Stroke is a significant contributor to the global burden of disease in adults. With the risk of recurrent stroke high, preventative medicines aimed at risk factor reduction are the method of choice for addressing the challenge of increased morbidity and mortality and improving patient outcomes. Research in stroke has shown that adherence to medication is problematic and survivors face considerable practical and physical barriers to taking prescribed medicines. Understanding these challenges can inform the development of strategies to improve medication taking behaviour through delivery of interventions in the primary care setting. This thesis aims to identify potential strategies to inform interventions to improve medication taking in stroke. The research: identified key barriers and facilitators of medication adherence for the secondary prevention of stroke - firstly from within the primary care setting and then from the perspective of an online stroke forum; explored the appropriateness of the online forum as a method of data collection for conducting qualitative research compared with a traditional qualitative interview approach; investigated medication taking among community stroke survivors to characterise patients who receive help with medicines and estimate the proportion who have unmet needs and miss medicines; and examined attitudes from across the stroke spectrum towards a novel approach to medication taking for secondary prevention (i.e. fixed-dose combination polypill). Findings showed that survivors face considerable barriers to medicine taking, but that facilitators, particularly the caregiver role, can encourage good medication taking practice. The online forum has potential as a source of data to understand stroke survivors' behaviour, and a novel strategy to taking stroke medicines has promise. These findings enhance current thinking around medicine taking behaviour in stroke and can inform the development of effective interventions to improve medication taking practices and address nonadherence among stroke survivors. Implications for clinical practice are discussed, and recommendations are provided for future research.

The cost of healthcare in the United States has increased due to growing numbers of patients who live with chronic health problems, such as heart disease. The cost of healthcare is compounded by the cost in terms of complications of cardiovascular disease secondary to medication non-adherence. Education about medication use and adherence, safety, and side effects was needed for patients in a cardiovascular unit to improve adherence to medications as prescribed. Results of a health care provider (HCP) and nursing staff needs assessment provided by the site showed the need for improved cardiovascular medication education. The project focused question asked if cardiovascular patient medication education provided to HCPs and nursing staff would be incorporated into practice by the HCPs and nursing staff. The purpose of the project was to improve the education provided to patients by the HCPs and nursing staff. A literature review provided content for the educational program. Strategies to promote adherence and medication safety and a patient education worksheet were presented with guidance on implementation. Post education qualitative results from HCPs and nursing staff showed that the sheet was implemented and helpful with educating cardiovascular patients. This project promotes positive social change by the implementation of a patient education program that may improve patient education and adherence to cardiovascular medications. As a result, improved adherence to medications may reduce patient and healthcare related costs long term.

Background: Diabetes is a common and serious chronic condition. If not well-managed, significant multi-system complications often arise, resulting in increased health care utilization and poor health outcomes. There is considerable evidence that people with diagnosed diabetes are not receiving recommended care. A comprehensive program aimed at improving adherence to recommended care can improve patient outcomes and result in cost-savings. The key aim of this study was to determine whether the long-term receipt of appropriate clinical procedures by patients with type 2 diabetes was associated with higher medical care costs. Methodology: A cohort of 20,288 diagnosed type 2 diabetes patients was identified using physician and hospital records. An analytic file was created by linking information on patient characteristics with utilization of physician and acute care services during a five-year period (1996 to 2001). Adherence to recommended clinical procedures for the assessment of blood glucose, blood pressure and cholesterol levels, as well as retinopathy and nephropathy, were measured during this same five-year period. Subjects were assigned to both a categorical (low, medium and high) and a binary (low and high) adherence group. Physician and acute care resource use was converted to constant 2000 Canadian dollars. Multivariate logistic regression was used to assess the relationship between patient characteristics, including adherence as a categorical variable, and utilization of physician and acute care services. Results: Long-term adherence was suboptimal, with patients receiving just 53% of recommended procedures. Adherence to recommended procedures, however, improved during the five year period. Patient characteristics associated with poor adherence include being male, younger, low socio-economic status, having no diabetes-specific complicating conditions and living in certain geographic areas. Patients with high long-term adherence (receiving 73% of recommended clinical procedures) were 59% more likely to use a high level of physician resources but 22% less likely to use a high level of acute care resources. On the other hand, patients with low adherence (receiving 31% of procedures) were 28% less likely to use a high level of physician resources but 17% more likely to use a high level of acute care resources. The utilization difference related to adherence was particularly noticeable in older adults with higher levels of morbidity. Elderly patients in this low adherence group were more likely to be hospitalized (64.3% vs. 55.8% over the five-year period) and, when they were hospitalized, tended to stay in hospital for longer periods of time (11.9 vs. 6.7 days) than patients in the high adherence group. Conclusion: Improving long-term adherence may result in the avoidance of $4 in acute care costs for every additional $1 in physician costs. If all patients moved into the high adherence category, as much as $3.1 million in annual costs might be avoided across the study sample. If this analysis is applied to all adults with diagnosed diabetes in the province of British Columbia, the annual costs avoided could reach the level of $34.4 million. Systemic changes are required in the provision of primary care to promote long-term adherence to recommended diabetes care.

Background: Diabetes is a common and serious chronic condition. If not well-managed, significant multi-system complications often arise, resulting in increased health care utilization and poor health outcomes. There is considerable evidence that people with diagnosed diabetes are not receiving recommended care. A comprehensive program aimed at improving adherence to recommended care can improve patient outcomes and result in cost-savings. The key aim of this study was to determine whether the long-term receipt of appropriate clinical procedures by patients with type 2 diabetes was associated with higher medical care costs. Methodology: A cohort of 20,288 diagnosed type 2 diabetes patients was identified using physician and hospital records. An analytic file was created by linking information on patient characteristics with utilization of physician and acute care services during a five-year period (1996 to 2001). Adherence to recommended clinical procedures for the assessment of blood glucose, blood pressure and cholesterol levels, as well as retinopathy and nephropathy, were measured during this same five-year period. Subjects were assigned to both a categorical (low, medium and high) and a binary (low and high) adherence group. Physician and acute care resource use was converted to constant 2000 Canadian dollars. Multivariate logistic regression was used to assess the relationship between patient characteristics, including adherence as a categorical variable, and utilization of physician and acute care services. Results: Long-term adherence was suboptimal, with patients receiving just 53% of recommended procedures. Adherence to recommended procedures, however, improved during the five year period. Patient characteristics associated with poor adherence include being male, younger, low socio-economic status, having no diabetes-specific complicating conditions and living in certain geographic areas. Patients with high long-term adherence (receiving 73% of recommended clinical procedures) were 59% more likely to use a high level of physician resources but 22% less likely to use a high level of acute care resources. On the other hand, patients with low adherence (receiving 31% of procedures) were 28% less likely to use a high level of physician resources but 17% more likely to use a high level of acute care resources. The utilization difference related to adherence was particularly noticeable in older adults with higher levels of morbidity. Elderly patients in this low adherence group were more likely to be hospitalized (64.3% vs. 55.8% over the five-year period) and, when they were hospitalized, tended to stay in hospital for longer periods of time (11.9 vs. 6.7 days) than patients in the high adherence group. Conclusion: Improving long-term adherence may result in the avoidance of $4 in acute care costs for every additional $1 in physician costs. If all patients moved into the high adherence category, as much as $3.1 million in annual costs might be avoided across the study sample. If this analysis is applied to all adults with diagnosed diabetes in the province of British Columbia, the annual costs avoided could reach the level of $34.4 million. Systemic changes are required in the provision of primary care to promote long-term adherence to recommended diabetes care.

Le document décrit une synthèse des travaux menés par l’auteur dans le domaine des bétons à hautes performances et de l’adhérence des chaussées. Conduite dans le cadre d’une thèse de doctorat à l’Université de Sherbrooke (Canada), la recherche sur le comportement à la fatigue permet de caractériser les bétons à hautes performances – tant du point de vue des matériaux que des éléments de structure – et de les comparer avec des bétons normaux. L’analyse des durées de vie utilisant des notions fiabilistes permet de calculer des probabilités de rupture, indicateur plus pertinent que la durée de vie moyenne. L’adhérence des chaussées représente ¾ du parcours de recherche de l’auteur, en tant que chercheur puis de responsable d’équipe et de projets. Les domaines abordés vont des facteurs influents de l’adhérence, notamment la microtexture de la chaussée, jusqu’à l’usage de la connaissance de l’adhérence – surtout lorsqu’elle est dégradée – pour avertir le conducteur, en passant par des aspects importants comme l’évolution de l’adhérence sous l’action du trafic et l’harmonisation européenne des méthodes de mesure. Ce cheminement progressif permet de traiter l’adhérence depuis ses aspects cognitifs (compréhension, modélisation) jusqu’aux applications, et de saisir les questions de passage laboratoire/route et de changement d’échelles. Ce parcours de 20 ans a permis à l’auteur de saisir différents aspects de l’animation de la recherche comme le montage de projets, le développement de partenariats – avec un accent fort sur l’ouverture internationale, l’encadrement de chercheurs ou encore la gestion d’un laboratoire. Indépendantes dans un premier temps, ces briques ont été ensuite structurées pour construire une méthodologie de direction de la recherche. Des pistes de recherche pour le futur (4 à 5 ans) sont également identifiées pour combler des lacunes perçues au cours de ce travail de synthèse.

The purpose of this study was to explore the lifelong physical activity (PA) stories of Latinas to determine motives that contribute to exercise adherence behaviors. Using an interview process, life histories were collected from six self-identified PA adherents of Hispanic descent. Three narrative analysis techniques were used to analyze the interviews and the transcript of a follow-up focus group meeting. In the first technique, the Holistic-Content perspective and Labovian transcription were used to identify major themes common in the interviews. Adherence themes that emerged were: 1) culture and family, 2) being pushed, 3) health, 4) role models, and 5) competence. A review of these themes resulted in several suggestions for teaching practitioners: 1) including enjoyment as a criteria for planning activities, 2) focusing on positive reinforcement from teachers and families, 3) providing early opportunities for success, and 4) interacting with strong female role models. A second analysis technique, Lakoff and Johnson's linguistic studies using metaphor to understand one idea in terms of another, yielded the concept of love as health. Study participants frequently used the terms love and addiction in connection with PA. Participants suggested the following as characteristics of healthy love relationships: loyalty, community, positive results, and variety. The term addiction, while not specifically a metaphor, emerged during this process as a powerful exercise adherence motivator. Euphoria and "not feeling right unless I exercise" were cited as primary reasons for adherence behavior. The third technique used was Borman's Symbolic Convergence Theory in which a rhetorical community is formed around a fantasy theme. The theme "perfect body" was identified in the stories as common to four of the participants. Via the media and pop culture, the rhetorical community communicates that a "perfect body" can be achieved with PA and diet. The oppressive gendered message here is that a woman's worth is largely determined by the look of her body, and having the perfect body is the way to success. Facilitating the shift from solely external motivators to a more balanced internal/external set of motivators and from solely negative motivators to positive reasons for exercise adherence is the recommended goal for teaching practitioners.

Ce travail a pour objet d'étude l'évolution de l'adhérence des chaussées routières. Son but est, à l'aide d'essais effectués principalement en laboratoire, de développer un modèle de prédiction de cette évolution, basé sur le modèle de Tang, et tenant compte de la nature et de l'intensité du trafic, du vieillissement du liant et des variations saisonnières. Expérimentalement, on utilise la machine Wehner et Schulze pour distinguer le rôle des poids lourds et des véhicules légers. L'appareil Weatherometer permet d'appliquer un vieillissement accéléré, que l'on compare au vieillissement naturel d'éprouvettes exposées aux intempéries. Enfin, l'influence de la température et des sédiments routiers est étudiée en laboratoire ou sur la piste de glissance du LCPC. En parallèle, des chaussées routières in situ sont suivies dans le temps avec la machine DFTester et la remorque ADHERA. Pour la construction du modèle amélioré, deux voies sont empruntées. Dans la première, un modèle incrémental, intégrant les trois phénomènes, est construit. L'autre voie consiste à simplifier la fonction d'usure du granulat en utilisant un modèle logarithmique. Les modèles permettent de reproduire les résultats de laboratoire, et de prédire les mesures in situ. Outils de compréhension, ils peuvent également permettre à l'ingénieur de choisir la formulation de la couche de roulement, de prévoir l'évolution de l'adhérence avant la construction d'une route, ou de gérer l'entretien de chaussée pendant la durée de service.

Studies have indicated that weight gain, and being overweight, are risk factors for the development of cardiovascular disease. Weight management is particularly intense in cardiac rehabilitation (CR) settings where the majority of participants are medically defined as overweight or obese and often have co-morbid risk factors. CR programs in Canada focus primarily on cardiovascular fitness, but have extended their program interventions to address cardiac risk factor modification, including diet management and weight loss. Health-related research has indicated that on average, CR participants show weight neutrality (no change from baseline weight) upon CR program completion. Prior to this study there was no substantive qualitative data exploring why this occurs. This doctoral study was a concurrent analysis of a larger funded qualitative study that explored the everyday practices of people with heart disease and type 2 diabetes who were participating in one of three large urban CR programs. A total of 33 participants were enrolled in the study (17 men and 16 women). Data was collected through the use of in-depth interviews, an activity journal, and field notes. Data analysis used sociologist Chris Shillings’ work related to body projects and corporeal realism in order to explore themes related to body size, diet management, and weight loss. Study results pointed to the importance of recognizing the role of social practice in health behaviour change, and the role of social discourses in determining how healthy bodies should look and act. Participants described how their social worlds shaped their eating practices, and relayed accounts of attempting to integrate their CR prescription into their daily routines. These findings suggest that a more nuanced approach to CR programming that takes into account the medical and social influences at work on CR participants while they attempt to modify health behaviours, may further inform the development of future CR weight loss and diet programming.

Studies have indicated that weight gain, and being overweight, are risk factors for the development of cardiovascular disease. Weight management is particularly intense in cardiac rehabilitation (CR) settings where the majority of participants are medically defined as overweight or obese and often have co-morbid risk factors. CR programs in Canada focus primarily on cardiovascular fitness, but have extended their program interventions to address cardiac risk factor modification, including diet management and weight loss. Health-related research has indicated that on average, CR participants show weight neutrality (no change from baseline weight) upon CR program completion. Prior to this study there was no substantive qualitative data exploring why this occurs. This doctoral study was a concurrent analysis of a larger funded qualitative study that explored the everyday practices of people with heart disease and type 2 diabetes who were participating in one of three large urban CR programs. A total of 33 participants were enrolled in the study (17 men and 16 women). Data was collected through the use of in-depth interviews, an activity journal, and field notes. Data analysis used sociologist Chris Shillings’ work related to body projects and corporeal realism in order to explore themes related to body size, diet management, and weight loss. Study results pointed to the importance of recognizing the role of social practice in health behaviour change, and the role of social discourses in determining how healthy bodies should look and act. Participants described how their social worlds shaped their eating practices, and relayed accounts of attempting to integrate their CR prescription into their daily routines. These findings suggest that a more nuanced approach to CR programming that takes into account the medical and social influences at work on CR participants while they attempt to modify health behaviours, may further inform the development of future CR weight loss and diet programming.

Probiotics are live microorganisms which when consumed in adequate amounts confer a health benefit upon the host. Commonly associated with the gastrointestinal tract of warm blooded animals, Lactobacillus species are often used as probiotics. Benefits of probiotic Lactobacillus use include improved digestive health, immune modulation, and increased resistance to enteric pathogens. Benefits of probiotic administration to poultry production include improved performance and feed conversion, reduced mortality, and improved food safety due to reduced colonization by human foodborne pathogens. Adherence to intestinal epithelia and persistence in the gastrointestinal tract is antecedent to the realization of benefits of probiotic lactobacilli. Lactobacillus species produce proteins, including fibronectin binding proteins, mucus binding proteins, and surface layer proteins, that associate with host factors and are responsible for bacterial adhesion. In vitro assays based on stable cell lines have been used to investigate adherence of Lactobacillus to epithelial cells. However, there have been no studies using poultry derived epithelial cell lines. In this study, we have developed an assay based on the chicken LMH epithelial cell line to investigate adherence and colonization of Lactobacillus species in poultry. Adherence assays revealed Lactobacillus crispatus ST1, Lactobacillus crispatus JCM 5810, Lactobacillus gallinarum ATCC 33199, and Lactobacillus gallinarum JCM 8782 were able to effectively adhere to the chicken LMH cell line when compared to low-adherent Bacillus subtilis and high-adherent Salmonella controls. Administration of these rifampicin resistant variants of these Lactobacillus cultures to broiler chicks revealed these cultures to transiently colonize the gastrointestinal tract. L. crispatus ST1 and L. gallinarum ATCC 33199 were found to persist more effectively than L. crispatus JCM 5810 and L. gallinarum JCM 8782. These studies of the adherence and colonization of poultry by Lactobacillus cultures are expected to contribute to improved understanding of the functionality of these microorganisms in poultry production.