The implementation of automatic transit data collection via Automatic Vehicle Location (AVL) and Automatic Passenger Counting (APC) systems provides an opportunity to create large, detailed datasets of transit operations. These datasets are valuable because they provide an opportunity to evaluate and optimize transit operations using methods that were previously infeasible and without the need for expensive manual data collection. This thesis develops a methodology to utilize data collected by typical AVL/APC system installations in order to (a) develop advanced performance measures to quantify schedule adherence and (b) automatically determine the causes of poor schedule adherence. The methodology addresses the difficulty that many small to medium sized transit agencies have in utilizing the data being collected by proposing a methodology that can be automated, thereby reducing resource and expertise requirements and allowing the data to be more effectively utilized. The ultimate output of the proposed methodology includes the following: 1. A ranked list of routes by direction (for a given time period) that identifies routes with the poorest schedule adherence performance. 2. Performance measures within any given route, direction, and time period that identify which timepoints are contributing most to poor schedule adherence. 3. Statistics indicating identified causes of poor schedule adherence at individual timepoints. 4. A visualization aid to be used in conjunction with the cause statistics generated in Step 3 in order to develop an effective strategy for improving schedule adherence issues. With this information, transit agencies will be able to act proactively to improve their transit system, rather than wait until they discover problems on their own or hear complaints from passengers and drivers. The methodology is tested and demonstrated through application to AVL/APC system data from Grand River Transit, a public transit agency serving Waterloo Region in Ontario, Canada.

Some pathogenic bacteria including Haemophilus influenzae and Neisseria meningitides produce a protease called IgA1 protease to impair a major antibody, immunoglobulin A1 (IgA1), on human mucosal surfaces. The iga mRNA is initially translated into a precursor containing four distinct domains: a 31-amino acids signal peptide which leads the precursor to the periplasmic space, an 105-kDa protease domain which cleaves host IgA1 molecule, a £]-domain responsible for autotransportation of the protease domain, and a short linker between the protease and the £]-domains. The autotransporter £]-domain can be further divided into three subdomains in Neisseria protease: an extracellular linking region £\-protein and a membrane-embedded £]-core, between which there is a distinguished sequence called surface region. The hydrolytic function of the protease and the transporter role of £]-core had been studied extensively, but the £\-protein and the surface regions were less defined, or had their role characterized. Thus this study is designed to reveal the possible pathogenic functions of the £\-protein and the surface region in bacterial adherence to human cell surfaces. To complete this project, recombinant £\-protein and the surface region were expressed in IgA1 protease-negative E. coli strain (UT5600) respectively and purified to homogeneity. These recombinant proteins were used in cellular assays for bacterial adhesion on human lung cancer cell (A549). Four different invasive strains of pathogenic bacteria (IgA1 protease-positive or negative), were recruited in adherence assays to determine the effect of the purified £\-protein and the surface region on bacterial adherence to A549 cells. Results showed that the both £\-protein and the surface region played a role in bacterial adherence in a species-dependent manner.

SAMMANFATTNING Sjuksköterskan tillämpar omvårdnadsprocessen genom att observera, värdera, prioritera, dokumentera och vid behov åtgärda och hantera förändringar i allmäntillståndet, samt motverka komplikationer i samband med sjukdom, vård och behandling. Andningsfrekvens (AF) är den vitalparameter som först förändras och signalerar en förändring i allmäntillståndet. Vid de flesta hjärtstopp på sjukhus finns tecken till försämring hos patienten redan några timmar eller upp till ett dygn före.  Syftet var att undersöka sjuksköterskans inställning och följsamhet till att mäta och bedöma AF hos akuta sjuka patienter, för att tidigt upptäcka en försämring i patientens hälsotillstånd. Genom en litteraturstudie framkom fyra teman. Rutiners betydelse, sjuksköterskans inställning till AF och varför den inte mättes, värdet av förändringsarbete samt möjliga arbetssätt för att undvika vårdskador. Rutiner för mätning av AF, olika poängsystem och mätmallar för bedömning av vitalparametrar, påverkade antalet mätningar och registreringar av AF. Den enskilda sjuksköterskans inställning inverkade på mätningen och bedömningen av AF. Flera anledningar till varför AF inte mättes fanns. Studier visade att förändringsarbete och implementering av nya arbetssätt var ett komplext område, insatser krävdes inom flera områden på olika nivåer. Vårdskador och plötslig oväntad död minskade när nya rutiner och arbetssätt kombinerades med utbildning, uppföljning och återkoppling till personalen. AF är en viktig vitalparameter. Används inte den kunskapen för att hitta patienter på väg att försämras, riskerar patienterna att drabbas av vårdskador. Ett utbildningsbehov finns, den senaste forskningen har påvisat att rätt genomförd implementering av övervakningsrutiner och förändrat arbetssätt kan ge ett bra utfall i minskat antal vårdskador och oförutsedd död. / ABSTRACT The nurse applies the nursing process by observing, evaluating, prioritising, documenting and when necessary manage changes in the condition of the patient, and to prevent complications associated with disease, care and treatment. Respiratory Rate (RR) is the vital sign that first changes and signals changes in a patient’s condition. In most cardiac arrests there are signs of deterioration of the patient a few hours up to a day before the event.    The aim of this study was to investigate the nurse´s attitude and adherence to measure and assess RR in acutely ill patients, for an early detection of deterioration in the patient's state of health. Through a literature study four themes were emerged. The importance of guidelines, the nurses' attitude and why the RR was not measured, the value of change of management and possible ways to avoid injuries. Guidelines for the measurement of RR, different scoring systems and observations charts for the assessment of vital signs all affected the measuring and scorings of RR. The individual nurse's attitude affected the measurement and assessment of RR. Several reasons why RR was not measured were found. The studies showed that the process of change and implementation of new ways of working is a complex, and efforts were needed in several areas and at different levels. Care injuries and sudden unexpected deaths decreased when new routines and working procedures were combined with training, monitoring and feedback to the staff.   Research shows that RR is an important vital sign. If this knowledge is not used to find patients about to deteriorate, these patients risk suffering from permanent health effects. There is a need for significant training in this area and recent research has shown that a correct implementation of the procedures provide a good outcome in a decreased number of medical injuries and unexpected death

Objective: To examine reasons why Multiple Sclerosis (MS) patients may not be adherent to disease-modifying therapies (DMTs). Also, to determine patient perceptions of MS as a disease and DMTs as a source of treatment, and compare these between patients with prior DMT experience and those who were DMT-naïve. Finally, to assess the level of MS symptoms reported in patients taking DMTs, and compare these between DMT users and non-users. Methods: Patients with MS who were affiliated with a regional health plan at any point between January 2005 and December 2010 were asked to fill out a survey, the Multiple Sclerosis Medication Questionnaire (MSMQ). For study purposes, non-adherence was defined as missing any doses in the previous 28 days by the patient. In addition, the MSMQ examined reasons why MS patients do not initiate or discontinue DMT use. For statistical analyses, chi-square tests were performed to detect differences and t-tests and Mann-Whitney U tests to confirm the results. Results: A total of 197 surveys were returned, of which 105 (53.3%) patients were currently on a DMT. Thirty-two (30.5%) of the DMT users were considered non-adherent. Of the non-adherent respondents, the most frequent reason for non-adherence that was at least moderately important was being "too busy" (n=13/29, 44.8%). Amongst patients who were not using a DMT, the most common barrier to DMT use was related to possible side effects of treatment (n=46/79, 58.2%). Analyzing the statements regarding barriers to DMTs revealed significant differences in the proportion of agreement regarding physician's lack of advocacy for DMT use between DMT-naïve patients and those who discontinued DMT use (44.7% vs. 17.1%, respectively, p[less than]0.01), as well as for dislike for using needles (24.3% vs. 46.3%, respectively, p=0.043). In terms of MS symptoms, patients using a DMT generally reported the symptoms posed less of a problem, although significant differences were not seen in chi-square analyses. Conclusion: The injectable nature of most DMTs seems to cause varying degrees of discomfort in MS patients, which may contribute to non-adherence. Reasons given by MS patients for DMT non-adherence in the MSMQ mirror the literature regarding this topic. MS patients who are not currently on DMT may not seek or remain on treatment for various reasons. It appears certain perceptions regarding MS and DMTs are associated with potential DMT use. / text

Physical activity reduces the risk for disease, improves overall health, and quality of life. Group exercise classes are large contributors for meeting physical activity recommendations. Improving long-term adherence to group exercise classes is essential in order to receive health and fitness benefits. Many contributing factors affect adherence rates including the role of the instructor. The instructor has great influence over the decision to return to a group exercise class. It is important to find out what qualities and characteristics are preferred among those who take classes to increase long-term adherence. Another important factor relating to adherence is body type, appearance and attractiveness of the instructor. These factors have been influential in other areas including performance enhancement consulting, counseling, teacher ratings, and willingness to accept health advice. However, little research has been done to determine if body type, appearance and attractiveness influence adherence to group exercise classes. Identifying if there are stereotypes associated with group exercise instructors will provide the opportunity to educate participants and improve the professional development of instructors. The purpose of this study is to determine the relationship between participants' perceptions of group exercise leaders and adherence to group exercise classes. Business cards will be distributed to participants after their exercise class, which will contain the web address to the survey. Participants will also have the opportunity to fill out a paper and pencil version of the survey if that is more convenient. The survey will be posted on surveymonkey.com. Flyers with the web address will also be posted around the facilities to promote the survey. Results showed that participants did not prefer significant differences in fatness and muscularity of the instructor nor were they related to motivation, effort, attendance, willingness to accept health information from the instructor, or perceived attractiveness. However, perceived attractiveness was related to attendance. Results also showed that participants preferred to be less fat and more muscular, similar to that of the current instructor body type, indicating that participants desired to have a physique similar to that of the instructor. Although, fatness and muscularity of the instructor were not associated with motivation or adherence to group exercise class, instructional quality was associated with these outcomes. It was found that instructional quality is more important to participants of a group exercise class than body type. Instructional quality was associated with motivation, effort, attendance, and willingness to accept health information. This demonstrates the importance of professional development of instructors. Results from the current study support that body type of the instructor is associated less with different psychosocial outcomes than instructional quality.

The objective of this study was to determine the influence of child and caregiver characteristics on asthma outcomes in Hispanic children. Specific research objectives of the study were to: (1) to asses the relative influence of family characteristics, caregiver level of education, asthma severity, insurance status and acculturation, on asthma outcomes in Hispanic children; (2) to asses the direct and indirect influence of acculturation on asthma outcomes in Hispanic children, while controlling for other variables; (3) to determine the relative influence of familial characteristics, parental level of education, asthma severity, insurance status and acculturation, as they predict utilization of asthma services. The Children's Health Survey for asthma, the abbreviated Multidimensional Acculturation Scale and components of the Children's Medicaid Managed Care Questionnaire were administered during a one time visit with Hispanic caregiver's of children with asthma in a primary care setting. The primary care setting was either a local pediatrician office in Hillsborough County or the local Hillsborough County Health Department. These facilities provide primary care for local residents of the county. The interviews were conducted to identify the relative influence of barriers to asthma outcomes in this at risk population. A sample of one hundred seventy eight caregivers of Hispanic children with asthma identified significant findings that have a profound effect on pediatric asthma outcomes. Findings suggest that factors such as caregiver age and asthma severity have a negative effect on asthma outcomes in Hispanic children. This study found that advanced caregiver age was associated with poorer healthcare outcomes. Acculturation was not found to be significantly associated with asthma outcomes, directly or indirectly even with use of service utilization as a mediator. In this subject sample the level of acculturation of the caregiver does not impact health care outcomes of the child. This study showed that asthma severity and acculturation significantly impacted service utilization. Children with higher asthma severity scores were found to utilize more services. Finally, acculturation was found to have a significant impact on service utilization. The more acculturated caregivers utilized more services than less acculturated caregivers.

Introduction: A protocol for management of sedation and pain for mechanically ventilated patients at Flagstaff Medical Center (FMC) was implemented in August 2013. It was unknown whether the protocol is being adhered to or whether it has had an impact on patient outcomes. Objectives: To develop an audit and feedback mechanism to monitor adherence to sedation protocol at FMC and determine whether the protocol has impacted patient outcomes. Methods: A retrospective manual chart review was conducted including all mechanically ventilated adult patients for four, one-month periods: 1) pre-protocol; and 2) one month, 3) six months, and 4) 12 months post-protocol implementation. Results: 132 total patients were included (32 pre; 100 post-protocol). Mean weighted adherence score for post-protocol study groups were 5.0±0.6, 5.0±0.7, and 5.2±0.7 (p=0.926) out of ten. Time of mechanical ventilation (p=0.003) and hospital length of stay (LOS) (p=0.023) were reduced post (56±58h; 9.8±7.9days) vs. pre-protocol (90±67h; 13±7days). The adherence score was weakly correlated with hospital LOS but not time of mechanical ventilation. Conclusion: This project demonstrates improvements in patient outcomes from utilization of a sedation protocol. However, this project also highlights several challenges associated with the monitoring of protocol adherence. A lack of audit and feedback may be a factor in the observed unchanged adherence over time. Both research and monitoring activities are impaired by EHR systems that do not allow for the easy extraction of data. Ensuring that adequate audit and feedback strategies are designed and available prior to implementation of new protocols is an essential step in planning the implementation of a new protocol.

Bakgrund: Bristande följsamhet till behandling leder till sämre behandlingsresultat och står för en stor kostnad för samhället. Individens egen kunskap, erfarenhet och tro på området har betydelse för de beslut denne fattar rörande sin behandling. Syfte: Litteraturstudiens syfte var att belysa patientens syn på mediciner, medicinering och livsstilsförändringar. Metod: Studien baserades på 17 vetenskapliga artiklar som analyserades med hjälp av kvalitativ innehållsanalys. Resultat: Patienternas syn på sina mediciner berodde på faktorer som sjukdomsacceptans, bedömning av medicinerna samt tillgång till och syn på information. När det gäller synen på livsstilsförändringar så var motivation till förändring den avgörande faktorn. Diskussion: Sjukdomsacceptans var en viktig faktor när patienterna fattade beslut om följsamhet till behandling och frånvaron av symtom kunde leda till sjukdomsförnekelse. Rädsla för negativa effekter hade stor betydelse för bedömningen av medicinerna. Livsstilsförändringar påverkade identiteten kraftigare än medicinering och upplevdes därför svårare att vara adherent till. Slutsats: Att få tillgång till patienternas åsikter på området är en grundläggande faktor för att kunna få till stånd en dialog om behandlingen.

Background Stroke is a serious condition that can have significant impact on an individual’s health and is a significant burden on public health and public finances. Secondary preventive drug treatment after stroke is important for decreasing the risk of recurrent strokes. Non-adherence to drug treatment hampers the treatment effect, especially in long-term preventive treatments. The aim of this thesis was to study the use of secondary preventive drugs after stroke among Swedish stroke patients in terms of inequalities in implementation in clinical practice and patient adherence to treatment over time. Methods Riks-Stroke, the Swedish stroke register, was used to sample stroke patients and as a source of information on background characteristics and medical and health care-related information including information on prescribed preventive drugs. The patients that were included had a stroke between 2004 and 2012. Individual patient data on prescriptions filled in Swedish pharmacies were retrieved from the Swedish Prescribed Drug Register and used to estimate patient adherence to drug treatment. Data on education, income, and country of birth were included from the LISA database at Statistics Sweden. A questionnaire survey was used to collect information about patients’ perceptions about stroke, beliefs about medicines, and self-reported adherence. Results Results showed that a larger proportion of men than women were prescribed statins and warfarin after stroke. There was also a social stratification in the prescribing of statins. Patients with higher income and a higher level of education were more likely to be prescribed a statin compared to patients with low income and low level of education. Statins were also more often prescribed to patients born in Nordic countries, Europe, or outside of Europe compared to patients born in Sweden. Primary non-adherence (not continuing treatment at all within 4 months of discharge from hospital) was low for preventive drug treatment after stroke. Data on filled prescriptions, however, indicated that the proportion of patients who continued to use the drugs declined during the first 2 years after stroke. For most drugs, refill adherence in drug treatment was associated with female sex, good self-rated health, and living in institutions and (for antihypertensive drugs and statins) having used the drug before the stroke. For statins and warfarin, a first-ever stroke was also associated with continuous drug use. Self-reported adherence 3 months after stroke also showed associations with patients’ personal beliefs about medicines; non-adherent patients scored higher on negative beliefs and lower on positive beliefs about medicines. Conclusion Inequalities between men and women and between different socioeconomic groups were found in the prescribing of secondary preventive drugs after stroke. Only a small proportion of Swedish stroke patients did not continue treatment after discharge from hospital, but the proportion of non-adherent patients increased over time. Poor adherence to preventive drug treatment after stroke is a public health problem, and improving adherence to drug treatment requires consideration of patients’ personal beliefs and perceptions about drugs.

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