Background: The utilization of telehealth has had a substantial impact on transforming and enhancing the methods by which healthcare is presently delivered. The potential benefits of telehealth in improving the health of vulnerable populations and underserved communities are substantial. The aims of this study were to examine the association between social determinants of health and patient perceptions of their experiences with telehealth. We will analyze how perceptions differ across specialization, race, gender, and other key determinants; examine how patient’s self-rated physical health and mental health influences perceptions and attitudes about telehealth utilization; and evaluate differences in perceptions and attitudes, experience with patient interactions and overall telehealth experiences between mental health providers and non-mental health providers. Methods: A scoping review was completed to explore literature regarding telehealth administration and underserved populations following the PRIMSA-ScR guidelines. Multivariable logistic regression was then conducted to assess the relationship between self-rated mental health and self-rated physical health and the primary predictor variables telehealth usability, telehealth satisfaction, and telehealth experiences. Finally, a mixed-methods study was conducted to evaluate differences in perceptions and attitudes, experience with patient interactions and overall telehealth experiences mental health-care providers and non-mental healthcare providers. Results: The scoping literature review highlights how telehealth is used in diverse settings, but more research needs to be done to determine best practices for both healthcare providers and patients utilizing telehealth. The study focused on self-reported health found significant associations between high mean scores on telehealth usability, telehealth satisfaction, and telehealth experiences and good self-reported mental and physical health. Lastly, the study looking at provider differences highlighted that the reliability of the telemedicine platform, the ability to trust the telemedicine application, and video visits being a convenient form of healthcare delivery was greater for mental healthcare providers than non-mental healthcare providers. Implications: These findings highlight the need for studies examining telehealth satisfaction, telehealth usability and telehealth experiences amongst providers and patients in underserved areas. Further research is needed to gain a deeper understanding of the telehealth access requirements of underserved communities and can aid in the development of evidence-based guidelines for the delivery of telehealth services.

The lifetime prevalence of alcohol in the United States is 8% and lifetime prevalence of illicit drug use is about 2-3%. Substance use is common among adolescents and polysubstance use is becoming a public health threat. The prevalence of adolescent physical dating violence was 8.2%, the prevalence of adolescent sexual violence was also 8.2% while the prevalence of dual adolescent physical and sexual violence was 2.6%. Compared to those who used only single substances, adolescents who did not use any substance were 60% less likely (OR = 0.42, 95% CI = 0.24 – 0.74) to experience physical dating violence, 50% less likely (OR = 0.45, 95% CI = 0.31 – 0.66) to experience sexual dating violence and 70% less likely (OR = 0.34, 95% CI = 0.16– 0.69) to have experienced both physical and sexual dating violence. The prevalence of adolescent criminal arrests was 17.2%. Adolescents who combined select illicit drugs with alcohol were 1.7 times more likely to be arrested (OR = 1.66 ,95% CI = 1.49 – 1.85). Adolescents who used both select illicit drugs and marijuana were 1.5 times (OR = 1.55, 95% CI = 1.46 – 1.65) more likely to be arrested than those who used only select illicit drugs. Also, adolescents who used all three substances (select illicit drugs, alcohol and marijuana) were 1.6 times (OR = 1.62, 95% CI = 1.50 – 1.75) more likely to be arrested than those who used only select illicit drugs. The prevalence of weapon-related injuries was 7.4%. Adolescents who did not use substances were 50% less likely (OR = 0.47, 95% CI = 0.29 – 0.75, p The odds of dating violence, criminal arrests and weapon-related were higher with polysubstance use than with either mono-substance or no substance use. Therefore, prevention of substance use may be beneficial in reducing these public health concerns.

The multi-million-dollar medical uniform industry has not utilized advancements in garment and textile technology that could positively impact the protection of healthcare professionals and patients. In most cases the uniforms meet basic requirements – they clothe the professional in a recognizable way. Little innovation in design, function and performance, has been applied to these garments. This is particularly evident in the case of the stereotypical white lab coat worn by many physicians, despite evidence indicating that these lab coats may carry contamination and play a role in the spread of deadly bacteria. Healthcare Associated Infections (HAIs) are among the most serious problems facing modern medical care, costing millions of lives and dollars annually worldwide. This research investigates the design and use of the physician’s lab coat – an immediately recognizable symbol of Western medicine. The research identifies the medical, functional, cultural and symbolic roles of the lab coat within the hospital environment and beyond, to the larger the global society. This thesis examines the extent to which the design of medical wear can impact the effect of hospital-acquired infections, support doctor/patient relationships and enhance the performance and behavior of the healthcare professional by envisioning a future lab coat which offers increased protection for physician and patient, aids in communication and enhances the performance of the doctor by utilizing digital technologies incorporated into the lab coat whereby the lab coat becomes the only tool necessary for the physician.

This dissertation is a collection of three separate essays on the health of women and children. In the first essay, I along with my co-authors, analyzed the impact of two large, national-level health policies (the Janani Suraksha Yojana (JSY) and the National Rural Health Mission (NRHM)) on maternal health outcomes (proportion of institutional deliveries) in India. We used data from the India Human Development Survey (IHDS) and found that the JSY and the NRHM had a greater impact on institutional deliveries in high-focus states. We also found that the conditions of the public health facilities, did not change after the implementation of the JSY and the NRHM. Finally, we found that adequacy of health facilities was not associated with the likelihood of mothers in high-focus states having an institutional delivery. In the second essay, I examined whether a key social determinant of health in South Asia- gender inequality, is associated with physical health outcomes among Indian women. I found that the gender inequality expressed as the gendered household practice of seclusion was negatively associated with body weight of Indian women. Further, I found that participation in all household decisions by women of the household was generally not associated with body weight outcomes. The association between gendered household practices and women’s body weight outcomes was generally similar among rural and urban Indian women. In the final essay, I examined whether perinatal food environments (FE), maternal gestational weight gain (GWG) and early childhood weight (ECW) outcomes are associated. I used data on mother-children dyads from the Early Childhood Longitudinal Study – Birth cohort (ECLS-B), Area Resource Files (ARF) and Current Business Practices (CBP). I found that maternal GWG was associated with ECW outcomes. I also found that measures of food environment were associated with ECW outcomes. Specifically, I found that having an additional full-service restaurant per one thousand population in the maternal perinatal county of residence was associated with lower Body Mass Index (BMI) among children at age two years. Finally, I found that GWG did not mediate the association between food environment and ECW outcomes.

The Brisbane Longitudinal Twin Study (BLTS) was being conducted in Australia and was funded by the US National Institute on Drug Abuse (NIDA). Adolescent twins were sampled as a part of this study and surveyed about their substance use as part of the Pathways to Cannabis Use, Abuse and Dependence project. The methods developed in this dissertation were designed for the purpose of analyzing a subset of the Pathways data that includes demographics, cannabis use metrics, personality measures, and imputed genotypes (SNPs) for 493 complete twin pairs (986 subjects.) The primary goal was to determine what combination of SNPs and additional covariates may predict cannabis use, measured on an ordinal scale as: “never tried,” “used moderately,” or “used frequently”. To conduct this analysis, we extended the ordinal Generalized Monotone Incremental Forward Stagewise (GMIFS) method for mixed models. This extension includes allowance for a unpenalized set of covariates to be coerced into the model as well as flexibility for user-specified correlation patterns between twins in a family. The proposed methods are applicable to high-dimensional (genomic or otherwise) data with ordinal response and specific, known covariance structure within clusters.

Metabolic syndrome (MetS), a global public health problem, is the primary cause of type 2 diabetes and cardiovascular disorders. Lifestyle modification interventions (dietary and physical activity modifications) are effective in preventing and ameliorating MetS and associated comorbidities. However, the impact of lifestyle changes on MetS among Mexican Americans has yet to be investigated, particularly due to high attrition rates in this population. The overall goal of the explanatory mixed-methods study presented in this dissertation was to identify efficacious lifestyle modification efforts directed towards Mexican Americans to promote their retention in lifestyle modification programs, ameliorate the severity of MetS, and understand underlying behavior modification process. In particular, we examined secondary data from an extensive study Beyond Sabor to 1) examine predictors of program completion, 2) compare variation in MetS severity scores (z-scores) between intervention (Beyond Sabor) and attention control (Healthy Living) groups, over time and, 3) investigate processual development of self-efficacy in a sample of 1153 disadvantaged Mexican Americans participants. Findings suggest that program completers were more likely to be older, had more years of education, lower fasting blood glucose levels, and participated in sites with high group cohesiveness. Results also revealed that when compared with the standard nutrition program, Healthy Living, the lifestyle modification intervention, Beyond Sabor, was more effective in ameliorating MetS severity, systolic blood pressure, triglyceride, and fasting plasma glucose levels among study participants. Qualitative results demonstrate the high acceptability of Beyond Sabor intervention. Four sub-themes emerged illustrating important underlying conditions contributing to participants’ improved self-efficacy: desire to gain knowledge about ways to improve health, development of social support, adoption of program teachings in family lifestyle, and improvement in health outcomes. Findings of the current study may allow researchers to identify Mexican Americans at risk of non-completion and to develop strategies to improve lifestyle modification program attendance, and thus health outcomes. Qualitative findings underscore the importance of sociocultural context on individuals’ attempts to make lifestyle changes to manage their chronic illnesses. Successful adaptation of lifestyle interventions such as Beyond Sabor for at-risk populations in community-based settings will be critical in stemming the tide of MetS.

Social networking sites (SNSs) are an increasingly popular channel for communication among college students. Often students disclose more freely via social networking sites than they would in other situations. These disclosures commonly include information about engaging in risky health behaviors (e.g., binge drinking). Study 1 examined students’ impression management goals and self-presentation tactics specifically related to self-disclosures of drinking behavior on SNSs. Findings suggest that students use differing self-presentation tactics across various SNSs in order to achieve their impression management goals and to avoid consequences associated with disclosing about risky health behaviors to certain audiences. Study 2 sought to develop and measure SNS communication about alcohol related activities (SNCAA). It used the theory of normative social behavior as framework for investigating and predicting SNCAA. Additional variables that predict SNCAA were also identified. Findings demonstrate partial fit of the TNSB as a framework for explaining SNCAA. The overarching results of this project suggest a need for interventions aimed at reducing students’ SNCAA as well as increasing their overall knowledge about privacy and safety online.

Though Argentine women have made marked advancements in terms of equality since the Latin American country’s return to democracy in the 1980s, they still face barriers to the full exercise of their sexual and reproductive rights in a number of arenas. For low-income women, the added dimension of poverty further erodes the ability to seek necessary services to maintain sexual and reproductive health. As a result, high rates of maternal mortality and adolescent pregnancy persist. Given the broad socioeconomic inequality among Argentine provinces, the policies created by Argentina’s government to address sexual and reproductive health lack widespread implementation and oversight. Furthermore, a strong opposition to these policies is in place, promoted by the heavy presence of the Catholic Church in Argentine institutions and society as well as deeply entrenched perceptions of motherhood. This study identifies the social, economic, legal, cultural, and political challenges that face the sexual and reproductive autonomy of Argentine women, evaluates the current policies in place to address them, and projects potential solutions for Argentina’s government, women’s movement, and NGOs.

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

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.