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.

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.