The purpose of the study was to explore factors that influenced safer sex practices in Malawi. A quantitative, explorative, descriptive study was conducted to determine why the prevalence of new HIV infections was still high in Malawi despite. Questionnaires were used to collect data. Sexually active men, women, boys and girls that participated in the Centre for Human Rights and Rehabilitation community awareness activities participated in this study. The study found that demographic, socio-economic and knowledge-related factors influence safer sex practices in Malawi. Various modifying factors played a role in influencing the individuals’ perception of susceptibility, severity, barriers and benefits of practising safer sex. The findings indicated that individuals generally had a broad knowledge of the spread and prevention of HIV. The Health Belief Model was used as theoretical framework for the study / Health Studies

This study investigated the implementation of the roll back malaria (RBM) programme at household and at health post levels and examined factors that negatively impact on malaria prevention and control activities. Quantitative, descriptive, analytic crosssectional research, guided by the conceptual framework of the Health Belief Model, was conducted. Structured interviews were conducted with 857 women (for the household survey in phase 1) and 53 health extension workers (HEWs) in phase 2 of the study, in nine malaria endemic districts of Sidama Zone, southern Ethiopia. Data were analysed using SPSS version 20. The study’s findings indicate that 53.3% (n=457) of the household respondents and 24.5% (n=13) of the HEWs had low levels of overall malaria-related knowledge. Household respondents aged 25-34 years, (p<0.01); regularly received malaria-related information, (p<0.001) and the less poor women (p<0.001) had good levels of knowledge. Of the households, 38.9% (n=333) reported poor RBM practices. Wealth, knowledge, perceived threat of malaria and perceived benefits of implementing malaria preventive measures were positively associated with good RBM practices. Indoor residual spraying (63.6%; 422 out of 664), consistent use of insecticide treated bed nets (51.6%; 368 out of 713), and environmental sanitation (38.6%; 331 out of 857) were the most commonly implemented malaria prevention strategies in the study area. Out of the 252 reported malaria cases, 53.6% (n=135) occurred among children under five years of age who also comprised 50.0% (n=16) of 32 reported malaria-related deaths. The RBM practices were poorly implemented in the study area despite malaria prevention and control efforts. Slow progress in behavioural changes among household members, lack of transportation services for referring malaria patients, lack of support given to HEWs and lack of feedback and supervision from higher level health care facilities were identified as potential challenges facing RBM implementation in the study area. Future efforts need to focus on effective behavioural changes based on intervention studies and regular monitoring of the RBM programme. The workloads of the HEWs should also be reconsidered and lay health educators should be used more effectively. Health posts should always have sufficient anti-malaria drugs and other resource such as rapid diagnostic kits. / Health Studies / D. Litt. et Phil. (Health Studies)

Rheumatoid arthritis (RA) is a chronic, progressive autoimmune disease causing inflammation of the synovium resulting in severe pain, joint disfigurement and disability as well as malaise, fatigue and a depressed immune system. Treatment consists of three broad phases; firstly, following diagnosis treatment is focussed on rapid reduction of pain and inflammation. Secondly, maintenance of quiescence is sought through medication. Finally, if disease activity remains high despite medication, escalation to anti-TNF α therapy is required to prevent permanent joint damage and disability. The primary course of treatment is prescription of disease modifying anti-rheumatic drugs (DMARDs) within 3 months of onset of symptoms. However, DMARDs can take 8-12 weeks to exhibit a noticeable benefit whereas unpleasant side effects can occur shortly after initiation. Also, DMARDs do not alleviate pain; therefore it is difficult for patients to attribute recovery to this medication. For these reasons, although it is imperative for future health and functioning to take DMARDs as prescribed, non-adherence is common at 30-50%. Non-adherence to treatment can be intentional, where a decision is made not to conform to the prescription, or unintentional which is often due to forgetting. To measure intentional non-adherence, a validated measure of adherence for rheumatoid arthritis was reduced through exploratory factor analysis from 19 items to 5 items by removing items that did not add to the explained variance of adherence. The CQR5 explained 53% of the variance in adherence and was shown to have a good fit to the data through confirmatory factor analysis. A discriminant function equation was generated that correctly identifies 88.5% of patients as high or low adherers and has high clinical utility due to the brevity for patients and unidimensionality for easy interpretation. The CQR5 was used throughout the programme of research to measure intentional non-adherence along with a separate measure of unintentional non-adherence. Four commonly used social cognition models of illness were measured in 227 RA patients to determine which had the best utility for predicting non-adherence to DMARDs. Patients were recruited to represent the three stages of illness including newly diagnosed, established on DMARD therapy and established with concurrent anti-TNF α therapy. Logistic regression analysis showed that the Self Regulatory Model best predicted intentional non-adherence as patients with perceptions of worse consequences of RA and longer disease duration were more likely to be highly adherent to DMARDs in cross-sectional analysis. In contrast, the Theory of Planned Behaviour better predicted patients who self-reported forgetting their DMARDs with patients with more confidence in being able to take their medications (Perceived Behavioural Control) being less likely to forget. 171 patients were successfully followed-up six months after baseline recruitment. The longitudinal results showed that the social cognition models differed for patients at different stages of the illness suggesting that their experience of living with rheumatoid arthritis influenced perceptions of their illness and medications. Newly diagnosed patients scored lower on factors measuring perceptions of disease chronicity and seriousness whereas patients that had escalated to anti-TNF α therapy scored higher on these factors. The newly diagnosed patients also showed more variability in the social cognition scores whereas the more established patients demonstrated stable models of illness. This supports Leventhal’s (1992) theory that illness representations will be regulated through integration of knowledge and experience of an illness. Structural equation modelling was used to establish the best predictors of intentional non-adherence at six month follow-up. In support of research in other chronic illnesses (Horne & Weinman, 2002; Niklas, Dunbar & Wild, 2010), the effect of perceptions of the consequences and chronicity of the illness on adherence are mediated by perceptions of the necessity of the medication. In addition, the impact of the emotional reaction to the illness on adherence to DMARDs is mediated by concerns about the medication. In addition, this study incorporated factors from the Theory of Planned Behaviour to explain medication adherence and found that the influence of friends and family impacts on the patient’s confidence to follow the prescription accurately which in turn as an effect on adherence to DMARDs. This large longitudinal study found that by combining factors from a number of social cognition models, it is possible to explain and predict intentional non-adherence and provides some evidence for best ways to intervene to improve adherence and prognosis. To provide a more comprehensive and clinically useful picture of non-adherence, a Cost of Illness study was carried which found that patients self-reporting low adherence to DMARDs also had significantly higher costs for this medication. This was caused by an increased incidence of Leflunamide prescribing for patients who often forget their medication and was maintained longitudinally. This association has not been previously reported in the literature and provides some evidence that non-adherence to DMARDs is having a concrete effect on the clinical management of patients. Finally, an SMS text message based reminder service designed to remind patients who self-report forgetting their medications was tested through a simulation study for the cost and likely benefit in health related quality of life using the health economic analysis of the longitudinal study and the results of a survey establishing the feasibility of implementing such a service in the rheumatology clinic. A sensitivity analysis testing the number of messages sent and the cost per message found that a reminder service for the sample of patients in this programme of research would cost between £1387.00 and £142.27 per year. This would equate to a cost per Quality Adjusted Life Year (QALY) gain of between £2889.58 and £296.40 by enabling patients to adhere more rigorously to their DMARD regimen. This programme of research is the first to test four commonly used social cognition models to predict adherence to DMARDs in a large, multi-centre longitudinal study of rheumatoid arthritis patients. Perceptions of the likely duration and consequences of the illness, as measured by the Illness Perceptions Questionnaire and the necessity of medications (measured by the Beliefs about Medications Questionnaire) along with self-efficacy (measured by the Theory of Planned Behaviour) explained 24% of the variance in intentional adherence over six months. The results show the importance of considering intentional and unintentional non-adherence separately as they appear to have different underlying mechanisms as well as patients in different phases of the illness as their experience influences their social cognition models of illness. A simple SMS based reminder service could act as a cue to action to reduce unintentional non-adherence whereas addressing issues surrounding maladaptive perceptions about the illness and the treatment could improve intentional non-adherence which has the potential to improve the prognosis and quality of life for patients as well as safe costs for the NHS.

This study used the Health Belief Model to examine the predictors of AIDS preventive behavior. The independent variables were the variables of individual perception, modifying factors (psychological variables), and likelihood variables. The respondents, the Taiwanese students of the University of North Texas, were influenced both by Chinese sexuality and Western values in their AIDS-risk behavior. The results revealed that 90% of the respondents were misinformed on the availability of AIDS vaccine. In addition, a majority of the students were either abstaining from sex or practicing monogamy. Using Pearson's correlation coefficient and multiple regression analysis, this study found that the psychological variables rather than cognitive variables significantly influenced the respondents' AIDS preventive behavior. Finally, suggestions were made for future research on AIDS, and for AIDS preventive behavior campaigns.

The overall aim of this study was to investigate the knowledge, awareness and practices regarding TB at a selected gold mine in Tanzania in order to enhance the paucity of knowledge in this area of public health. The mining population is considered to be at high risk of tuberculosis infection and illness. However, there is little data available on the knowledge, awareness and practices in the mining population in Tanzania. A quantitative, descriptive study, using the Health Belief Model as the conceptual framework, was conducted among 100 workers in order to give a detailed description of the knowledge and awareness of tuberculosis. The study confirms the role of the media, particularly radio broadcasting, health workers, teachers, and the community in promoting information and education on TB. Fever as a symptom was a problem. The study area is a malaria endemic area where fever is the commonest presentation hence every fever is regarded as malaria. This complicated picking up and identifying other causes of fever. Despite feeling compassion for and wanting to help TB sufferers, most avoided them, which emphasised people’s general fear of TB. This indicated the general isolation and stigmatisation of TB sufferers. The findings highlighted the need for on-going education about TB and its treatment, especially early diagnosis and adherence to treatment. / Health Studies / M.A. (Public Health)

This study investigated the implementation of the roll back malaria (RBM) programme at household and at health post levels and examined factors that negatively impact on malaria prevention and control activities. Quantitative, descriptive, analytic crosssectional research, guided by the conceptual framework of the Health Belief Model, was conducted. Structured interviews were conducted with 857 women (for the household survey in phase 1) and 53 health extension workers (HEWs) in phase 2 of the study, in nine malaria endemic districts of Sidama Zone, southern Ethiopia. Data were analysed using SPSS version 20. The study’s findings indicate that 53.3% (n=457) of the household respondents and 24.5% (n=13) of the HEWs had low levels of overall malaria-related knowledge. Household respondents aged 25-34 years, (p<0.01); regularly received malaria-related information, (p<0.001) and the less poor women (p<0.001) had good levels of knowledge. Of the households, 38.9% (n=333) reported poor RBM practices. Wealth, knowledge, perceived threat of malaria and perceived benefits of implementing malaria preventive measures were positively associated with good RBM practices. Indoor residual spraying (63.6%; 422 out of 664), consistent use of insecticide treated bed nets (51.6%; 368 out of 713), and environmental sanitation (38.6%; 331 out of 857) were the most commonly implemented malaria prevention strategies in the study area. Out of the 252 reported malaria cases, 53.6% (n=135) occurred among children under five years of age who also comprised 50.0% (n=16) of 32 reported malaria-related deaths. The RBM practices were poorly implemented in the study area despite malaria prevention and control efforts. Slow progress in behavioural changes among household members, lack of transportation services for referring malaria patients, lack of support given to HEWs and lack of feedback and supervision from higher level health care facilities were identified as potential challenges facing RBM implementation in the study area. Future efforts need to focus on effective behavioural changes based on intervention studies and regular monitoring of the RBM programme. The workloads of the HEWs should also be reconsidered and lay health educators should be used more effectively. Health posts should always have sufficient anti-malaria drugs and other resource such as rapid diagnostic kits. / Health Studies / D. Litt. et Phil. (Health Studies)

Weight loss among HIV-infected African American women (AAW), results in the fall of the cluster of differentiation (CD4) cell count and an increase in the viral load. There are 48,126 HIV-infected AAW who reported weight loss within the first year. AAW who report more than 10% weight loss within the first year progress to AIDS due to a deficiency in micronutrients and poor linkage to care. The phenomenon that occurs with individuals living with HIV does not necessarily occur among individuals who have cancer, heart disease, or some other life-threatening illness, and this phenomenon indicates a direct threat to the individual's physical, mental, and social survival beyond the effects of chronic diseases. Using the health belief model in this study helped emphasize the physical change that occurs during weight loss among HIV-infected AAW. The research questions addressed if there was a direct correlation between the use of micronutrients and the decrease in weight, decrease in CD4 cell count, and the increase in viral load. The results of the multilinear regression revealed there was direct correlation between the use of micronutrients and the increase/maintain in weight, an increase in CD4 cell count, and a decrease in the viral load, thus promoting the need for more research and funding. The need to educate HIV-infected AAW on the use of micronutrients was evident. Providing research to providers on changes in standard of care for HIV-infected AAW would allow for an increase in the social, economic, and personal impact on the way an individual approaches care and treatment to prevent the progress to AIDS.

The obesity epidemic continues to be a major concern in the United States. The World Health Organization reported that 1.4 billion adults were either obese or overweight. African American (AA) women have the highest incidence of obesity worldwide. The obesity rate among AAs has continued to rise over the past 2 decades. The problem is that AA women prepare and consume high caloric foods that contribute to obesity. This qualitative descriptive study explored the perceptions that obese AA women have about altering how they prepare soul food to make it a healthier soul food. The empowerment model and the health belief model were used to frame this study. Data were collected using a non-probability purposeful sampling strategy. The sample for this study consisted of 4 focus groups with 6-7 obese AA women (n = 25) who prepare and consume high caloric soul foods and have a body mass index of 30 and above. Focus group transcripts were analyzed using a constant comparative analysis and NVivo 11 computer software. It was found that obese AA women were willing to alter their traditional soul food preparation only if it tastes good. It was also found that participants would maintain new healthier eating behaviors depending on the taste, availability of recipes to use, low cost of healthy ingredients, accessibility of the ingredients, learning how to substitute various herbs and spices, and amount of food waste. Barriers that could limit participation in an intervention designed to develop healthier eating habits were identified as ignorance and laziness, transportation issues, lack of motivation, lack of education, lack of time, no incentives, and bad reviews.

Primary-care-related emergency department (PCR-ED) visits by Hispanic patients enrolled in a not-for-profit Medi-Cal and Medicare health plan resulted in longer wait times in the emergency department (ED) at a regional medical center in Southern California. This congestion decreased access for those with true emergencies, created capacity issues, increased ED length of stay, and resulted in potential safety risks. This project focused on decreasing PCR-ED visits in the Hispanic population using patient navigators in Southern California. Applying the health belief model and Lippitt's theory of change, this doctoral project involved the creation and implementation of a culturally appropriate, population-specific patient navigator model for the Hispanic population. Evaluation of outcomes was accomplished using electronic health record (EHR) results, which demonstrated a reduction of PCR-ED visits and revisits. The project exceeded the goal of 10% reduction in PCR-ED visits and revisits in the target population and resulted in a 14.31% reduction of PCR-ED visits and revisits within 1 month of implementation. Emergency Severity Index levels, wait time associated with each Emergency Severity Index level, and visits of the targeted Hispanic population enrolled in the health plan were analyzed to evaluate the success of the program. This project may lead to improvements in nursing practice and positive social change by supporting population health management and continuum of care to a primary care physician through safe and efficient patient navigation to treatment and care.

Older African American (AA) women are at increased risk for HIV and STDs. The purpose of this quantitative study was to examine the influence of provider-initiated condom use education on condom use among unmarried, heterosexually active AA women aged 50 and over using the constructs of self-efficacy and attitudes of the health belief theoretical model. The relationships between provider education on condom use, condom use self-efficacy, condom use attitudes, and actual condom use were tested individually, and provider education on actual condom use was tested after controlling for condom use self-efficacy and attitudes among 95 study participants recruited primarily from Raleigh-Durham, NC. A 2-tailed sample t test or analysis of covariance was used for analysis. Provider education on condom usage failed to show a benefit with regard to condom usage, condom use self-efficacy, and attitudes toward condom usage. Additionally, women who received provider education on condom use were less likely to use condoms. Possibly these women had a low perception of risk and vulnerability to HIV and STDs, which correlated with lower condom use. The counter intuitive findings could also be related to another variable that was not tested and should spur more research. Results could be used to contribute to the design of an intervention model that specifically addresses the sexual behaviors of older AA women. Results of this study, combined with previous research, can help emphasize the need for improved patient-provider communication so that provider communication produces a more positive outcome and helps limit the spread of HIV and STDs, a limitation that would benefit individuals, whole communities, and the nation.