The Surgeon Generals Conference on Childrens Mental Health held in 2000 brought attention to the fact that children and adolescents with mental health and substance abuse problems are an underserved population. Rates of psychiatric disorders are high among this population, yet very few adolescents who need help actually receive it. A comprehensive literature review was undertaken to examine various aspects of adolescent health, including rates of mental health and substance abuse as well as treatment and mental health service utilization among this population. Barriers to care are discussed, with emphasis on gender, ethnicity, psychiatric diagnosis, treatment setting, and parental influences. In the past, the specialty mental health care sector has been relied on to provide treatment for adolescents. This thesis examines school-based mental health services, and Student Assistance Programs in particular, as alternatives to treatment for the adolescent population. School-based clinics have the potential to reduce some barriers to care, hence increasing rates of care for adolescents with mental health and substance abuse problems. Other recommendations to reduce barriers to care and increase rates of treatment are presented. Mental health and substance abuse have a significant impact on the health of the nation. These disorders cause or exacerbate numerous health problems, including cancer and heart disease. In 1996, mental health problems cost the United States $150 billion in direct and indirect costs (USDHHS, 2000). The relevance of public health in this thesis is exemplified by the potential of public health to decrease the health consequences associated with these disorders by working to increase rates of treatment.

Timely use of emergency contraception after all contraceptive failures could prevent up to 50% of all unintended pregnancies. In 2002, 85% of adolescents pregnancies were unintended, resulting in almost 500,000 births and 235,000 abortions. Emergency contraceptive services may be especially useful to adolescents because of their erratic patterns of sexual behavior and contraceptive use. Providing these services during emergency department hospital visits is vitally important in helping adolescents to prevent unwanted pregnancies. This IRB-approved study aimed to expand upon current data in the literature by assessing the type and amount of emergency contraceptive services provided to adolescents in these hospital settings nationwide. Research included in this thesis represents a pilot study of thirty-two physicians who work in twenty-one childrens hospital emergency departments across the United States. Telephone surveys were conducted with these physicians to assess the types of EC services available in their emergency departments and their attitudes regarding these services. Recommendations for undertaking a full-scale study of this same target population include improving response rates by modifying the survey administration protocol and increasing the number of contacts made with each physician. Results indicate that childrens hospital emergency department physicians are not meeting the current standard of care for emergency contraceptive counseling and prescribing practices with adolescents. These results support the need for increased education and awareness for emergency department physicians in childrens hospitals regarding emergency contraception and strategies to optimally communicate this information to their adolescent patients. The relevance of public health in this thesis is exemplified by the potential of the research to inform both the public health and medical communities about how emergency contraception is provided to female adolescents in children's hospital emergency departments. Comparison of results from both this pilot study and the full-scale study that will be based on this pilot study may lead to legislative and hospital policy change to improve the availability of emergency contraceptive services to adolescents, and hence to a reduction in the unintended pregnancy rate among adolescents.

Many older adults perceive spirituality as an important resource in their lives and spiritual practices as crucial to their health and well-being. Unfortunately, there is limited knowledge of how spirituality is defined by African American and Caucasian American men and women aged 65 years and older. In addition, less understanding on the role spirituality played in the self-management of chronic illness among this population. The purpose of this qualitative study was to define, explore, and describe spirituality in the life of chronically ill elders and to examine its relationship to self-management of chronic illness in terms of gender and race. The grounded theory approach guided the study design and analysis. This study used both comparative method and thematic content analysis in a sample of eighty-eight older adults in the �Self-Care Study,� a NIA-funded study on the process of self-care among older adults. The analytic technique of comparative method defined spirituality while thematic content analysis identified patterns of spirituality and self-management. Each in-depth interview was audiotaped and transcribed verbatim. Results identified three types of spirituality: transpersonal transcendence, interpersonal transcendence, and intrapersonal transcendence. In describing the spiritual/self-management connection nine themes emerged: 1) God: the healer, 2) God: the enabler through doctors, 3) faith in God, 4) prayer as a mediator, 5) spirituality as a coping mechanism, 6) combining traditional medicine and spiritual practices, 7) selected spiritual practices of self-care, 8) empowering respondents to practice health-promoting activities, and 9) personal responsibilities in the self-management of illness. These findings suggest a new direction for public health practice, education, and research. Spirituality is a pervasive factor in this population and may help to ensure positive health-promoting behaviors. The public health significance of this study is great because it is important for public health educators to understand the role spirituality plays in the self-management of chronic illness among the elderly. The implications for public health educators and researchers are the possible collaboration with faith-based institutions to assess, plan, develop, and evaluate interventions within the context of older adults.

In the United States between 1991 and 2001, there was an increase of over 848% in new AIDS cases in African American women fifty and older. This increase is due in part to changes in reporting. Because of the startling statistics and scarcity of studies in this population, this study examines the HIV prevention needs of two groups of African American women over fifty, injection drug users and non injection drug users. Focus groups were used to collect data on general HIV knowledge, experience with HIV prevention, psychosocial factors, drug involvement, and risks and barriers to HIV infection and prevention. Data was also collected through a survey that gathered information on demographics, sources of HIV information, HIV testing and risks including knowledge of risk, belief of risk and risk behaviors. This study found that lack of education and misconceptions regarding disease transmission act as a barrier for prevention efforts; a need for inclusive HIV prevention efforts such as multi-generational in-home programs, multi-family programs and the incorporation of prevention messages with existing health services; a need for skills building, condom negotiation skills and self-empowerment. Effective methods suggested were techniques that align with African American culture and heritage such as storytelling, inclusion of family and community. In order to generalize findings from this study, future research must include a representative sample of African American women 50 years and older such as churchgoers, sorority women, health conscious women, ex offenders, past injection drug users, infected or affected women and newly single women. The findings of this study are significant to public health research because they add to a growing body of knowledge regarding the HIV prevention needs of this group, can be used to design prevention messages for the population from which they were gathered, and most importantly provide insight to what a subpopulation of this group views as effective prevention methods. Recommendations for future research are also provided for federal government agencies, state public health agencies, community organizations, the family structure, HIV service groups, physicians, universities and researchers.

With the growing number of older adults and, therefore, the increasing importance of disability as a public health outcome, it is important to better understand the causes and correlates of functional decline and disability in the elderly. Traditionally, most research on disability has focused on individual risk factors. However, a growing body of research is finding evidence of the role of the social and physical environment in health outcomes generally. But to date, limited research has examined the neighborhood environment as a causal factor in disability among older adults. This dissertation examines the influence of the socioeconomic and social characteristics of neighborhoods and municipalities in Allegheny County, Pennsylvania on individual functional status prevalence and change among a sample of adults 65 and older in the County. The research suggests that some effects of neighborhood social environments on functional status may be present, but are weak relative to individual risk factors. Neighborhood effects were not found for disability prevalence in this sample, but were found for change in function over a period of 20 months. The analysis indicates that neighborhoods with higher rates of serious crime are associated with declines in function. Also, neighborhoods with more concentrated social and economic disadvantages as well as those with more concentrated affluence were both associated with some improvement in function. The association of disadvantage with improvement in function requires further clarification. The analysis suggests that more sensitive measures of disability and function may be required to detect neighborhood effects. This type of research is of great public health relevance because it has the potential to suggest and inform a range of new community-based public health interventions to improve the functional health of the elderly.

The use of dietary supplements by individuals with cancer is increasing. Many individuals with the diagnosis of cancer consume these supplements while undergoing treatment for cancer, including those enrolled in clinical trials. Clinical trials may involve the use of drugs or investigative agents, which are being studied to determine their safety and efficacy in the treatment of cancer. The focus of this study was to determine if individuals enrolled in clinical trials for the treatment of cancer use dietary supplements (vitamins, minerals and herbs) and the reasons why they are using them. The study's aims were (1) to document the use of dietary supplements among patients with breast, prostate, and colorectal cancer who are enrolled in a clinical trial, (2) to evaluate the perceptions of oncologists regarding their patients use of dietary supplements, and (3) to evaluate the design of clinical trials to determine the proportion that specifically address the use of dietary supplements. The study employed an exploratory, descriptive design whereby 99 patients with cancer who were enrolled in a clinical trial for the treatment of cancer were interviewed. A total of 53 oncologists were surveyed and the design of 70 multi-institutional breast, prostate and colorectal cancer clinical trials were reviewed. The study findings indicate that patients with breast, prostate and colorectal cancer are consuming dietary supplements while enrolled in clinical treatment trials. In general, the reasons they are using the dietary supplements are to enhance their health and to do something to help themselves. The patients perception is that they communicate this information to their oncologists, however, detailed information about the dietary supplements such as brand, type, dosage and frequency, is not routinely assessed and documented. In general, the design of the clinical trials did not specifically address the use of dietary supplements, and there were often discrepancies between the description in the study body and the accompanying case report forms. The importance of these findings from a public health perspective is that patients are consuming unregulated substances while enrolled in a clinical trial for the treatment of cancer and potentially may be at risk for drug interactions.

Sexually transmitted disease (STD) testing among sexually active young women is essential in preventing and controlling the STD epidemic. STD testing is critical because infections such as Chlamydia trachomatis and Neisseria gonorrhoeae are primarily asymptomatic in women. If women do not routinely test for STDs, this can facilitate the spread of these diseases and lead to serious sequelae. The research presented explores socio-demographic, psychosocial, and health-related factors that may be associated with young womens STD testing behaviors. The Health Belief Model (HBM) provides the theoretical framework for explaining the relationships that exist between background factors, HBM perceptions of STDs and STD testing, and the total number of STD tests completed during the two-year study. The population studied for this research is a sample of 14 29 year old women, approximately 80% of whom are African-American. Univariate regression analysis between background factors and the outcome indicated that age, race, education, having symptoms of an STD at baseline, current antibiotic use, and having condom problems were associated with an increasing number of STD tests completed. A similar analysis between HBM perception variables and the outcome showed that only perceived severity was significant. A multivariate stepwise linear regression model of significant background and perception factors revealed that having symptoms at baseline, current antibiotic use, and having condom problems were significant to an increasing number of total STD tests completed. These findings demonstrate that an assessment of behaviors and current health status of young women can be helpful in understanding utilization of STD services. The results also suggest that the HBM may not be sufficient in characterizing STD testing behaviors, however, improved measures of these constructs can better assess trends in the data. The public health significance of this study is that it provides theoretical and empirical attention to factors associated with STD testing behaviors, an area of research that has received limited consideration.

Functional health literacy is one path through which the educational system, health system, culture and society intersect to influence health outcomes and their associated costs. Inadequate functional health literacy can impair oral and written communication and subsequently the ability to understand the prevention and self-management of disease. Despite these concerns, the national prevalence of inadequate, marginal and adequate functional health literacy and their association with health status, health care utilization and subsequent health care outcomes remain largely unknown. For those tasked with the responsibility of managing population health, there is a void of tools and techniques that can be used to efficiently identify those at greatest risk of inadequate functional health literacy. Using standard regression modeling and diagnostic techniques, this study was the first to develop and validate a model to estimate functional health literacy and to confirm its direct relationship with preventive health services utilization in a nationally representative sample of elderly >= 65 years of age. The national prevalence of inadequate and marginal functional health literacy was estimated to be 39%. Preventive health care utilization varied by functional health literacy category. Individuals with inadequate or marginal functional health literacy had odds of not receiving a flu shot within the past 12 months that was 1.26 times that of individuals with adequate functional health literacy (OR = 1.26, 95% CI (1.11 - 1.43)) after controlling for income, insurance coverage, having a usual source of care, and self-reported general health status. Women with inadequate or marginal functional health literacy had odds of not ever having a mammogram that was 2.21 times that of women with adequate functional health literacy (OR = 2.21, 95% CI (1.85 - 2.65)) in multivariate analysis. This research confirms the national public health relevance of functional health literacy in preventive health care utilization in the elderly. Race, education and age-related disparities in preventive health care utilization may, in part, be mediated through functional health literacy. As we move to equalize health care access, utilization and quality for all, functional health literacy must be considered part of the solution if we are to empower those in greatest need.

There were approximately 3,000 international students, scholars and their dependent spouses and children associated with the University of Pittsburgh in 2003-2004. As the accompanying wife of an international student or scholar proceeds to take care of practical home and family tasks in a new and unfamiliar environmentthe U.S.she may experience negative mental health outcomes such as anxiety, frustration, depression, isolation, etc. These adverse outcomes are a significant public health problem for the population of international wives because they decrease quality of life and sense of wellbeing. The symptoms can also have negative affects on the husbands and dependent children of the international wives. Using an ecosystemic approach, the current study contributes to the literature on international student wives by exploring the following research questions at the intersection of the individual and meso-system levels of interaction: (1) What tasks must international wives accomplish in the U.S.? (2) How do international wives access community in order to more successfully accomplish these tasks? (3) What ideas do wives have for how their communities could be enhanced? Using qualitative, in-depth, semi-structured interviews with seven Asian wives of Asian international students and scholars, the current study is an exploration of the tasks that international wives feel they need to accomplish in Pittsburgh and the social systems they access. Three themes emerged from the interviews which described the wives transition from dependency to agency, their strategies for maintaining cultural identity and the use of virtual communities. The study concludes with practical recommendations of population-specific social support interventions which may be implemented by public health practitioners and other interested purveyors of mental and social support.

During a two-year term as an admissions counselor, I had the opportunity to interview over 60 students at Armand Hammer United World College (UWC) of the American West in Montezuma, New Mexico. I learned that the internationally diverse population of secondary students there and at ten other UWCs across the globe were united under the UWC mission: to become responsible citizens, politically and environmentally aware, and committed to the ideals of peace and justice, understanding and cooperation, and the implementation of these ideals through action and personal example. All that I learned, combined with personal aspirations to a career in public health and an interest in helping young people reach their potential, led me to set a goal of some day teaching public health to UWC students, and students with a similar sense of purpose at other schools. This thesis addresses my aspirations as it presents a public health curriculum that could be applied to the UWC movement. Within the thesis, I summarize existing public health curricula that target youth; describe theories and concepts that demonstrate the importance of public health curricula for adolescents; present my current progress in creating a partnership with the United World Colleges, basing the discussion in community development concepts; consider project limitations and devise strategies that may drive the collaboration process forward in the future; outline the curriculum development process; and present the preliminary course. This work is of great public health significance because existing and future public health issues the world over require the most creative, culturally sensitive professionals for solutions. I argue that the future professionals best suited to tackle such an important task are the adolescents of the present because they stand in a unique position to realize their potential as individuals, family and community members, citizens, and future leaders in their chosen vocations. Investing in the public health education of adolescents is a health intervention we can all participate in and benefit from with dividends to spare.