An Audit and Feedback Intervention for Reducing Antibiotic Prescribing in General Dental Practice : The RAPiD Cluster Randomised Controlled Trial

Funding: This study was conducted as part of the TRiaDS programme of implementation research which is funded by NHS Education for Scotland (NES). The Health Services Research Unit which is funded by the Chief Scientist Office of the Scottish Government Health and Social Care Directorates supported the study. The funder had no influence over the design, conduct, analysis and write up of the study.

Perception des facteurs de mise en oeuvre d'habiletés spécifiques à l'intervention de groupe chez des intervenants

Thèse numérisée par la Direction des bibliothèques de l'Université de Montréal.

Application du modèle transthéorique dans un programme d'intervention infirmière en cessation du tabagisme auprès de personnes hospitalisées pour une maladie cardiovasculaire

Thèse numérisée par la Direction des bibliothèques de l'Université de Montréal.

Les modèles d'intervention utilisés par les travailleurs sociaux auprès des victimes d'événements traumatiques

Mémoire numérisé par la Direction des bibliothèques de l'Université de Montréal.

Essays on the Role of Government Incentives in the Private Provision of Social Goods

The economic rationale for public intervention into private markets through price mechanisms is twofold: to correct market failures and to redistribute resources. Financial incentives are one such price mechanism. In this dissertation, I specifically address the role of financial incentives in providing social goods in two separate contexts: a redistributive policy that enables low income working families to access affordable childcare in the US and an experimental pay-for-performance intervention to improve population health outcomes in rural India. In the first two papers, I investigate the effects of government incentives for providing grandchild care on grandmothers’ short- and long-term outcomes. In the third paper, coauthored with Manoj Mohanan, Grant Miller, Katherine Donato, and Marcos Vera-Hernandez, we use an experimental framework to consider the the effects of financial incentives in improving maternal and child health outcomes in the Indian state of Karnataka.

Grandmothers provide a significant amount of childcare in the US, but little is known about how this informal, and often uncompensated, time transfer impacts their economic and health outcomes. The first two chapters of this dissertation address the impact of federally funded, state-level means-tested programs that compensate grandparent-provided childcare on the retirement security of older women, an economically vulnerable group of considerable policy interest. I use the variation in the availability and generosity of childcare subsidies to model the effect of government payments for grandchild care on grandmothers’ time use, income, earnings, interfamily transfers, and health outcomes. After establishing that more generous government payments induce grandmothers to provide more hours of childcare, I find that grandmothers adjust their behavior by reducing their formal labor supply and earnings. Grandmothers make up for lost earnings by claiming Social Security earlier, increasing their reliance on Supplemental Security Income (SSI) and reducing financial transfers to their children. While the policy does not appear to negatively impact grandmothers’ immediate economic well-being, there are significant costs to the state, in terms of both up-front costs for care payments and long-term costs as a result of grandmothers’ increased reliance on social insurance.

The final paper, The Role of Non-Cognitive Traits in Response to Financial Incentives: Evidence from a Randomized Control Trial of Obstetrics Care Providers in India, is coauthored with Manoj Mohanan, Grant Miller, Katherine Donato and Marcos Vera-Hernandez. We report the results from “Improving Maternal and Child Health in India: Evaluating Demand and Supply Side Strategies” (IMACHINE), a randomized controlled experiment designed to test the effectiveness of supply-side incentives for private obstetrics care providers in rural Karnataka, India. In particular, the experimental design compares two different types of incentives: (1) those based on the quality of inputs providers offer their patients (inputs contracts) and (2) those based on the reduction of incidence of four adverse maternal and neonatal health outcomes (outcomes contracts). Along with studying the relative effectiveness of the different financial incentives, we also investigate the role of provider characteristics, preferences, expectations and non-cognitive traits in mitigating the effects of incentive contracts.

We find that both contract types input incentive contracts reduce rates of post-partum hemorrhage, the leading cause of maternal mortality in India by about 20%. We also find some evidence of multitasking as output incentive contract providers reduce the level of postnatal newborn care received by their patients. We find that patient health improvements in response to both contract types are concentrated among higher trained providers. We find improvements in patient care to be concentrated among the lower trained providers. Contrary to our expectations, we also find improvements in patient health to be concentrated among the most risk averse providers, while more patient providers respond relatively little to the incentives, and these difference are most evident in the outputs contract arm. The results are opposite for patient care outcomes; risk averse providers have significantly lower rates of patient care and more patient providers provide higher quality care in response to the outputs contract. We find evidence that overconfidence among providers about their expectations about possible improvements reduces the effectiveness of both types of incentive contracts for improving both patient outcomes and patient care. Finally, we find no heterogeneous response based on non-cognitive traits.

A Qualitative Study of Contextual Factors’ Impact on the Adaptation of a Caregiver-mediated Early Autism Intervention in South Africa

Background: Autism Spectrum Disorder (ASD) is a major global health challenge as the majority of individuals with ASD live in low- and middle-income countries (LMICs) and receive little to no services or support from health or social care systems. Despite this global crisis, the development and validation of ASD interventions has almost exclusively occurred in high-income countries, leaving many unanswered questions regarding what contextual factors would need to be considered to ensure the effectiveness of interventions in LMICs. This study sought to conduct explorative research on the contextual adaptation of a caregiver-mediated early ASD intervention for use in a low-resource setting in South Africa.

Methods: Participants included 22 caregivers of children with autism, including mothers (n=16), fathers (n=4), and grandmothers (n=2). Four focus groups discussions were conducted in Cape Town, South Africa with caregivers and lasted between 1.5-3.5 hours in length. Data was recorded, translated, and transcribed by research personnel. Data was then coded for emerging themes and analyzed using the NVivo qualitative data analysis software package.

Results: Nine contextual factors were reported to be important for the adaptation process including culture, language, location of treatment, cost of treatment, type of service provider, familial needs, length of treatment, support, and parenting practices. One contextual factor, evidence-based treatment, was reported to be both important and not important for adaptation by caregivers. The contextual factor of stigma was identified as an emerging theme and a specifically relevant challenge when developing an ASD intervention for use in a South African context.

Conclusions: Eleven contextual factors were discussed in detail by caregivers and examples were given regarding the challenges, sources, and preferences related to the contextual adaptation of a parent-mediated early ASD intervention in South Africa. Caregivers reported a preference for an affordable, in-home, individualized early ASD intervention, where they have an active voice in shaping treatment goals. Distrust of community-based nurses and health workers to deliver an early ASD intervention and challenges associated with ASD-based stigma were two unanticipated findings from this data set. Implications for practice and further research are discussed.

Non-Pharmacological Approaches for Pain Management in Sickle Cell Disease: Development of a Mindfulness-Based Intervention

Background: Sickle Cell Disease (SCD) is a genetic hematological disorder that affects more than 7 million people globally (NHLBI, 2009). It is estimated that 50% of adults with SCD experience pain on most days, with 1/3 experiencing chronic pain daily (Smith et al., 2008). Persons with SCD also experience higher levels of pain catastrophizing (feelings of helplessness, pain rumination and magnification) than other chronic pain conditions, which is associated with increases in pain intensity, pain behavior, analgesic consumption, frequency and duration of hospital visits, and with reduced daily activities (Sullivan, Bishop, & Pivik, 1995; Keefe et al., 2000; Gil et al., 1992 & 1993). Therefore effective interventions are needed that can successfully be used manage pain and pain-related outcomes (e.g., pain catastrophizing) in persons with SCD. A review of the literature demonstrated limited information regarding the feasibility and efficacy of non-pharmacological approaches for pain in persons with SCD, finding an average effect size of .33 on pain reduction across measurable non-pharmacological studies. Second, a prospective study on persons with SCD that received care for a vaso-occlusive crisis (VOC; N = 95) found: (1) high levels of patient reported depression (29%) and anxiety (34%), and (2) that unemployment was significantly associated with increased frequency of acute care encounters and hospital admissions per person. Research suggests that one promising category of non-pharmacological interventions for managing both physical and affective components of pain are Mindfulness-based Interventions (MBIs; Thompson et al., 2010; Cox et al., 2013). The primary goal of this dissertation was thus to develop and test the feasibility, acceptability, and efficacy of a telephonic MBI for pain catastrophizing in persons with SCD and chronic pain.

Methods: First, a telephonic MBI was developed through an informal process that involved iterative feedback from patients, clinical experts in SCD and pain management, social workers, psychologists, and mindfulness clinicians. Through this process, relevant topics and skills were selected to adapt in each MBI session. Second, a pilot randomized controlled trial was conducted to test the feasibility, acceptability, and efficacy of the telephonic MBI for pain catastrophizing in persons with SCD and chronic pain. Acceptability and feasibility were determined by assessment of recruitment, attrition, dropout, and refusal rates (including refusal reasons), along with semi-structured interviews with nine randomly selected patients at the end of study. Participants completed assessments at baseline, Week 1, 3, and 6 to assess efficacy of the intervention on decreasing pain catastrophizing and other pain-related outcomes.

Results: A telephonic MBI is feasible and acceptable for persons with SCD and chronic pain. Seventy-eight patients with SCD and chronic pain were approached, and 76% (N = 60) were enrolled and randomized. The MBI attendance rate, approximately 57% of participants completing at least four mindfulness sessions, was deemed acceptable, and participants that received the telephonic MBI described it as acceptable, easy to access, and consume in post-intervention interviews. The amount of missing data was undesirable (MBI condition, 40%; control condition, 25%), but fell within the range of expected missing outcome data for a RCT with multiple follow-up assessments. Efficacy of the MBI on pain catastrophizing could not be determined due to small sample size and degree of missing data, but trajectory analyses conducted for the MBI condition only trended in the right direction and pain catastrophizing approached statistically significance.

Conclusion: Overall results showed that at telephonic group-based MBI is acceptable and feasible for persons with SCD and chronic pain. Though the study was not able to determine treatment efficacy nor powered to detect a statistically significant difference between conditions, participants (1) described the intervention as acceptable, and (2) the observed effect sizes for the MBI condition demonstrated large effects of the MBI on pain catastrophizing, mental health, and physical health. Replication of this MBI study with a larger sample size, active control group, and additional assessments at the end of each week (e.g., Week 1 through Week 6) is needed to determine treatment efficacy. Many lessons were learned that will guide the development of future studies including which MBI strategies were most helpful, methods to encourage continued participation, and how to improve data capture.

Social-Cognitive Determinants of Success in Online Communities for Weight Management

Background: Online communities may be an effective, convenient, and relatively inexpensive intervention platform for individuals seeking assistance with weight management. Recent research suggests that these communities may be as effective as in-person treatments for weight management; however, very little is known about the characteristics that predict weight loss amongst those using an online community. Methods: Within a social-cognitive framework, we sought to identify the psychosocial characteristics that are associated with successful weight management for users of MyFitnessPal, a popular online community for weight management. We recruited participants who were new to the online community and asked them to complete 2 surveys (one at baseline and one 3 months later) that assessed various psychosocial constructs as well as self-reported height and weight. Results: Participants in our sample reported losing, on average, 4.55 kg during the 3-month time period. We found that engaging in weight control behaviors (e.g., monitoring food intake, weighing oneself, etc.) fully mediated the relationship between several of our variables of interest (i.e., baseline self-efficacy and perceived social support within the community) and weight loss. We also found that participants who expected to lose more weight at baseline were significantly more likely to have lost more weight at follow-up. Conclusions: On average, participants in our study lost a clinically meaningful amount of weight. Predictors of weight loss within this community included perceived support within the community (mediated by weight control behaviors), baseline self-efficacy (mediated by weight control behaviors), and baseline outcome expectations. Results of this study can ultimately serve to inform the design of future eHealth interventions for weight management.

Perception des facteurs de mise en oeuvre d'habiletés spécifiques à l'intervention de groupe chez des intervenants

Thèse numérisée par la Direction des bibliothèques de l'Université de Montréal.

Application du modèle transthéorique dans un programme d'intervention infirmière en cessation du tabagisme auprès de personnes hospitalisées pour une maladie cardiovasculaire

Thèse numérisée par la Direction des bibliothèques de l'Université de Montréal.

Les modèles d'intervention utilisés par les travailleurs sociaux auprès des victimes d'événements traumatiques

Mémoire numérisé par la Direction des bibliothèques de l'Université de Montréal.

HELPING YOUTH WITH AUTISM SPECTRUM DISORDER DEVELOP SOCIAL COMPETENCE IN COMMUNITY-BASED SETTINGS

The purpose of the current dissertation is to identify the features of effective interventions by exploring the experiences of youth with ASD who participate in such interventions, through two intervention studies (Studies 1 and 2) and one interview study (Study 3). Studies 1 and 2 were designed to support the development of social competence of youth with ASD through Structured Play with LEGO TM (Study 1, 12 youths with ASD, ages 7–12) and Minecraft TM (Study 2, 4 youths with ASD, ages 11–13). Over the course of the sessions, the play of the youth developed from parallel play (children playing alone, without interacting) to co-operative play (playing together with shared objectives). The results of Study 2 showed that rates of initiations and levels of engagement increased from the first session to the final session. In Study 3, 12 youths with ASD (ages 10–14) and at least one of their parents were interviewed to explore what children and their parents want from programs designed to improve social competence, which activities and practices were perceived to promote social competence by the participants, and which factors affected their decisions regarding these programs. The adolescents and parents looked for programs that supported social development and emotional wellbeing, but did not always have access to the programs they would have preferred, with factors such as cost and location reducing their options. Three overarching themes emerged through analysis of the three studies: (a) interests of the youth; (b) structure, both through interactions and instruction; and (c) naturalistic settings. Adolescents generally engage more willingly in interventions that incorporate their interests, such as play with Minecraft TM in Study 2. Additionally, Structured Play and structured instruction were crucial components of providing safe and supportive contexts for the development of social competence. Finally, skills learned in naturalistic settings tend to be applied more successfully in everyday situations. The themes are analysed through the lens of Vygotsky’s (1978) perspectives on learning, play, and development. Implications of the results for practitioners and researchers are discussed.

The Social Environment in Children’s Sport: Cohesion, Social Acceptance, Commitment, and Enjoyment

The primary purpose of the current study was to determine whether perceptions of cohesion mediated the relationship between social acceptance and individual commitment and enjoyment in children’s sport. A secondary purpose involved the assessment of the temporal nature of cohesion over the course of an athletic season. A total of 209 (Mage = 9.87 years; SD = 1.34) recreational soccer players completed questionnaires at three time points (T1 – social acceptance, cohesion; T2 – cohesion; T3 – commitment, enjoyment, cohesion) during an athletic season. Using structural equation modeling, the results indicated that task cohesion mediated the relationship between social acceptance and commitment and enjoyment, whereas social cohesion did not. In addition, individual perceptions of cohesion did not vary significantly over the course of the season. These results will be discussed in terms of their theoretical and practical implications. As one example, the relative stability in terms of perceptions of cohesion in this population could inform future intervention work aimed at enriching the social environment

The Efficacy of a Novel Video Game Intervention (MindLight) in Reducing Children's Anxiety

Anxiety disorders are the most prevalent form of psychopathology among children and adolescents. Because demand for treatment far exceeds availability, there is a need for alternative approaches that are engaging, accessible, cost-effective, and incorporate practice to reach as many youth as possible. One novel approach is a video game intervention called MindLight that uses two evidence-based strategies to target childhood anxiety problems. Using neurofeedback mechanics to train players to: (1) attend to positive rather than threatening stimuli and (2) down-regulate arousal during stressful situations, MindLight teaches children how to practice overcoming anxious thoughts and arousal in a fun and engaging context. The present study examined the effectiveness of MindLight versus online cognitive-behavioural therapy (CBT) based psychoeducation sessions as a comparison in reducing anxiety in a sample of 144 anxious children, which was measured in three ways: (1) anxiety symptoms, (2) state anxiety in response to stress, and (3) psychophysiological arousal in response to stress. Children between the ages of 8.05–17.78 years (M=13.61, SD=1.79) were randomly assigned to play MindLight or complete psychoeducation for five hours over three weeks. State anxiety and psychophysiological arousal were assessed in response to two stress tasks before and after exposure to MindLight or psychoeducation. Anxiety symptoms were also measured via a questionnaire. Overall, participants showed significant reductions in anxiety symptoms and state anxiety in response to stress, but not psychophysiological arousal in response to stress. Moreover, the magnitude of reductions in anxiety did not differ between interventions but by age and sex. Specifically, older participants showed a greater decrease in severity of state anxiety in response to a social stressor than younger participants and girls showed a greater decrease in severity of state anxiety in response to a cognitive stressor than boys. The present study suggests that playing MindLight results in similar reductions in anxiety as one of the more common means of delivering CBT principles to youth.

Reconceptualising International Intervention: Statebuilding, ‘Organic Processes’ and the Limits of Causal Knowledge

This article examines the transformation in the conceptual understanding of international intervention over the last two decades. It suggests that this conceptual shift can be usefully interrogated through its imbrication within broader epistemological shifts highlighting the limits of causal knowledge claims: heuristically framed in this article in terms of the shift from policy interventions within the problematic of causation to those concerned with the management of effects. In this shift, the means and mechanisms of international intervention have been transformed, no longer focused on the universal application of Western causal knowledge through policy interventions but rather on the effects of specific and unique local and organic processes at work in societies themselves. The focus on effects takes the conceptualisation of intervention out of the traditional terminological lexicon of International Relations theory and instead recasts problems in increasingly organicised ways, suggesting that artificial or hubristic attempts at socio-political intervention should be excluded or minimised.