at examining the prescribing behaviours of Consultant Psychiatrists. Using The Critical Incident Technique, the author interviewed Consultant Psychiatrists in the Republic of Ireland to gather information relating not only to their patterns of prescribing for learning disabled populations, but also to examine reasons influencing their prescribing in addition to several related factors. Part two of this thesis presents the findings from this study and a number of issues are raised, not only in relation to attempting to account for the findings from part one of the thesis, but also with respect to implications for improved management and clinical practice.

Micropropagation of Begonia and a study of genome stability in Begonia rex

The development of procedures and media for the micropropagation of B. rex are described. Media for the production of plantlets from a number of other Begonia hybrids are also provided. Growth analysis data is given for plants produced in vivo from leaf cuttings and in vitro from mature leaf petioles and immature leaves derived from singly and multiply recycled axenic plantlets. No significant difference was found in phenotype or quantitative vegetative characters for any of the populations assessed. The results presented from studies on the development of broad spectrum media for the propagation of a number of B. rex cultivars using axenic leaf explants on factorial combinations of hormones illustrate the major influence played by the genotype on explant response in vitro and suggest media on which a range of B. rex cultivars may be propagated. Procedures for in vitro irradiation and colchicine treatments to destabilize the B. rex genome have also been described. Variants produced from these treatments indicate the utility of in vitro procedures for the expression of induced somatic variation. Colour variants produced from irradiation treatment have been cultured and prove stable. Polyploids produced as variants from irradiation treatment have been subcultured but prove unstable. Media for the induction and proliferation of callus are outlined. The influence of callus subculture and aging on the stability of the B. rex genome is assessed by chromosomal analysis of cells, in vitro and in regenerants. The B. rex genome is destabilized in callus culture but attenuation of variation occurs on regeneration. Diploid cell lines are maintained in callus subcultures and supplementation of regenerative media with high cytokinin concentrations, casein hydrolysate or adenine failed to produce variants. Callus aging however resulted in the production of polyploids. The presence and expression of pre-existing somatic variation in B. rex pith and root tissue is assessed and polyploids have been produced from pith tissues cultured in vitro. The stability of the B. rex genome and the application of tissue culture to micropropagation and breeding of B. rex are discussed.

The psychology of immersion and development of a quantitative measure of immersive response in games

This study sets out to investigate the psychology of immersion and the immersive response of individuals in relation to video and computer games. Initially, an exhaustive review of literature is presented, including research into games, player demographics, personality and identity. Play in traditional psychology is also reviewed, as well as previous research into immersion and attempts to define and measure this construct. An online qualitative study was carried out (N=38), and data was analysed using content analysis. A definition of immersion emerged, as well as a classification of two separate types of immersion, namely, vicarious immersion and visceral immersion. A survey study (N=217) verified the discrete nature of these categories and rejected the null hypothesis that there was no difference between individuals' interpretations of vicarious and visceral immersion. The primary aim of this research was to create a quantitative instrument which measures the immersive response as experienced by the player in a single game session. The IMX Questionnaire was developed using data from the initial qualitative study and quantitative survey. Exploratory Factor Analysis was carried out on data from 300 participants for the IMX Version 1, and Confirmatory Factor Analysis was conducted on data from 380 participants on the IMX Version 2. IMX Version 3 was developed from the results of these analyses. This questionnaire was found to have high internal consistency reliability and validity.

Work experience in transition year: a mixed methods study of subject and career choices

Transition Year (TY) has been a feature of the Irish Education landscape for 39 years. Work experience (WE) has become a key component of TY. WE is defined as a module of between five and fifteen days duration where students engage in a work placement in the broader community. It places a major emphasis on building relationships between schools and their external communities and concomitantly between students and their potential future employers. Yet, the idea that participation in a TY work experience programme could facilitate an increased awareness of potential careers has drawn little attention from the research community. This research examines the influence WE has on the subsequent subjects choices made by students along with the effects of that experience on the students’ identities and emerging vocational identities. Socio-cultural Learning Theory and Occupational Choice Theory frame the overall study. A mixed methods approach to data collection was adopted through the administration of 323 quantitative questionnaires and 32 individual semi-structured interviews in three secondary schools. The analysis of the data was conducted using a grounded theory approach. The findings from the research show that WE makes a significant contribution to the students’ sense of agency in their own lives. It facilitates the otherwise complex process of subject choice, motivates students to work harder in their senior cycle, introduces them to the concepts of active, experience-based and self-directed learning, while boosting their self-confidence and nurturing the emergence of their personal and vocational identities. This research is a gateway to further study in this field. It also has wide reaching implications for students, teachers, school authorities, parents and policy makers regarding teaching and learning in our schools and the value of learning beyond the walls of the classroom.

The human papillomavirus and cancer: a multiphase study investigating preventative behaviours in young males

Background: The Human Papillomavirus (HPV) is one of the world’s most common sexually transmitted infections, and a causative factor of oropharyngeal, anal and penile cancers in males. Worldwide, an estimated 39,000 HPV-associated cancers occur each year in men. The highest rates of HPV infection are found in adults aged 18 to 28 years. Clinical evidence indicates that use of a condom in addition to obtaining the HPV vaccine provides the greatest protection from HPV infections. Aim: To explore young men’s attitudes, beliefs, and behavioural intention in relation to receiving the HPV vaccine and using a condom correctly and consistently. Collectively, both behaviours are linked to the prevention of HPV transmission and associated infections with HPV. Method: A multi- phase study, underpinned by the Theory of Planned Behaviour, involving a qualitative belief elicitation, pilot, and quantitative cross-sectional study was conducted. A belief elicitation (n=12) phase was used to generate items to include in a newly developed research instrument. Post pilot the research instrument was utilised in a cross sectional online survey to explore the attitudes, beliefs, and behavioural intention of young men (n= 359) with regard to receiving the HPV vaccine, and using a condom correctly and consistently. Data Collection: Data collection took place over a three month time frame. Male participants were recruited from a university in Southern Ireland via a student email system, as well as posting advertisements on numerous health, social and sports websites. Sample: Three hundred and fifty nine male participants aged 18- 28 years completed the online questionnaire. Data Analysis: Data were analysed using SPSS. Descriptive, correlational, multiple and hierarchical regression analysis were performed on the indirect and direct variables of the Theory of Planned Behaviour i.e. attitude, subjective norm, perceived behavioural control, and intention. Status variables were also included in descriptive analysis and hierarchical regressions. Findings are presented through text and graphical representation. Results: Alarming sexual health statistics identified that only 44.3% of participants always used a condom, and 78.6% never used a condom for oral sex. Furthermore, findings reveal that the constructs of the Theory of Planned Behaviour adequately measure male’s attitudes, beliefs and behavioural intention with regard to both behaviours. The Theory of Planned Behaviour has assisted in identifying how social pressures play an influential role in relation to males receiving the HPV vaccine. Attitudes presented as the most significant predictor of male’s intentions to use a condom correctly and consistently. Intention to perform both behaviours was identified as moderate to high. Conclusion: This study has contributed to the field of HPV research, as it is the first piece of research to explore preventative HPV behaviours i.e. receiving the HPV vaccine, and condom use, amongst young males, utilising the Theory of Planned Behaviour. A deeper understanding of young male’s attitudes, beliefs, and behavioural intention on this topic has been achieved. Additionally, a new robust research instrument has been constructed. Findings from this study will undoubtedly help in the implementation of the HPV vaccine in Ireland, as well as influence health promotion campaigns aimed at young males, addressing the topic of condom use.

Vulnerability and adaptation to climate change in Guam – a case-study of the perceptions, attitudes, behaviors, and knowledge of a small rural community towards their watershed

This thesis argues that examining the attitudes, perceptions, behaviors, and knowledge of a community towards their specific watershed can reveal their social vulnerability to climate change. Understanding and incorporating these elements of the human dimension in coastal zone management will lead to efficient and effective strategies that safeguard the natural resources for the benefit of the community. By having healthy natural resources, ecological and community resilience to climate change will increase, thus decreasing vulnerability. In the Pacific Ocean, climate and SLR are strongly modulated by the El Niño Southern Oscillation. SLR is three times the global average in the Western Pacific Ocean (Merrifield and Maltrud 2011; Merrifield 2011). Changes in annual rainfall in the Western North Pacific sub‐region from 1950-2010 show that islands in the east are getting much less than in the past, while the islands in the west are getting slightly more rainfall (Keener et al. 2013). For Guam, a small island owned by the United States and located in the Western Pacific Ocean, these factors mean that SLR is higher than any other place in the world and will most likely see increased precipitation. Knowing this, the social vulnerability may be examined. Thus, a case-study of the community residing in the Manell and Geus watersheds was conducted on the island of Guam. Measuring their perceptions, attitudes, knowledge, and behaviors should bring to light their vulnerability to climate change. In order to accomplish this, a household survey was administered from July through August 2010. Approximately 350 surveys were analysed using SPSS. To supplement this quantitative data, informal interviews were conducted with the elders of the community to glean traditional ecological knowledge about perceived climate change. A GIS analysis was conducted to understand the physical geography of the Manell and Geus watersheds. This information about the human dimension is valuable to CZM managers. It may be incorporated into strategic watershed plans, to better administer the natural resources within the coastal zone. The research conducted in this thesis is the basis of a recent watershed management plan for the Guam Coastal Management Program (see King 2014).