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Background: To explore the effectiveness of a multi-layered health promotion approach in rural China. Methods: A two-year intervention was applied to the 18 intervention rural villages while the 18 controls received standard health communication materials. Data were collected at baseline and post-intervention respectively to evaluate the effectiveness. Results: All intervention villages had developed healthy policies addressing prioritized health issues such as livestock captivity, garbage disposal, etc.; however, no healthy policies had been developed in the controls. The two-week morbidity rate and incidence of diarrhea of the intervention villages decreased to 13.4% from 18.5% (p = 0.009), and to 9.5% from 13.0% (p = 0.038), respectively, whereas no statistically significant change was found in the controls. The knowledge about hepatitis B and rabies transmission had increased significantly among the intervention villagers (hepatitis B from 27.5% to 34.4%, p = 0.005; rabies from 12.0% to 24.6%, p < 0.001) but not in the control for rabies (p > 0.05). Among both intervention and control groups, the proportion of proper hand-washing and chopping board use increased significantly (all p < 0.01). Greater changes had been found in physical inactivity and alcohol drinking among the intervention group than the control. No change was found in smoking rate among both groups. Score values (mean ± SD) for environmental quality, livestock captivity, and vector density (e.g., mosquitoes, flies, rats, and cockroaches) increased significantly from 2.8 ± 0.9 to 3.4 ± 0.7, from 1.9 ± 0.9 to 2.5 ± 0.9, and from 0.6 ± 0.9 to 1.8 ± 0.4, respectively (p < 0.05) in the intervention villages. Conclusions: The two-year multi-layered health promotion approach shows real promise in empowering the rural communities to take control over, and protect their own health.

The trans and gender-nonconforming (TGNC) community has a complex relationship with psychiatry. The need for access to transition-related medical services is complicated by an increasing amount of activism that refuses the pathologization of TGNC identities through the diagnosis of Gender Dysphoria and the rejection of the biomedical model of mental illness more broadly. TGNC activists have mobilized concepts from critical disability studies and Mad studies, namely the biomedical and social models of mental illness, to describe their aversion to, and proposals against pathologization. However, this binary relationship between the biomedical and social models is problematic, as it is increasingly evident that conceptualizing TGNC mental health within this binary does not account for the complex reality of the lives of trans and gender-nonconforming people who must navigate between fighting pathologization without sacrificing access to publicly funded transition-related medical procedures, counselling services, and disability benefits. Consequently, in this thesis, I seek to trouble the binary relationship between the biomedical and the social, pointing to the shortcomings of mainstream disability discourses within TGNC mental health policies and practices in Ontario, using Foucault’s notion of biopower and Pamela Moss’ perching model to trace both the consequences of, and alternatives to, these limiting conceptualizations.

This thesis explores a recent innovation in First Nations health, the formation of Canada's First provincial-wide First Nations Health Authority (FNHA). Analyzing this service model against Indigenous assertions of a Treaty Right to Health expressed in the Numbered Treaties, I argue that the realizations of the Treaty Right to Health cannot solely be met under neoliberal models of increased Indigenous capacity in health care service administration. I assert that these models of devolution do not enable Treaty First Nations to achieve Indigenous self-determination in accordance with Treaty rights, relationships and responsibilities. The current discourse on First Nations health care only minimally accounts for the Treaty Right to Health, and where it does, it is devoid of Indigenous understandings of a Treaty Right to Health that encompasses access to healthy lands, waters, and livelihood for an achievement of holistic wellness. Mobilizing an Indigenous auto ethnographic approach which accounts for my own embodied positionally, this thesis problematizes the exclusion of holistic visions of health and well-being against settler governments' orientations toward a neoliberalized health care system. This thesis extends a comparative analytical lens to the political mobilizations of Indigenous advocacy bodies in the province of British Columbia, whose efforts under the New Relationship paradigm in Indigenous-state relations has resulted in an unprecedented practice of health care devolution. / Graduate

Youth substance abuse in Oregon reached epidemic proportions in the early 1980s. A response to this social issue from the Governor's Office, the state legislature, and the Office of Alcohol and Drug Programs during 1983-1985 is the foundation of this case study. Oregon, a small state of three million, was faced with a growing problem of youth and adult substance abuse. Legislative leaders, agency staff, and Governor Atiyeh recognized an opportunity to create public policy to solve problems of substance abuse including crime. The focus on substance abuse included streamlining several budgets with substance abuse monies in various state agencies. The intent of this study was to recreate the development of public policy specifically in the area of youth substance abuse during the years 1983-1985. The final policy, Oregon House Bill 2124 (1985), represented the work budgets with alcohol and drug monies in various state agencies. The intent of this study is to recreate the development of public policy specifically in the area of youth substance abuse during the years 1983-1985. The final policy, Oregon House Bill 2124 (1985), represented the work of several political entities, and presented recommendations for substance abuse treatment, budget alignments among several agencies with alcohol and drug monies, and finally, prevention of youth substance abuse. This dissertation established that leadership and politics affected policy development more than the variables of economics, special interest groups, or research which were chosen from the literature in policy development. Research was the variable studied in depth to determine if policy developers utilized what was known about youth substance abuse to develop policy goals. Several barriers to the use of research and rational methods for policy development were uncovered. The study found that the use of research was regarded as important among policy developers, but their practice was not at all congruent with that belief. There were many studies on youth prevention and social competency training available to policy planners which may have supported more specific policy recommendations. No collaborations between researchers and policy developers occurred in this case study. The barriers to collaborative efforts with researchers and the use of policy analysis methods were uncovered in this study. The final policy document presented to the legislature lacked specific recommendations for well researched programs which appeared to be the result of political considerations rather than rational policy development. Finally, this case of policy development revealed a process that was inconsistent, politically driven, disregarded available research, and resulted in broad policy goals which have not been exceptionally successful in limiting or even addressing youth substance abuse over the nine years of implementation by the same administrator who significantly helped to develop them.

When family members no longer have the capacity to meet Alzheimer's Disease (AD) caregiving demands at home, a move to a nursing home or other formal care facility becomes the only solution. Recognizing this as a time of transition, three research questions were identified: (1) What do family caregivers to AD individuals experience as they shift their caregiving from home to formal care settings? (2) How does caregiving in formal care differ from caregiving at home? and (3) How do family caregivers perceive the relationships that develop between families and formal care staff? Specific attention was paid to the experiences of spouses and adult children. Using a qualitative approach, two specific bodies of data were investigated. First, transcripts of a series of 30 focus groups with 179 caregivers, and second, ten follow-up interviews were analyzed. Both spouses and adult children overwhelmingly identified physical exhaustion and often emotional exhaustion as the pervasive common experience. After reaching this state, caregivers identified the pivotal nature of events in contributing to placement. These kinds of events turn out to be more like turning points than crises. Caregivers in this study identified five themes that were influential in their decision-making process. In order of their importance to the caregivers, they were: events, the health care system, caregiver-care receiver relationship, support, and options and availability. A male spouse caregiver was likely to cite a turning point event centered on an incontinence problem, while for a female spouse caregiver, it was an AD safety issue. The health care system was usually a negative influence and served to delay the placement decision. Immediately, after placement, family caregivers noted shifts in control, involvement and personal reorganization. Family caregivers frequently noted the development of a caregiving relationship with staff. The individuals whom the family caregivers mentioned most often were the aides. Their bottom line was that staff deliver quality care, which they equated with caring about the resident rather than only taking care of them. The findings from this study have implications for theory development, family caregivers, formal care staff, and health care policy.

Improving the quality of remaining life for individuals who are terminally ill and their families is an issue that has become increasingly important in recent years. This issue has evolved from perceived deficiencies of conventional health care institutions in meeting the needs of people who are in the final stages of their life, when curative measures are no longer deemed appropriate. In response to deficiencies in care of the terminally ill and their families, there has been a movement toward humanizing conventional health care and making it more holistic. Hospice care, which is consistent with this movement, has evolved as an alternative to hospitals and nursing homes. The purpose (of this study was to investigate the physical environment (building and grounds) of a free-standing hospice facility to identify the features that would contribute to the design and renovation of other hospices and health care facilities that plan to adopt a hospice program of care. In this study, an attempt was made to examine how architectural factors combine in a hospice setting to meet the needs of the dying and their families and those who work in hospices. Specifically, this study used a qualitative, case study approach to describe and develop an understanding of the feelings and experiences of the users of a particular hospice facility concerning the physical environment of that facility. Post Occupancy Evaluation Methodology, which is a process to assess the performance of the built environment after it has been occupied for some time, was employed. Qualitative analysis of the data revealed three distinct environments within the facility to be of major importance to the users when discussing the physical surroundings. The three separate areas of importance were the grounds, the administrative offices, and the patient care unit. The findings of the study will be of use to designers, architects, and planners, as well as hospice advocates, as they will assist them in conceptualizing essential components of hospice design and in creating better hospice facilities in the future.

Indiana University-Purdue University Indianapolis (IUPUI) / Introduction: The U.S. is faced with a primary care (PC) workforce shortage; an estimated 43 percent of the population has unmet health care needs and 18.2 percent of the adult population lacks a usual source of care (USC) provider. The workforce shortage limits even those with a USC from receiving the full scope of recommended clinical services. One promising solution is reforming scope-of-practice (SOP) policies for PC nurse practitioners (NPs). Objectives: The primary objective of this dissertation was to assess the impact of NP SOP policy implementation on NP practice patterns and patient access to PC by evaluating NP time spent delivering patient care, NP role as USC providers, patient travel times, and appointment availability. Methods: The studies discussed in this dissertation leveraged cross-sectional data from the National Sample Survey of Nurse Practitioners (NSSNP), time-series data from the Medical Expenditure Panel Survey (MEPS), and the Nurse Practitioner Professional Practice Index (NPPPI) to quantify variations in state policy environments. We used generalized mixed effects models to examine relationships in the cross-sectional data analyses and two-way fixed effect models to evaluate longitudinal data. Results: Our analyses revealed several key findings: NP SOP policies do impact the percentage of time NPs spend providing direct patient care; the NP workforce role as USC providers has increased as SOP policies have changed; states with supportive reimbursement policies have more NPs working as USC providers; and states with fewer NP supervision requirements have shorter patient travel times to USC providers. Conclusion: The U.S. health care system must continue to evolve to address the growing demand for PC services. While strategies to increase the supply of PC providers may be an effective long-term solution, our findings suggest that NP SOP reform may be a viable and complementary strategy to increasing the capacity of the PC workforce, providing more immediate relief. / 2 years

Indiana University-Purdue University Indianapolis (IUPUI) / Introduction Mobile health (mHealth) applications (apps) are increasingly accessible and popular. In 2015, over 60% of smartphone users used their phones to look up health related information. mHealth apps related to maternal and child health (MCH) are particularly prevalent and frequently used. As high as 73% pregnant women and new mothers reported the use of MCH apps, with 27% using them daily. Methods A cross-sectional sample of MCH apps was extracted from the Apple App and Google Play stores using a JavaScript Scraper program. A multivariable linear regression, and series of ordinal logistic regression assessed the relationship between MCH app characteristics and two outcomes, end users’ perceived satisfaction (star ratings), and intent to use (downloads). Next, theory-based content analysis reviewed the presence and use of behavior change techniques (BCTs) in popular MCH apps using the mHealth app taxonomy framework. Finally, a qualitative inductive analysis assessed user self-reported experiences, perceived benefits, and general feedback for MCH apps. Results Seven hundred and forty-two apps met the inclusion criteria. A large majority of MCH apps were developed by non-healthcare developers. Google Play store apps had higher user ratings; while, apps within health & fitness genre, with older updates, and no agerestrictions had fewer user ratings. Furthermore, lower priced apps, with high star ratings, in-app purchase options, and in-app advertisement presence had high downloads. And, apps belonging to medical and health & fitness genre had fewer user downloads. Content analysis revealed that popular MCH apps on an average include 7.4 behavior change techniques (BCTs) with a median of 6 BCTs. Apps developed by healthcare developers had higher BCTs present within app content. Qualitative analysis shows that consumers value apps that are low cost, with superior features, smooth technical aspects, high quality content, and easy to use. Conclusions Healthcare providers, app developers, and policymakers may benefit from a better understanding of MCH apps available in two popular app stores and may consider strategies to review and promote apps to consumers based on information accuracy and trustworthiness. / 2020-11-06

Indiana University-Purdue University Indianapolis (IUPUI) / Neonatal abstinence syndrome (NAS), the constellation of withdrawal symptoms experienced by neonates exposed to opioids prenatally, is an epidemic affecting an estimated 23,580 infants each year with an annual cost of $720 million. The purpose of this study was to examine factors associated with the incidence and severity of NAS as measured by the need for initiation of neonatal medication, peak medication dose, hospital length of stay (LOS), and hospital costs among newborns born to opioiddependent mothers. A retrospective review of medical records was conducted with two convenience samples: 204 infants born to mothers who used opioids during pregnancy; and 121 of these infants who required treatment with morphine to control symptoms of NAS. Data from April 2011 to September 2017 were collected from medical records of a large Midwestern hospital. Exploratory analysis and descriptive statistics were performed. Associations between independent variables and outcomes were examined using correlations, chi-square, t-tests, analyses of variance, and linear regression. Of the 204 neonates who were exposed to opioids prenatally, 121 (59%) developed symptoms of NAS requiring treatment with morphine. Neonates requiring morphine had significantly higher gestational ages than those who did not (37.7 vs 36.4 weeks; p = < .001) and their mothers were present at the neonates’ bedside a lower proportion of their total hospital stay (mean = 0.5684 of days vs 0.7384 of days; p = < .001). Compared to maternal use of buprenorphine, maternal methadone use was associated with higher peak morphine doses needed to control the neonate’s withdrawal symptoms (0.089 mg/kg versus 0.054 mg/kg; p = .023), and with longer hospital length of stay when compared to maternal use of buprenorphine and other opioid analgesics (34.2 vs. 20.8 vs. 22.5 days, respectively; p=0.02). Higher visitation time from the primary caregiver was correlated with lower hospital LOS (r = -0.421; p = < .001). Future research is needed to examine these relationships prospectively in a larger and more diverse sample. An effective response to the epidemics of opioid use during pregnancy and the incidence of NAS requires ongoing coordinated research and intervention in clinical care, public health, and health policy. / 2019-11-06