<p>The thesis presents three papers discussing some of the methodological issues regarding studies investigating complex community-based cardiovascular health interventions. All three studies involved the Cardiovascular Health Awareness Program (CHAP), a standardised blood pressure and risk factor assessment and educational sessions held in pharmacies or other locally accessible areas in small to mid-sized communities in Ontario, Canada.</p> <p>The first paper reviews the literature and proposes a guide on how to develop a theoretical framework for complex community-based interventions using CHAP as an example. The paper describes a stepwise process of developing a theoretical framework including challenges encountered and strategies employed to overcome them.</p> <p>The second paper presents how recently published randomized controlled trials evaluating complex community-based cardiovascular health interventions monitored and reported implementation fidelity based on a structured review of the published articles and a survey of their primary authors. The results showed that fidelity reporting of included studies was better than those described in previous reviews. Fidelity was verified through self-reports by implementers and supervision by researchers. Strategies described to standardize intervention delivery were through training of implementers and use of implementation guides. The authors’ survey results were consistent with the review results though there were some gaps which could be improved to strengthen fidelity reporting.</p> <p>A data analysis issue with studies investigating complex community-based interventions is that outcomes can be affected by factors from multiple levels. The third paper explores the association of individual, partnership, and community-related factors with CHAP participants’ use of health-related community resources and cardiovascular risk behaviours. This was a cross-sectional analysis of an on-going cohort study. The results showed that individual factors (age and self-efficacy) had the most consistent association with the outcomes. Community and partnership level variables showed less consistent association with the outcome. Methodological and analytical challenges were presented.</p> / Doctor of Philosophy (PhD)

Background: Studies regarding number of pregnancies and coronary heart disease have shown inconsistent results. In the present study, we assessed the association between number of pregnancies and heart attack (HA) in women.Methods: Using data from NHANES III a cross sectional data analysis of 10634 women aged 17 and above was conducted. We considered socio-demographic factors and other potential risk factors including physical activity, smoking, alcohol, diabetes, hypertension, hypercholesterolemia, BMI, age, and family history of heart attack. We conducted Bivariate analysis to determine prevalence and crude odds ratios. Multivariate logistic regression analysis was used to adjust for confounding variables using SPSS. Results: The prevalence and 95% CI of HA was 3.4% (3.0% – 3.7%). The age adjusted odds ratios for 7+ pregnancies was 2.33 95% CI [1.42-3.81], but this became insignificant when a fully adjusted model was used (odds ratio, 1.68: 95% CI, 0.89 to 3.16). For those with 4 pregnancies the risk was lowest in both age adjusted and fully adjusted models confirming the well known "J" shaped non linear relationship between number of pregnancies and heart attack. Conclusion: We found an association that was not significant between number of pregnancies and heart attack. Further studies using physician-confirmed diagnosis is needed to appropriately asses the potential relationship of gravidity and heart attack.

Purpose: Marijuana is the most widely used illicit drug in the United States. However, marijuana and cannabinoid derivatives have potential therapeutic uses. Studies in cannabis users have yielded contradictory results with regard to long-term effects on cognitive functions. There is no prospective study assessing this issue, and such studies may raise ethical issues in humans, whereas mice have been shown to exhibit similar cannabinoid-mediated behaviors as humans. The purpose of this study was to assess the consequences of chronic administration of Δ9-THC, the major psychoactive component of marijuana, in a mouse memory model. Methods: In Experiment 1, the dose-response relationship of Δ9-THC was assessed in the object recognition task, a well-documented rodent memory model. In Experiment 2, mice were treated repeatedly with either escalating doses of Δ9-THC or vehicle for one week, and then challenged with the drug to assess whether tolerance had developed. Results: Acute Δ9-THC dose-dependently interfered with memory as assessed in the object recognition task (ED50 95% C.I. = 0.5 (0.1 to1.7) mg/kg). No tolerance to the memory disruptive effects of 1 mg/kg Δ9-THC was evident after chronic treatment. Conclusions: Considerably low doses of Δ9-THC impaired memory. The failure of chronic Δ9-THC to produce tolerance in this model was surprising considering that a similar dosing regimen has been reported to produce tolerance in non-mnemonic behaviors. The results suggest that memory is particularly sensitive to the disruptive effects of Δ9-THC and chronic cannabis use is likely to elicit persistent impairment of cognitive function. Caution should be applied in advocating chronic use of medicinal cannabinoids. Potential solutions lie in reinforcing education on the harm caused by cannabis use and availability of alternative solution to cannabis users, especially among youth that have shown to be more vulnerable to this drug.

Objectives: The description of the raccoon rabies epizootic in Virginia over fifteen years (1989-2003). Methods: Using simple statistical methods and a geographic information system (GIS)-based approach, and fifteen years worth of animal surveillance data, the progress of this epizootic has been charted in terms of the geographic spread of the disease, the major animal species affected by the disease and its spread, and the exposure and risk to humans and livestock animals presented by the expansion of the geographic range. Results: The resulting descriptive study illustrates the eastward expansion of the epizootic, the mushrooming of the disease in the northern region of the state, and the rates of rabid animal submissions for every health district and selected important animal species. Human exposures to rabid animals are mapped and compared to human population densities. Strong seasonal trends in human and livestock exposures to rabid animals are illustrated, with animal exposures predominating in the spring and autumn, while human exposures peak in the summer; also shown is the possible emergence of new strains of rabies virus and the possible extinction of the previously dominant strain. Conclusions: Some potentially positive developments have been found, such as substantially increasing levels of bat submissions across time, which may signify greater public awareness of the disease. Serious deficiencies in the monitoring system are discussed, centering on the accuracy and comparability of the data collected, and suggestions for improvement are offered. While several potentially interesting new areas of study are put forward, the standard approach to rabies control (pet vaccination and control, education of at-risk populations, orally vaccinating wild animals) is not found to be in need of significant modification, aside from the specifics of the approach being tailored to better meet local conditions.

Tobacco use is one of the most preventable sources of death and disease, and yet remains a worldwide problem. With the rising costs of healthcare, the focus of efforts to control them has honed in on lifestyle behaviors that contribute to the escalating costs. Within the scope of this scrutiny, the prevention or cessation of smoking and tobacco usage has become a global priority and a major focal point of worldwide anti-tobacco initiatives. The World Health Organization (WHO) has identified cessation interventions by health care professionals as a crucial factor in successful patient smoking cessation, and studies have shown that personal smoking behaviors by health care professionals are a barrier to effective smoking cessation interventions by those professionals (Lally et al., 2008; Radsma & Bottorff, 2009). This knowledge fueled the creation and distribution of global surveys by the WHO, the Centers for Disease Control and Prevention (CDC), and the Canadian Public Health Association (CPHA) to investigate the prevalence of smoking behaviors in health care professionals and in health care students (“Global Health Professions,” 2014; “WHO/CDC Global,” 2014). This study utilized the Global Health Professions Student Survey. The current study investigated the prevalence of smoking in nursing students of all educational levels at East Tennessee State University, with the expectation that the percentage of students who currently smoke would be substantially lower than that of students who do not smoke. The survey also investigated attitudes towards the role of health professionals in patient smoking cessation and towards personal smoking behaviors.

Suicide is a major public health issue in the United States. Some studies show decreased suicide rates in religious populations, but it is unclear how religiosity might be linked to suicidal behavior of adolescents emerging into adulthood. To this point few studies have examined the relationship between adolescent suicidal ideation and several risk factors at once and the role of religiosity in these relationships. Drawing from Waves I-III of the National Longitudinal Survey of Adolescent Health data from 1994 to 2002, I sought to explore the relationship between religiosity (i.e. religious affiliation, service attendance, prayer, perceived importance of religion) and suicidal ideation of adolescents over time. Additionally, associations between risk factors (i.e. poor parental relationship, low self-esteem, depressive symptoms, suicidal behavior of friends and family, drug use, alcohol use, aggressive behavior) and risk of suicidal ideation were assessed by simple logistic regression analyses. Multivariate analyses were then used to examine the relationships among the risk factors and suicidal ideation. In a second step of the multivariate analyses, religiosity was added to the model to test if there would be a change in the odds ratios. Results of the simple logistic regression indicated adolescents’ religiosity was negatively correlated with suicidal ideation, while the selected risk factors were positively correlated with suicidal ideation among adolescent participants. However, as participants became young adults, one religiosity measure (i.e. prayer) and one aggressive behavior measure (i.e. access to weapons) were no longer significantly related to their suicidal ideation. Also, females and Whites were more likely to report suicidal ideation than males or African Americans, respectively. In the multivariate models all the selected suicide risk factors were positively correlated with suicidal ideation. When religiosity was added to the model, it had a positive impact on aggressive behavior among older adolescents in Wave II (35% reduced risk) and drug use among younger adolescents in Wave I (14% reduced risk). Religiosity had marginal impact on the rest of the risk factors: 0.1% – 2.4% reduced risk in some and 0.2% – 1.6% increased risk in others in all 3 waves.

School-aged children’s health needs have changed over the last several decades to the present day population of many overweight and obese children with health complications (Centers for Disease Control & Prevention, 2015). Tennessee has implemented the Centers for Disease Control and Prevention’s (CDC) model for Coordinated School Health (CSH) in all public schools. Leading each school district’s program is a CSH Coordinator. The role of CSH Coordinators is to provide leadership to district and school administrators while effectively and efficiently implementing the CSH program (Wechsler, 2012). The purpose of this quantitative study was to explore the self-perceived leadership styles and practices of Tennessee CSH Coordinators. The focus of many public health initiatives in America is childhood health. Research conducted by the CDC has shown that school health interventions have been effective in improving physical activity, comprehensive health education, and nutrition. Good health is essential for academic success (McKenzie & Richmond, 1998). CSH Coordinators are the leaders of health for school systems (Wechsler, 2012). How these individuals implement the CDC model for CSH varies based on leadership style and practices. Many studies exist on the topic of CSH but few consider the people leading the program (Strickland, 2012). By obtaining information regarding the leadership style of current CSH Coordinators, this research provides insight into best practices and continuing education for current and future leaders. The study population consisted of all 137 Tennessee CSH Coordinators. Seventy (51.1%) CSH Coordinators participated in the demographic, best practices, and Multifactor Leadership Questionnaire (Appendix A). Findings indicated that all of the CSH Coordinators self-reported leadership style was transformational. There were no significant differences reported between the degree to which CSH Coordinator identified as transformational leaders compared by years of experience, gender, school district size, education level, and number of best practices implemented.

The purpose of the present study is to conduct a secondary qualitative analysis to examine parent, teacher, and high school adolescents’ perceptions of social support for physical activity (PA) for high schoolers in Southern Appalachia. Social support for PA is linked to higher rates of PA participation in adolescents. Parents, siblings, and peers provide key sources of support. Social support for PA may be even more important in under-resourced communities such as Appalachia, where geographic, economic, and environmental barriers negatively impact PA engagement. During 2013-2014, focus groups and semi-structured interviews were conducted with parents of adolescents (n=39), high school teachers (n=38), and high school students (n=21) in six counties across rural Southern Appalachia as part of a grant-funded qualitative study to assess parental involvement strategies in school-based adolescent obesity prevention programs. We conducted a secondary analysis of the dataset from this study, focusing specifically on participants’ responses about family and peer supports for PA for adolescents. We used thematic analysis to analyze the data and develop overall themes. Four categories of social supports for PA emerged: instrumental, conditional, motivational, and informational supports. Instrumental supports included providing transportation, paying fees, enrollment in sports, and access to PA equipment at home. Performing PA with adolescents, modeling, watching/supervising, and prioritizing PA emerged as conditional supports. Several motivational supports were also identified: encouragement over life course, force, and admiration of people who are active. Participants also identified key informational supports including discussion by parents/teachers about how to be physically active, its importance and benefits and general advice/information. While some supports were widely available (e.g., equipment and encouragement), others such as transportation were limited in availability. Moreover, students highlighted being made fun of by peers when engaging in PA together as a constraint. Differences emerged in how the three groups conceptualized and attached meaning to the types of supports. While a range of social supports for PA exist for high schoolers in Southern Appalachia, supports emphasized by students, parents, and school personnel vary. These findings can be used to inform program and practice in PA research in rural Appalachia.

Recent research shows that 7.7% of individuals who use indoor tanning beds do so in private homes,1 but little is known about this group. This study evaluated the tanning practices, reasons for tanning, and association with tanning addiction of adults who use tanning beds in private residences.

The objective of this study was to compare the accuracy of self-reported skin cancer risk outcome measures proposed as standards by prevention experts to aggregated estimates of behavior from weekly diaries. Weekly electronic diaries of ultraviolet radiation (UVR) behaviors, initially validated by comparison with daily electronic diaries, were used to assess the accuracy of commonly used end-of-summer self-reported measures among 250 adults. Results revealed low biases, and good correspondence between simple open-ended self-reported estimates of days outside, hours outside, sunbathing days and hours, and days outside when not protected by either sunscreen, long-sleeved shirts, hats, or shade. Rating scale measures commonly used in the current literature and those recently recommended as standards by a workshop of experts showed evidence of being non-interval and lacking precision for more frequent behavior (e.g., >1 h sun exposure daily). These data indicated that open-ended frequency self-reports of skin cancer risk behaviors that follow procedures designed to increase accuracy were reliable over a summer-long period.