Doctor of Philosophy

dissertationQuality nursing home care is a national health concern. Projections of increasing residency rates are coupled with growing concern about nursing home staff capacity and ability to provide quality care. The Institute of Medicine Committee of the Future Health Care Workforce for Older Americans suggests that efforts are needed toward improving nursing home workforce skill. Nurses and certified nursing assistants (CNAs) comprise the majority of the nursing home workforce; CNAs provide 80% of resident care. Despite their significant role as direct caregivers, little is known about nurse-CNA interactional processes, including how they communicate. This relative lack of existing information suggested a need for better understanding of even fundamental communication processes from nurse and CNA perspectives. A grounded theory approach guided this study to gain understanding of nurse-CNA communication processes and factors that influence the processes from the perspective of nurses and CNAs when providing direct care to nursing home residents. Goffman's dramaturgical concept of front- and back-stages, supported by the premises of symbolic interactionism, provided an analytical framework for exploring nurse-CNA communication processes in the complex context of the nursing home setting. Data were obtained from observation, shadowing, and interviews of nurses and CNAs on two ~ 40-bed long-term care units in a nursing home. Systematic procedures 13 for inductive data analysis suggested that nurse-CNA communication processes were guided by four "rules of performance": (1) maintaining information flow, (2) following procedure, (3) fostering collegiality, and (4) showing respect. Nurses and CNAs communicated as opportunity arose in the midst of resident care and described their communication processes in relation to efficiency of care that was affected by the presence or absence of cooperation, initiative, and reciprocity. Role ambiguity stemmed from nurse-CNA hierarchical position associated with delegation and supervision; contextual ambiguity resulted from the dual purpose of the nursing home as a health care institution and the resident's "home." The interplay of "rules of performance" on the front- and back-stages of direct care should be considered in the development of contextually applicable policy and practice strategies that are relevant to nurses and CNAs providing care to nursing home residents

Reducing the Decline in Physical Activity during Pregnancy: A Systematic Review of Behaviour Change Interventions

Purpose: Physical activity (PA) typically declines throughout pregnancy. Low levels of PA are associated with excessive weight gain and subsequently increase risk of pre-eclampsia, gestational diabetes mellitus, hypertension disorders, delivery by caesarean section and stillbirth. Systematic reviews on PA during pregnancy have not explored the efficacy of behaviour change techniques or related theory in altering PA behaviour. This systematic review evaluated the content of PA interventions to reduce the decline of PA in pregnant women with a specific emphasis on the behaviour change techniques employed to elicit this change. Search and Review Methodology: Literature searches were conducted in eight databases. Strict inclusion and exclusion criteria were employed. Two reviewers independently evaluated each intervention using the behaviour change techniques (BCT) taxonomy to identify the specific behaviour change techniques employed. Two reviewers independently assessed the risk of bias using the guidelines from the Cochrane Collaboration. Overall quality was determined using the GRADE approach. Findings: A total of 1140 potentially eligible papers were identified from which 14 studies were selected for inclusion. Interventions included counselling (n = 6), structured exercise (n = 6) and education (n = 2). Common behaviour change techniques employed in these studies were goal setting and planning, feedback, repetition and substitution, shaping knowledge and comparison of behaviours. Regular face-to-face meetings were also commonly employed. PA change over time in intervention groups ranged from increases of 28% to decreases of 25%. In 8 out of 10 studies, which provided adequate data, participants in the intervention group were more physically active post intervention than controls. Conclusions and Implications: Physical activity interventions incorporating behaviour change techniques help reduce the decline in PA throughout pregnancy. Range of behaviour change techniques can be implemented to reduce this decline including goals and planning, shaping knowledge and comparison of outcomes. A lack of high quality interventions hampers conclusions of intervention effectiveness

Stalled scale-up of opioid agonist therapies for HIV prevention in Kazakhstan: history, policy, and recommendations for change

HIV incidence and mortality are increasing in Eastern Europe and Central Asia and are concentrated in people who inject drugs. Maintenance with opioid agonist therapies (OAT) like methadone or buprenorphine is the best treatment for opioid use disorder and a key HIV-prevention strategy in the region. In Kazakhstan, the scale-up of methadone has been minimal since methadone’s introduction in 2008 and has been supported through international charitable organizations. As the Republic of Kazakhstan is designated to assume financial and administrative oversight of OAT, legislative gains can ensure treatment continuity and scale-up. Here, we review legislative barriers to OAT scale-up in Kazakhstan using an implementation science lens. We review legislative, political, and cultural barriers that undermine the efficient distribution and allocation of medications and impose burdensome clinical and administrative demands on patients and clinicians. Legislative reform is required to support further OAT expansion. We therefore provide policy recommendations to overcome these barriers to increase access to this life-saving, life-prolonging, evidence-based medical treatment. Minimally, these include increased numbers of clinical sites and patients at these sites; re-engineering OAT delivery across the country and directly to patients; introducing newer formulations of OAT; and creating an open bidding process to procure treatment medications

Virulence characteristics of hcp (+) Campylobacter jejuni and Campylobacter coli isolates from retail chicken.

BACKGROUND: Recently the Type VI secretion system (T6SS), which can play a significant role in bacterial survival and pathogenesis, was reported in Campylobacter spp., having the hcp gene as a key component. METHODS: Campylobacteriosis is associated with the consumption of infected chicken meat. Our study aimed to explore the presence of T6SS in C. jejuni (n = 59) and C. coli (n = 57) isolates, from retail raw chicken and to investigate their pathogenic potential. The hcp gene was used as an indicator for the T6SS presence. RESULTS: Using multiplex PCR we have identified a significantly higher prevalence of hcp in C. coli isolates (56.1%) than in C. jejuni (28.8%) and AFLP analysis of the isolates showed a high degree of genetic similarity between the isolates carrying the hcp gene. Genome sequencing data showed that 84.3% of the C. coli and 93.7% of the C. jejuni isolates had all 13 T6SS open reading frames. Moreover, the virulence characteristics of hcp + isolates, including motility and the ability to invade human intestinal epithelial cells in vitro, were significantly greater than in the control strain C. jejuni 12502; a human isolate which is hcp positive. CONCLUSION: Overall, it was discovered that hcp (+) C. coli and C. jejuni isolated from retail chicken isolates posses genetic and phenotypic properties associated with enhanced virulence. However, since human infections with C. coli are significantly less frequent than those of C. jejuni, the relationship between virulence factors and pathogenesis requires further study

Prescribers\u27 Satisfaction with Delivering Medications for Opioid Use Disorder

BACKGROUND: Expanding access to medications for opioid use disorder (MOUD), such as buprenorphine and extended release (XR) naltrexone, is critical to addressing the US opioid epidemic, but little is known about prescriber satisfaction with delivering these two types of MOUD. The current study describes the satisfaction of prescribers delivering buprenorphine and XR-naltrexone while examining whether satisfaction is associated with current patient census and organizational environment. METHODS: As part of a cluster randomized clinical trial (RCT) focused on expanding access to medication for opioid use disorder, 41 MOUD prescribers in Florida, Ohio, and Wisconsin completed a web-based survey. The survey included measures of prescriber satisfaction with delivering buprenorphine treatment and XR-naltrexone. In addition, the survey measured several prescriber characteristics and their perceptions of the organizational environment. RESULTS: Prescribers were generally satisfied with their work in delivering these two types of MOUD. Prescribers reporting a greater number of patients (r = .46, p = .006), those who would recommend the center to others (r = .56, p \u3c .001), and those reporting positive relationships with staff (r = .56, p \u3c .001) reported significantly greater overall satisfaction with delivering buprenorphine treatment. Prescribers who more strongly endorsed feeling overburdened reported lower overall buprenorphine satisfaction (r = -.37, p = .02). None of the prescriber characteristics or perceptions of the organizational environment were significantly associated with overall satisfaction with delivering XR-naltrexone treatment. CONCLUSIONS: The generally high levels of satisfaction with both types of MOUD is notable given that prescriber dissatisfaction can lead to turnover and impact intentions to leave the profession. Future research should continue to explore the prescriber characteristics and organizational factors associated with satisfaction in providing different types of MOUD. REGISTRATION: ClinicalTrials.gov. NCT02926482. Date of registration: September 9, 2016. https://clinicaltrials.gov/ct2/show/NCT02926482

Test of a Workforce Development Intervention to Expand Opioid Use Disorder Treatment Pharmacotherapy Prescribers: Protocol for a Cluster Randomized Trial

Background: Overdoses due to non-medical use of prescription opioids and other opiates have become the leading cause of accidental deaths in the USA. Buprenorphine and extended-release naltrexone are key evidence-based pharmacotherapies available to addiction treatment providers to address opioid use disorder (OUD) and prevent overdose deaths. Treatment organizations’ efforts to provide these pharmacotherapies have, however, been stymied by limited success in recruiting providers (physicians, nurse practitioners, and physician assistants) to prescribe these medications. Historically, the addiction treatment field has not attracted physicians, and many barriers to implementing OUD pharmacotherapy exist, ranging from lack of confidence in treating OUD patients to concerns regarding reimbursement. Throughout the USA, the prevalence of OUD far exceeds the capacity of the OUD pharmacotherapy treatment system. Poor access to OUD pharmacotherapy prescribers has become a workforce development need for the addiction treatment field and a significant health issue. Methods: This cluster randomized controlled trial (RCT) is designed to increase buprenorphine and extended-release naltrexone treatment capacity for OUD. The implementation intervention to be tested is a bundle of OUD pharmacotherapy capacity building practices called the Prescriber Recruitment Bundle (PRB), which was developed and piloted in a previous statewide buprenorphine implementation study. For this cluster RCT, organizational sites will be recruited and then randomized into one of two arms: (1) control, with treatment as usual and access to a website with PRB resources, or (2) intervention, with organizations implementing the PRB using the Network for the Improvement of Addiction Treatment organizational change model over a 24-month intervention period and a 10-month sustainability period. The primary treatment outcomes for each organizational site are self-reported monthly counts of buprenorphine slots, extended-release naltrexone capacity, number of buprenorphine patients, and number of extended-release naltrexone patients. This trial will be conducted in Florida, Ohio, and Wisconsin, resulting in 35 sites in each arm, for a total sample size of 70 organizations. Discussion: This study addresses three issues of substantial public health significance: (1) the pressing opioid misuse epidemic, (2) the low uptake of OUD treatment pharmacotherapies, and (3) the need to increase prescriber participation in the addiction treatment workforce. Trial Registration: ClinicalTrials.gov NCT02926482

The Spatial Distribution of Dust and Stellar Emission of the Magellanic Clouds

We study the emission by dust and stars in the Large and Small Magellanic Clouds, a pair of low-metallicity nearby galaxies, as traced by their spatially resolved spectral energy distributions (SEDs). This project combines Herschel Space Observatory PACS and SPIRE far-infrared photometry with other data at infrared and optical wavelengths. We build maps of dust and stellar luminosity and mass of both Magellanic Clouds, and analyze the spatial distribution of dust/stellar luminosity and mass ratios. These ratios vary considerably throughout the galaxies, generally between the range $0.01\leq L_{\rm dust}/L_\ast\leq 0.6$ and $10^{-4}\leq M_{\rm dust}/M_\ast\leq 4\times10^{-3}$. We observe that the dust/stellar ratios depend on the interstellar medium (ISM) environment, such as the distance from currently or previously star-forming regions, and on the intensity of the interstellar radiation field (ISRF). In addition, we construct star formation rate (SFR) maps, and find that the SFR is correlated with the dust/stellar luminosity and dust temperature in both galaxies, demonstrating the relation between star formation, dust emission and heating, though these correlations exhibit substantial scatter.Comment: 15 pages, 18 figures; ApJ, in press; version published in the journal will have higher-resolution figure

Radiative and mechanical feedback into the molecular gas in the Large Magellanic Cloud. I. N159W

We present Herschel SPIRE Fourier Transform Spectrometer (FTS) observations of N159W, an active star-forming region in the Large Magellanic Cloud (LMC). In our observations, a number of far-infrared cooling lines including CO(4-3) to CO(12-11), [CI] 609 and 370 micron, and [NII] 205 micron are clearly detected. With an aim of investigating the physical conditions and excitation processes of molecular gas, we first construct CO spectral line energy distributions (SLEDs) on 10 pc scales by combining the FTS CO transitions with ground-based low-J CO data and analyze the observed CO SLEDs using non-LTE radiative transfer models. We find that the CO-traced molecular gas in N159W is warm (kinetic temperature of 153-754 K) and moderately dense (H2 number density of (1.1-4.5)e3 cm-3). To assess the impact of the energetic processes in the interstellar medium on the physical conditions of the CO-emitting gas, we then compare the observed CO line intensities with the models of photodissociation regions (PDRs) and shocks. We first constrain the properties of PDRs by modelling Herschel observations of [OI] 145, [CII] 158, and [CI] 370 micron fine-structure lines and find that the constrained PDR components emit very weak CO emission. X-rays and cosmic-rays are also found to provide a negligible contribution to the CO emission, essentially ruling out ionizing sources (ultraviolet photons, X-rays, and cosmic-rays) as the dominant heating source for CO in N159W. On the other hand, mechanical heating by low-velocity C-type shocks with ~10 km/s appears sufficient enough to reproduce the observed warm CO.Comment: accepted for publication in A&

Early hospital discharge of infants born to group B streptococci‐positive mothers: a decision analysis

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/90120/1/j.1471-0528.2011.03249.x.pd