Researchers have considered HIV/AIDS in Kenya as the largest HIV pandemic in the world, with about 6.3 million individuals living with the disease as of 2013. About 25% of new HIV patients are adult women, aged 15 to 24 years old. Guided by the health belief model (HBM), the purpose of this quantitative cross-sectional survey research study was to explore the influence of various dimensions of HIV/AIDS stigma (public, self, enacted, and structural) on the uptake of HIV testing among Kenyan Diaspora women in United States. Multiple linear regression analysis was used to test if there was a correlation between HIV/AIDS stigma and the uptake of HIV testing on Kenyan Diaspora women. Preliminary analyses showed the relationships were approximately linear with the residuals normally distributed, as assessed by skewness and kurtosis statistics, and there were no outliers. The results for these four research questions were not significant. The results of the study indicated that perceived levels of stigma among Kenyan Diaspora women living with HIV/AIDS did not correlate with differing levels of uptake for testing and treatment. This study promoted positive social change through encouraging HIV testing by raising awareness and understanding about HIV/AIDS, especially during the early stages of the disease. Thus, promoting positive social change in encouraging Kenyan Diaspora women to engage in HIV testing to ensure they were safe for sexual encounters or to breastfeed their children. Similar studies could carry out research to examine the influence of factors other than stigma on uptake of testing and treatment for those living with HIV/AIDS.

Surgical site infection (SSI) is the most common healthcare-associated infection. Approximately 2% to 14% of surgical patients are diagnosed with SSI, which may extend length of stay in the hospital or lead to readmission and may necessitate another surgical procedure. Patient readmission due to SSI costs health care industries about $3,000 to $29,000 per case and a total of $10 billion per year. The purpose of this quantitative cross-sectional retrospective study was to examine the association between SSI and teaching status, hospital ownership, and number of beds in the hospital. The epidemiological triad was used as a framework to describe the relationship between the person (hospital is the unit of analysis), place (regional location), and time (one year of data). The dataset used in this study was retrieved from Centers for Medicare & Medicaid Services. A hospital was classified as having a high SSI rate if its rate was in the highest third. Contingency tables were used to test the relationships. The chi-square tests revealed that teaching hospitals were more likely to have high SSI rates than were nonteaching hospitals. Forty percent of teaching hospitals had high SSI rates compared to 26% of nonteaching hospitals (p < 0.001). Hospital ownership, bed size, and region were not significant predictors of high SSI rates. Findings from this study may lead toward further reductions in SSI by guiding infection control efforts toward hospitals with higher rates.

Diabetes is among the leading causes of death in Connecticut. An approximate of 330,000 adults in Connecticut have diabetes (diagnosed and undiagnosed). Those with diabetes have almost twice the risk of premature death throughout various age groups. The purpose of this cross-sectional study was to investigate whether disparities exist in access to medical care due to race and ethnicity; among adults with diabetes in the state of Connecticut. Furthermore, this study used the Andersen's behavioral model framework. Survey data from the behavioral risk factor surveillance system (BRFSS) were also analyzed. The research study covered 3 years (2013 to 2015) of data collection in the BRFSS (N = 3,091). Race and ethnicity were the primary independent variables. The 3 dependent variables were: source of care, length of time since routine check-up, and doctor's visit during the past 12 months. The overall data suggest that the disparity is significant in household income. Those who had healthcare coverage, higher income, and older age were significantly different from their counterparts in terms of length of time since the last routine checkup. In the regression analysis, healthcare coverage, income level and educational were the significant predictors of log length of time since the last routine checkup. Those who are Black, single, higher annual household income, and higher educational level, were significantly different from their counterparts in terms of doctors' visits during the past 12 months. The implication for social change is that policymakers must act both to eliminate barriers and challenge structures that encourage disproportionate income advantages for White households.

Diarrhea in children remains a major public health problem in Uganda and other countries in the region and acts as one of the leading contributors to child mortality. Most of the risk factors for diarrhea in children are preventable. This study, guided by the socioecological model, was conducted to investigate the association between the occurrence of diarrhea in children and length of breastfeeding, coinfection with acute respiratory infection (ARI), and vaccination status of the child. These variables were identified in the literature as risk factors for diarrhea that had not been investigated in Uganda. The source of the data for this study was the Uganda Demographic and Health Survey 2011 dataset. Data analyses included descriptive statistics of all variables, bivariate analysis using binary logistic regression and multivariable logistic regression. Findings indicated that longer breastfeeding duration was associated with lower incidence of diarrhea. This was particularly significant when breastfeeding was continued beyond 24 months of age. Children who had ARI were twice as likely to have diarrhea as compared to children without ARI. Vaccination status was not significantly associated with occurrence of diarrhea. Increasing age of the child as well as higher age and higher education level of the mother were found to be associated with less occurrence of diarrhea in the child. This study may contribute to positive social change through recommendations that could reduce the burden of diarrhea in children. These recommendations include longer breastfeeding periods up to at least 3 years, integrated management of ARI and diarrhea, and policy support for women in this region to attain higher education levels and engage in less early childbearing.

Cholera remains a major public health problem affecting high-risk populations such as camps of internally displaced persons. During a cholera outbreak, it is essential to reduce transmission and minimize new infections. The Miasma theory, host-agent-environment model and Ecosocial theory were utilized for this study. This study was a retrospective comparison to determine whether historical cholera control measures are effective during current cholera outbreaks within camps of internally displaced persons. A quantitative approach ascertained changes in incidence and mortality rates following implementation of primary and/or secondary control measures. Cholera outbreaks were identified from the World Health Organization's (WHO) Disease Outbreak News reports issued between 1996 and 2017. Each reported cholera outbreak was categorized into one of eight outbreak cohorts -- each cohort having the same primary control measure. The WHO Data Repository was used to identify cholera incidence and/or mortalities and the World Bank data set was used for population total to calculate incidence and/or mortality rates for the years prior to and the year of the outbreak to calculate the case percentage change and death percentage change. Analysis of covariance was used to assess statistical significance in rate change within each intervention cohort. No statistical significance was noted within various cholera control intervention. Limitations of this study provide the basis for continued research on this topic; also aligning with the Global Task Force on Cholera to reduce infections by 90% by the year 2030.

African Americans are disproportionately burdened by colorectal cancer, the third most commonly diagnosed cancer and the third leading cause of cancer death among men and women in the United States. The highest colorectal cancer incidence and mortality rates are observed among African Americans, compared to other racial/ethnic groups. Furthermore, African Americans are more likely to develop large, more-advanced colorectal adenomas, the primary premalignant lesion of colorectal cancer, which have greater potential to progress into colorectal cancer. Reasons for the increased risk of colorectal cancer and elevated occurrence of high-risk adenomas in this racial group have not been completely elucidated. This indicates that more research is needed to better understand the etiology of colorectal cancer and adenoma among African Americans and identify potential prevention strategies that could reduce the cancer burden. In this dissertation, I analyzed two potential risk factors for colorectal cancer, low vitamin D status and circadian disruption, and a potential preventive factor for colorectal adenoma, use of aspirin or non-aspirin NSAIDs, among a group of African American women. For all three analyses, I utilized data from the Black Women’s Health Study, an ongoing prospective cohort study of African American women begun in 1995. Prior studies among mostly White populations, indicate that low vitamin D levels increase risk of colorectal cancer. African Americans tend to have lower vitamin D levels compared to other populations. In my first dissertation study, I assessed the relation of vitamin D status with colorectal cancer risk using predicted vitamin D score, derived from a previously validated vitamin D prediction model, as a proxy measure for vitamin D status. Using Cox proportional hazards regression to estimate hazard ratios (HR) and 95% confidence intervals (CI), I found that women in the lowest quartile of predicted vitamin D score were estimated to have a 41% (HR=1.41, 95% CI 1.05–1.90) increased risk of colorectal cancer compared to those in the highest quartile. Predicted vitamin D score was similarly associated with colon (HR for lowest vs. highest quartile=1.44, 95% CI 1.02–2.01) and rectal cancer (HR=1.34, 95% CI 0.70–2.56). The association was not modified by age, BMI, or supplemental vitamin D intake. My findings suggest that low vitamin D status may contribute to the disproportionately high incidence of colorectal cancer among African Americans and higher vitamin D status may reduce incidence. Research shows that disruption of the human circadian clock can have carcinogenic consequences. African Americans, who have shorter endogenous circadian periods, sleep less, and often have less flexible work schedules may be more susceptible to this disruption. In my second study, I examined the impact of two novel markers of circadian disruption, chronotype and residential position within a time zone, on colorectal cancer risk, using Cox proportional hazards regression. I found that neither marker (evening vs. morning chronotype: HR=0.96, 95% CI 0.73–1.27; Per 5-degree longitude increment in residential position from eastern to western border of time zone: HR=0.92, 95% CI 0.82–1.03) was associated with colorectal cancer, overall or within strata of age, geographic region, BMI, night shift work, or latitude. These results suggest that chronotype and residential position in a time zone may not be associated with an increased risk of colorectal cancer in African American women. However, more research on these novel markers is necessary. Accumulating evidence suggests that use of aspirin or non-aspirin NSAIDs is associated with a reduced occurrence of colorectal adenoma, but few studies have explored associations among African Americans. Thus, in my third study, I analyzed aspirin or non-aspirin NSAID use in relation to colorectal adenoma occurrence using logistic regression for longitudinal data. Aspirin use was associated with a reduced odds of adenoma (OR=0.88, 95% CI 0.76–1.02). The association was stronger for rectal adenoma (OR=0.63, 95% 0.37–1.06) and adenomas <1 cm in size (OR=0.83, 95% 0.70–0.97). In contrast, non-aspirin NSAID use was associated with an increased odds of adenoma (OR=1.20, 95% 0.99–1.45), particularly adenoma in the proximal colon (OR=1.30, 95% CI 1.04–1.61) and adenomas <1 cm in size (OR=1.31, 95% CI 1.07–1.61). My findings suggest that aspirin use may be a useful strategy to reduce adenoma occurrence among African Americans. The unexpected positive association between non-aspirin NSAIDs and adenoma warrants further study. Findings from this dissertation suggests that low vitamin D status may contribute to the disproportionate burden of colorectal cancer among African Americans, while aspirin use may help reduce the burden. / 2025-01-31T00:00:00Z

Substance use has been linked to adverse health and social costs, including morbidity and mortality. Substance use patterns are driven not only by individual-level determinants, but also by social, political and ecological factors. Given this inter-connected web, further exploration into the interactions between individuals and their environments may help inform strategies to intervene and reduce substance use and related risk behaviors. The purpose of this dissertation was to examine the dimensions of place in determining an individual’s substance use behaviors. In the first two studies, we explored the policy dimension of an individual’s environment, specifically how the state-level policy environment shapes frequency of alcohol use. We used data from the National Longitudinal Survey of Youth 1997 (NLSY97) cohort, a nationally representative, longitudinal sample of emerging adults. In the first study, we examined associations between stringency of an individual’s state-level policy environment (as measured via the Alcohol Policy Scale, APS) and past 30-day drinking and binge drinking. We found that 10-unit higher (more stringent) APS score at interview was associated with small reductions in past 30-day drinking (-0.03 drinking days, 95% Confidence Interval (CI) -0.17, 0.11) while associations were null for past 30-day binge drinking (0.004, 95% CI -0.06, 0.06), after adjusting for individual and contextual confounders. Given interest in impacts of policy changes on drinking, we also assessed associations for cross-interview change in APS. The mean interview-to-interview (roughly 1 year) change in APS score was 0.4 (+/- 2.6, range -38.1 to 39.7). In confounder-adjusted models, a 10-unit greater increase in APS change score across an interview interval was associated with -0.15 reduced drinking days (95% CI -0.30, 0.01) while reductions in binge drinking days were smaller (-0.05, 95% CI -0.14, 0.05). For the change in APS analyses, stratification by prior (starting) APS score showed the largest reduction among those in the highest quartile of prior APS (-0.25 drinking days, 95% CI -0.57, 0.07) while those in the lowest quartile of prior APS had the largest reductions in binge drinking (-0.10, 95% CI -0.13, -0.07). Age-based stratification showed the impacts were primarily driven by years when individuals were under age 21 (under legal drinking age). The second study of this dissertation also used data from the NLSY97 cohort, but focused on alcohol use over time rather than drinking at single time points. Specifically, our second study identified sub-groups of longitudinal drinking patterns—or trajectories—across 18 years of follow-up using latent class growth analysis. We then estimated the association between state-level policy score (APS) at baseline and trajectory group membership. For both the past 30-day drinking and past 30-day binge drinking outcomes, distinct trajectories were identified and described. For drinking days, a 5-group solution was the best fitting model. The 5 drinking-days groups were: late escalating (10.8%), normative (19.0%), high frequency (5.6%), low frequency (47.0%) and no/infrequent use (17.7%). A 10-unit higher baseline APS score was associated with slightly higher odds of membership in the late escalating group (adjusted Odd Ratio, aOR = 1.13, 95% CI 0.98, 1.31) and reduced odds of membership in the normative group (aOR = 0.94, 95% CI 0.81, 1.10) compared with membership in the no/infrequent group. In a separate trajectory model, we identified 5 binge drinking-days groups: later onset (10.5%), high frequency (4.4%), once-a-month (34.8%), earlier onset (11.3%), and no/infrequent (39.1%). A 10-unit higher baseline APS score was not associated odds of binge drinking group membership compared to the no/infrequent comparator outcome. For study 2 overall, we found weak associations between state-level APS at approximately age 14 and drinking or binge drinking trajectory membership. However, we also found a consistent, slight decreased odds of membership in the normative drinking days group (compared to both the no/infrequent and low frequency drinking groups) with a more stringent policy environment. Furthermore, sensitivity analyses showed APS score may decrease odds of membership in drinking day trajectory groups typified by earlier initiation of alcohol use. In study 3, we examined a more granular environmental exposure—the neighborhood environment. Using baseline data from participants in a human immunodeficiency virus (HIV) prevention study who lived in Baltimore, we evaluated the association between neighborhood disorder and substance use behaviors. We compared neighborhood-level disorder at residential address (live/sleep neighborhood) to a more dynamic definition of exposure to neighborhood disorder based on where individuals reported spending their time engaged in specific activities (activity spaces). Using data from a previously collected Neighborhood Inventory for Environmental Typology (NIfETy) instrument assessment, we calculated objective neighborhood disorder scores for participants (live/sleep scores and activity-weighted scores). While higher live/sleep neighborhood disorder was associated with higher prevalence of self-reported harmful alcohol use, results were imprecise (adjusted prevalence ratio, PR: 1.14, 95% CI 0.94, 1.37). We found a similar directional relationship between live/sleep disorder and injection drug use in the past 6 months (adjusted prevalence ratio: 1.03, 95% CI 0.88, 1.22). The relationship of live/sleep disorder to injection-related risk behaviors (among those who injected drugs in the past 6 months) was inconsistent. Higher live/sleep neighborhood disorder was associated with reduced prevalence of non-alcohol related treatment (among those with a history of drug use; adjusted prevalence ratio: 0.97, 95% CI 0.89, 1.07). Contrary to our hypothesis, there was little variation in results or model fit between the live/sleep and activity-weighted exposures. However, time spent in live/sleep location modified observed relationships for harmful alcohol use and injection drug use. Understanding exposure to factors such as disorder at a micro-space level (both location and time spent at a location) may help explain risk behaviors and identify priorities for intervention. These three studies highlight state policy and neighborhood as two of the many environmental forces that influence individual substance use behaviors. A better understanding of how state-level policy and neighborhood environments influence behavior is critical to initiatives focused on substance use and related harm reduction. These findings are therefore relevant to policy makers and community advocates at both the state and local-level. These dissertation studies also highlight the complexity inherent in quantifying and assessing the impact of both policy and neighborhood exposures on individuals. Further research is needed to examine critical time periods for the influence of neighborhood and state-level policies on substance use across the life-course.

No description available.

No description available.

Includes bibliographical references. / South Africa faces the world’s largest pediatric HIV epidemic. Combination antiretroviral therapy (ART) is the only effective treatment for HIV virus suppression. Pediatric HIV care has traditionally been provided in academic research and tertiary care facilities, however efforts to improve ART availability for children are ongoing through decentralization. Tygerberg Hospital physicians with training in pediatric HIV management are providing care in seven community-based primary health care (PHC) clinics in the greater Cape Town region. ART initiation and ongoing ART management for those down-referred from tertiary and district level facilities are provided. The HIV-related outcomes of this cohort have yet to be reported.