Breast cancer remains the most common type of female cancer across all populations in the United States. However, a gap remains in understanding the perceptions women have as they relate to breast health and the breast health Continuum of Care, which includes screening, diagnosis, treatment, and follow-up care. Many existing studies lack appropriate data which explore these perceptions. Through a partnership between the University of Pittsburgh Graduate School of Public Health and the Pittsburgh Affiliate of Susan G. Komen for the Cure®, community-based participatory research was used to examine and understand the range of factors which affect a womans ability to engage in the Continuum of Care. Concept mapping, an intensive, structured conceptualization process that produces a framework for how a group views a particular topic, was used. A strength of the method is that participants actively contribute to the research process through the generation of data, ensuring the final outcome is representative of their perspectives versus that of the researcher. Thirty-one women and one man from three areas in western PA (Pittsburgh, Meadville, and Huntingdon) participated in the concept mapping sessions. They identified 94 factors perceived to be related to the breast health Continuum of Care. Examples of factors include trust in doctors, cost of transportation, number of treatment choices, and cancer diagnosis no longer is a death sentence. Results were shown in a seven cluster concept map. Notable difference in cluster importance by location were explored. The public health significance of this research offers insight into the deficiencies and strengths of the health care community in addressing breast health and breast cancer needs of women. These findings are important for further research as it relates to womens perceptions around breast health and breast cancer. The research and partnership between the Graduate School of Public Health and Komen Pittsburgh has the potential to influence advocacy efforts, create a healthier environment in western PA, and inform testable hypotheses for future qualitative and quantitative, multi-level research on this topic.

HIV/AIDS has been a looming public health threat for decades. With an estimated 15 million AIDS-related deaths in Africa since the emergence of the disease, over 14 million orphans have been left in its wake. Generations of parents lost to AIDS have created a vacuum of care for the orphans they leave behind. The burden of care is placed on ill-equipped aging relatives, older siblings, or caregivers in local orphanages. Evidence from the literature indicated that orphans are plagued with emotional trauma following parental loss and suffer worse health outcomes without emotional, social, and financial support. Data collected from questionnaires administered in Arusha, Tanzania indicated that orphans lack many resources paramount to their healthy growth, and that caregivers desire to learn skills to help them become better orphanage leaders. Without the means to generate income and skills in child psychology, HIV/AIDS education, and first aid, orphanage caregivers cannot provide the best support for the orphans in their care. This has public health significance because without proper socialization, these orphans may become trapped in the cycle of poverty, leading to health problems including HIV infection, and a lack of economic productivity in adulthood. Understanding the facets of caregivers and orphans lives in sub-Saharan Africa through the literature, questionnaire data, and interviews exposed the need for continued caregiver training, the implications for further research and intervention creation, and the limitations faced. In this applied research and theory intervention, a pilot program was designed for caregivers in Arusha to learn various requested skills through training sessions over the course of one year. The programs goal is to increase knowledge and skills in child psychology, HIV/AIDS education, first aid, small business creation and management, and training so caregivers can better care for and teach their orphans. The proposed training program has four intended outcomes for the participants: first, to have a workable knowledge of the skills taught; second, to train their peers in the skills they have learned; third, to improve their care of orphans by implementing the skills they have learned; and fourth, to create a social network for the caregivers to provide an emotional and intellectual support system. From these outcomes, caregiver and orphan emotional and physical health statuses will improve and a sustainable social network will foster continued skill building and support.

Background: Over 300,000 pregnant women experience intimate partner violence during the course of their pregnancies each year, exposing both the mother and fetus to physical and emotional harm. Though many programs are available to victims of intimate partner violence, there continues to be a lack of effective interventions available to women who are pregnant while experiencing abuse. Objective: To identify current research and programming as well as explore the perceptions of women who have experienced abuse during their pregnancies. Methods: Semi-structured interviews were conducted with two women between December 2010 and February 2011. Results: Three similar topics surfaced in both interviews conducted. First, the women interviewed articulated feeling trapped in staying with their abusers due to their pregnancies. Second, financial support emerged as a reason why participants stayed with their abusers. Finally, both participants expressed that they wish they had known of people to talk to about their abuse during the course of their pregnancies. Conclusions: There appears to be a need for consistent and effective screening of intimate partner violence during prenatal appointments. In addition, there should be an increase in the development and implementation of programs that focus on providing individual support and placing emphasis on social support. Public Health Significance: Intimate partner violence continues to be the leading cause of injury and death in women of childbearing age in the United States. Paired with pregnancy, the risks of negative health outcomes to both mother and fetus are high and the repercussions include short and long term injury, emotional distress, and even death. Economically, costs of the harm caused by intimate partner violence during pregnancy exceed close to six billion dollars each year. Intimate partner violence during pregnancy is of major public health concern and continuing to address it in research and the development of interventions is necessary in mitigating the impact that it makes on the lives of those who experience it.

Men who have sex with men (MSM) in the US experience great disparities in health outcomes, most notably in HIV. This dissertation will take a look at these disparities and offer a framework for understanding their etiology and for understanding the processes by which these disparities are sustained, propagated and eventually broken down. First, we provide an overview of the literature regarding health disparities among MSM and the current theories that exist to understand where these disparities come from. Specifically, we focus on Syndemics Theory and the Theory of Syndemic Production as the best models for understanding health among MSM. Finally, we suggest a new theoretical model, Cultural Resilience Theory, which can be used to conceptualize health promotion within the syndemic framework. We also test components of Syndemics Theory interaction and mediation that until now have functioned as assumed premises with no empirical support for their assertion. Finally, we test Cultural Resilience Theory as a model that can be used in prevention programming to break down syndemic processes among MSM. In the final chapter we look into the practical implications of Cultural Resilience Theory as it applies to the prevention (or abatement) of health disparities among MSM. The findings of this study have great public health significance and important implications for HIV prevention among MSM. First, the synergism analysis is the first to test the assertion that co-occurring psychosocial health conditions interact to increase HIV risk among MSM. These results suggest that there is a synergistic effect present. Likewise, the mediation analysis is the first to test the theory of syndemic production that states that early life adversity impacts HIV outcomes through syndemic processes; an assertion that was supported by these analyses. These two studies further our understanding of how syndemics function within MSM to produce health disparities. Finally, we identify several variables that break down syndemic processes through either their negative association with poor health outcomes, or by buffering the pathways from adversity to HIV risk through syndemics. These results will provide the foundation upon which a culturally tailored Theory of Cultural Resilience among MSM can be developed.

OBJECTIVE: Previous research demonstrated that financial distress is associated with depressive symptoms, and that religiosity/spirituality buffer the effects. Yet, research on the interaction between these factors or what factors may contribute to financial distress is limited. The purpose of this study was: 1) to examine the relationship between perceived financial distress and depressive symptoms; 2) to identify financial priorities and needs that may contribute to financial distress; and 3) to explore if religious coping and/or social support act as moderators in the relationship between financial distress and depressive symptoms. METHODS: Surveys from 111 African American women, ages 18-44, who reside in Allegheny County, PA were used to gather demographic information and measures of depressive symptoms, financial distress, social support, and religious coping. Correlation and regression were used to examine relationships. Two open-ended questions were analyzed to assess priorities and needs. RESULTS: Perceived financial distress was significantly associated with levels of depressive symptoms. Priorities identified by the participants were paying bills and debt, saving, purchasing a home or making home repairs, and/or helping others. Needs identified by the participants were tangible assistance and/or financial education. Religious coping (total, internal, and external) and total social support were not moderators between perceived financial distress and depressive symptoms. However, tangible social support was found to be a moderator, in that higher levels resulted in lower levels of depressive symptoms for individuals with high and average levels of financial distress. CONCLUSION: Ways to manage and alleviate financial distress as well as identifying organizations, programs, services, and or individuals that can provide tangible social support should be considered when addressing the mental health of African American women. PUBLIC HEALTH SIGNIFICANCE: Perceived financial distress is significantly associated with levels of depressive symptoms and this can be used to create new and/or enhance existing programs, services, and/or interventions that not only focus on and treat women at risk for depression but that also address personal finances and tangible support. This finding also draws attention to the need for collaborative efforts among professionals in different disciplines.

Objectives/Research Questions: This descriptive research describes the reported uptake of CDC Controlling High Blood Pressure and Controlling High Cholesterol Indicators among funded state programs for heart disease and stroke prevention. The Indicators serve as evidence-based performance measures which aim to streamline the implementation and evaluation of the National Heart Disease and Stroke Prevention Program. Methods: Participants included 42 state health departments funded by the CDC for heart disease and stroke prevention initiatives. Fourteen states were funded as Basic Implementation programs (to implement and evaluate interventions) and 28 states were funded as Capacity Building programs (to enhance capacity for implementing interventions). Documentation of Indicator uptake was extracted from the 2009-2010 and 2010-2011 Work Plans for all funded programs. Results: In general, all programs reported increased uptake of Indicators over time. On average, from 2009 to 2011, Basic Implementation programs reported more Indicators per Work Plan compared with Capacity Building programs. Conclusions: While this study provides documentation of the uptake of Indicators in Work Plans, a subsequent analysis should research if the appropriate use of Indicators as a performance measure improves documentation of the actual reach and impact for heart disease and stroke interventions. Implications for Public Health: Contributions to the public health field include: (a) providing guidance to state programs, (b) visualizing the trends and patterns in the reported use of Indicators for Controlling High Blood Pressure and Controlling High Cholesterol among state programs, (c) encouraging accountability, and (d) sharing the strengths and/or areas for improvement with state programs to foster better programming and enhance Communities of Practice.

There has been a documented increase in incidence and prevalence of noncommunicable diseases, in particular cancer, in low- and middle-income countries. With a lack of healthcare facilities and trained health care providers to support this new patient population, relatives and close friends provide the majority of care. The majority of research examining the emotional and physical impact of providing care to a loved one with cancer has been conducted in developed nations; however, there is a paucity of research examining the experience of providing care to a loved one with cancer in low- and middle-income countries, specifically in Tanzania. The overall goal of this study was to gain an in-depth understanding of the experiences of cancer caregivers in Tanzania. This study utilized a qualitative, cross-sectional design. Family caregivers of cancer patients were administered face-to-face interviews that lasted for approximately two hours. The participants were queried regarding sociodemographic information as well as overall well being, difficulties and positive aspects of providing care, access to information and resources, family and friends, and health care provider communication. These interviews were audiotaped and transcribed verbatim. Content analysis was used to identify the emergent themes. Ten themes emerged from the participant interviews. The themes that were relevant to the specific aims of this study were accessibility of information, social support, providing care, and end of life. Other themes that emerged from the interviews and are important to highlight are: access to medication, time to diagnosis, no hope/no cure, access to hospital, symptom management, and formal healthcare. The results of the analysis suggest that caregivers have several unmet needs throughout the care situation and experience increased feelings of emotional and financial burden. With the rising incidence of cancer in Africa and the lack of institutional facilities and specialists to support this new patient population, family and friends become the primary caregiver. If caregivers emotional and physical health is not preserved, the quality of care they deliver may suffer and more demands placed on the health care system by both the patient and caregiver.

Chlamydia trachomatis is a bacterial infection spread through sexual contact, including oral, anal and vaginal sex. This largely asymptomatic infection is highly prevalent in the United States and has been for the past 40 years: indeed, chlamydia is the most common sexually transmitted disease (STD) in the United States. Left untreated, chlamydia can cause Pelvic Inflammatory Disease (PID), ectopic pregnancy, and infertility in women; complications are rare in men. Screening for this infection is necessary for its control and prevention and is a matter of great importance to public health. Currently, the Centers for Disease Control and Prevention (CDC) recommend annual chlamydia screening for all sexually active women aged 25 years and younger, older women with risk factors (new sex partners or multiple sex partners), and all sexually active men who have sex with men (MSM). This thesis examines the history of the CDCs chlamydia screening recommendations, the implications of the CDCs recommendation that all sexually active young women be screened for the infection, and the barriers to following current chlamydia screening recommendations. Through a close analysis of available evidence, this thesis asserts that the CDCs chlamydia screening recommendations are inconsistent, have not been updated to align with current diagnostic testing developments, place the burden of the disease upon women, further stigmatize people who are marginalized, and most importantly, fail to include sexually active heterosexual young men, a population that transmits the infection to women. New chlamydia screening recommendations are necessary based on the lack of control over disease prevalence, the unequal burden of the disease on women, and the increased feasibility of diagnostic measures for men. Consequently, the CDCs guidelines should be updated. The guidelines should continue to recommend the annual screening of all sexually active women aged 25 and under and also recommend the annual screening of all sexually active young men aged 25 and under, as well as men and women over the age of 25 with risk factors.

Background: Older adults prefer to maintain an independent lifestyle even though there are physical, psychological, and social factors that sometimes affect their ability to maintain this style of living. Support and Timely Attention for You (STAY) is an aging in place program that helps older adults remain independent and delays their movement to higher levels of care such as those offered in assisted living or skilled nursing facilities. To determine whether STAY increased the number of days in independent living and decreased the number of hospital admissions, an outcomes evaluation was conducted. Methods: Independent living residents were divided into two groups, those receiving STAY services, (STAY), and those not receiving STAY services (nSTAY). The number of falls, hospital admissions, number of days in independent living, and scores from the Senior LIFEsteps assessment were analyzed before and after the program began. Results: A number of findings suggested STAY was having a positive impact. For example, return to independent living (IL) following a hospital admission increased. Nearly 70% of hospital admissions in 2010 involved a STAY resident, and of these, 72.7% of the residents were able to return to IL. The percentage of STAY residents admitted to the hospital decreased from 44.7 % in 2009 to 33% in 2010. Interpretation of the Senior LIFEsteps data indicates the health status of STAY residents did not decline over the years. The majority of falls and illnesses involved STAY residents. Conclusions: The STAY program provides a high quality of care to the residents. Due to the difficulties in obtaining a control group, it was impossible to determine whether the STAY program increases the number of days in independent living. However, there appears to be a number of positive findings relative to program impact. A stronger design would be needed to demonstrate these outcomes are due to STAY. Public Health Significance: The STAY program provides a unique way for older adults to maximize their quality of life as they age in place. This type of program has the potential to decrease healthcare cost by reducing hospital admissions caused by medication non-adherence, falls, and illnesses.

There is an urgent need for culturally appropriate strategies to promote the health of the refugee population and facilitate its successful adaptation in the United States. Without this adaptation, refugees in the United States being at risk of developing and maintaining high levels of negative health outcomes, which creates a significant public health problem. Healthy Girls Circle- Youth and Elders Sharing (HGC-YES) program aims to 1) educate Somali Bantu female refugees who now reside in Pittsburgh on health related topics such as reproductive health, exercise, and nutrition, and 2) train the participants as lay health educators so they can disseminate the health related information to members of the Bantu community, specifically elder females. Process and outcome measures were used to gain a better understanding of program effectiveness and its ability to fulfill its objectives. Evaluation measures indicated that participants experienced a consistent increase in knowledge of health related topics, but participants failed to document their dissemination of information into the Bantu community. Additionally, varying attendance rates due to scheduling conflicts and miscommunication between HGC-YES staff and participants contributed to the programs difficulty in achieving its objectives. Since the HGC-YES supervisor has developed a trusting relationship with the Bantu community over several years, there are opportunities for change. The HGC-YES program holds a great deal of potential in promoting the health of the refugee population and facilitating its successful adaptation in the United States.