The unprecedented growth of the aging population in Tennessee is a significant demographic trend that highlights the necessity for healthcare policy that tackles end-of-life issues. This study examined the perceived quality of end-of-life healthcare in Tennessee, areas that are in need of improvement, policies that have the potential to influence improvements, and the role of politics in end-of-life healthcare policy. It also assessed the support for end-of-life healthcare policy that would advance quality of care and expand end-of-life choices for Tennesseans, while evaluating the policy-making process that legislators employ. For this study, data were collected using semi-structured, in-depth interviews with an open interview guide. These interviews were conducted in a two-tiered format. Tier 1 included ten leading experts in various areas of end-of-life healthcare and aging in Tennessee. Tier 2 included nine legislators who were members of the health committees of either the Tennessee House of Representatives or the Tennessee Senate. Qualitative data were organized into numerous categories, and an initial phase of open coding was completed. From this phase of coding, emergent themes and focuses were discovered. This was followed by focused coding on all nineteen interviews using coding software to organize subtleties. Findings of the Tier 1 interviews indicated that there are many areas of end-of-life healthcare that need improvement including increased funding, expanded caregiver support, improved doctor-patient communication, and increased use of advance directives. Emergent themes included the influence of money, having difficult conversations, the stigma of death and dying, and supporting the caregiver. Tier 2 findings highlighted the motivations behind voting decisions and the level of awareness legislators have in areas of end-of-life healthcare policy. Both tiers also explored the support and opposition of physician-assisted death. The findings of this dissertation are intended to inform health professionals and state legislators. The data gathered through this exploratory research and the knowledge gained will lead to a greater understanding of end-of-life healthcare in Tennessee, and what needs to be done to improve its quality. This will allow individuals and families faced with end-of-life decisions to navigate the process with expanded options, access, and support.

Background: Community pharmacists are a key intervention point in efforts to prevent and mitigate the impact of prescription drug abuse and misuse (PDA/M); yet pharmacists' perceptions regarding PDA/M have been explored only briefly in the literature. Objectives: 1) To explore Tennessee community pharmacists' perceptions regarding opioid pain reliever (OPR) prescribing, dispensing and abuse; 2) to explore community pharmacists' self-efficacy beliefs regarding PDA/M-specific communication; and 3) to evaluate perceived barriers to engaging patients in PDA/M-specific communication. Methods: A 55-item survey instrument was developed using the Theory of Planned Behavior (TpB) as a theoretical framework. Questionnaires were mailed to a stratified sample of 2000 licensed Tennessee pharmacists using the Tailored Design Method of survey administration during October and November, 2012. Results: A response rate of 40% was obtained. A majority of pharmacists (87.5%) perceived OPR abuse to be a problem in their practice settings. On average, a little more than half (53%) of prescriptions issued for OPRs were estimated to be for patients with one or more legitimate medical reasons justifying the medication(s). A small fraction of pharmacists (13%) reported having addiction treatment facility information in their practice settings, and only a small percent reported strong self-efficacy beliefs regarding PDA/M patient communication. Job-related time constraints were perceived as the primary barrier to engaging in PDA/M communication. Conclusions: Community pharmacists in Tennessee are aware of PDA/M by patients receiving opioid prescriptions and value their role in communicating with these patients but indicate their ability to do so effectively is hindered by a lack of confidence, training, and time. Further research to identify and test methods for facilitating PDA/M communication by pharmacists is indicated.

ABSTRACT Oceano Community Health Plan Phillip Brennan Recent, mounting research shows that chronic disease, the leading causes of death and primary driver of health care costs, cannot be effectively addressed through education or preventative health alone. A physical environment that promotes health—through access to healthy food, opportunities for physical activity, quality housing, transportation options, and safe schools—is an integral part of making our communities healthier. This research and accompanying Healthy Community Plans will serve as a way for the County to begin looking in-depth at the ways the built environment (our streets, parks, and neighborhoods) contribute or detract from the health of the community. Though the creation of a healthy general plan may be unattainable for the County in the short term, a focus on a small yet cohesive part of the county presents an opportunity to affect these changes. Under the direction of the SLO County Health Agency and the Health Commission, we have written Healthy Community Plans for the unincorporated communities of Cayucos and Oceano, California. Both of these plans were greatly informed by their respective communities through input garnered through outreach, interviews, surveys and personal interactions with community members. This project examines the relationship between the built environment and public health, and explores ways planning professionals are beginning to address health issues through infrastructure, land use, creative zoning, and planning strategies that promote health and active living in policy. The planning documents, modeled after health elements currently being included in general plans throughout California, have integrated the fields of planning and public health to provide Cayucos and Oceano an assessment of its residents’ health, a description of the current built environment conditions that may be helping or hindering physical activity and access to nutritious food sources, as well as establish goals, policies and implementation strategies that will set a course of action toward healthier communities. Key Words: planning, public health, physical activity, built environment, community, active transportation

Substance Use Disorder (SUD) has plagued families of rural Appalachia for many years, perpetuating involvement in the criminal justice system as well as generational trauma for people diagnosed with SUD and their children. This points to the necessity of a trauma-informed, restorative-justice based framework for rehabilitative services to most effectively heal families, address trauma, and re-integrate people diagnosed with SUD into society. A restorative justice-based program would provide health care services for addiction and any comorbid mental health disorders as well as teach parents how to properly provide for themselves and their families, manage finances, obtain employment, and further education. Current rehabilitative program structures were evaluated in the literature, and it was found that typically, rehabilitative programs provide either strictly addiction services or mental health services, but not both. It was also found that the criminal justice system tends to sentence to 28-day inpatient rehabilitative services, which provides people diagnosed with SUD an opportunity to achieve sobriety and establish some stability; however, with little or no follow up, these people are significantly more likely to relapse. These findings were compared with the structure of Ballad Health STRONG Futures, an outpatient addiction services and behavioral health clinic located in Greeneville, TN; Red Legacy Recovery, a recovery initiative serving incarcerated women in Elizabethton, TN; and Families Free, a 501(c)3 organization providing outpatient services to Northeast Tennessee through the Tennessee Department of Mental Health and Substance Abuse Services. It was found that rehabilitative care structures that addresses trauma, addiction, and aspects of daily living such as parenting, finances, education, and employment provides clients with the tools and stability needed to be successful in their respective recovery journeys. This work will provide significant insight for the creation and implementation of other substance use clinics and initiatives across the country and encourage them to address mental health and aspects of daily living to promote clients' success and break cycles of generational trauma.

BACKGROUND: The barriers in accessing healthcare for gay, lesbian and bisexuals individuals are not well explored. These challenges as well as a lack of knowledge concerning this understudied group has prompted the Institute of Medicine to create a research agenda to build a foundational understanding of gay, lesbian and bisexual health and the barriers they encounter.1 the primary aim of this study will be to compare the differences in health care access and utilization between gay/lesbian, bisexual and heterosexual individuals using a large, nationally representative dataset of the U.S. population. METHODS: Data from 2001 to 2012 from the National Health and Nutrition Examination Survey was pooled. Using logistic regression, we calculated the unadjusted and adjusted odds ratios of having health insurance, having a routine place and seeing a provider at least one in the past year. RESULTS: We found that gay men were more likely to have health insurance coverage (ORadj:2.13 95%CI: 1.15,3.92), while bisexual men were at a small disadvantage in having health insurance coverage (ORadj:0.82 95%CI: 0.46,1.46). Bisexual men were more likely to have received health care in the past 12 months (ORadj:3.11 95%CI: 1.74,5.55). Lesbian women were less likely to have health insurance coverage (ORadj-lesbian:0.58 95%CI: 0.34,0.97). CONCLUSION: This study contributed to the limited knowledge on understanding the health care access and utilization among gay, lesbian and bisexual individuals, which was classified as a high priority by the Institute of Medicine. Expanding health insurance coverage through the Affordable Care Act and Universal Partnership Coverage may reduce the disparities among gay, lesbian and bisexual individuals.

Background. Emerging evidence suggests that youth with attention deficit/hyperactivity disorder (ADHD) may engage in sub-optimal health behaviors including high levels of screen time, low physical activity participation, and consumption of poor diets. These are independent risk factors for adverse health outcomes, and health-related behavior patterns established in childhood can track into adulthood. Thus, identifying and addressing dietary and physical activity habits in sub-populations of youth have important implications for health over the lifespan. The specific aims of this dissertation were to: (1) compare screen time between youth with and without ADHD and to assess its relationship to ADHD symptomatology; (2) compare participation in physical activity (PA) between adolescents with and without ADHD and to assess the relationship of PA participation to ADHD symptomatology; and (3) evaluate the association of diet quality and dietary patterns to ADHD symptomatology among youth ages 8-15 years. Methods. The aforementioned outcomes of interest were analyzed using data from the continuous National Health and Nutrition Examination Survey (NHANES) 2001-2004. These waves of NHANES included a structured DSM-IV-based interview administered to parents that identified youth with ADHD and also yielded symptom counts for hyperactivity/impulsivity and inattention. Screen time and physical activity data were obtained from questionnaires that queried the amount of time spent watching television, playing videos, or using the computer outside of school time, and also surveyed the types, frequency, and duration of PA in which youth participated. Diet quality and dietary patterns, which included consumption of sugar-sweetened beverages (SSBs), total calorie intake, and eating frequency, were obtained by a 24-hour dietary recall using the Automated Multiple Pass Method of interviewing. Linear and logistic regression models adjusted for sociodemographic factors and anxiety/depression were employed to address the specific aims. Results. The findings suggest that youth with ADHD are at the same, if not higher, risk for engaging in suboptimal health behaviors. Overall, youth participating in NHANES engaged in excessive amounts of screen time, failed to acquire sufficient physical activity, and consumed diets of poor quality. However, our findings suggest that ADHD symptomatology places youth at higher risk for sedentary behavior and poor diet quality. Relative to screen time, youth with ADHD showed a trend toward increased screen time, as did youth who took medication. ADHD symptoms were also associated with over two hours of daily TV viewing and overall increased screen time, and this was particularly true for children ages 8-11 years. Relative to physical activity, the outcomes did not differ between youth with and without ADHD, but the majority of youth did not meet the recommended guidelines of 60 minutes or more of moderate-to-vigorous PA each day. Diet quality was poor across the population of youth who participated in NHANES, and hyperactive/impulsive symptoms were associated with an even greater decrease in diet quality in both children and adolescents. In males, the presence of hyperactive/impulsive symptoms was associated with a decrease in diet quality, whereas in females, inattentive symptoms accounted for a decrease in diet quality. No differences in the other dietary patterns (i.e., SSB consumption, total energy intake, and eating frequency) were observed. Conclusions. The diagnosis of ADHD and/or its symptoms are associated with less-than-recommended levels of screen time and poor diet quality, though youth in general were found to be engaging in suboptimal sedentary, physical activity, and dietary behaviors. The mechanisms for why youth with ADHD may have increased vulnerability to poorer health behaviors are not yet well understood. The findings from this dissertation support the need for ongoing efforts to address lifestyle factors among the nation’s youth generally, but may also stimulate new hypotheses about the needs of youth with ADHD from both public health and clinical perspectives, and encourage research on the implications of ADHD symptomatology on health-related behaviors and lifestyle factors.

The purpose of this study was to examine parents’ management styles when caring for adult children with serious mental illness (SMI), as well as parents’ perspectives on what type of community-based mental health interventions would support and/or enhance overall family functioning. This qualitative descriptive study was undergirded by Knafl and Deatrick’s Family Management Style Framework. Thirty parents (N = 30) caring for adult children with SMI over age 18 were recruited as participants. Demographic data included age, gender, ethnicity, educational level, annual income, and National Alliance on Mental Illness membership. Parents were interviewed in their homes or other private setting. Verbal informed consent was obtained. Audio-recorded, individual, semistructured interviews were conducted until redundancy was achieved. Data were analyzed using qualitative content analysis. Four major themes emerged from the data. These themes described prolonged, difficult, and confusing phases that parents and the family undergo in caring for an adult child with SMI. These phases have a progressive nature, moving from parents recognizing that their child has a SMI to redefining family life as a result of caring for an adult child with SMI. Successful management of these phases must include increasing access to mental health information, mental health screening, early interventions, violence prevention, and various treatment options for adult children and their families.

Sex trafficking is one form of human trafficking, a heinous human rights violation that transcends international borders. People who have been trafficked often present with complex neurobehavioral, psychological, emotional, physiological, sensory, and developmental difficulties. The United Nations developed the international 3 p protocol to guide governmental agencies, non-governmental groups, and individuals in developing programs and legal actions of trafficking prevention, protection, and prosecution. Protection encompasses the recovery of trafficking survivors and community integration has been identified as an essential foundation for successful recovery. Measurable components of community integration include safe housing, stable employment, and vocation-focused education. This Capstone describes the organization, implementation, and results of a six-week community integration group experience for five women in a sex trafficking residential recovery program. Key words: Human trafficking, sex trafficking, recovery, trauma, posttraumatic stress disorder, occupational therapy, childhood sex abuse, protection, protection, prosecution, 3P Paradigm,

Dyslipidemia is increasing among U.S. children, and the prevalence is highest among children with diabetes and obesity. Recently, vitamin D deficiency has been suggested as a possible dietary risk factor for dyslipidemia. Despite the high prevalence of vitamin D deficiency amongst children, virtually no studies have evaluated the association between vitamin D and dyslipidemia among children. We evaluated the vitamin D and dyslipidemia relationship among 240 children and adolescents aged 2 through 21 years who were outpatients of a pediatric endocrinology unit at a large tertiary care facility in Western Massachusetts from April 2008 to April 2010. Eligible children were those with either obesity and/or type 1 or 2 diabetes mellitus. A total of 17.4% of children had severe (<15.0 ng/ml) vitamin D deficiency, 19.2% had moderate (15.0-19.9 ng/ml) deficiency, 36.3% were insufficient (20.0-29.9 ng/ml), and 27.1% had normal (≥30.0 ng/ml) levels. A total of 28.8% of children had high total cholesterol (TC ≥180 mg/dL), 19.6% had high triglycerides (TG; <10years: ≥110 mg/dL, ≥10years: ≥130 mg/dL), 21.3% had low high density lipoprotein (HDL <40 mg/dL), and 6.7% had high low density lipoprotein (LDL ≥130 mg/dL). Moderate vitamin D deficiency was associated with increased risk of high TC (adjusted odds ratio [OR adj] = 2.9, 95% confidence interval (CI): 1.0, 8.8) compared to children with normal vitamin D levels. Severe vitamin D deficiency was associated with an increased risk of low HDL (OR adj = 3.5, 95% CI: 1.0-12.3) and high TG (OR adj = 11.7, 95% CI: 1.9, 70.3) compared to children with normal vitamin D levels. Children with moderate vitamin D deficiency had approximately 3-fold increased risk of high TC compared to children with normal vitamin D levels. In comparison to children with normal vitamin D levels, severe vitamin D deficiency was associated with a strong and significant increased risk of low HDL and high TG; with a significant dose-response relationship. Additionally, in linear regression analyses, we found that an increase in vitamin D deficiency was associated with a significant mean increase in all four measures of dyslipidemia. Vitamin D adequacy may reduce the risk of dyslipidemia in children.

The rate of overweight and obesity among adolescents aged 12-19 years has more than tripled since 1980, and disproportionately impacts low-income and marginalized populations. Reduction in adolescent obesity rates may result in decreased health risks, decrease healthcare costs, and increased quality of life. Effective intervention methods for adolescent participants have incorporated nutrition knowledge and culinary skill building into afterschool programs. This study examines whether building knowledge, skills, and confidence through a culinary intervention can improve adolescent participants’ choices of healthful foods through increased fruit and vegetable intake. Pink and Dude Chefs (PDC) is an afterschool nutrition education and culinary skills program for middle-school adolescents aged 11-14 years. This project aimed to improve eating behavior in participants by increasing culinary and nutrition self-efficacy. PDC was implemented in Shandon, California from Spring 2014 to Fall 2014, and in Santa Maria, Guadalupe, and New Cuyama, California from Fall 2015 to Summer 2016. Eighty-three middle school students participated and completed surveys in the 12-lesson program that covered food safety, micro- and macronutrients, meal planning, and USDA MyPlate guidelines. Participant fruit and vegetable consumption improved following participation. Girls’ frequency of overall fruit consumption increased from a mean of 1.8 (SD 0.9) to 2.0 (SD 1.0). Girls’ vegetable consumption increased from 1.2 (SD 0.8) to 1.5 (SD 0.9). Boys’ fruit consumption increased from 1.9 (SD 1.0) to 2.2 (SD 1.0), and boys’ vegetable consumption increased from 1.1 (SD 0.9) to 1.3 (SD 0.8). More research is needed to evaluate the long-term effect of participation in nutrition education and culinary skills programs. If obesity prevention programs that incorporate a skill-based culinary approach continue to show promising outcomes for adolescents, larger scale efforts may contribute to decreasing the public health and economic burdens associated with obesity.