A fundamental worldwide public health concern is the growth of HIV incidence rates and the fact that two thirds of this global pandemic is located in sub-Saharan Africa. A concerted effort to control the diseases prevalence within integrated comprehensive care frameworks for underserved populations remains a critical international priority. Integration of services to halt the spread of HIV is of significant international public health relevance and will require greater collaboration at local, national, and international policy levels. Comprehensive care is a simple concept that is profoundly complex to implement in countries that have previously established vertical tuberculosis treatment regimes and sexual and reproductive health programs. In resource poor countries such as Mozambique, there is a great deal more research and learning necessary to assure the efficacious delivery of anti-retroviral therapy as part of improved medical adherence follow-up programs. Evidence from the literature revealed that many HIV-infected persons are not responding to medication regimens due to a lack of medication adherence that includes loss-to-follow-up cases and a lack of access to health care services. For this applied research project, a pilot program was designed for the University of Pittsburgh, School of Medicines Treatment and Care Initiative in Beira, Mozambique. This programs goal is to increase adherence to HIV treatment regimens within a comprehensive care model that recognizes the impact of social determinants of health. The proposed intervention has five intended outcomes: first, to develop a five-year plan with stakeholder input; second, to improve clinician, medical student and patient communication regarding the barriers and solutions to HIV medical adherence; third, to develop a baseline for loss to follow-up cases through a health care worker outreach effort; fourth, to integrate medication treatment regimens for co-infected HIV/TB patients with Central Hospital of Beira; and fifth, to conduct an outcome evaluation assessing project impact on HIV/AIDS medical adherence. Mozambican cultural factors that may influence medical adherence behavior also were examined.

The public health significance of sleep extends to both the impact of sleep on health outcomes and the demographic disparities of the experience of poor sleep. Sleep is often under-appreciated as a health factor. The purpose of this thesis is to provide a synthesis of the literature on the epidemiology of sleep and the health outcomes of poor sleep. METHODS: A literature review was conducted and compared to analysis of data from the Patient-Reported Outcomes Measurement Information System (PROMIS) sleep assessment study. The PROMIS sample is comprised of 258 individuals who self-reported symptoms of a sleep disorder. RESULTS: Literature revealed that gender, race, marital status, and socioeconomic status are factors that are associated with sleep. The literature also stresses the impact of sleep on several cardiovascular conditions. Among the PROMIS study sample of individuals with sleep disorders, marital status, and socioeconomic status were associated with sleep quality. Correlations were found between sleep disturbance and income, education, and body mass index. Wake disturbance (daytime functioning problems) was associated with diabetes and was correlated with age, income, and education. A diagnosis of insomnia was associated with the Caucasian race, depression, and low income. Obstructive sleep apnea diagnosis was associated with high blood pressure, being overweight or obese, being married or living with a partner, and having an income from $50,000 - $99,999. Restless legs syndrome was associated with having high blood pressure. CONCLUSIONS: Though the literature and the PROMIS study analysis were generally in agreement, gaps and incongruities exist both within the literature and between PROMIS and the literature. Specifically, the PROMIS sample found no association between sleep and gender. It is important to note that the comparison is between a literature synthesis of sleep in the general population and a data analysis of sleep-disordered individuals. More research is needed to better understand the epidemiology of sleep and the health effects resulting from poor sleep. Suggestions for future research and interventions are provided.

Purpose: This research aimed to determine how health communication, risk communication, and website evaluation criteria could be utilized to evaluate environmental health information on the Internet. Public Health Significance: Concerns exist about the quality of health information on the Internet. Environmental health plays a considerable role in public health but can be difficult to communicate effectively, especially in a dynamic and diverse system like the Internet. An evaluation tool tailored specifically for environmental public health messages on the Internet should be developed to assess the quality of those sites. Methods: A literature review identified previous website evaluation tools and general health and risk communication techniques. Using those tools as a framework, a website evaluation tool tailored for assessing environmental health information on the Internet was developed. In order to pilot test this tool, five government websites and one emerging environmental health issue, particulate matter (PM), were selected and evaluated. Results: The key criteria identified in the literature review and incorporated into the website evaluation tool included: Basic Website Information, Content (with subsections: Scope, Accuracy, Risk Communication, Authority, Up-to-Date, Links, and Writing Quality), Appearance/Layout, Purpose/Audience, and Access/Use. The website evaluation tool showed considerable practicality and ease of use in identifying the strengths and weaknesses of the five websites during the pilot testing. The Environmental Protection Agencys website received the highest overall score and in the content section. The Kansas Department of Health and the Environments website received the lowest scores in most of the evaluation categories and overall. None of the websites passed the tools readability criteria. Conclusions: Consensus exists regarding the need for evidence-based and validated website evaluation tools. A tool developed by consolidating communication recommendations from varying fields of study provides researchers throughout the interdisciplinary field of public health with a research base and evaluation framework for future Internet-based environmental health communication projects. Additionally, the organizations responsible for the pilot-tested websites can use the individualized results from the evaluations to improve and guide their online environmental health communication efforts.

Teenage pregnancy in Kenya, East Africa, has emerged as a significant public health concern because of its contribution to increased fetal and maternal mortality, increased spread of sexually transmitted infections (STIs) and the declining socio-economic status of women in Kenya. At present 25% of Kenyan females ages 15-19 are either pregnant or have children and 85% of females 15-19 do not use contraceptives. If the country fulfills its unmet need for family planning thus reducing incidences of teenage pregnancy, it can help Kenya significantly reduce the cost of achieving five of the eight Millennium Development Goals (MDG) goals set by the United Nations. To meet their unmet family planning needs, youth nearing or entering their sexual debut need instruction on family planning/sex education. Comprehensive sex education, which includes education on abstinence and birth control methods, has proved effective in delaying sexual debut, reducing frequency of sex, reducing the number of sexual partners and increasing condom or contraceptive use. Comprehensive sex education does not encourage teenage sexual activity nor does it lead to early initiation of sexual activity. Instead participating in a comprehensive sex education programme improved adolescent decision- making skills and boosted self-confidence. An on-line search for functioning comprehensive sex education programmes targeting girls between the ages of 14-18 in Kenya, East Africa, was conducted from January to March 2009. Five programmes were identified: 1) Primary School Action for better Health, 2) Teen Web, 3) The World Starts With Me, 4) Tuko Pamoja [We are One] and 5) Youth for Youth. These programmes met the inclusion criteria used for this paper, all programmes are conducted in Kenya, were initiated after 1990 and are still running, target either adolescent girls or the general adolescent population ages 14 to 18 and must teach comprehensive sex education. Programmes that taught only abstinence were excluded. This paper discusses these comprehensive sex education programmes, examines curriculum design and content and critiques how effectively they met seventeen criteria of a well designed comprehensive sex education (CSEP) curriculum as outlined by Douglas Kirby, a senior research scientist and one of the worlds leading experts on the effectiveness of school and community programmes in the reduction of adolescent sexual risk-taking behaviours. This paper also discusses barriers to implementing nation-wide CSEPs in Kenya and strategies to improve and institutionalize available CSEPs.

This paper critically reviews HIV/AIDS prevention strategies in Kenya. Since HIV/AIDS was discovered over twenty years, it has continued to be a public health problem throughout the world. While global prevalence has stabilized in recent years, the number of people living with HIV is increasing because of new infections with longer survival times. High rates of transmission result from failure to use effective strategies and tools, and failure to target high risk groups. Kenya is no exception to this situation. Objective of this study is to identify gaps in HIV prevention and make recommendations for improvement. Methods The study methodology follows three steps. 1. A benchmark of proven HIV prevention strategies by the HIV prevention working group is identified. 2. Ugandas HIV prevention efforts, a country that has had success in the fight for AIDS, are presented to compare to Kenyas efforts 3. Kenyas prevention strategies have been identified through examination of reports and websites from three umbrella bodies representing the government, non-governmental and community organizations, and international organizations. Examination and comparisons between the three groups will help identify gaps in Kenyas prevention efforts and make recommendations. Results Overall, Kenya has put effort in HIV prevention including using several proven strategies, including, voluntary counseling and testing for HIV (VCT), STI diagnoses and management, abstinence, being faithful condom use and male circumcision (ABCCs), prevention of mother to child transmission (PMTCT), behavior change communication (BCC), safe blood supply and injection safety. Despite these efforts, gaps still exist. First, regional differences in HIV infection, second, most vulnerable and high risk groups need intensive programs, third, prevention efforts lack integration with other programs. Finally there are gender differentials and inequality, insufficient programs for young people and cultural barriers. Conclusions Universal coverage of prevention efforts is necessary. Social factors like inequalities, gender differentials and cultural barriers need to be addressed, especially women empowerment. Youths should be targeted through age specific sex education programs. High risk and vulnerable populations should be prioritized. Local leaders and peer training are necessary to reach these populations. A comprehensive and integrated approach to HIV prevention is advocated

Objective: Given the dramatic increase of new interactive features on the Internet known as Web 2.0 sites, the objective of this study was to determine how features such as member profiles, personal blogs and online social networks were used in virtual communities related to type 2 diabetes and to describe the potential differences between the social ecology model of these virtual communities and traditional physical communities. Methods: All original posts and replies in two diabetes discussion forums in web 2.0 enabled virtual communities were recorded for ninety days. Utilization of these features and content from publicly available components of profile pages were recorded from a purposive sample of 60 members. Content was analyzed using qualitative coding techniques. Utilization of other Web 2.0 features was recorded to determine frequency of use among sampled members. Results: 272 original posts and 3605 replies were generated by the participants in the discussion threads. Discussion forum analysis revealed that food, medication and blood glucose levels were major themes for original posts. Replies usually included the empathic and personal experiences of other members. Group guidance emerged from the cumulative responses provided by the community and provided the individual with a sense of the normalized behaviors of the community. Analysis of the utilization of various Web 2.0 features revealed that those who withheld gender information used the features less often than those identifying with a gender. Utilization also appeared to be dependent on the design attributes of the website. Analysis of 204 personal blog entries revealed the daily struggles of the members and rarely discussed diabetes. Replies to personal blogs were more likely to include religious guidance and expressions of empathy and love. Strong social ties were evident between individual blog entries and those providing the replies. Discussion and Public Health Significance: Discussion forums provided members with the ability to gather disease specific information from a large network of individuals with salient experiences. Personal blogs and other features facilitated the formation of strong social ties to develop. The combination of these features online provides a unique opportunity for public health practitioners to develop comprehensive and multifaceted interventions.

This dissertation project examined protective factors against HIV infection among API MSM. First, we evaluated the literature for scientific evidence that may explain the lower HIV prevalence among API MSM. Four of the ten hypotheses provided some partial explanations or needed further investigation: 1) API MSM's sexual networks may be primarily composed of MSM of low HIV risk profiles; 2) Prevalence of seroadaptive behaviors is higher among API MSM; 3) HIV-positive API MSM have better access to care and treatment; 4) Ethnic heritage acculturation may be protective. Second, we examined race and age mixings among API MSM. It appeared that overall patterns of race and age mixing among API MSM tended to be more assortative. API MSM were more likely to be partnered with other API men than expected and the age difference between API participants and their partners were narrower than that among other participants. In addition, young API MSM were more likely to be aware of their partners's HIV status as a majority of their partners were main partners. Finally, we found that prevalence of seroadaptive behaviors differed little by race/ethnicities, which does not point to seroadaptation as protecting API MSM against HIV infection. Of concern, the significantly lower prevalence of serodisclosure behaviors among API MSM did not appear to translate into lower levels of seroadaptation. Our findings have significant public health implications. First, more research on how structural factors affect HIV infections among MSM are needed. Second, the socio-cultural and structural contexts of partner selection need to be explored. Third, public health professionals should be aware of changing behaviors within MSM communities so that new and innovative interventions can be developed. Fourth, a strength-based approach to studying protective factors against HIV infection among API MSM is overdue. Qualitative studies are needed to develop some strength-based conceptual frameworks. Fifth, it seems that certain Asian/API cultural issues or values would be worth investigating. Lastly, while HIV prevalence remains low among API MSM, bio-behavioral surveillance should keep monitoring HIV incidence and risk behaviors among this population and culturally appropriate interventions should be delivered to them, before it is too late to intervene.

Adolescents engage in risky health behaviors more than young children and adults. This risk taking is thought to be a result of biological and environmental factors influencing adolescent behavior. Teenagers' engagement in risky sexual behavior puts them at a higher risk for morbidity and social stress resulting from unintended pregnancy and sexually-transmitted infections. This increased risk of morbidity emphasizes the public health significance of adolescent risk behavior. Parental monitoring has been identified as an important protective factor for adolescents' negative sexual health outcomes. However, the distinction between rule-setting and coercive discipline is critical in understanding the influence that parents have over their adolescent's risk taking behavior. Without recognition of the importance of a supportive and trusting parent/adolescent relationship, parental monitoring studies and interventions will be less effective in bringing about behavior change in adolescents and their parents. Perceptions of parental monitoring can vary greatly between adolescents and parents, and thus there is a need for a scale to measure actual parental knowledge of adolescent risk behavior. It is also important to consider the quality of parent and adolescent relationships when attempting to understand the effects of parental monitoring. As a result, the examination of barriers to parental monitoring and the nature of the parent/adolescent relationship are crucial for making a lasting positive impact on adolescent sexual health outcomes.

Antenatal depression and anxiety are significant public health problems. Birth and neonatal outcomes suffer as a result of maternal depression and anxiety during pregnancy. As such, effectively treating depression and anxiety in the expectant mother is imperative to the overall health of mother and child. Psychopharmaceuticals are effective in alleviating depressed and anxious symptoms, but the evidence of the safety of their use during pregnancy is inconclusive. Furthermore, pregnant women themselves express the desire for non-psychopharmaceutical options when deciding how to manage their depression or anxiety. Mindfulness-based interventions show promise as a non-invasive, non-pharmaceutical option for managing negative affective states. To help predict the likelihood of a successful adoption of mindfulness-based interventions, midwives perspectives on using mindfulness in clinical settings with their depressed or anxious patients were investigated. Results indicated favorable attitudes towards using mindfulness, along with various barriers that may prevent the adoption of mindfulness in clinical settings.

Complete knowledge of a patients medications, including over-the-counter and alternative medicines, is essential to the healthcare professional in providing quality care. In addition to the multiple steps from prescribing, dispensing to administering of a drug medication, there are several factors that increase an individuals risk for an adverse event and approaches to reduce medication errors. The movement of healthcare systems to an electronic medical record provides the potential of building a better health care system. This retrospective study compares five sources of medication, medical record chart, specialist, electronic medical record, pharmacy, insurance provider and patient, to determine what is the most accurate source of documentation, and what factors leading to better knowledge and documentation of all of a patients medications. This study also identifies additional risk factors, specifically drug affordability and the influence it has on a patients behavior, and discusses some considerations for reducing medication errors. The prevention and reduction of adverse events is of public health significance as there is both a health and financial cost to treating these adverse events.