Public Health - Doctoral Theses
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Item Implementation of health and social care standards in health and social care services: development and feasibility testing of an implementation support tool(University College Cork, 2023) Kelly Daly, Yvonne; Hegarty, Josephine; O'Rourke, Niamh; Keyes, Laura M.; Health Information and Quality Authority (HIQA); Health Research BoardIntroduction Health and social care standards are complex quality improvement interventions. Standards are typically made up of evidence-based statements that describe safe, high-quality, person-centred care as an outcome or process of care delivery. They involve multiple stakeholders from multiple levels in the health system and apply to diverse services. There is limited evidence to inform implementation strategies specifically tailored to support the implementation of standards. There is a need to apply evidence-based, rigorous and transparent methods when selecting strategies to support the implementation of standards. Researchers have consistently highlighted a research-to-practice gap in this area. This PhD research aimed to develop and test an evidence- and theory-informed intervention to guide the identification of appropriate implementation strategies and the selection of tailored support tools and actions for use when implementing a set of standards. Methods The Medical Research Council (MRC) framework for developing and evaluating complex interventions guided a multi-methods sequential approach. A) Standards were conceptualised by narratively synthesising 12 definitions of standards used by standard-setting bodies internationally. B) The evidence-base was gathered by conducting: a systematic review (n=35 included studies) to identify and describe enablers and barriers to implementing (inter)nationally endorsed standards; and C) a qualitative exploration (focus groups (n=6), individual interviews (n=8)) of individuals’ (n=38) experiences, enablers and barriers to implementing nationally endorsed standards in Ireland. D) These enablers and barriers were used alongside implementation science theory, tools and methodologies to develop a digital intervention. Programme theory guided the development process. The Consolidated Framework for Implementation Research (CFIR), CFIR-ERIC (Expert Recommendations for Implementing Change) matching tool and the Behaviour Change Wheel (BCW) were used to develop a prototype of the content and interactive logic within a digital intervention. E) Co-design workshops (n=3) were held to refine the digital intervention with intended users (n=7). F) A feasibility study was undertaken with end-users (n=14) using a survey that measured acceptability, appropriateness and feasibility. Results A) There was variation in how standard-setting bodies define standards. The commonalities among definitions included the terms ‘quality’, ‘statements’ and ‘performance.’ B) Thematic statements describing enablers (n=22) and barriers (n=24) were created. The most frequently reported enablers related to available support tools, education and shared learning. The most frequently reported barriers related to a lack of knowledge of standards, staffing issues and insufficient funds. C) Six themes were generated from qualitative interviews. Key enablers identified related to teamwork, support tools, leadership and inspections. Key barriers related to workforce issues, a lack of awareness of standards and fear of inspection outcomes. D) Twenty-three enablers and barriers were prioritised using set criteria. E) Iterative feedback led to refinements of the intervention, creating the prototype for the feasibility study. The intervention was entitled SITAS (Selecting Implementation Tools and Actions for Standards). F) SITAS was perceived as acceptable and feasible in preliminary feasibility testing. Conclusion A feasible intervention was developed, enhanced by user involvement. SITAS is a practical digitally enabled intervention that can facilitate bridging the research-to-practice gap. SITAS aims to guide the process of selecting and tailoring implementation strategies to specific contexts, using core concepts of implementation science. Further research is required to undertake formal piloting on SITAS using a larger sample size before spread and scale up.Item The Kidscope Study: an analysis of a community paediatric development clinic set in a disadvantaged area of Ireland(University College Cork, 2024) Buckley, Lynn; Curtin, Margaret; Gibson, Louise; Cornally, Nicola; Harford, Katherine; Irish Research Council; Higher Education Authority; Child and Family Agency; Cork City CouncilBackground: Set in the disadvantaged community of Cork city northwest, Kidscope is the only community paediatric development clinic in Ireland to offer assessment, care, and onward referral within a highly vulnerable area. The complex healthcare intervention provides early developmental assessment and care for children aged zero to six years. Disadvantaged communities often experience a lack of empowerment and limited engagement with services, and high-quality services for children can be inconsistent and limited. Ireland’s disjointed disability system sees children from more affluent communities access health and developmental supports faster through paid private assessment. Kidscope attempts to intercept the gap within the system by providing timely and accessible health and developmental care to vulnerable children. A detailed analysis of Kidscope and its value for supporting the health and development of a vulnerable population was warranted. Methods: Analysis of Kidscope was carried out through a retrospective mixed-methods realist evaluation examining if and how engagement with Kidscope supports the health and developmental needs of vulnerable children. ‘Context (c) + mechanism (m) = outcome (o)’ configurations explained under what contexts, for whom, and how Kidscope achieves this. Underpinned by the Ecological Systems Theory and guided by the Medical Research Council Framework for Complex Interventions, realist evaluation involved three phases: 1. Develop initial programme theories (IPTs), 2. Test IPTs, and 3. Refine programme theory. From 2019 to 2023, five studies tested and refined IPTs using multiple data sources and methods of analysis. Results were collated and analysed in a convergent approach to refine programme theory and develop a set of comprehensive findings to answer the research question. Findings: Ten IPTs were tested and refined through a systematic review of international evidence and four Kidscope-specific empirical studies: a stakeholder analysis, process evaluation, experience and meaning study, and comparison study examining models of care employed in Kidscope and a hospital-based equivalent clinic. Kidscope is set in an area of social disadvantage with higher levels of adversity and complex needs. Families encounter multiple barriers to healthcare access. A long history of community collaboration provides solid foundations for implementation, and contextual elements facilitate delivery: an accessible and welcoming space cognisant of community needs; care delivered over multiple touchpoints; and, embedded practitioner training and education. Mechanisms triggering delivery of child health and developmental support include: utilising and enhancing local expertise through Infant Mental Health (IMH) approaches; relational working; timely and coordinated health and developmental assessment, care, and onward referral; care from a range of specialists; innovative and flexible implementation processes; child and family advocacy; and bridging gaps between services and sectors. Kidscope supports the health and developmental needs of vulnerable children by 1. Developing an innovative and responsive, community-driven child and family model of care, 2. Growing a coalition of IMH-informed child development professionals, 3. Building strong relationships, 4. Meaningfully engaging vulnerable families, and 5. Tackling barriers to highquality healthcare access. Conclusions: Kidscope contributes to breaking the cycle of intergenerational poverty by disrupting the impacts of exclusion to healthcare on child development. By examining interrelationships between context, mechanisms, and outcomes using a realist lens, findings explain how engagement with Kidscope supports the health and developmental needs of a vulnerable population. National healthcare policies promising efficient developmental assessment and integrated care have yet to achieve such goals. The research offers important insights into the health needs and values of a vulnerable population that can be used to thoughtfully examine models of care within contemporary child health practices in Ireland and further afield. Findings provide evidence to support implementing similar models of care across disadvantaged areas to benefit the most vulnerable in society.Item Practical new approaches to delivering biologically rational vector control in the context of conflict, displacement, extreme weather events and other natural disasters(University College Cork, 2023) Allan, Richard James; Killeen, Gerry; Cunningham, Colette; BASF Construction Chemicals ItaliaConflicts and extreme weather events have multiplied since the 1960s, disproportionately affecting some regions and displacing escalating numbers of people annually. By 2022, 114 ongoing armed conflicts, mainly in countries with endemic vector borne diseases (VBD), left 274 million people dependent on humanitarian assistance, including 103 million forcibly displaced facing dreadful journeys, often without shelter, followed by years living in camps. The UN predict numbers needing humanitarian assistance will rise to 339 million during 2023. Extreme events often generate hazardous environmental conditions in which arthropod vectors thrive and human vulnerability to VBD increases. Related morbidity and mortality rates escalate in the early weeks of new humanitarian crises, remaining high until implementation of effective vector control (VC) measures. In the most challenging contexts, disease transmission may continue uncontrolled due to lack of suitable VC tools. Roll Back Malaria halved annual malaria deaths by 2015, and averted 2 billion malaria cases (2000 to 2021). Distribution of >2.5 billion insecticide treated nets (ITNs) and targeted indoor residual spraying were credited for 69% and 10% of cases averted, respectively. These tools exploit the specialized behaviours of just a few largely nocturnal mosquito species, together with humans’ night-time behaviour in houses, making these very efficient malaria vectors highly vulnerable to control. Mosquito species without this sterotypical behaviour may avoid control and continue to transmit malaria. For homeless displaced people sleeping outside or in flimsy temporary shelters in high malaria burden countries in Africa, standard VC house tools can be poorly adapted. Between 2015 and 2021, annual global malaria deaths rose by 41%; just eleven countries accounted for 80% of these, with eight affected by humanitarian crises. This thesis covers research investigating the feasibility, acceptability, durability, and effectiveness of existing and new VC measures for suppressing disease transmission throughout the hellish journeys of the forced displaced. The first study compared 12-month performance of Interceptor® LLIN and conventional ITNs amongst returnees to rural villages in Liberia. User-perceived effectiveness drove high (94%) retention and utilization, with 11 >50% reduction of malaria prevalence. Laboratory analysis revealed just 22% total insecticide loss in Interceptor® over 12 months. The durability of the LLINs most commonly distributed in 2000-2011 (Interceptor®, Olyset® and Permanet®) was investigated amongst displaced and host families living in grass and stick shelters and mud huts, during conflict in Chad. Fourteen months post-distribution, standard hole index (STI) categorisation classed 69.5% of LLIN in “poor” or “very poor” condition, with “poor” condition 4.2 times more likely in polyester compared to polyethylene LLINs. Performance of PermaNet® Dumuria, an innovative non-mesh polyester LLIN, with UV protectant, was assessed amongst nomadic people sleeping outdoors in north-east Kenya. Data analysis revealed 95.3% of respondents liked this LLIN at 12 months, with 98.0% retention at 22 months and 97.1% nets in “good” condition (STI); acceptable insecticide levels (WHO definition) were found in 100% and 66.7% of nets after 18 and 22 months outdoor usage, respectively. Studies exploring an alternative VC option for displaced populations confirmed that temporary shelters constructed fully with novel insecticide-treated plastic sheeting were safe and reduced malaria incidence among young refugee children by 61% in camps in Sierra Leone. Finally, a randomised cluster trial of durable wall lining (DWL) was carried out amongst Liberian returnees. The DWLs contained Abamectin and Fenpyroximate, never previously used for controlling malaria mosquitoes. DWL installed on internal walls and ceilings of houses in 20 villages resulted in a reduction of malaria 12 months later (p=0.022), although this effect was limited to upland villages. Rapid reduction of bioefficacy after 12 months indicates the need for further research and development. In conclusion, this thesis helps inform practical and biologically-rational VC planning in different humanitarian crises’ contexts. It provides insights into the overall effectiveness of conventional and practical technical variations on the deployment of insecticide-treated materials to physically shelter crisis victims and target the anthropophagic vectors responsible for most of their night-time malaria exposure. The thesis reviews published work on the need to integrate VC strategies and develop new tools, to control the wider range of 12 insects that then thrive among living conditions associated with newly settled human communities as populations emerge from crisis and either resettle back into their rural homes or move permanently into poor, overcrowded, informal urban settlements.Item Who gets ongoing service and why? An exploration of assessment, judgments and decision making during initial assessments in child protection and welfare social work in Ireland(University College Cork, 2022-10-07) O'Leary, Donna; Christie, Alastair; Perry, Ivan J.; Irish Research Council; TuslaBackground: Deciding whether or not to provide ongoing services following an Initial Assessment of alleged child abuse and or welfare concerns is one of the most important decisions that Social Workers make in Child Protection and Welfare. Despite this, very little is known about this practice or decisions at the conclusion of Initial Assessments or about the characteristics of children and families involved and their service needs. To fill these gaps, this thesis addresses the following issues: (i) current Irish policy for assessment and decision-making with reference to international developments; (ii) the organisational context for assessment practice; (iii) judgment and decision-making strategies that social workers use to determine eligibility for ongoing service; (iv) the characteristics of children and families who undergo Initial Assessment compared to the general population; (v) factors that are associated with the decision to provide ongoing service following an Initial Assessment; and (vi) comments on the efficacy of the current legislative and policy framework for assessment practice. Methods: Two empirical studies were informed by an extensive narrative literature review. A case study was designed to explore assessment practice in nine social work departments within a large administrative region of Tusla during the first quarter of 2016. Information collected from case file records (n=45) and interviews with SWs (n= 2 teams; n= 7 individuals) was thematically analysed to gain insight into the context for practice and into the sense-making and rationales provided for decisions. Secondly, a descriptive and analytic cross-sectional study was designed to profile children in Initial Assessments and to identify factors associated with the decision to provide ongoing service. Descriptive and multivariable analysis was applied to a complete sample of 480 children whose Initial Assessments concluded in seven social work departments in Tusla in the first quarter of 2016. That study also explored the use of the California Structured Decision Making© Family Risk Assessment (NCCD, 2017) to support decision-making. Results: The case study revealed that consistent with the literature, in situations of limited resources, a number of heuristic strategies were used to make decisions for ongoing service provision. Although social workers operate under a dual mandate of welfare and protection, in situations of high demand they prioritised caseload management over individual risk management leading to regret about judgments and decisions made in this specific practice context. The descriptive findings of the cross-sectional study revealed that families involved in Initial Assessments have greater burdens compared to the general population in addition to the specific child abuse and welfare-related difficulties investigated. The prevalence of exposures to risk factors is identified. Almost 2 in every 5 children (38.5%, n=185) remained open for ongoing service following Initial Assessment. In a multivariable model, several clinical and organizational factors were associated with ongoing service. In the analysis, the Irish model was compared to the California Structured Decision Making© Family Risk Assessment tool. The latter model would have allocated more children to ongoing service. Conclusions: The study makes many novel and important contributions to the literature. Through the originality of the study design, the research presents an in-depth exploration of the context for assessment practice and a detailed understanding of how SWs make decisions for ongoing service provision within this situated context. The findings are discussed in relation to their theoretical, practical, and research implications.Item Real-time surveillance for evidence-based responses to suicide contagion and clustering(University College Cork, 2022-04-01) Benson, Ruth; Arensman, Ella; Rigby, Jan; Brunsdon, Chris; Health Research BoardBackground: Although a rare phenomenon, suicide clusters are a cause for great community concern. In recent years, strong emphasis has been placed on the importance of detection and real-time surveillance of suicide clusters. Cluster detection increases understanding on the aetiology of a suicide cluster and provides the basis for targeted intervention to mitigate further contagion through the identification of linked cases and socioecological factors associated with the increased risk of clustering in the affected area or population. Policy makers and public health officials benefit from detection of suicide clusters by means of implementing targeted evidence-based interventions in identified vulnerable populations and high-risk areas in a timely manner. To date, suicide cluster detection has been largely restricted to retrospective investigations, limiting its capacity as a tool for intervention. Aim: The aim of this research was to provide a comprehensive understanding of the real-time surveillance, detection, and responses to suicide contagion and clustering. Methods: The thesis is comprised of five interrelated studies, based on both primary and secondary research. Primary data collection was conducted on coronial records of post-inquest cases of confirmed suicide or open verdicts meeting the criteria for probably suicide, as well as pre-inquest cases of suspected suicide. This research also involved quantitative Census data from the Central Statistics Office (CSO). The retrospective and prospective space-time scan statistics based on a discrete Poisson model was employed via the R software environment using the ‘rsatscan’ and ‘shiny’ packages to conduct the space-time cluster analysis and deliver the mapping and graphic components of the dashboard interface in study 3. Evidence synthesis was conducted by means of narrative review of existing literature in studies 1 and 4, and by comparative review of response to a structured questionnaire in study 2. Study 5 employs a secondary research approach to report on policy and practice implications of real-time suicide surveillance. Results: Study 1 synthesised the existing evidence on quantitative techniques to detect suicide and self-harm clusters detection, revealing that a Poisson-based scan statistical model is most effective in accurately detecting point and echo suicide clusters, while mass clusters are typically detected by a time-series regression model, albeit that limitations exist. Study 2 demonstrated more commonalities than differences in a comparison of the components and practices of real-time suicide surveillance systems internationally. Commonalities included rapid, routine surveillance based on minimal, provisional data to facilitate timely intervention and postvention efforts. Identified differences include timeliness of case submission and system infrastructure. Study 3 tested the validity of the scan statistic as a cluster detection approach inbuilt in a dashboard prototype developed to visually display real-time suicide surveillance data. Study 4 identified consistency in both increased quantity of media reports and portrayal of specific details of suicide cases to be significantly associated with suicide contagion and increased suicide rates or mass clusters. An elevated period of risk of suicide contagion has been found to take place between the first days up to the first three months following the media coverage of suicide. Study 5 demonstrated the importance of real-time suicide surveillance in the context of policy and practice, with a particular reference to public health emergencies and humanitarian crises. Conclusions: The findings of this thesis are of relevance in furthering our knowledge of monitoring, detecting, and responding to suicide clusters. Collectively, the findings from this thesis indicate that we can work more efficiently and collectively to mitigate further suicidal behaviour by utilising real-time, provisional suicide data to guide quicker action. The outcomes of this research have methodological implications in terms of suicide and self-harm cluster detection and real-time suicide surveillance. The implications of this research further extend to suicide prevention and mental health policy, clinical practice, means restriction, crisis planning and response, and media reporting of suicide.