BACKGROUND: Understanding the reach and representativeness of participants enrolled in behavioral trials, including nutrition and physical activity trials, helps inform the generalizability of study findings and potential public health impacts. Exploring the reach and representativeness of trials that target low socioeconomic and low health literate participants in rural and medically underserved areas, such as southwest Virginia (SWVA), is especially important. The proposed research is part of Talking Health, a six-month, pragmatic randomized-control trial aimed at decreasing sugar-sweetened beverage (SSB) consumption (SIPsmartER) as compared to matched contact control targeting improving physical activity (MoveMore). This community-based trial targets an 8-county region in SWVA. OBJECTIVES: Guided by the reach dimension of the RE-AIM framework, the primary objectives of this study were to determine if eligible and enrolled participants in the Talking Health trial were representative of: 1) eligible, but declined participants, and 2) the broader targeted 8-county region based on 2010 US county level census data. We hypothesized that eligible and enrolled participants would be represented in terms of age, race, ethnicity, educational attainment, income, and health literacy when compared to eligible and declined participants, as well as to the broader US census data. We also hypothesized that males would be underrepresented. METHODS: Eligibility requirements for the study included being 18 years of age or older, having reliable access to a telephone, drinking 200 kilocalories of SSB per day, and being a resident of SWVA. A variety of recruitment strategies were used such as active recruitment at health departments, free clinics, and local businesses with help from Virginia Cooperative Extension agents along with passive methods such as flyers, newspaper ads, and word of mouth. The eligibility screener included basic demographic information such as gender, age, race, marital status, occupation, income, educational attainment, number of children in household, and insurance provider. The screener also had three validated subjective health literacy questions. Statistical analysis included descriptive statistics, independent sample t-tests, Chi-square tests, and One Way ANOVA tests to examine the representativeness of enrolled participants. RESULTS: In total, 1,056 participants were screened, 620 were eligible (58.7%), and 301 (48.5%) enrolled. On average, demographic data for enrolled participants included: 93% Caucasian; 81.4% female; income of $23,173±$17,144; 32% high school (HS) education; and health literacy score 4.5±2.2(3=High, 15=Low). Among eligible participants, when comparing enrolled vs. declined participants there were significant differences (p<0.05) in educational attainment [enrolled=32% HS, declined=48% HS], health literacy scores [enrolled=4.5(2.2), declined=5.0(3.1)], gender [enrolled=81% female, declined=73% female], age [enrolled=41.8(13.4) years, declined=38.3(13.6) years], and race [enrolled=93% white, declined=88% white]. However there were no significant differences in ethnicity and income. When compared to average US Census data across the eight counties, enrolled participants had a higher educational attainment [enrolled sample=68%HS, Census=58%HS], higher proportion of females [enrolled sample=81%, Census=48%], and lower mean income [enrolled sample= $23,173, Census=$36,675]. There were no meaningful differences in terms of race and ethnicity between the enrolled sample and Census data. DISCUSSION: Contrary to our hypothesis, eligible and enrolled participants differed from non-enrolled participants in terms of age, race, education, and health literacy. Our enrolled sample was slightly older, predominately Caucasian, with higher educational attainment and higher health literacy. However, as hypothesized, there were no significant differences for ethnicity and income status, and men were underrepresented. When the study sample was compared to US Census data, the sample was well represented in terms of age, race, and ethnicity; however, enrolled participants had a much lower average annual income and a higher educational attainment. Men were also underrepresented when compared to the census data. There was no census data to compare health literacy status, which limits information regarding the representativeness of the enrolled sample. Importantly, this study has revealed the representativeness of individuals enrolled in this behavioral trial, helps inform the generalizability of study findings, and identifies future research for community-based studies targeting rural and medically underserved areas in SWVA. For example, future behavioral interventions need concerted recruitment strategies to target males, individuals with lower health literacy status, and individuals with less than a high school degree. Exploring and addressing barriers for study enrollment among these sub-groups is also important. / Master of Science

This dissertation explored the multifaceted issue of radon exposure and its connection to lung cancer, focusing on knowledge gaps and proposing mitigation strategies. Despite extensive research, inconsistencies persist in understanding the health impacts, public awareness, and effective mitigation of radon, particularly in regions like Tennessee that are disproportionately burdened by high radon levels. This work addresses this gap by integrating findings from three distinct studies: a scoping review, a cross-sectional survey, and a policy analysis. The review examined national literature about residential radon exposure, revealing variations in exposure levels and conflicting evidence regarding the risk of lung cancer. The cross-sectional study investigated radon Environmental Health Literacy (EHL) and testing behavior among Health Council participants in Northeast Tennessee, which uncovered disparities and associated risk factors. Finally, the policy analysis examined existing radon regulations across federal, state, and local levels, focusing on Tennessee, and proposed strategies for improvement, including standardized licensing for radon professionals. The combined findings of this study highlight the need for interdisciplinary collaboration to address radon challenges effectively in Tennessee. The review underlines the variability in exposure-risk associations, while the survey emphasizes the importance of tailored educational interventions to improve awareness and ameliorate testing rates. The policy analysis advocates for standardized certification to ensure reliable radon services in Tennessee. Overall, this dissertation offers valuable insights into radon's impact on public health and proposes strategies for mitigation through improved regulations, increased awareness initiatives, and targeted interventions, which all depends on collaborative efforts between stakeholders.

Purpose: To determine if a quality improvement project involving individualized, one-on-one Diabetes education will improve health literacy and Diabetes outcomes in adults with Type 2 Diabetes in a rural primary care clinic. Diabetes is a chronic condition affecting the United States with 9.6% of Virginia’s population living with Diabetes. Aims: To improve patient’s Diabetes literacy scores, BMI, and Hemoglobin A1c levels through Diabetes education. Processes: There are pre- and post-education phases. Data to be collected at the end of both phases consist of DNT15 scores, BMI, and A1c. In the pre-education phase, BMI was obtained, DNT15 was administered, and Diabetes education was provided. Then, A1c was obtained, and patients were scheduled to return in the month of May. Post-education phase starts at the follow-up where participants retake DNT15 and BMI and A1c will be obtained. Results: Only pre-education data has been collected from the participants. Post-education data will be collected throughout the month of May during 3-month follow-up appointments. Expected results include 10% improvement of BMI, A1C, and Diabetes literacy scores. Limitations: Increased use of GLP1 prescriptions in clinic could affect results. Some patients were sent to the ED after being seen requiring prompt follow-ups while others obtain A1c results from other disciplines and may not have results sent to this clinic by the end of the data collection period. There have also been several no shows. Patients and staff have been receptive to the quality improvement initiative. Conclusion: Education has been provided to 25 patients. Follow-ups are scheduled for post-education data collection in May.

Background: Low health literacy and increased sugar-sweetened beverage (SSB) consumption are two broad public health concerns facing the United States. For example, it is estimated that 90 million Americans have insufficient literacy skills (IOMC, 2004) and low health literacy is associated with poorer health outcomes (Berkman et. al., 2011). Furthermore, SSBs contribute about 80% of added sugars in the diet (Nielsen & Popkin, 2004) and have been associated with poor health outcomes, including obesity, type II diabetes, bone fractures, dental caries, and coronary heart disease. Despite these findings, there is limited research related to how to effectively decrease SSB intake among adults. Additionally, there have been few studies investigating health literacy interventions that target health behaviors in community settings (Allen et.al, 2011). Objective: As guided by the Theory of Planned Behavior (TPB) and constructs of health literacy, this 5-week, 2-arm randomized controlled pilot trial, used mixed methods to examine the effects of an intervention to decrease SSB (SipSmartER), as compared to a matched-contact control condition targeting physical activity (Move More). The primary aims of this pilot project were to evaluate participant's feedback through process and summative evaluation as well as evaulate intervention content and/or delivery through process evaluation by staff tracking for quality improvements. Secondary aims included the assessment of changes in theorized mediating variables and health behaviors among participants. Methods: Twenty-five participants (mean age = 42±14 years, mean BMI = 34.3±7.5 kg/m₂, 19 females, 12 African Americans, 9 (high school education) residing in Roanoke, VA were randomized to either SipSmartER (n=14) or Move More (n=11) to begin the 5-week intervention. Inclusion criteria consisted of participants being 18 years of age or older, English speaking, consuming greater than 200 kcal/day of SSB, and being without medical conditions in which physical activity would be contraindicated. Both 5-week interventions included two interactive small group sessions (Weeks 1 & 5) and three support telephone calls (Weeks 2, 3 & 4). Pre-post data was obtained using previously validated instruments including Beverage Intake Questionnaire (Bev-Q), Theory of Planned Behavior constructs addressing SSB and physical activity, media literacy, subjective numeracy, Stanford Leisure-Time Activity Categorical Item (L-CAT), and quality of life. Descriptive statistics, ANOVA, and regression models were used in data analysis. Results: Although SSB consumption decreased more among the SipSmartER participants (-257±622.6 kcal/day) than Move More (-200±404.6 kcal/day) there were no significant group by time differences. However, among all participants, changes in TPB constructs significantly predicted changes in SSB (R²=0.592; F=2.485; p=0.080) and physical activity behaviors (R2=0.621; F=2.813; p=0.056). Participant and staff feedback were very positive, ranging from 4.2-5.0 on a 5-point likert scale that included questions about intervention organization, flow, effectiveness, engagement, and enjoyment. Favorite themes that emerged with SipSmartER participants when asking about small group sessions included, realizing how much sugar is found in SSBs, understanding the health risks associated with drinking too much sugar, realizing how much sugar was being consumed during the day, and learning about better alternatives. Conclusion: Findings suggest promise for the piloted intervention to reduce SSB consumption through targeted TPB and health literacy strategies. This pilot study has allowed further refinement and execution of a larger trial that includes a larger sample and longer study duration (i.e. 6-months) and follow-up period (i.e. 18-months). / Master of Science

Low health literacy in parents has been linked to increased obesity risk for their children. When providing information to patients with low health literacy, teach-back (TB) and teach-to-goal (TTG) methods are recommended, but no studies have examined the degree to which TB/TTG strategies can be implemented with fidelity in community-based programs. A study was conducted to determine if type of delivery staff (community or research) is related to implementation fidelity; the degree to which TB/TTG methods are necessary for parent/caregiver understanding of childhood obesity learning objectives; and if baseline parent/caregiver health literacy level is related to support call response. Ninety-four families with overweight/obese children aged 8-12 years were enrolled in a pilot childhood obesity intervention that included 6 bi-weekly parent/caregiver support calls integrating TB/TTG methods into a 5 A's approach. Research partners (n=2) delivered all calls in Wave 1. During Waves 2 and 3, community staff (n=5) delivered a majority of calls with training and support from research staff. ). Average completion rate across calls was 62% and did not differ according to participant health literacy level. Community partners were more likely than research partners to complete calls with participants (68% versus 57%), but this trend was not significant. Both research and community partners adhered to call scripts with high fidelity (97% versus 98%). A significant main effect of health literacy level on TB/TTG performance was found for Call 1 and Call 3 during Wave 1 and for Call 1 during Waves 2 and 3 of iChoose (p<0.05, 0.01, and 0.05). An interaction effect of health literacy level and question number was found for Call 3 during Wave 1 only (p<0.05). For all calls in which TB/TTG performance differed significantly by health literacy level, participants with adequate health literacy were found to have better performance. Following the program, participants expressed they felt satisfied and comfortable with follow-up calls (9.1 (2.0) and 9.5 (1.2) on a 10-point scale), while agreeing that calls helped improve their eating and PA habits (8.1 (2.6) and 7.5 (2.7)) and helped them learn class material better (8.1 (2.7)). Trained community partners were able to deliver the same support call content with similarly high fidelity, completion, and acceptability. Although participant baseline health literacy level had less impact on the need for TB/TTG and on program perception than we anticipated, our findings open up different possibilities to utilize these strategies while using precious resources more efficiently. / Master of Science / Low health literacy – meaning a limited capacity to access and understand basic health information that is needed to make suitable health decisions – has been linked to a plethora of poor health behaviors and outcomes, including increased obesity risk for the children of low health literate parents. When sharing information to patients with low health literacy, teach-back (TB) and teach-to-goal (TTG) methods are recommended in which health care professionals ask patients to repeat instructions or explain key concepts using their own words and then re-instruct patients as needed until they master these concepts. No studies thus far have examined the degree to which TB/TTG strategies can be implemented with fidelity – meaning adherence to protocol and competence in delivery – in community-based programs. A study was conducted to determine if type of delivery staff (community or research) is related to implementation fidelity; the degree to which TB/TTG methods are necessary for parent/caregiver understanding of learning objectives in a program to improve health-related behaviors; and if baseline parent/caregiver health literacy level is related to support call response. Ninety-four families with overweight/obese children aged 8-12 years were enrolled in a pilot childhood obesity intervention that included 6 bi-weekly parent/caregiver support calls integrating TB/TTG methods into an evidenced-based 5 A's approach for behavioral change. Research partners delivered all calls in Wave 1 of the pilot trial, while community staff delivered a majority of calls during Waves 2 and 3 with ongoing training and support from research staff. Average completion rate across calls was 62% and did not differ according to participant health literacy level. Community partners were more likely than research partners to complete calls with participants (68% versus 57%), but this difference was not significant (it may have been due to chance). Both research and community partners followed guided call scripts with high fidelity. The health literacy level of participants at the start of the program was associated with TB/TTG performance during calls, but this effect was limited to only a few calls. In all of these instances, participants with the higher level of health literacy (adequate) were found to have better TB/TTG performance. Following the program, participants expressed they felt satisfied and comfortable with follow-up calls, while agreeing that calls helped improve their eating and physical activity habits and helped them learn class material better. Trained community partners were able to deliver the same support call content with similarly high fidelity, completion, and acceptability. Although participant baseline health literacy level had less impact on the need for TB/TTG and on program perception than we anticipated, our findings open up different possibilities to utilize these strategies while using precious resources more efficiently.

In comparison to other high-income nations, the U.S. maintains the highest maternal mortality rate, especially among Black women. Factors like the growing maternal age and restricted family planning clinics have been noted to contribute to this phenomenon. However, the impact of health literacy on maternal has yet to be reviewed. Health literacy in the U.S. has long been determined to be a social determinant of health more broadly, and it may likely play a role in maternal health as well. Consequently, a systematic review of health literacy and its association with maternal health outcomes is warranted. The goal of this study is to examine research that has been conducted over the past ten years to determine the state of evidence on the association of health literacy and maternal health outcomes. I will utilize the research databases of PubMed, CINAHL, and PsycINFO alongside a carefully curated search hedge to find articles that best align with pre-determined inclusion criteria. After articles have been screened at title/abstract and full-text levels, all remaining articles will be appraised for quality. Articles strictly pertaining to health literacy and its relationship to maternal health outcomes will be evaluated. I expect this systematic review to shed light on the role of health literacy as a potential strategy to improve maternal health outcomes.

Objectives: To determine oral health literacy levels among Hispanic adults living in Iowa, and assess the relationship between oral health literacy and dental utilization. Methods: This cross-sectional study included a convenience sample of self-identifying Hispanic/Latino adults. Participants were recruited via mass email, word of mouth, and from faith-based organizations that provided church services in Spanish. Participants were recruited from urban and rural communities in Central and Eastern Iowa. Participants were asked to complete a questionnaire, in either English or Spanish, that contained questions pertaining to: oral health literacy, dental utilization, acculturation, language proficiency, demographic information, country of origin, number of years living in the United States, and preferences pertaining to the characteristics of their dental providers (e.g. importance of dentist to be able to speak Spanish). Oral health literacy was assessed using the Comprehensive Measure of Oral Health Knowledge (Macek and colleagues). Oral health knowledge levels were categorized as low (0-14) or high (15-23). Dental utilization was defined as visiting a dental provider within the past 12 months or more than 12 months ago. Bivariate analyses were conducted using the Chi-square test with oral health knowledge and dental utilization being the two main outcome variables. Multiple logistic regression models were created to identify the variables related to low oral health knowledge irregular dental utilization. Statistical significance was set as p<0.05. IRB approval was obtained prior to conducting the study. Results: Three hundred thirty-eight participants completed the questionnaire. Sixty-seven percent of participants (n=228) completed the questionnaire in Spanish. The mean oral health knowledge score was 14 (low knowledge =51% vs. high knowledge = 49%). Thirty-five percent reported visiting the dentist <12 months ago. Bivariate analyses revealed that the following respondents were more likely to have low oral health knowledge (p<0.05): being older (i.e. 55-71 years of age), male, self-reporting low health literacy, having less than a high-school education, earning ≤$25,000, not having dental insurance, having low acculturation, being born outside of the United States, preferring a dental provider who speaks Spanish, perceiving one’s oral health to be fair/poor/or not knowing the status of one’s oral health, seeking dental care someplace other than a private dental office, and being more likely to seek care for a problem related visit rather than routine care. Having low oral health knowledge was statistically significantly associated visiting a dentist >12 months ago. Many other variables were also associated (p<;0.05) with infrequent dental utilization: low health literacy, being male, having <12th grade degree or a high school diploma, earning ≤$25,000, not having dental insurance, having low acculturation, reporting fewer years living in the United States, preferring a dental provider who speaks Spanish, perceiving one’s oral health to be fair/poor/or not knowing the status of one’s oral health, and seeking dental care someplace other than a private dental office. Final logistic regression analyses indicated that having less than a 12th grade education, lack of dental insurance, and a preference for receiving care from a Spanish speaking dental provider were associated with low oral health literacy. Furthermore, final logistic regression results predicting irregular dental utilization demonstrated that the following variables were statistically significant: being male, earning ≤$25,000 per year, not having dental insurance and having a history of tooth decay. Conclusion: Dental utilization and oral health knowledge appear to be associated. Patients with low oral health literacy may be less likely to utilize dental care, thus decreasing the opportunity to increase dental knowledge. Dental teams should recognize which patients are more likely to have low oral health literacy and provide dental education in patients’ preferred language.

No description available.

Background: High prevalence of mental health problems and underutilization of mental health treatment are more severe among the Native Hawaiian and Other Pacific Islander (NHPI) population and remain misunderstood and understudied. Examining mental health literacy (MHL)–the knowledge and beliefs about mental disorders which aid their recognition, management, or prevention–has been shown to identify barriers to seeking and receiving care. Objectives: This study aimed to assess the level of MHL in Polynesian NHPIs and identify associated demographic variables. Methods: Data for this pilot cross-sectional study were collected from 298 US Polynesians via an online questionnaire of the Mental Health Literacy Scale (MHLS). Results: The overall mean MHLS score was 121 (standard deviation = 17.3), with statistically significant higher scores in female participants, > 31 years old, Tongan, more educated, and with higher income. Conclusion: This study demonstrated that overall MHL is comparable among Polynesians compared to the current literature. However, Polynesian men < 30 years old and with lower income had lower MHL, which may be linked to the mental health disparities specific to this population. Current interventions should focus on increasing knowledge of risk factors, causes, self-treatments, and available professional help regarding mental disorders. Efforts to improve the MHL of Polynesians should target men < 30 years with lower income (<$50,000).

Cultural activities have in recent years started to be acknowledged in health promotion. The concept can include a various kind of activities such as dance, art, and theatre. Läget is a project which has junior high school- and high school students as a target group and the project use cultural activities to illustrate health issues of young people in Västmanlands County. The health issues that are contained within the project is based on data from the survey Liv och Hälsa Ung which is responded by junior high students in 7th and 9th grade and high school students in 2 grade. Liv och Hälsa Ung is carried out every third year in Västmanlands County. The aim of this study was to examine the experiences of participants of the project in terms of their participation and whether their participation gained knowledge about health. Furthermore the study aimed to inquire their thoughts about the project as a method for illuminating health issues. A qualitative approach was used and four participants who had been involved in the art exhibition in the project were interviewed.  The material from the interviews were analysed using a manifest content analysis. The result showed that high school students experienced that the projected had been satisfying working with and that their knowledge in health issues had increased. They also considered the art exhibition in Läget as a suitable method for mediating knowledge about health. The theoretical framework of the study were empowerment and health literary. The result of this study can be useful for gaining knowledge about how a project in art can be related to health among high school students. / På senare år har kulturaktiviteter börjat att erkännas allt mer i det hälsofrämjande arbetet. Kulturaktivitet är ett vidsträckt begrepp som bland annat kan innefatta dans, konst, och teater för att ge några exempel. Projektet Läget tillämpar kultur i olika uttrycksformer för att uppmärksamma hälsofrågor och har högstadie- och gymnasieelever som sin målgrupp. Hälsofrågorna som lyfts fram i projektet har sin grund från enkätundersökningen Liv och Hälsa Ung. Det är en enkätstudie som genomförs i Västmanlands län var tredje år och besvaras av elever i årskurs sju och nio samt årskurs 2 på gymnasiet. Syftet med denna studie var att undersöka gymnasieungdomars upplevelser av att delta i projektet och om de ansåg att projektet ökat deras kunskaper i hälsofrågor. Vidare undersöktes deras tankar om projektet som metod för att uppmärksamma hälsofrågor. Studiens metod var kvalitativ och datainsamlingen genomfördes genom intervjuer med fyra personer som varit delaktiga i projektets konstutställning. Intervjumaterialet analyserades sedan genom en manifest innehållsanalys. I resultatet framkom att gymnasieungdomarna upplevde att projektet varit tillfredsställande att arbeta med och att de fått ökade kunskaper i hälsofrågor. Lägets delprojekt om konst ansågs även vara en bra metod för att förmedla kunskap om hälsa. Det teoretiska perspektivet i studien är teorierna empowerment och health literacy. Resultatet av studien kan bidra till att få kunskap om hur ett projekt om konst kan relateras till hälsa hos gymnasieelever.