Background: Obesity remains a major public health problem and a risk factor for developing chronic diseases. Substance use such as e-cigarette, marijuana, and alcohol have been associated with the risk of being obese. However, the results from previous studies have been inconsistent. The purpose of this study is to determine the association between substance use and obesity among adults in the United States. Method: Data from the 2016 Behavioral Risk Factor Surveillance System (BRFSS), an annual cross-sectional survey administered to 446,687 adults in all 50 states to collect information about their health-related risk behaviors, chronic health conditions and the use of preventive services, was used in this study. Data was collected via a self-reported questionnaire validated by CDC. A multiple logistic regression model was conducted to determine the association between exposure variables (e-cigarette, marijuana, and alcohol abuse) and obesity. The model was adjusted for possible confounders such as demographics (age, sex and race) and behaviors such as tobacco smoking and physical activity. The data was analyzed using SAS v 9.4. Results: Individuals who used marijuana during the past 30 days were 32.4% less likely (adjusted odds ratio (aOR): 0.676, 95% CI: 0.631-0.723, P<0.001) to be obese compared to those who did not. The odds of being obese among heavy alcohol drinkers was 30% less (aOR: 0.70, 95% CI: 0.679-0.721, p<0.001) compared to those who were not heavy alcohol drinkers. Conclusion: The study findings demonstrate that marijuana and heavy alcohol drinking are significantly associated with reduced likelihood of obesity. However, e-cigarette use was not significantly associated with obesity. Further longitudinal studies to explore the relationship between these substances and obesity will be beneficial.

BACKGROUND: Service-learning functions as one aspect of the experiential learning continuum, placing equal importance on both service and learning, while emphasizing the reciprocity between the provider and the recipient. Along with reciprocity, the core tenants include engagement, course integration, and reflection. The basis for service-learning arose from philosophical ideas challenging the traditional classroom model and the growing sentiment towards social activism. Today, service-learning has been incorporated into various educational programs, including undergraduate, medical, and various health professions. LITERATURE REVIEW FINDINGS: This thesis contains a comprehensive review of service-learning programs within various educational arenas and their reported benefits and effects on students. Composed of both qualitative and quantitative studies, the literature revealed the increasing trend of incorporating a service-learning experience, largely voluntary, into medical and health science education. Across the different fields, students engaging in service-learning reported high levels of personal and practical gain, including improvements in teaching and communication skills. However, the effects of service-learning within physician assistant curriculum have not been widely explored. PROPOSED PROJECT: This project aims to objectively assess the effectiveness of adding Anatomy Academy, a teaching-based service-learning opportunity, into the curriculum of the Boston University PA program. The study will quantitatively evaluate the effects on students’ skills in patient communication, teaching, and self-perceived confidence, as well as students’ willingness to engage in future service as health care providers. The study will also qualitatively assess student satisfaction with the course and perceived utility in future practice. CONCLUSIONS AND SIGNIFICANCE: The results obtained herein will provide an invaluable assessment of the potential effects of a mandatory service-learning program within a PA curriculum. Beneficial outcomes for the students will serve as motivation and evidence for a larger adoption of service-learning into PA curriculum across the country. For future healthcare providers, service-learning provides an effective framework to train essential skills such as teaching and communication, while forging important community bonds and implementing the principles of preventive medicine.

Background: Sugar sweetened beverages (SSBs) comprise the largest source of added sugars in US adolescents’ diets. SSB consumption is pervasive in US culture and is a critical risk factor for weight gain and obesity in adolescents. This thesis evaluates multi-level factors that influence adolescent SSB consumption. Methods: The first two aims of this thesis utilized data from the cross sectional, internet based Family Life, Activity, Sun, Health and Eating (FLASHE) study to: 1) examine availability of SSBs in multiple settings (home, school, neighborhood) and adolescent SSB consumption, 2) examine the associations between perceptions of parenting practices and adolescent SSB consumption. The third aim used focus group discussions to understand adolescents’ perceptions about SSBs. Results: We found that SSB availability in the home was an important predictor of adolescent SSB consumption, regardless of SSB availability in other settings. Also, parenting practices that facilitate adolescent SSB consumption are associated with higher adolescent SSB consumption, but discussing/negotiating SSB behaviors is not associated with adolescent SSB consumption. Adolescents’ described their attitudes, reinforcements, knowledge, and sources of influence around SSBs which are multifactorial and complex. Conclusions: This thesis identified potential targets for addressing adolescent SSB consumption through availability of SSBs at home, parenting practices, and adolescent perceptions around SSBs. These are important modifiable factors in the adolescents’ sociocultural environment that should be targeted in future dietary interventions to influence adolescent SBB consumption.

<p><em>Objectives: </em> (i) To determine the types and impact of uncertainty in the decision-making process of policy-makers regarding the implementation of the human papillomavirus (HPV) vaccine. (ii) To determine the relative strengths and limitations of qualitative and quantitative knowledge synthesis methodologies as well as their contributing role to the policy-making regarding the HPV vaccine.</p> <p><em>Methods</em>: A systematic review and a meta-ethnography were conducted concurrently. Four different search strategies, of nine different databases, were used to target all potential quantitative and qualitative literature published from 1990 to 2011. Studies were selected after abstract and full-text screening by two reviewers, with disagreements resolved by consensus. English language studies of any study design that addressed the HPV vaccine and policy were eligible for inclusion. Quality appraisal of included studies was undertaken using available criteria and tools according to study design. The criteria sets by Tong and colleagues and CASP were used for the qualitative literature while the economic evaluations were appraised with criteria set by Nujiten and colleagues. Quality of the cross-sectional study was not systematically appraised. Data extraction forms were designed for each study type. The data extracted included: study characteristics, types of uncertainty, number of types within each study, policy decision measured as the authors’ final recommendation, and perceptions of the confidence of these recommendations as rated by the reviewers. Chi-square tests were conducted to determine if presence or absence of uncertainty influenced decisions. Pearsons Correlations were conducted to determine the relationship between the amount of uncertainty and perceived certainty of the decision. The qualitative analysis was conducted using steps outlined by Noblit and Hare to determine how studies were related, to translate studies into one another, and to synthesize translations.</p> <p><em>Results:</em> Of the initial pool (n= 865), 21 studies met inclusion criteria and were considered; 17 quantitative and 4 qualititative. (i) The simulation cohorts of the decision analytic models did not vary by study appreciably. Chi square analyses failed to find evidence that policy decisions were influenced by presence or absence of uncertainty. Further, no statistically significant correlation was found between amount of uncertainty and perceived certainty with the funding decision. At least four types of uncertainties were identified in each qualitative study including but not exclusive to cost, public acceptance due to the sexually transmitted nature of HPV, as well as the health care system’s ability to implement and monitor the vaccine. After employing the Noblit and Hare translation process, four broad types were identified: uncertainties around managing different public acceptability viewpoints, the manufacturer’s role and input, the actual vaccine’s characteristics, and the system’s ability to implement a vaccination program. (ii) Specific and measurable outcomes could only be identified <em>a priori</em> for the quantitative studies due to the nature of questions asked. Locating relevant qualitative studies was more complex and time-consuming due to variation in the manner that each study’s defining features and information are catalogued and searched. A lack of reporting in both the qualitative and quantitative studies disabled a thorough assessment of methodological quality. Data extraction only varied in the manner that the data was recorded. The quantitative results consisted of specific types of data (numerical or categorical) while qualitative results were descriptive.Within data analysis, the types of uncertainty were determined through reciprocal translation while the impact of uncertainty was tested using two statistical techniques. These differences highlight the rigidity and flexibility of quantitative and qualitative literature, respectively.</p> <p><em>Conclusions:</em> Using both qualitative and quantitative methods enabled a more complete understanding of the role of uncertainty within the decision-making process. Regardless of the methodology used, each type of knowledge synthesis method provided relevant data in regards to the HPV vaccine; simply from different perspectives.</p> / Master of Science (MSc)

The project effects arise from specific projects or programmes that are undertaken in the context of the Games, but which could be implemented in the absence of such an event. The evaluation of these could be improved if either a prospective cohort study (where the participants in the projects can be predicted in advance) or retrospective cohort study (where the participants will only be known after they have taken part) is arranged. This will require to be undertaken in combination with qualitative studies and the creation of a theory of change to understand why any such project effects are (or are not) seen. The direct impacts of the Games, that is the impacts that occur as a direct result of playing host (such as the impact on tourism), require a different approach to achieve a quality evaluation. First, a theory of change to identify the critical pathways in generating impacts should be elucidated. Next, a combination of a cohort study and an ecological study (using routine data and a series of comparison areas identified in advance), should be used to identify the attributable impacts of the Games. Qualitative work alongside these studies will be required to understand why the impacts occur (or not). For the economic impacts specifically, an ecological design or economic modelling should be performed using routine statistical data (rather than estimates) and taking account of the opportunity costs. The catalytic impacts are particularly difficult to evaluate as it is not yet clear what these impacts might be. These potential impacts will require being identified using regular qualitative work with key individuals within the public and private sector in Glasgow, and this information will then need to be used to design quantitative studies to test these hypotheses. The synthesis discussed whether or not the Games could legitimately be described as a health improvement intervention. It found that some of the critical steps in the intervention were very similar to the tried and tested mechanisms used over many decades in the West of Scotland in attempt to improve the health and social conditions (economic growth and improved environment), without success. The ability of the Games to impact on the other critical steps (sports participation, increased volunteering and increased pride) is not supported by the evidence from previous events, and it is difficult to see what is different about the plans for the 2014 Games that might generate a different result. It was therefore concluded that the 2014 Games are unlikely to be an effective health improvement, and are unlikely to generate the plethora of social and economic benefits that pepper the bid document and legacy plans. Discussion: There are high expectations from Government that the 2014 Games will deliver a plethora of health and social benefits. The evidence from previous events is of poor quality, and there is an absence of evidence of positive impacts occurring. Given that a publication bias towards positive impacts is expected, it is unlikely that large positive health or socioeconomic benefits have occurred from major multi-sport events in the last 30 years. Health impact assessment can be used as an effective method of engaging the public and can be used to inform policy-making with evidence. Although the HIA did not predict the net overall impact of the Games, it is possible to make evidence-informed recommendations that are likely to maximise the potential for positive impacts and minimise the potential for negative impacts. The quality of evidence on the impacts of major sports events could be improved if a theory of change evaluation framework was applied to the event and if this was used to design a series of qualitative, cohort and ecological studies with appropriate comparison groups. However, it is unlikely that the 2014 Games will have a large positive impact on the health of Glaswegians or on socioeconomic outcomes because there is little evidence that the likely critical pathways have been successfully used in generating positive impacts despite similar attempts in the past. Some critics of major sports events have also made a plausible case for their being important negative consequences from playing host. The strengths of the thesis include the use of robust methodologies for the systematic review and health impact assessment, and the innovative use of a critical pathways approach for estimating whether or not the net impact of the Games will be positive. The weaknesses of the thesis include the reliance on the Government’s published work to discern the theory of change; the 34 studies that could not be obtained for possible inclusion in the systematic review; the limited evidence base upon which to make recommendations in the HIA; and the reliance on an accurate theory of change to predict the net impact of the Games, including the absence of emergent impacts from the complex Glaswegian context. Conclusions: The 2014 Games are unlikely to generate a large positive impact for health or the socioeconomic determinants of health. There is potential for unintended negative consequences to occur. The impacts of the Games are most likely to be optimised if the HIA recommendations are acted upon by decision-makers, and these impacts will only be accurately known if there is work to improve the quality of the evaluation. It is possible that the marketing of the Games as an intervention for health and social improvement might deflect attention from more important determinants of health in the city. In that vein, it may be more reasonable to make few other claims for the Games than that it will provide public entertainment and a festival for the population, and to minimise the opportunity costs that the Games will generate.

Background: Low socioeconomic position throughout the life course is associated with a number of adverse health outcomes in older people. However, whether life course socioeconomic position influences subjective outcomes in early old age, such as quality of life, is not well known. There is a lack of life course research that considers the wider structural determinants of health. In particular, it is not well understood if the association between life course socioeconomic position and quality of life is the same across European societies that have differing welfare state arrangements. This thesis addressed two key aims: (1) Investigate whether, and how, life course socioeconomic position influences the quality of life of Europeans in early old age. (2) Examine differences in this relationship by welfare regime. Methods: Two methodological approaches were taken to address the research objectives: (1) A systematic review of quantitative studies examining the influence of life course socioeconomic position on quality of life was conducted, with a narrative synthesis. (2) An empirical analysis was carried out examining the influence of life course socioeconomic position on the quality of life of individuals in early old age, as measured by CASP-12 and life satisfaction. This used secondary data from 13 European countries (representing Southern, Scandinavian, Post-communist, and Bismarckian welfare regimes) that were part of Wave 2 of the Survey of Health, Ageing, and Retirement in Europe (SHARE) and SHARELIFE, which collected retrospective life histories of respondents. Two statistical techniques were used to analyse the data: multilevel modelling and path analysis. Slope indices of inequality were calculated to enable measures of socioeconomic position to be compared. Results: The systematic review identified 12 relevant studies, which varied in terms of the outcomes examined, study quality, and populations. No studies were identified from Bismarckian or Post-communist welfare regimes, with most containing populations from the Scandinavian or Liberal regime types. Some supportive evidence was found for a latent effect of low childhood socioeconomic position on quality of life among women. Social mobility models were generally not supported. High quality studies addressing inter-generational mobility were lacking and few studies examined cumulative and pathway effects. Results from the analysis using SHARE suggested that the most proximal measures of socioeconomic position were the strongest predictors of quality of life. In most welfare regimes, inequalities in quality of life were largest by current wealth, but among women in the Southern and Post-communist regimes inequalities by education level were particularly large. In the Scandinavian regime there were very small differences in quality of life between the least and most educated. Generally, there was little difference in the magnitude of socioeconomic inequalities in quality of life between Scandinavian and Bismarckian regimes. Support for a latent effect on quality of life was lacking, using most measures of childhood socioeconomic position. The findings from both the multilevel models and path analysis supported the pathway theory whereby childhood socioeconomic position chiefly influenced quality of life through later socioeconomic experiences. However, the number of books in childhood exhibited a weak association with quality of life even when taking into account current measures of socioeconomic position, suggesting a small latent effect for this measure. When stratifying by welfare regime, the potential direct effect from the number of books in childhood was specific to particular welfare regimes and genders. A greater number of socioeconomically advantaged positions over the life course was associated with higher quality of life in early old age, but the results suggested this was mainly due to the influence of socioeconomic advantage during adulthood. The association between life course socioeconomic position (as measured by a cumulative socioeconomic advantage score) and quality of life was weaker in the Scandinavian regime and stronger in Southern and Post-communist regimes. Including a measure of current financial distress greatly attenuated these associations. There was generally a lack of supportive evidence for an effect of social mobility on quality of life. Conclusions: Socioeconomic inequalities in quality of life were apparent in all welfare regimes and were largest by more proximal measures of socioeconomic position. Overall, Scandinavian and Bismarckian welfare regimes exhibited both higher quality of life and narrower inequalities in quality of life, compared to Southern and Post-communist regimes. Interventions to reduce socioeconomic inequalities across the life course are needed, but those which buffer the effect of financial distress in early old age may be particularly beneficial for improving quality of life and producing a more equitable distribution.

Literature suggests that the public sector has a unique responsibility to promote sustainable practice from within. Food systems impact on planetary, social, economic and human health, and Ecological Public Health (EPH) is making these holistic connections explicit. This study developed a new methodological approach based on the principles of EPH, which for the first time are used to empirically investigate a complex foodservice system, the hospital foodservice system. In addition, Street Level Bureaucrat theory is used at the ward level for the first time deepening understanding of workers’ practices, particularly on the theme of choice. Using a case study based within one Welsh Health Board, this research considered the translation of a new Welsh policy into practice through an exploration of two key elements within the foodservice system: menu planning and food service at ward level. Following the systemic and interdisciplinary thinking promoted by EPH, a multi-methods approach was taken using documents and formal interviews with 28 key stakeholders in the case study Health Board. Ward based studies took place in three Health Board hospitals: lunch service on a total of nine wards was explored through observation, 33 informal interviews, 104 patient experience questionnaires, waste data and an in-depth study of one meal (lasagne) with 48 participants. The study showed mixed findings in the translation of policy into practice: aspirations to improve sustainability through procurement and waste reduction did not materialise in practice, and the individualised approaches of workers led to high levels of food waste and inconsistent approaches to choice. Patient satisfaction with choice increased under new menus, but a drop in satisfaction around menu changeability was found, particularly for longer stay patients. Finally, the lasagne study showed that patients had diverse responses to the same dish, and that liking the dish did not mean enough was eaten to meet nutritional needs. Such findings, in drawing the fields of nutrition and sustainability together, have multi-disciplinary impact, particularly for nutrition, environmental and hospitality management studies. In turn the findings demonstrate the value of research that draws on the principles of EPH.

Those who misuse alcohol are a burden on health services, the economy and society generally. Compared to their peers, British adolescents report some of the highest levels of alcohol use in Europe. Community organisations can potentially play an important role in the delivery of policy interventions aimed at reducing alcohol misuse. However, little is known about British adolescents’ engagement with these organisations, and related activities, and therefore the role that participation in community activities plays in adolescent alcohol use. This thesis presents findings from an investigation into young people’s participation in organised activities (OAs), such as sports and special groups. While the research was primarily motivated by psychological theories of adolescent risk taking their application was in an ecological framework that identified broader social and environmental determinants of behaviour. An explanatory mixed method design was used. This consisted of two longitudinal studies using data from the Avon Longitudinal Study of Parents and Children (ALSPAC), two cross-sectional studies of male young offenders and non-offenders and a qualitative study involving practitioners involved with the care and management of vulnerable young people. Findings revealed that individual-level characteristics associated with risk-taking behaviours predicted OA participation and that more vulnerable young people participated less in OAs. The analysis of qualitative data indicated that there were barriers to youngsters’ participation in OAs at multiple levels. Longitudinal analyses showed that those participating in sport OAs were more likely to report alcohol use compared to adolescents who did not participate in any OA and participants in non-sport OAs. Cross-sectional analyses showed that young offenders in team sports reported lower levels of hazardous alcohol use compared to young offenders who did not participate in any OA. Qualitative work explored how OA participation might impact vulnerable young people’s alcohol use and showed that the structures of organisations were important for how practitioners worked and the mechanisms identified. These findings highlighted OA participation inequalities among British adolescents and the importance of community contexts for future adolescent alcohol use interventions.

Community pharmacies in England provide a variety of services including essential services such as the dispensing of medicines, advanced services such as Medicine Use Reviews, and enhanced and locally commissioned services, for example the minor ailments scheme. In October 2011 a new advanced service called the New Medicine Service (NMS) was introduced. It aimed to improve adherence to newly prescribed medicines for patients with certain long term conditions and reduce medicines wastage. This thesis aims to evaluate the implementation of the NMS by exploring how the service was developed and implemented, identifying both potential and actual barriers and facilitators to NMS implementation, investigating the proportion of prescription items that are eligible for the service, and examining the uptake and provision of the service. In order to achieve this several studies were carried out. Interviews were conducted with stakeholders involved in the service’s development and implementation. Focus groups were conducted with community pharmacists complimented by interviews with superintendent pharmacists both before and after the introduction of the NMS. Data regarding the number of prescription items eligible for the service were collected in community pharmacies, and an analysis of service records for a large national chain of pharmacies was carried out. The studies determined that there were four stages to the development and implementation of the NMS; pre-negotiation, negotiations, the launch phase, and post-implementation. Both community pharmacists and superintendent pharmacists were enthusiastic about the potential of the service prior to the introduction of the service and anticipated good uptake of the service which was confirmed by post-implementation results. Several barriers were identified prior to implementation, the most important of which was the payment structure. Post-implementation results confirmed that the payment structure had affected NMS implementation, and direct observations in pharmacies, that the opportunity rate to provide the service was nearly half of the payment structure’s theoretical rate. Analysis of service data showed the uptake of the NMS was greater than the uptake of MURs in 2005. The findings of this thesis provide policy makers, pharmacy stakeholders, community pharmacists, and researchers with knowledge of how pharmacy services are developed. It also provides insights about factors that can facilitate or hinder service provision, including pharmacist attitudes towards a service, certain service and pharmacy characteristics (such as the ability to carry out telephone consultations), company encouragement to provide the service, the experience of conducting other pharmacy services, pharmacist workload, the accreditation procedure, and the services payment structure. These insights can be used to improve future pharmacy services’ implementation.

Obstructive sleep apnoea (OSA) and insomnia are the two most prevalent sleep disorders. Their respective treatments Continuous Positive Airway Pressure (CPAP) and Cognitive Behaviour Therapy for insomnia (CBT-I), are effective, but at the same time challenging. It is this challenge that may translate to poor adherence, which ultimately leads to a reduction in treatment effectiveness. The evaluation of these treatments should not fall short of understanding effectiveness by only considering efficacy; the effort to establish what influences adherence makes up a large part of that goal. The aim of this thesis is to contribute to the literature by adopting a biopsychosocial approach (BPS). That is, the consideration of biomedical, psychological and social factors and how they interact to influence behaviour. The implications for both CPAP and CBT-I adherence literature were tested in the context of four experimental studies. Semi-structured interviews were conducted with 11 CPAP users, with 5 individuals completing the three required interviews prior to, at 1 week and 3 months after treatment initiation. The core themes emerging from a thematic analysis were ‘internal conflict around acceptance and adherence’, ‘integration of CPAP into life’ and ‘motivators and resources for CPAP use’. The interviews with 11 individuals having completed a CBT-I program revealed three important issues: ‘Making sense of CBT-I’, ‘Ongoing evaluation of components’ and ‘Obstacles to implementation’. Both studies reveal potential psychological and social factors contributing to adherence to CPAP and CBT-I, which need to be considered in a BPS framework. A patient-level meta-analysis of three randomised placebo-control studies showed that the relationship between CPAP adherence and improvements in daytime sleepiness was caused by both physiological (high use of real CPAP reduced sleepiness more than high use of placebo and more than low use of real CPAP) and psychological effects (high use of placebo was superior to low use of placebo), possibly as a result of an expectation of benefit. The results support the importance of considering both biomedical and psychosocial factors and their interactive effects on adherence. The translation of the BPS approach to clinical practice will be facilitated by the development of brief, reliable and valid measures to assess psychological iii and social variables in addition to the existing biomedical tools. The Stage of Change Scale for Insomnia (SOCSI) assessing components of the transtheoretical model (stage of change, self-efficacy, decisional balance and processes of change), was constructed and cognitively pre-tested in 13 individuals completing CBT-I. The reliability and validity of this comprehensible scale was subsequently examined in the context of a sleep restriction trial. Insomnia-related symptoms at post-treatment and follow-up, which were significantly different from baseline in the 27 individuals with insomnia, were associated with actigraphdetermined adherence to the agreed bed window. The SOCSI was deemed a valid tool with participants in the self-identified action/maintenance stage revealing significantly better adherence, higher motivation and self-efficacy than those in the contemplation and preparation stage. Test-retest reliability of the SOCSI was excellent and the content analysis of open-box responses revealed information for further validation of decisional balance and processes of change scales. This thesis provides novel information about the variables that influence adherence to CPAP and CBT-I. It distinguishes itself from previous efforts by acknowledging the need for the adoption of a BPS framework. This approach is necessary to successfully advancing not only the CPAP and CBT-I adherence literature individually, but potentially the adherence field in general.