Approximately 30% of adolescents in the United States have engaged in delinquent acts. Juvenile delinquency is related to the development of Conduct Disorder and other mental health disorders including: Substance Abuse, Attention Deficit Hyperactivity Disorder, Depression and Anxiety. Within the juvenile court system, mental health assessments are utilized in order to identify the complex treatment needs of juvenile offenders; however, implementation of the report recommendations is challenging. This project explored the implementation and adherence of psychological recommendations completed in the Second Judicial Circuit Redeploy Illinois program, a juvenile diversion program. Effectiveness of the psychological assessments conducted in the Redeploy program at reducing commitment to the Illinois Department of Juvenile Justice was evaluated. A process evaluation examined the sample of youth who completed assessments, determined who received reports, and evaluated recommendation adherence, barriers to treatment, and perceived effectiveness of recommendations. Information was collected via reviews of archival data and surveys distributed to legal guardians, probation officers, judges and administrators. An outcome evaluation was completed to determine whether Recommendation Adherence and Program Completion predicted reduced days in detention or commitment to IDJJ within six months following the psychological assessment. Age, ratings of parent and child relationships, and intellectual ability were explored as individual predictors of days in detention and sentencing to IDJJ. Results of the process evaluation indicated that juvenile offenders completing psychological assessments within the Redeploy Illinois program were similar to the national profile of juvenile offenders. Psychological reports were distributed to probation officers, judges and administrators appropriately; however, legal guardians received reports less frequently and indicated that reports were less effective than other stakeholders. Nevertheless, the psychological assessments were successful at completing the intended goals of the Redeploy program. Adherence to recommended interventions was very low for all youth. Barriers to recommendation adherence included lack of social support, unavailable services and feelings that recommendations were inappropriate. Recommendation adherence did not significantly predict the number of days in detention, nor commitments to IDJJ, but successful program completion was a significant predictor. Interpretations of these findings and recommendations were provided to help improve psychological assessments within the Second Judicial Circuit Redeploy Program.

Poor adherence is common in patients with diabetes mellitus and other chronic diseases that require extensive self-management. This behavior has been linked to increased complications, mortality rate, and health care costs. Although much effort has been put into studying the barriers to adherence and ways to improve both patient self-care and clinical outcomes, little success can be observed in the long run. Literature review of studies related to medication adherence in diabetes has shown a lack of uniformity in study parameters and statistical analysis making the juxtaposition of studies difficult and unreliable. Intervention studies in the field have shown general improvement in adherence rate in a short period of time, but rarely making any significant differences in clinical outcomes. Since diabetes mellitus is a chronic disease, it would be important to design studies measuring long term effects of interventions in the future.

Dietary adherence is the degree to which participants follow prescribed dietary protocol. Without measuring adherence, it is not possible to validly measure the effect of the intervention. Assessing adherence allows the investigator to better determine whether the results are due to the diet itself. The overall goal of the analyses presented in this thesis was to assess if dietary adherence was higher on a whole grain versus refined grain provided food protocol with specific prescription for calorie consumption. Eighty-two men and women between the ages of 40-65 were assigned to either a refined or whole grain feeding protocol, using a 3-day rotating menu for 6 weeks. Daily food logs were used to assess adherence to the prescribed diets and calculate total energy consumed and macronutrient content. The first objective was to determine the caloric and macronutrient content of the assigned diets, and to compare whether the reported nutrient content was the same as the provided nutrient content. Overall, the median whole grain group consumption was 45.0 kcal per day more than they were assigned to, and the median refined grain group consumption was 10.5 kcal per day less than assignment. The refined grain diet's macronutrient composition was 52.1% carbohydrate, 19.9% protein, and 28.1% fat, whereas the whole grain group's macronutrient composition was 54.4% carbohydrate, 18.0% protein, and 27.6% fat. Both diets were within the average daily macronutrient recommendations of 50-55% carbohydrate, 15-20% protein, and 25-30% fat. There was a statistically significant difference in the percentage of carbohydrate and protein between groups. The second objective was to determine if two different diets had any effect on deviation from the protocol. Overall, there was an 8.9 kcal/day difference in deviation between the two groups throughout the study. When stratifying by diet level, there was no consistent pattern of deviations from the assigned protocol. On the 2000 kcal diet, those in the refined grain group consumed 184.5 kcals/day more than those in the whole grain group. In contrast on the 2500 kcal diet, the whole grain group consumed 105.0 kcal/day more than the refined grain group, while on the 3000 kcal/day diet, those in the refined grain group consumed slightly more kcals/day on average (12.5kcal/day) than the whole grain group. The study found no consistent difference in caloric consumption between the whole and refined grain groups, as well as no consistent difference in deviations from the assigned diet protocol. These results imply that dietary adherence can be achieved in a provided food whole grains study.

Background - Mobile health (mHealth) interventions to promote medication adherence have shown promise; among patients primarily diagnosed with Coronary Heart Disease (CHD), however, there is a lack of evidence for nurse-led mHealth interventions, in this particular group in Iran. Aim - To refine and evaluate a pre-developed nurse-led mHealth intervention to promote cardiovascular medication adherence in Iranian adult, male and female Cardiac Rehabilitation (CR) outpatients. Methods - A quantitative-dominant mixed methods study was conducted drawing upon the Medical Research Council’s (MRC) Framework on the development and evaluation of complex interventions. Phase 1 comprised of a self-completion CHD patients’ survey (n=123) and three focus groups with cardiac nurses (n=23) within three public university-affiliated hospitals in Tehran, which in turn informed Phase 2 (the exploratory trial phase). The automated Short Message Service (SMS) medication reminder was designed based on the dimensions of adherence suggested by the World Health Organisation (WHO) and Bandura’ Self-efficacy Theory. The intervention was refined according to the findings from Phase 1 and then piloted in an Iranian CR setting. Seventy eight CHD patients who were 18 years or older, and had mobile phone access were recruited and randomised to receive either daily SMS reminders (n=39) or usual care (n=39) for 12 weeks. The primary outcome was the effect on cardiovascular medication adherence as measured by the self-reported Morisky Medication Adherence Scale; secondary outcomes explored the feasibility of the mHealth intervention, intervention effect on medication adherence selfefficacy, cardiac ejection fraction, cardiac functional capacity, hospital readmission/ death rate and health-related quality of life. Patient acceptability was assessed through completion of a post-intervention survey. Results - Feasibility was evidenced by high ownership of mobile phones in CHD patients, high application of SMS messaging, positive patients’ perception about the intervention, suboptimal cardiovascular medication adherence and patients’ high interest in receiving SMS reminders for their medications. Participants in the intervention group showed higher self-reporting of medication adherence compared to the usual care group χ2 (2) = 23.447; P < 0.001. The Relative Risk (RR) was indicated that it was 2.19 times more likely for the control group to be less adherent to their medications than the intervention group (RR = 2.19; 95% Confidence Interval (CI) 1.5 - 3.19). All secondary outcomes improved in the intervention group at the end of the study. Acceptability was evidenced by participants who received the intervention reporting that they perceived the SMS reminders useful. Conclusion - The SMS medication reminder intervention was well accepted and feasible with significantly higher reporting of medication adherence in Iranian CHD patients. Effect sizes were established for use in future follow-up evaluations of the mHealth intervention.

The thesis examines the effectiveness of acquis communautaire on anti-discrimination with a focus on the Roma minority in the EU accession state - Hungary. Therefore, it critically evaluates the European Union’s (EU) competence in terms of monitoring and enforcement of relevant legislation, such as the Race Equality Directive 2000/43/EC (RED), which is central to the research question. The thesis argues that the EU needs to demonstrate a firmer grip on this issue along with a consistent application of its legislation including the RED under the acquis communautaire in order to have a visible impact on the ground. The scenario is compounded by the implementation and enforcement mechanisms of Hungary despite having an elaborate legal and policy framework for minority protection. The doubt on the ‘political will’ of both the EU and Hungary emerged repeatedly throughout the thesis, which signifies the relative weight of the topic. An empirical study conducted through expert interviews in Hungary supplemented the existing data and enabled to identify the ‘causal factors’ behind the implementation and enforcement issues of policy and legislation under the auspices of the RED. The thesis concludes that legislation will prove to be impracticable; unless and until societal dialogue can be established, especially between the minority and the majority at a local level. Thus, there is scope for making recommendations in line with the identified ‘causal factors’ from interdisciplinary perspectives in the context of the competences of both the EU and Hungary.

Background: Celiac Disease (CD) is a chronic, autoimmune disease that prevents individuals from being able to process gluten. When individuals ingest gluten, their digestive system becomes severely damaged, leading to many adverse, health effects. It is, therefore, significantly crucial that individuals with CD adhere to a Gluten-Free diet (GFD). However, the adherence rate is well below optimal in the adult, CD population. Hence, it is crucial to identify and understand the factors that impact their ability to maintain a GFD. Objective: To develop a systematic review that critically appraises and synthesizes evidence on the facilitators and barriers that affect adherence to GFD among the adult population with CD. Data Sources: Ovid Medline, CINAHL, PsychInfo, and Embase were included, using a combination of keywords to retrieve relevant articles. The Inclusion Criteria consisted of empirical studies that focus on Adults with CD. Only English studies were considered. A coding scheme was developed to retrieve uniform information from each of the included studies, including: study design, population characteristics, facilitators and barriers presented, limitations, and a summary of each study. Results: Facilitators and Barriers were organized based on a Social ecological model, derived from the bioecological theory of development, which emphasizes that individuals make choices in their lives based on the impact of various ecological levels that exist. The ecological levels include: System, Community, Organizational, Interpersonal, and Individual. The studies included in this systematic review reported many facilitators and barriers that exist at the different ecological levels, which significantly affect adherence to GFD. Based on the frequency of articles that reported each facilitator and each of the studies’ level of evidence, the most significant facilitators were: increased patient education; celiac association membership; financial compensation/food subsidies; and increased intention/self-regulatory efficacy. When taking into consideration the frequency of articles that reported each barrier along with each of the studies’ level of evidence, the most significant barriers were: restaurant dining/supermarket shopping; poor patient education from practitioner; specific cultural factors; and low intention/motivation to adhere to a GFD. Although other factors have been reported, there was limited evidence to support them due to weak study designs, limited samples, and inconsistencies found across the different studies. It is important to understand that there are many additional facilitators and barriers retrieved in the systematic review that do not have as much evidence to support them. These are discussed in the thesis. Conclusion: Introducing policy changes at a health systems level will have the most influential impact on all the ecological layers in an individual’s life. Based on the magnitude of the results and the level of evidence of each of the studies, improvements to physician-patient communication, patient education interventions, and food subsidies, will create the most significant opportunity to positively impact the remaining ecological levels in one’s life, with the ultimate goal of improving adherence rates to a GFD among adults with CD in Canada. Registration: Prospero registration ID number is CRD42018091854.

This study aimed to compare the acute effects of two independent warm-up (WU) protocols, neuromuscular warm-up (NMWU) and standardized soccer warm-up (STWU), on three soccer-specific performance tests in adolescent male and female soccer players. Substantial evidence exists of NMWU programs reducing Anterior Cruciate Ligament (ACL) injuries, particularly in soccer. Regardless of this reduced risk of injury, NMWU program adherence is low. Enhanced athletic performance has been reported to encourage consistent WU adherence more effectively than injury risk, especially in youth athletes. Therefore this study compared the effects of a NMWU and a STWU on physical performance in youth soccer players to encourage adherence and implementation. Following familiarization with a locally developed NMWU, 35 (11 female, 24 male) student-athletes (mean age: 14.7 yrs) from two high school-based soccer academies completed four sessions over a two week period evaluating the effects of WU on three soccer specific performance tests. Performance tests included T-test (agility), vertical jump (Peak Power Output), and 20-m sprint (acceleration and speed). The first week of testing consisted of NMWU familiarization, Yo-Yo Intermittent Recovery Test Level 1, and the collection of physical characteristics. The second week of testing consisted of two testing sessions, WU protocols were randomly assigned to the testing sessions ahead of time (session 1: STWU; session 2: NMWU) and were completed at the beginning of the session prior to testing. A series of five two-tailed repeated measures ANOVA were conducted to determine significant differences in WU means. The overall group demonstrated a significant increase in Peak Power Output (p=0.001) and agility (p=0.016) following the STWU compared to the NMWU. Neither WU demonstrated a measurable effect on 5m,10m, and 20m times. The findings of this research may have been influenced by the single use of the NMWU which may have limited the NMWU potential to enhance the three soccer-related performance tests. In order to explore the effectiveness of NMWU on performance enhancement as a means of improving its adherence in youth players, further research implementing NMWU over an extended period of weeks or months should be carried out, consistent with studies demonstrating NMWU impact on ACL injury risk in youth and adults. / Graduate

In the course of this work a novel strategy has been developed for linking the adjuvant Escherichia coli heat-labile enterotoxin subunit B (LTB) to Simian Immunodeficiency Virus (SIV) proteins via an antibody bridge and the systemic and mucosal immunogenicity of such SIV-MAb-LTB complexes have been investigated. A short peptide tag, termed Pk, was joined to the 3'-end of the gene coding for LTB and expression studies revealed that the gene product, LTB-Pk, could be efficiently synthesised and secreted from non-pathogenic Vibrio sp.60. Analysis of the functional properties of LTB-Pk demonstrated that LTB-Pk , like native LTB, was a heat-labile oligomer, that could bind to the glycolipid GM1-ganglioside and was immunogenic in vivo. In attempts to purify LTB-Pk for immunisation studies, both hydrophobic and ion-exchange chromatography schedules were analysed, the latter procedure being more efficient. Strategies were developed for joining LTB-Pk to one arm of an anti-Pk MAb, (MAb SV5-P- k) and Pk-linked SIV proteins to the other arm, and such SFV-MAb-LTB complexes bound to GM1 -ganglioside in vitro. Systemic immunisation studies suggested that SIV-MAb-LTB complexes, using recombinant p17 as the target antigen, promoted both humoral and cell- mediated immunity to the recombinant p17. In addition, it was later shown that conjugation of LTB-Pk to recombinant SIV proteins via an antibody bridge, resulted in a more efficent presentation of the recombinant SIV protein to the immune system, than co-administration of LTB-Pk with the recombinant SIV protein. However, intranasal administration of p17-MAb-LTB complexes did not induce immunity to recombinant p17. Subsequently it was shown that the recombinant p17 was highly susceptible to mucosal degradation, suggesting the poor mucosal immunogenicity of p17-MAb-LTB complexes may be related to the instability of recombinant p17 in the mucosal environment. Further investigations into the stability of other recombinant SIV proteins in the mucosa, revealed that recombinant p27 was more resilient to mucosal degradation. p27-MAb-LTB complexes were constructed and initial intranasal immunisation studies revealed that both systemic and cell-mediated immunity to recombinant p27, could be induced following intranasal administration. Furthermore, mucosal immunity to recombinant p27 was evident in the lungs of vaccinated mice, with anti-recombinant p27 IgG-secreting cells predominating.

Probiotics are living microorganisms, which contribute to health improvement. The bacteria of the genus Bifidobacterium are one of the most commonly used probiotics. These bacteria are naturally occurring especially in the digestive tract of mammals. They affect the digestive process by helping to optimize the composition of the intestinal microbiota. The probiotic bacteria are expected to survive in the digestive tract and to be able to colonize the intestinal mucosa. The aim of this diploma thesis was to test bifidobacteria of different origin for certain functional properties. Three strains of bifidobacteria were selected: Bifidobacterium animalis ssp. lactis DAN (isolated from Danone yoghurt), Bifidobacterium bifidum JKM (isolated from infant feces) and Bifidobacterium longum ssp. suis 5/9 (isolated from feces of a calf); and tested in vitro a in vivo. The ability to survive in simulated conditions of digestive tract was tested. The bifidobacteria were exposed to low pH and bile salts. All the strains survived the conditions in unaltered amount till the end of the test. Autoaggregation was observed as well. The strain Bifidobacterium animalis ssp. lactis DAN showed average autoaggregation only 7,69 %. The other two strains had average autoaggregation 16,10 % and 79,05 %. The autoaggregation correlated with adherence. Adherence was tested on intestinal cell lines HT-29, Caco-2 and HT29-MTX, which differed in their ability to produce mucin. The strain Bifidobacterium bifidum JKM showed the best ability to adhere to intestinal cells among all the tested bifidobacteria. They best adhered to Caco-2 cells. Further, it was necessary to determine if the in vitro study is in correlation with in vivo testing and the bifidobacteria strain with the best ability to adhere will survive in the digestive tract of adult volunteers for the longest time. Rifampicin resistant variants of tested bacteria were given to adult volunteers to distinguish the introduced bifidobacteria and the bifidobacteria naturally occurring in intestine. All the tested bacteria survived the passage through the digestive tract in large numbers (106 a 107 KTJ/g), the bacteria were not detected 12th day after the introduction. None of the strains is able to permanently colonize the colon of the volunteers. The hypothesis was not confirmed that the most adherent strain in the digestive tract will survive the longest.

Phenylketonuria is a rare genetic disorder that causes cognitive impairment unless treated with a strict, protein-restricted diet. Due to the challenges of treatment adherence, caring for a child with PKU may affect parental wellbeing, and many children and adolescents have poor metabolic control. The overall aim of the thesis was to examine influences on parental wellbeing and treatment adherence. Paper 1 is a systematic literature review of the demographic and psychosocial influences on blood phenylalanine concentration for children and adolescents with PKU. The aim was to identify factors that were robustly linked with metabolic control and could potentially be used to inform clinical practice. Findings from 29 identified studies indicated that whilst a number of demographic and psychosocial factors were related to metabolic control, the most reproducible association was with child age. Quality assessment of the studies indicated some methodological limitations, and a paucity of research in some areas highlighted the need for further research. The limitations of the evidence-base, clinical implications, and directions for future research are discussed. Paper 2 presents an investigation of the psychological impact of parenting a child with PKU, the determinants of parental wellbeing, and the association between parental wellbeing and treatment adherence. Forty-six caregivers of children with PKU completed questionnaires examining psychological distress, parenting stress related to caring for a child with an illness, resilience, perceived social support, and child dependency. The proportion of blood phenylalanine concentrations within target range in the preceding year was used a measure of treatment adherence. Results showed that more than half of caregivers had clinical levels of psychological distress, which was predicted by their parenting stress and resilience. Whilst treatment adherence was not associated with parental distress, it was predicted by child age and caregiver perceived support from family. The limitations of the study, implications for clinical practice, and future research directions are discussed. Paper 3 provides a critical evaluation of Papers 1 and 2 and a personal reflection of the research process.