<p> Background. Norovirus disease is of great public health significance as evidenced by the health and economic burdens each year in the United States. Although norovirus disease afflicts all ages in the general population, vulnerable segments of the population include the young and elderly. Currently there is no norovirus vaccine on the market to prevent norovirus infection nor is there prescribed medical treatment other than supportive care for self-limiting symptoms. </p><p> Methods. Surveillance data on norovirus outbreaks obtained from the Centers for Disease Control National Outbreak Reporting System, school enrollment data obtained from the National Department of Education, healthcare resource utilization data obtained from the Healthcare Cost and Utilization Project, and results from published research findings were used to estimate the health and economic burdens of norovirus disease among the school age population. Decision analysis was used to model the costs and benefits of norovirus vaccination. Cost effectiveness analysis was conducted from the societal and healthcare perspectives in order to determine the incremental cost-effectiveness ratios for the alternative health strategy compared to the current standard health strategy. Univariate and multivariate analyses were conducted in order to examine uncertainty associated with parameters and assess how the uncertainty affects the outputs of the decision model. Probabilistic sensitivity analysis was conducted in order to assess and quantify the impact of varying all parameters at the same time. </p><p> Results. Norovirus results in high numbers of illnesses and high direct medical, direct non-medical and indirect costs among school age children. In terms of health burden, there were a greater number of cases requiring supportive care than any other health outcome. The cost of supportive care is relatively inexpensive until indirect costs are factored in to the total cost of one episode of norovirus illness. </p><p> The results of the present study indicated that when comparing the standard health strategy of no norovirus vaccination to that of the alternative health strategy of norovirus vaccination, vaccination was found to be optimal. The results of probabilistic sensitivity analysis indicated that the alternative health strategy was marginally cost effective. </p><p> Conclusion. The results of the present study represent the first attempt to estimate the health and economic burdens of norovirus disease among the school age population with a focus on norovirus disease spread occurring in closed (schools) environments. The study findings will illustrate the uniqueness of closed environments in perpetuating norovirus spread and the feasibility of norovirus vaccination among school age children. The results of cost-effectiveness analysis indicated vaccination was an optimal strategy but is marginally effective. </p><p> Given the numerous limitations of using passive surveillance data, future research efforts should use higher quality and more accurate sources of data in order to estimate the health and economic burdens of norovirus disease and examine the other hidden costs of norovirus outbreaks such as environmental decontamination, school closure, student and staff absenteeism and other intangible costs. In addition, future research efforts should use the findings from this and other studies that have identified high prevalence of norovirus disease among younger age groups in order to establish priority age groups for vaccination when a vaccine becomes available on the market. Clinical trials are underway and development of a norovirus vaccine is expected within the next few years. </p>

<p> Farmworkers and their families may experience increased levels of agricultural pesticides in their homes due to both (1) take-home/soil track-in on shoes, clothes and skin, and (2) air infiltration from nearby agriculture fields via agricultural pesticide drift in the vapor phase or adhered to resuspended soil particles. This dissertation estimates the relative contributions o the take-home/soil track-in and air infiltration pathways of agricultural pesticides into homes, as well as identifies the risk factors for increased in-home agricultural pesticide levels for farmworkers and their families living near agriculture fields. Samples of outdoor air, yard soil, and house dust from 21 farmworkers' homes in Yuma County, Arizona were collected and analyzed for a suite of agricultural pesticides. To capture household information, such as behaviors, demographics, and housing structure, a participant questionnaire was administered at the time of the sampling. A pesticide transport model was developed, evaluated, and applied to quantify relative contributions of the air infiltration and the take-home/soil track-in pathways of agricultural pesticides into the house dust of the farmworkers&rsquo; homes. To explore a wide-range of potential risk factors for increased agricultural pesticide levels in the homes, traditional statistical methods and Classification and Regression Tree (CART) analyses were used. The results of this study, found that the air infiltration pathway contributes to over 90% of some agricultural pesticides in the house dust found in the farmworkers&rsquo; homes. In addition, among the influential risk factors for increased in-home agricultural pesticide levels was the home being a closer distance to an agricultural field, as well as the home having carpeted floors, more farmworkers per square footage of the home, and less months of heating and cooling the home. It is suggested that future intervention efforts to reduce in-home agricultural pesticide levels put more emphasis on targeting the air infiltration pathway, and take into consideration relevant risk factors for increased pesticide levels in the home.</p>

The Chinese construction industry is China's third biggest industrial killer. Accidents causation analysis revealed that more than 80% of accidents are caused by unsafe human behaviour. The current research was focused on exploring and examining the factors affecting safety rule violations among Chinese construction workers through four main studies in which a combination of qualitative and quantitative methodologies were used. In the first study, on-site observation and organisational document analysis were conducted in fourteen construction companies to familiarise the author with the research settings and to obtain triangulation evidence for the following studies. It was followed by the second study in which interviews and focus groups were conducted among 97 managers, safety officers and workers in order to explore the factors associated with workers' rule violation. Thematic analysis revealed four main categories of factors, i.e., individual factors, managerial factors, sectoral and labour market factors, and national and cultural factors. The qualitative study was followed by questionnaire surveys (n = 700) to test in a larger management sample the qualitative study's results. Survey results complemented the qualitative study's findings. Based on the obtained results, a fourth study using the Delphi method and the modified G1 method was conducted among 17 experts in order to calculate the importance levels of each factor in influencing workers' rule violation. Although managerial factor was ranked as the most influential factor compared with other categories, some extra-organisational factors and situations were ranked at high positions amongst 24 specific factors. The results suggested that workers' behaviour need to be scrutinised not only within the context of organisational safety management, but also from the particular background and characteristics of Chinese migrant workers, Chinese construction sector, as well as the society and the culture.

<p> Sickle cell disease is a disabling chronic autosomal recessive blood disease characterized by abnormal hemoglobin, pain crises, and frequent emergency department visits. Adherence to hydroxyurea therapy has been shown to improve these patient outcomes. Guided by the theory of comfort, the purpose of this project was to determine if an educational intervention would increase adherence to hydroxyurea therapy in pediatric patients between 2 and 17 years of age recruited from an urban university hospital hematology clinic. The RE-AIM model was used to support the translation of evidence and the change process. An educational video produced by AFLAC was viewed by patients&rsquo; parents 4 weeks after enrollment into this pretest/posttest design project. A total of 22 African-American parent participants completed the 8-item Morisky Medication Adherence Scale at baseline and again at 8 weeks to assess hydroxyurea adherence. The Short Test of Functional Health Literacy in Adults tool was used to assess parents&rsquo; health learning needs; all parents met the adequate literacy level at baseline. Using <i>t</i> test statistics, no statistically significant differences were found pretest to posttest on the Morisky Medication Adherence Scale scores, mean corpuscular hemoglobin, and fetal hemoglobin percentages. Wilcoxon Signed Rank tests showed no significant differences in emergency room visits nor number of pain crisis. Although no significant changes emerged in short-term hematologic findings, emergency room visits, and pain crises, social change in the health care setting was promoted by confirming parents were able to understand education and a high level of hydroxyurea adherence was maintained; literature indicated that long-term adherence to hydroxyurea limits severe attacks.</p>

<p> Women and men&rsquo;s preferences for delivery services in rural Ethiopia Nancy Beam Aims: This study aims to determine the combination of facility-based delivery care attributes preferred by women and men; if gender differences exist in attribute preferences; and key demographic factors associated with attribute preferences. </p><p> <b>Background:</b> Despite programs to promote facility-based delivery, which has been shown to decrease maternal and neonatal mortality, 80% of women in rural Ethiopia deliver at home without a skilled birth attendant. </p><p> A review of the Ethiopian literature on factors associated with delivery location revealed several weaknesses in research methods that need to be addressed. First, research participants were almost exclusively women, although male partners often make decisions about delivery location. Second, most quantitative study designs are similar in content to the Ethiopian Demographic Health Survey, limiting the generation of new knowledge. Third, cultural practices identified in qualitative studies as barriers to facility-based delivery have not been included in quantitative studies. This study addressed these weaknesses by using discrete choice experiment methodology to elicit preferences for delivery service attributes, including support persons in the delivery room, staff training and attitude, cost, distance and transportation availability. </p><p> <b>Methods:</b> A cross-sectional, discrete choice experiment was conducted in 109 randomly selected households in rural Ethiopia in September-October 2015. Women, who were pregnant or who had a child &lt; 2 years old, and their male partners were interviewed. After completing a demographic questionnaire, male and female respondents were asked separately to choose between facility-based scenarios that reflected various attributes for delivering their next baby. Data were analyzed using a multilevel mixed-effects logistic regression model. </p><p> <b>Results:</b> Both women and men preferred health facilities where medications and supplies were available, a support person was allowed in the delivery room, cost was low, and doctors performed the delivery. Women also valued free ambulance service, while men favored nearby facilities with friendly providers. Men are disproportionately involved in making household decisions, including decisions about whether their wives seek health care. Yet, men are often unaware of their partners&rsquo; prenatal care attendance. </p><p> <b>Implications:</b> The Ethiopian government and health facilities could increase facility births in rural areas by responding to families&rsquo; delivery service preferences.</p>

Background Motor Vehicle Crashes (MVCs) are a major cause of morbidity and mortality worldwide. This thesis explores the potential use of large databases of primary care medical records to investigate the epidemiology of MVCs in the United Kingdom and to supplement the data available from national statistics, which are believed to understate both the number of crashes, and the number of injuries which occur as a result. Methods Details of all individuals enrolled in The Health Improvement Network (THIN) database whose primary care records indicated involvement in a MVC were used to calculate a series of summary measures describing the burden and consequences of MVCs. These were compared with data available from police accident reports and from hospital admissions. Data from THIN were used to conduct a series of studies of the impact of health and healthcare-related factors on the risk of involvement in MVCs. Specifically: a case-control study of the impact of modifiable lifestyle factors on the risk of MVC; case-crossover and self-controlled case-series studies of the effect of exposure to prescribed medications on the risk of MVC; a case-control study investigating the impact of disordered sleep on the risk of MVC; a case-control study of the risk of involvement in MVC among individuals with diabetes relative to the general population; and; a cohort study assessing whether there is evidence to suggest that involvement in a MVC may indicate the presence of undiagnosed disease which may impair driving performance. Results The socio-demographic characteristics of individuals involved in MVCs recorded in THIN differ markedly from those recorded in police accident reports and hospital admissions data. There was no evidence of consistent trends in MVC incidence over time in the three data sources. Differences in data collection methodology and the severity and scope of crashes recorded may account for these variations. Evidence was found of an association between having a high Body Mass Index and involvement in MVCs, and between past (but not current) smoking and involvement in MVCs, however the recording of data on lifestyle-related exposures such as smoking and alcohol consumption in the age-groups most likely to be involved in MVCs was poor, complicating interpretation of these results. Current exposure to benzodiazepines and preparations containing opioid analgesics was found to increase the risk of involvement in MVCs, as was longer-term use of non-benzodiazepine hypnotics, selective serotonin reuptake inhibitors and antihistamines. No increased risk of MVC was observed with exposure to beta-blockers or tricyclic antidepressants. Individuals reporting insomnia or snoring to their primary care practitioner were found to be at increased risk of MVC, as were individuals with diagnosed sleep apnoea. This association was independent the use of sedative or antidepressant medications. Individuals with diabetes were not found to be at an increased risk of MVC compared with the general population, and there was no difference in risk between those receiving different forms of treatment. Involvement in a MVC was associated with an increased risk of being diagnosed with cardiac disease in the two years following the crash. Conclusions Current sources of data about MVCs in the UK use different data collection methodologies, none of which is likely to accurately describe the overall burden of MVCs in the population. Primary care data remain a useful resource for those wishing to study the epidemiology of MVCs, but care must be taken to ensure that the uses to which the data are put are appropriate. Studies investigating lifestyle-related exposures are unlikely to produce reliable results as primary care recording of such factors is poor in the age-groups most likely to be involved in MVCs. Primary care data are more useful when studying the time course of pharmacological effects, or the effects of diagnosed illness, and can successfully detect previously observed associations. Primary care data is currently of little use in the study of injuries associated with involvement in MVCs as it is rare for both an injury and its proximate cause to be recorded. The investigation of methods by which this problem might be resolved is an important avenue for future research.

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This thesis draws upon data gathered during research undertaken with a grant from the Resuscitation Council (UK). It explores the use of Automatic External Defibrillators (AEDs) by laypeople, which is known as Public Access Defibrillation (PAD). Whilst an abundance of research has been undertaken about this phenomenon, it has predominately been conducted using quantitative methods; however the data I am using was collected using a qualitative approach. During the research, fifty-three semi-structured interviews were carried out. Most of these were with laypeople who had been trained to use AEDs, and nine involved those who delivered the training. These interviews were conducted at sites typical of those where these devices have been introduced, such as railway stations and airports. The geographical area of these locations covered the East and West Midlands, South and West Yorkshire, Lincolnshire and Essex. The aims of the research were quite broad and included exploring how to make training more realistic, how debriefing and support for those who had used an AED should be organised and how the interviewees perceived the technology inherent in the AED. This thesis reanalyses the data that was collected during that research and focuses on two themes. Firstly, some of the theories of technologies in transition are used to illustrate how AEDs were developed in a laboratory and progressed from that setting to become commonplace in public locations. The actor-network theory is adopted to argue that these technological devices exert an influence on the human actors in the networks that exist within society. Specifically, my analysis is informed by the work of Timmermans (1998; 1999; 1997) whose theories about external chest compressions I have developed and applied to AEDs. They suggest that these devices achieved universality, in part, through the influence of debates and medical protocols. One significant factor was that AEDs allowed for defibrillation to be redefined from a medical, to a first aid procedure. Eventually, using these devices was included in the protocols for first aid and this legitimised their use by laypeople. These theories are observable in the data through the interviewees’ accounts of how they came to accept being trained to use AEDs. The experiences of those who had used an AED during a resuscitation attempt are provided and suggest that these are distressing and unpleasant events. Consequently, a key component of this thesis is a discussion of the necessity to provide psychological debriefing for those who have been involved in these incidents. The findings of this thesis suggest that laypeople who have used an AED usually have questions about the actions they took during the attempted resuscitation and need to address these with someone soon afterwards. Generally, they prefer to discuss these issues with a person who has experience of resuscitation and using a defibrillator. However, the provision of such support is often not well organised and individuals are sometimes not aware of what is available to them. I conclude by suggesting that it is important that those who are asked to use an AED have a clearly identifiable person to contact should they need to discuss any issues which may arise. I argue that the responsibility for ensuring that such mechanisms are in place lies with those who instigate the schemes which place AEDs in these locations. Public access defibrillation is a relatively new concept in the UK and I believe that this thesis makes an important contribution to the body of knowledge relating to this phenomenon.