Previous studies have shown that women exposed to certain air pollutants are at an increased risk for preterm delivery and/or delivering a low birth weight newborn. Preterm delivery and low birth weight are associated with an increased risk for morbidity and mortality. In an effort to better understand the impact of local environmental factors on pregnancy health, duration and outcomes, this study investigated the relationship of hazardous air pollutant chemicals released by local industries and the adverse pregnancy outcomes of preterm delivery and term low birth weight in Allegheny County, PA. This study included 2,798 singleton birth records for deliveries that occurred in Allegheny County in January through March of 2004. The Toxic Release Inventory provided data for 2003 fugitive and stack air releases of all facilities in Allegheny County reporting air releases of lead and toluene. This data was used for determining proxy maternal exposure measurements. ArcGIS software was used to calculate the distance from each maternal residence to each TRI facility. The distances and reported total pounds of release from each facility were then used to calculate a total lead and toluene exposure value for every birth record. Binary logistic regression was used to assess maternal characteristics effects on birth outcomes. Chi square tests were used to assess maternal characteristics and levels of exposure to lead and toluene. Chi square tests and binary logistic regression were then used to assess pregnancy outcomes in relation to quartiles of exposure. This study found that mothers with certain age, race, education, and marital characteristics were significantly associated with lower exposure levels of lead and toluene. However, exposure to higher levels of lead or toluene, as measured in this study, was not significantly associated with an increased risk for preterm delivery or term low birth weight. Adverse pregnancy outcomes negatively impact an individuals immediate and lifelong health. Decreasing the incidence of preterm delivery and low birth weight are of great importance to public health. Research that helps to identify environmental determinants of adverse pregnancy outcomes is of vital public health significance.

Depression is the most common mood disorder after traumatic brain injury (TBI). This study evaluated how the presence and/or severity of depression post-TBI affect a persons cognitive status and quality of life (QOL). Demographic variables, injury severity, and pre-morbid psychiatric histories were documented from patient interview and medical records. Persons with TBI were assessed at 6 and 12 months post-injury for posttraumatic depression using the Patient Health Questionnaire (PHQ-9). They were also evaluated for cognitive status and QOL at the same time points. Results indicate that persons with moderate/severe TBI exhibit worse cognitive status and report lower QOL post-injury than persons with no depression. Persons with mild depression report lower QOL than persons with no depression, but do not display worse cognitive functioning. The severity of posttraumatic depression, not just the presence of depression, affects a persons cognitive status and QOL after injury. TBI and posttraumatic depression are chronic conditions. The Chronic Care Model is a framework for identifying and improving care at multiple levels within the health care system including delivery system design, decision support, clinical information systems, self-management support, and within the community. The current health care delivery for persons with TBI suffering from posttraumatic depression and treated in southwestern Pennsylvania is discussed and areas for improvement within the system are identified. The public health significance of this research is important for understanding the relationship of depression, cognition and QOL after TBI and effectively targeting persons with posttraumatic depression to formulate interventions which allow for better outcome and QOL post-injury.

Latina immigrants living in the United States face many challenges when trying to access prenatal care, including lack of insurance, lack of citizenship, language barriers, and financial limitations. There has been little research conducted on prenatal care for Latinas from the clinical perspective. Bridging this research gap has the potential to significantly improve quality of care. Prenatal care providers in Allegheny County, PA, were interviewed on various topics regarding care for their Latina patients, focusing on challenges, protective factors, and opportunities for improvement. Providers included obstetrician/gynecologists, family medicine physicians, nurses and doulas. An interview guide was developed based on existing literature on prenatal care for Latinas and quality measurement theory, including Donabedians theoretical framework. Language, citizenship issues, lack of health insurance, and financial burdens were some of the primary barriers identified by the providers also specified in the literature. Inadequate domestic violence and family planning resources were among the interview responses that were not emphasized in the literature. Recommendations included the expansion of state sponsored health insurance to all women during pregnancy, increasing the number of Spanish-speaking prenatal care providers, and improvements to informed consent procedures in the hospital system. In terms of public health significance, this research is directly related to several Healthy People 2010 goals, including increasing the number of women who receive adequate prenatal care and improving infant mortality rates.

The Physician Orders for Life-Sustaining Treatment (POLST) form was designed to help individuals in the last stages of life express their wishes regarding life-sustaining treatment. End-of-life care is often provided in a multitude of health care settings including hospitals, skilled nursing facilities, hospice centers, and in patients homes. Communication failure between these facilities and patients or their families often leads to care that is in opposition to the patients desires. In addition, living wills and advance directives that are currently in use do not provide health care workers with the information needed to properly carry out the patients last wishes specific to life-sustaining treatment. POLST seeks to overcome these barriers by creating a simple, understandable form that is easily transferred between care settings. The POLST form was created in Oregon in 1991 and has since been used throughout the state. Numerous studies conducted in the state have found that the use of POLST ensures that patients receive the desired level of care during the end stages of life. The Commonwealth of Pennsylvania has been using the POLST form in a limited number of settings since 2000; however, widespread use of the form has yet to occur. As Pennsylvania has an aging population, quality care for those in the end stages of life is of particular public health importance. This paper examines the literature surrounding the development and implementation of POLST in Oregon, its spread throughout the United States, and its current status in Pennsylvania in order to answer the following questions: 1) Should Pennsylvania adopt widespread use of the POLST? And (2) if yes, how should the Commonwealth go about overcoming the barriers to implementation?

The role that schools play in the health of our youth is of public health significance because they have the ability to provide health services directly to children and affect health outcomes. Many of todays health challenges among youth are onset by behavioral choices that they make. Schools are in the unique position to make an impact on behavioral choices through the use of health education programs and services. As adolescent issue become more complex, it is essential for schools to take on a comprehensive school health education program. The comprehensive approach focuses on increasing knowledge, self-efficacy, and behavior intention, while providing an environment that is conducive to maintaining and sustaining positive health behaviors into adulthood. This paper advocates for the use of comprehensive health education programs to target adolescent problem areas and increase overall health and well-being. The main concept and theme in this paper is establishing, improving, and increasing self-efficacy using comprehensive school health programs to address the particular needs of adolescents based on theories of health behavior change that are discussed throughout the paper. Evidence from successful school-based programs suggests that the comprehensive approach is powerful in increasing knowledge, self-efficacy, and behavior intention/change. Policies need to be centered on improving school health, and schools also need to take the initiative to implement a strong framework into their systems. An increase in morbidity and mortality among adolescents suggests the need for continued coordinated efforts in order to decrease negative behaviors that may carry into adulthood.

People living in rural America face unique social circumstances that often prevent them from achieving optimal health status. Economic instability significantly contributes to higher rates of chronic disease and poor mental health among rural residents. The social conditions associated with rurality are gendered with rural women bearing the brunt of social and psychosocial detriments to their health. Income, education, role responsibilities, living circumstances and personal and community health resources are among the main areas challenging rural women today. The psychosocial stressors that result from the demands of rural life affect rural womens mental health, functioning and behavior. Considering the social context of individual rural areas in the light of health behavior interventions is essential to increasing their potential effectiveness. Health campaigns targeting smoking, nutrition and physical activity- chronic disease risk factors- can no longer be indifferent to social circumstances. Without recognition of the unique social context and experiences of rural women, the solutions implemented to meet health care needs in rural areas have little hope of achieving success. The examination of rural social contextual factors is of utmost importance and public health significance as intervening to improve social circumstances may result in decreased incidence of some diseases in rural women.

BACKGROUND: Social capital is the term used to describe the results of social relationships formed by reciprocal exchanges among members of social networks such as religious, political, and other kinds of organizations. Research about this complex, widely debated concept has focused on cognitive and structural measures formed around several broad constructs: sense of community; trust and reciprocity; social support; social networks; participation; and collective efficacy. These constructs can be analyzed using individual, ecological, and multilevel analyses. However, the social capital literature provides little evidence about the relationship between social capital and health or the causes and consequences of this relationship. This lack can be attributed to definition and measurement issues within the literature, which also sustain the question of what the health benefits are from social capital. METHODS: Using a meta-analysis to examine the breadth of the social capital literature, I seek to characterize the literature and provide an overall estimated effect size that statistically describes the relationship between social capital and health. RESULTS: Meta-analysis of studies cited in the literature shows a modest positive relationship between social capital and self-reported health, social capital and all-cause mortality, and also significant, previously unexamined differences among the studies themselves: first, whether they reported an effect size or if an effect size was estimated; and second, there was a marginal difference in whether they focused on self-reported health or all-cause mortality. CONCLUSIONS: There is a modest positive association between social capital and health which suggests unexplained factors that drive the relationship between social capital and health. PUBLIC HEALTH SIGNIFICANCE: The results of this study indicate a need for social capital research to clearly define its constructs and measures and to provide more evidence about the relationship between social capital and health. Future research should identify micro- to macro-level factors that can influence this relationship. Such evidence can guide the design of future studies that seek to increase the stock of social capital for individuals and communities.

Utilizing concept mapping, the primary goal of this dissertation research was to explore the range of factors that influence food buying practices. A total of twenty five participants from two low-income zip codes in Pittsburgh, PA completed the concept mapping process. The participants were recruited based on residential proximity to a supermarket. This dissertation is organized around the presentation of three manuscripts. The first manuscript presents an exhaustive review of the literature related to food deserts. The research presented in manuscript two identified perceptions of factors influencing food buying practices among residents of an urban food desert (n=12) compared to a food oasis (n=13). Results identified 121 unique statements that were grouped by participants into 12 clusters, or unique concepts. Analyses show that overall, the average cluster ratings for residents of the food desert were higher than residents of the food oasis. Research presented in manuscript three addressed how residents perceptions of factors influencing food buying practices differ by food security status. Findings show that food insecure participants rated clusters higher than food secure participants. A secondary aim was to explore how important these factors are to hindering healthy eating based on food desert and food security statuses. Overall, cluster rankings were similar for food secure participants in a food desert and food secure participants in a food oasis. However, participants in the food desert rated all of the clusters higher than participants in the food oasis. In comparing food insecure participants in a food desert to a food oasis, findings show that although cluster rankings were different, average cluster ratings were similar. The public health significance of this study is that it contributes to our understanding of factors that influence food buying practices based on neighborhood and individual-level characteristics, an area that has received limited consideration. Based on findings from this research, areas for future research, and policy and program development have been uncovered to address the lack of access to healthy foods for urban residents of low-income areas.

Multiple studies have shown that African Americans have less access than do Whites to healthy food in many cities in the US. Less is known, however, about how African Americans perceive their neighborhood nutrition environment, and how this affects their diet. We studied people's perceptions of their access to healthy food in majority-African American neighborhoods in and around the city of Pittsburgh using a mixed methods approach. Supermarket addresses were geocoded using ArcGIS and the location of supermarkets with respect to majority-African American census tracts was determined. A convenience sample of 236 people completed a self-administered survey, and two focus groups (n=14) were conducted. Results demonstrate that whereas some Black neighborhoods are proximal to supermarkets, others are two miles or more away. People's perceptions of the quality of food and service available to them are strongly determined by the identity of the store at which they shop. Satisfaction with the quality of food available in the primary grocery store is positively correlated with self-efficacy (confidence in their ability) to find healthy food; it is correlated with self-efficacy to afford healthy food in high-income, but not in low-income respondents. Focus group data suggest that while African Americans perceive that the quality of food and service in supermarkets serving the Black community are worse than at branches of the same chain that serve white neighborhoods, they continue to frequent these "Black Identified" supermarkets because of loyalty to Black ownership of some stores, a perceived fear that failure to support stores in their neighborhoods may result in closure, as well as because of the easy access to "Jitneys" (unofficial taxis), which make regular trips to these supermarkets. We conclude that access to grocery stores that afford a high level of satisfaction with the quality and selection of produce is a predictor of self-efficacy to engage in a healthy diet. Every effort must be made to ensure that stores that cater to African Americans address the perceptions and needs of their clients and provide an environment that enables healthy eating: this will help prevent chronic disease, an objective of huge public health significance.

The purpose of this thesis is to review the literature on behavioral interventions for sexual health promotion that target Latino adolescent in the United States. A systematic review of the literature was conducted using five online databases to identify sexual health behavior interventions in Latino adolescents. Articles were included if they were published between 1993 and 2008, and provided measureable objectives of increasing knowledge; changing attitudes or intentions; or decreasing risky behavior, STD infections and/or pregnancy. The interventions are analyzed for use of a theoretical framework, content, methodology, assessment of measured outcomes, and effectiveness. Additionally, the interventions are classified using the Social Ecological model as a framework to identify the levels (i.e., the individual, interpersonal, community levels) at which they influence health behavior. Fifty three articles were identified, but only 11 are included in the review. Interventions were found to have fundamental similarities and differences between their targeted populations, objectives, theoretical frameworks, content, intervention designs, duration and intensity, participation and attrition rates, mode of outcome assessment, measured outcomes, effects, methodological quality, and limitations. With the exception of two interventions, all studies integrated the established criteria for methodological quality. The most frequently reported limitation was the concern for representativeness of the intervention sample to the United States Latino adolescent population, and insufficient time for follow-up evaluation. The findings from this literature review suggest that among the behavioral interventions targeting Latino adolescents, very few have addressed adolescent sexual health. In the reviewed interventions, the most common intervention objective was the prevention or reduction of sexually transmitted diseases including HIV/AIDS, focusing on changing behaviors at the individual and the interpersonal levels. Major strengths and weaknesses are discussed about the Latino adolescent sexual health research agenda. Furthermore, the needs are identified in the Latino adolescent sexual health promotion from a social ecological perspective. Adolescent sexual health among United States Latinos is a fairly new field of research with multiple problems of great need and of much public health significance. More research is needed in producing new or validating existing, age-specific, and culturally-sensitive sexual health interventions for Latino adolescents in the United States.