<p> Type 2 diabetes is a chronic metabolic disorder and the seventh leading cause of death in the United States. Type 2 diabetes is linked to many chronic diseases, including cardiovascular disease, stroke, and chronic kidney failure. African American adults have a high prevalence of Type 2 diabetes with early onset of diabetes complications. Poor dietary behavior is the primary cause of Type 2 diabetes and its complications, changing dietary behaviors can prevent the onset of diabetes complications or impede existing ones. The purpose of this phenomenological study was to explore patients&rsquo; perceptions of diet-only therapy in the prevention of diabetes complications. Face-to-face interviews were conducted with six African American adults with Type 2 diabetes between 40 to 64 years using purposeful sampling method. Health belief model formed the conceptual framework of the study. I applied inductive coding process and manually analyze data for themes. Participants expressed fear of diabetes complications, acknowledged effectiveness of dietary therapy, physician communication and strong family support in Type 2 diabetes management. Findings can produce positive social change among African American adults with type 2 diabetes. Patients can be motivated to change their dietary behaviors to prevent disability and death from diabetes complications. Adherence to diet can reduce medical costs associated with Type 2 diabetes and its complications at the individual, family, community, and government levels. Health care providers can apply the findings in their interactions with patients to provide a more patient-centered education that integrates patients&rsquo; cultural and dietary preferences to facilitate adoption of dietary interventions and long-term adherence.</p><p>

Thesis (B.S.)--Massachusetts Institute of Technology, Dept. of Biology and Public Health, 1930. / Includes bibliographical references (leaves 67-68). / by Lawrence Parker Abare. / B.S.

Thesis (Ph. D.)--Massachusetts Institute of Technology, Dept. of Biology and Public Health, 1935. / Includes bibliographical references. / by John Langworthy Fuller. / Ph.D.

Discrimination is a predictor of increased drug use initiation. Thus, discrimination may systematically marginalize stigmatized individuals into risky social networks (e.g., networks with high burden of disease) that facilitate HIV transmission. Therefore, even when individual risk behaviors are low, membership in high risk network may perpetuate disease transmission. Studies have shown that black and Hispanic drug users exhibit lower drug and sexual risk behaviors, yet they are most affected by HIV. Since blacks and Hispanics experience discrimination more often than whites, this relationship may explain their increased likelihood of HIV prevalence. In order to assess whether an association between discrimination and risky social networks existed and whether this relationship was modified among blacks and Hispanics, we used data from the Social Ties Associated with Risk of Transition (START) study. START (n=652) is a prospective cohort study among non-injection drug users (never injected and used non-injection heroin/crack/cocaine ≥ year at least 2-3 times/ week) and a cross-sectional sample of newly initiated injection drug users (heroin/crack/cocaine injectors ≤ 3 years) recruited through respondent driven sampling and targeted street outreach in ethnographically mapped high drug activity NYC neighborhoods. We also combined START data with 2000 US Census data to examine whether neighborhood structural factors (e.g., poverty, education, minority composition and social cohesion) exacerbated the relationship between discrimination and risky social networks. Using log-binomial regression and population average modeling for neighborhood analyses, discrimination was shown to be significantly associated with more drug and sexual risk networks. Among blacks, discrimination due to race and drug use were important for having more embedded sex networks. Among whites and Hispanics, discrimination due to incarceration and drug use was significantly associated with embedded heroin and injection networks. Finally, the relationship between drug use discrimination and more embedded heroin and injecting networks was also magnified among illicit drug users that are members of neighborhoods characterized by lower minority composition, less education and poorer social cohesion. More research is needed to better understand the how race/ ethnicity and neighborhood influence the socio-contextual process between discrimination and risky social networks.

This collection examines mainstream economics discourse as it relates to three topics in sustainable development: health equity, sustainable non-renewable resource management and development approaches. The themes of the three papers are as follows: Political Dimensions of Health Equity in Mozambique - In order to promote equity in health, analysis should look beyond the standard economic definitions used to identify underserved and vulnerable populations. Human and Social Capital, Compensation or Cost? Reexamining the Hartwick Rule - In order to achieve sustainable non-renewable resource management, planners must go beyond the current economic theoretical framework and consider the direct impacts of extraction on human and social capital. The Materialism Paradigm - Neither Sustainable, nor Development - The way economists have understood prosperity is materialistic and development is exporting this welfare-reducing paradigm. The synthesis of the series - The frameworks used in economics to address a variety of issues in sustainable development have limited efficacy and would benefit from insights originating outside the discipline.

This dissertation addresses several critical gaps in the evidence-base with regard to urinary fistula care and treatment in developing countries. First, I systematically reviewed and synthesized the small but growing body of literature examining the patient, fistula and facility-level factors that influence repair outcomes in developing countries. There was insufficient evidence to support a role of patient characteristics in influencing repair outcomes. In contrast, the weight of evidence suggested that some fistula characteristics, particularly scarring and urethral involvement, may influence the risk of failure to close the fistula, residual incontinence following closure and any incontinence. Results from randomized controlled trials examining prophylactic antibiotic use and repair outcomes were inconclusive, and observational studies examining the influence of peri-operative procedures were limited by small sample sizes and lack of statistical adjustment for potential confounding factors. Secondly, using data from a multi-country facility-based prospective cohort study, I examined the prognostic value of five existing classification systems - those developed by Lawson, Tafesse, Goh, the World Health Organization (WHO) and Waaldijk - for predicting fistula closure, and evaluated the prognostic value of a score derived empirically from the data from this study. The scoring systems representing the Tafesse, Goh and WHO and empirically-derived classification systems were similar, and had the highest predictive values. However, none of the scores evaluated achieved good discriminatory ability (AUC > 0.70), suggesting that other factors unrelated to fistula characteristics may be equally or more important in predicting repair outcomes. Finally, I examined several issues surrounding two peri-operative procedures related to fistula surgery: abdominal versus vaginal route of repair, and catheterization duration greater than 14 days (compared to 14 days or less). Specifically, I explored the factors influencing the choice of these procedures, the influence of each of these procedures on repair outcomes independent of indication for repair or repair prognosis, and whether indication for the procedure or fistula prognosis moderates the influence of each of these procedures on repair outcomes. Abdominal route of repair was independently associated with site, parity > 3, and having a fistula that met indications for an abdominal route of repair (limited vaginal access due to extensive scarring or tissue loss, genital infibulation, ureteric involvement, or trigonal, supra-trigonal, vesico-uterine or intracervical location, or other abdominal pathology). Surgeon experience conducting complex repairs and mid-vaginal location were inversely associated with abdominal route of repair. Increased prognostic score was independently associated with catheterization > 14 days, as were site and surgeon experience doing complex repairs. Vaginal route of repair was independently associated with increased risk of failure to close the fistula, relative to abdominal route of repair; however, stratified analyses suggested that the risk of failed repair among those repaired vaginally may be particularly elevated among women who met common indications for abdominal route of repair. Duration of catheterization > 14 days was associated with failure to close the fistula, after adjusting for repair prognosis and surgeon experience; however, residual confounding by indication and reverse causation cannot be excluded as explanations for this finding. Additional research is needed to confirm our findings regarding the discriminatory value of the classification systems evaluated. Further, since the value of a classification system lies not only in its discriminatory ability but also its reliability and ease of use, tests of inter- and intra-rater reliability of these systems are priority area for future research. Given the cost and health implications associated with abdominal route of repair and longer duration catheterization, additional studies examining the influence of these procedures on repair outcomes are warranted. Such studies must ensure adequate control of confounding by indication and prognosis of repair.

HIV/AIDS prevalence within correctional settings and among populations with criminal justice histories are several times that of the general population. Despite prior investigations that have empirically identified associations between criminal justice system involvement and HIV risk behavior, few studies have investigated mechanisms of autonomy and relationship dependencies as mediating mechanisms between incarceration history and HIV risk behavioral outcomes. The purpose of this dissertation is to examine the role of relationship dependencies (reliance on a partner for drug and non-drug related expenses) and autonomy (personal access to resources including housing, employment and educational opportunities, relationship dependency) as a pathway linking prior incarceration and HIV risk behavior. An integrated theory combining General Strain Theory and the Theory of Gender and Power informed the hypothesis for this dissertation. It was hypothesized that incarceration history would be associated with HIV risk behaviors among drug involved adults. Relationship dependencies and autonomy was also hypothesized to be associated with HIV risk behaviors among drug involved adults, relationship dependencies and autonomy were hypothesized to mediate any observed positive relationships between incarceration history and HIV risk behavior. This investigation represented a cross-sectional design using a baseline dataset of street recruited heterosexual couples participating in a NIDA funded randomized HIV prevention intervention trial (343 men, 346 women). Findings showed that incarceration had significant associations with HIV risk behaviors including sex exchange, injection drug use and sharing injection equipment among women but not among men. It was also found that autonomy had significant negative relationships with HIV risk indicators among women, with no significant associations being found among men. Multivariate results also suggested that relationship dependencies regarding expenses for drugs were associated with HIV risk indicators including sex exchange and injection drug use for women, and sex exchange for men. Although incarceration history was significantly associated with relationship dependencies for drug expenses among women, there was not sufficient evidence to suggest that relationship dependencies or autonomy were mediating mechanisms of HIV risk outcomes. Results of this study have important implications for the development of practice and policy level harm reduction and HIV prevention interventions for drug involved adults.

Influenza pandemics pose an imminent risk to society. Yearly outbreaks already represent heavy social and economic burdens. A pandemic could severely affect infrastructure and commerce through high absenteeism, supply chain disruptions, and other effects over an extended and uncertain period of time. Governmental institutions such as the Center for Disease Prevention and Control (CDC) and the U.S. Department of Health and Human Services (HHS) have issued guidelines on how to prepare for a potential pandemic, however much work still needs to be done in order to meet them. From a planner's perspective, the complexity of outlining plans to manage future resources during an epidemic stems from the uncertainty of how severe the epidemic will be. Uncertainty in parameters such as the contagion rate (how fast the disease spreads) makes the course and severity of the epidemic unforeseeable, exposing any planning strategy to a potentially wasteful allocation of resources. Our approach involves the use of additional resources in response to a robust model of the evolution of the epidemic as to hedge against the uncertainty in its evolution and intensity. Under existing plans, large cities would make use of networks of volunteers, students, and recent retirees, or borrow staff from neighboring communities. Taking into account that such additional resources are likely to be significantly constrained (e.g. in quantity and duration), we seek to produce robust emergency staff commitment levels that work well under different trajectories and degrees of severity of the pandemic. Our methodology combines Robust Optimization techniques with Epidemiology (SEIR models) and system performance modeling. We describe cutting-plane algorithms analogous to generalized Benders' decomposition that prove fast and numerically accurate. Our results yield insights on the structure of optimal robust strategies and on practical rules-of-thumb that can be deployed during the epidemic. To assess the efficacy of our solutions, we study their performance under different scenarios and compare them against other seemingly good strategies through numerical experiments. This work would be particularly valuable for institutions that provide public services, whose operations continuity is critical for a community, especially in view of an event of this caliber. As far as we know, this is the first time this problem is addressed in a rigorous way; particularly we are not aware of any other robust optimization applications in epidemiology.

The purpose of this research is to examine select baseline characteristics and drug use and sexual behaviors by duration of injection drug use among young, newly initiated injection drug users (IDUs) to better understand factors associated with risk of infection during the early stage of an injection drug users' career. This research was conducted using questionnaire data from the Collaborative Injection Drug Users Study II (CIDUS-II), a CDC-sponsored prospective study of young (18-29) and/or newly initiated IDUs (duration of injection < 6 years). The study was conducted at six sites in five United States' urban areas: Baltimore, Chicago, Los Angeles, New Orleans, and New York City (Harlem and the Lower East Side). Investigators conducted interviews to assess baseline characteristics and injection drug use and sexual risk factors and obtained serum for testing of bloodborne infections including Hepatitis C (HCV). Duration of injection was calculated from the age of first injection to age at the time of the interview and roughly divided into tertiles by duration while maintaining years as whole numbers: 0-1 year, 2-3 years, and 4-6 years. Among the 1836 participants included in the analysis, 34% (n = 619) had been injecting for 0-1 year, 38% (n = 697) for 2-3 years, and 28% (n = 520) for 4-6 years. Overall HCV prevalence was 34%. By duration of injection, HCV prevalence differed by site of recruitment. In Baltimore for blacks HCV prevalence increased from 33.3% among IDUs injecting <2 years to 79% among IDUs injecting 4-6 years. HCV prevalence in other cities (Chicago, Los Angeles, New Orleans and New York) showed less difference by duration. By racial and ethnic group, HCV prevalence was higher in blacks than non-blacks (=80% white) in all cities (OR = 1.43, 95% CI: 1.00 - 2.05) except Baltimore where prevalence was higher in whites (OR = 5.20, 95% CI: 2.94 - 9.18) than blacks (OR = 2.52, 95% CI: 1.38 - 3.07) as compared to whites in all other cities. The IDU groups of <2 years duration (n = 691) and 2-3 years duration (n = 697) had higher odds than the 4-6 year group (n = 520) of reporting injecting with others (Odds Ratio, OR = 1.52, and OR = 1.47, respectively) and injecting on average more now (OR = 1.44 and OR = 1.44, respectively). The associations remained after multivariate adjustment for demographic variables. In addition, the frequency of several other important risky injection practices were found to be higher among more newly initiated including indirect sharing (sharing of cookers, cotton and rinse water) and backloading, and certain preventive behaviors was found to be lower among this group as well, including use of new needles and NEPs. Duration of injection did not appear to be associated with sexual risk behaviors such as giving or receiving sex for money or drugs or frequency of condom use with sex partners. These data confirm high prevalence of HCV soon after initiation of injection, and increases in HCV prevalence by duration of injection that differed across U.S. cities and by racial/ethnic group. In addition, these data provide support to the ongoing discussions about increased risk among young, newly initiated injection drug users, with risky injection practices higher among more newly initiated IDUs. These findings help to improve our understanding about the periods of increased risk and provide important information about certain baseline characteristics and injection practices among young, newly initiated IDUs -- essential data to consider when developing risk reduction programs.

Countries with substantial Muslim populations are experiencing rapid changes in HIV prevalence. HIV testing and circumcision, as biomedical interventions, are the focus of this dissertation since biomedical strategies are the among the most efficacious HIV interventions. This dissertation examines the relationship of multilevel effects to HIV stigma, HIV risk behavior, and HIV status with two evidence-based HIV prevention intervention strategies (HIV testing and male circumcision) and a third HIV prevention intervention strategy (female circumcision) that is highly disputed, via three separate and distinct papers. This study is theoretically guided by the Ecological Perspective and the Social Network Conceptual Model. The sample for the first paper on Central Asia includes Kazakhstan (n=14,310), Kyrgyzstan (n=6,493), Uzbekistan (n=13,404), and Tajikistan (n=4,677), for a total n=38,884. The second paper sample is drawn from India: 65,356 men between the ages of 15 and 54. The third paper sample is drawn from Mali: 14,583; all of these participants are ever-married women of reproductive age (15-49 years old). Multilevel modeling was used in all three papers. This innovative methodology produced empirical evidence for the association of context with the behavior of the individual. A finding consistent in all three papers is that: context does matter. This dissertation examines context in terms of family and community membership. Specifically, the context of different levels of stigma and family/community membership impacts individuals' HIV testing and circumcision. In Central Asia, HIV stigma at the individual, family, and community levels is significantly associated with decreased HIV testing uptake and receipt of HIV test results. HIV stigma is associated with male circumcision status (i.e., whether a male is circumcised or uncircumcised) on individual, family, and community levels in India. In Mali, female circumcision was significantly associated with increased odds of HIV positive status, and circumcision status was not associated with HIV risk behavior. Family and community membership was also associated with HIV status and HIV risk behavior in Mali. The findings of the dissertation have important implications for practice, policy, and research.