Research investigating women's alcohol use has been limited, and generally fails to consider the social context and environment pertaining to the experiences of women. The purpose of this phenomenological study was to explore the perspectives of college women on the meaning of drinking in their lives, its role in fostering growth enhancing relationships, and the role of alcohol in their campus culture. The study used the Relational-Cultural Model of psychological development (Kaplan, 1994; Gleason, 1994; Miller & Stiver, 1997) as a conceptual framework to understand the binge drinking phenomenon. Participants were recruited from a large co-educational university and a women's college. Data collection methods included a focus group with 16 sorority leaders and individual interviews with an additional 19 college women between January and September 2003. Five domains of inquiry were explored during these interviews: (1) the role of drinking in forming and maintaining relationships, (2) the extent to which drinking is viewed as a learning experience, (3) feelings about oneself as related to drinking practices, (4) definitions of dangerous drinking practices among women, and (5) personal use and beliefs around alcohol consumption. The participants perceived many benefits from drinking, especially in terms of friendship and self-identity. Their experiences reflected drinking not only as a way to form and maintain relationships with others, but also revealed feelings of shame and guilt as a result of regretted actions and disconnection from self and others. This dissertation discusses five central themes that emerged from participants' stories related to their drinking behavior. Three themes were reflective of connection: bonding, care taking, and storytelling. The other two themes were indicative of disconnection from self, as exemplified by the good girl/bad girl duality concept, and drinking to cope with relational conflict. Implications for substance abuse prevention specialists, health educators, counselors, and college administrators are discussed.

This exploratory case-control study used questionnaire data to determine risk factors in parents related to having a child with Wolf-Hirschhorn syndrome (WHS). The study included information on 181 case mothers, 174 case fathers, 135 control mothers, and 128 control fathers. When demographic, lifestyle, and reproductive risk factors were considered, case mothers were less likely than control mothers to consume alcohol a few times a month or more in the year preconception (crude POR = 0.53, 95% CI: 0.29–0.96; adjusted POR = 0.57, 95% CI: 0.31–1.06). Also, case parents were more likely than control parents to have this pregnancy reported as unplanned (crude POR = 1.75, 95% CI: 1.10–2.79; adjusted POR = 1.47, 95% CI: 0.88–2.45), and case mothers were less likely than control mothers to have ever taken birth control pills preconception (crude POR = 0.58, 95% CI: 0.34–0.99; adjusted POR = 0.66, 95% CI: 0.38–1.15). When preconception exposure to x-rays was considered, it was found that case fathers were more likely than control fathers to have had at least one non-dental head x-ray ever preconception (adjusted POR = 2.06, 95% CI: 1.11–3.84). When number of x-rays was considered by site, case fathers were more likely than control fathers to have had three or more non-dental head x-rays preconception (adjusted POR = 5.54, 95% CI: 1.21–22.45), and they were also more likely to have had three or more abdominal x-rays preconception (adjusted POR = 8.24, 95% CI: 1.02–66.32). Case mothers were less likely than control mothers to have had preconception dental x-rays once every couple of years (adjusted POR = 0.32, 95% CI: 0.14–0.73) or once per year or more (adjusted POR = 0.31, 95% CI: 0.14–0.71). In this study of WHS only 43% of eligible case families referred a friend or neighbor family for use as a control. Subsequent analyses revealed significant differences between case families that did and did not have a matched control family in the study. The main variables affecting this were education at conception, race, and months married at conception. Case families with mothers who had graduated college at conception, white mothers, white fathers, and parents married 25 months or more at conception were more likely to have a friend or neighbor control family in the study.

Background: Sexual violence policy frameworks and service delivery models are well defined in Kenya. However, little is known about the extent to which different sectors effectively work together to ensure survivors receive comprehensive care. The need for a multi-sectoral response framework has been cited in the literature. Nonetheless, it is not clearly defined what this entails in the Kenyan context. Aim: This thesis aimed at reviewing and documenting the processes involved in the delivery of services by the different sectors with a focus on patient flow, data systems, community perceptions and referral mechanisms The study also aimed to develop an in-depth understanding of the factors that influence reporting of cases of sexual violence, provision of services and uptake of available services. Also explored were the requisites for a coordinated and multi-sectoral approach to sexual violence. Methods: This is a cross-sectional study that applied a mixed-methods approach. Qualitative interviews were conducted with 23 service providers, survivors and caregivers. The quantitative component entailed abstraction of service statistics from records maintained for survivors. A total of 1259 records were obtained from two hospitals, two police stations and two courts in two counties in Kenya. Key informant guides were used for the qualitative interviews, while an Excel data abstraction tool was implemented to capture data obtained from service statistics. Thematic analysis of qualitative data was undertaken using NVivo 12. The records were analysed using SPSS Version 20.0 The Anderson model (1973) informed the interpretation of the qualitative data. Data were triangulated during the analysis across the interviews and service records. Findings: Defilement constitute the largest proportion of cases of sexual violence reported across different sectors. Poor quality of sexual violence data maintained for survivors across different service delivery points presents a difficulty in tracking survivors to examine completeness in service uptake. Existent difficulties persist in determining the extent to which the different sectors are responsive to the survivor's need for quality and comprehensive services. Survivors--more so female and children--do not have autonomy in decision making regarding whether to report a sexual violation meted on them or not. Lack of a standardized multi-sectoral referral framework contributes to survivor frustration in accessing services due to the multiple referral pathways, costs and time delays involved. There is continued reliance on informal community level arbitration of cases despite the existing legal provisions in the Sexual Offences Act. Conclusion: The Anderson (1973) framework provides a basis for an in-depth understanding of survivors' service utilization related behaviours and decisions. The findings reveal the interconnectedness of predisposing enabling and need factors in the context of the available services and decision making on what service to take up. While the health sector and police continue to play a key role in response to sexual violence, there still exist gaps that impede the comprehensiveness in response. Communities still prefer reaching out to informal sources of support. However, there is a disconnect between formal and informal sources of support. The need for a multi-sectoral and coordinated approach to sexual violence is critical, and its design should be informed by the needs of survivors. Measures should be put in place to address enabling factors to service access through training of providers on the management of survivors. This study provides anecdotal evidence to be utilized in informing development and implementation of multi-sectoral models of post-sexual violence service delivery models in Kenya and in Sub-Saharan Africa.

Background: In response to the persistently high incidence of HIV in adolescent girls and young women in South Africa, the Global Fund invested in a combination HIV prevention intervention aimed at adolescent girls and young women in 10 high priority districts. The HERStory study evaluated the combination HIV prevention intervention after two years of implementation. Using the findings of the HERStory evaluation, this study aims to contribute towards the literature related to understanding factors related to successfully accessing communities and gaining community buy-in or support for community based interventions. The HERStory study explored the identification of the gaps and challenges in the intervention components and the intervention implementation to be able to revise and improve the intervention and its implementation. Methods: In-depth interviews and focus group discussions with community leaders, program implementers and intervention facilitators were conducted. The data consisted of 32 transcripts; a subset of the qualitative data collected for the HERStory evaluation. The analysis for this study sought to better understand the barriers and facilitators of community access and the importance of community buy-in using the HERStory evaluation. Thematic analysis of the data was conducted, supported by Nvivo 12 qualitative data analysis software. Results: The main themes of this secondary analysis were 1) the complexity of negotiating access to communities through key stakeholders, 2) challenges to gaining buy-in, and 3) facilitators and barriers to community based intervention implementation. There were clear facilitators to community access and intervention buy-in such as creating clear communication lines between stakeholders and scheduling regular meetings. Delayed or rushed community engagement resulted in misunderstandings and was identified as barriers to community access and intervention buy-in. Conclusion: Quality community engagement was essential in the facilitation of access and intervention buy-in to promote successful intervention implementation. Recommendations for future interventions include planning enough time for community engagement throughout the intervention including the design phase and establishing clear and effective communication channels between intervention implementers and community stakeholders.

Nearly 1 in 5 Medicare inpatients are readmitted within 30 days of discharge, costing the Medicare program approximately $15 billion per year. The Centers for Medicare & Medicaid Services (CMS) implemented the Hospital Readmission Reduction Program (HRRP) in 2012, which penalizes hospitals with higher than expected 30-day readmissions for patients with certain conditions. In the first study, we evaluated whether the HRRP was associated with lower readmission rates for targeted conditions. Overall, we find that HRRP implementation led to a 1.4 percentage-point reduction in readmission rates at penalized hospitals. Hospitals were responsive both to a “labeling effect” of receiving any penalty, as well as to an “incentive effect” associated with the size of the penalty. The HRRP is intended to penalize hospitals based on the quality of care they provide to patients, but not characteristics of the communities they serve. However, the program does not account for the availability of post-discharge care within hospitals' service areas. In study 2, we examined the association between post-discharge care supply (e.g., PCPs, nursing homes, skilled nursing facilities, hospices) and hospitals' readmission rates. We find that readmissions were positively associated with the per capita supply of home health agencies and nurse practitioners, and negatively associated with hospices, PCPs, and palliative care. Our results suggest potential modifications to the HRRP's risk adjustment, in order to avoid punishing hospitals that lack access to certain community resources. Hospitals have engaged in a variety of activities to reduce readmissions such as redesigned discharge processes, improved coordination with post-discharge sites of care, or through specific quality-of-care interventions. In the final study, we sought to enhance our ability to predict these patient readmissions, using cutting-edge techniques developed in the field of machine learning. We used the Nationwide Readmissions Database to estimate twelve individual machine learning algorithms and then combine them using mathematical optimization. The resulting 'super learner' predicts readmissions better than what's possible with the individual algorithms, or traditional regression methods. To the extent that patients at high risk of readmission may be identified, interventions and healthcare resources may be targeted towards them in a cost-effective manner. / 2023-01-19T00:00:00Z

Health care providers can play a significant role in empowering women to make informed decisions when selecting suitable contraceptive methods during contraceptive counselling. This study explores the experiences and perceptions of primary health care providers delivering contraceptives services in Cape Town to gain a deeper understanding of the delivery of contraceptive services. Ten in-depth interviews were conducted at five public primary health care facilities in urban areas in Cape Town, South Africa. Eligible participants included primary health care providers providing contraceptive services and willing to participate in the study. The qualitative software package NVivo was used to sort and manage data. Data was analysed using a thematic analysis approach. Overall, providers emphasized supporting women in contraceptive decision-making. Sexual and reproductive health training increased providers confidence to deliver appropriate contraceptive services. Furthermore, contraceptive prescribing practices were also influenced by medical eligibility criteria and women's preferred bleeding patterns. However, contraceptive prescribing practices were also influenced by providers' attitudes towards younger and older women. Challenges experienced by providers when providing contraceptive services included: contraceptive stockouts; time constraints of employed women accessing the service; and work pressure due to providing other health services. Health care providers play a critical role in facilitating women's right to accessing high quality contraceptive services. Providers in the study perceived themselves as negotiators during contraceptive counselling by considering both women's preferences and provider recommendations for contraception, whilst enabling women to make informed contraceptive decisions through provision of reproductive health information. Consequently, shifting contraceptive counselling to focus on shared decision-making may encourage autonomy during decision-making and help to limit the influence of provider attitudes on contraceptive prescribing and counselling.

abstract: Research on acceptability of mindfulness-based interventions (MBIs) for populations with substance use disorders (SUD) is extremely limited. Intervention development and testing guidelines note that acceptability of the intervention by the target population is important for retention, efficacy, and intervention integrity. Yet, MBIs for SUD studies have not measured acceptability or have done so in a cursory manner, therefore, the question remains of whether MBIs are acceptable to populations in SUD treatment. The proposed study seeks to fill this knowledge gap by undertaking a conceptually-grounded empirical approach to assess acceptability of Moment-by-Moment in Women’s Recovery (MMWR), which is an MBI for women with SUD. This document is divided into five chapters. Chapter 1 introduces the topic and provides background literature. Chapter 2 systematically reviews MBIs for SUD studies to assess measurement of acceptability. Chapter 3 analyzes the psychometric properties of two acceptability surveys used in MMWR. Chapter 4 examines the associations among the acceptability surveys, personal characteristics of the participants, and application of intervention techniques. And Chapter 5 summarizes the previous chapters and discusses future directions for this line of work. There is a need for a greater understanding of which factors may influence participants’ abilities to accept an intervention. The results identify sociodemographic and clinical characteristics that can inform future intervention adaptations, screening, or pre-intervention programs to increase efficiency of SUD intervention delivery and relevance. The long-term goal is to improve fit and efficacy of MBIs for SUD for minority and underrepresented populations. / Dissertation/Thesis / Doctoral Dissertation Nursing and Healthcare Innovation 2020

A selection of common children’s games were measured in a laboratory-based study to be enjoyable and to elicit sufficient physical activity energy expenditure (PAEE) in 3rd grade children to combat the purported chronic energy surplus of childhood obesity (∼100 kcal·day -1). PAEE during the games was similar for boys and girls, yet overweight children expended greater PAEE relative to body weight than healthy weight children. During a subsequent simulated recess program, the enjoyment declined over the 10-session program with no significant decline in PAEE. Using the enjoyable games of known energy cost in a structured recess program for 9 weeks successfully increased total daily PA compared to the control school who reported substantially greater amount of free-play time. The greater amount of acquired PA in the intervention school children did not affect the amount of time spent in sedentary pursuits but it did result in a smaller increase in body weight after 9 weeks. More research is needed to expand on this initial list of games that reduce the excessive weight gain in children when incorporated into a structured recess intervention.

Lung Cancer mortality associated with arsenic trioxide exposure at the Anaconda Smelter was studied in the context of the multistage model, using a risk difference formulation. Expected lung cancers were based upon a nonsmoking population selected for the contrast it provided for the smoking information. The Anaconda data supported the multistage model used reasonably well but several trends in the data were conflicting, given model predictions. Lung cancer rates were higher as arsenic exposure, smoking habit and duration of employment increased. Mortality increased with increasing age at first exposure when controlled for duration, and increased with time lapsed since exposure ceased as well. These last two patterns indicate different stages of effect within a multistage framework. The observed latency period was long for a late stage carcinogen, though all of the analyses suggested that the late stage model was the best. The results obtained in this analysis are consistent with those of Brown and Chu (1983a, 1983b) even with the addition of smoking habit information. Both the stratified and multivariate analyses of the smoking and arsenic data failed to rule out the presence of a multiplicative effect for the two exposures. The data were too sparse to make a judgment with confidence. Lung cancer rates among nonsmokers or light smokers seemed proportionally higher in this population than in others examined. There was evidence of possible confounding between arsenic and smoking in the Anaconda data. The continued inconsistencies in the evidence suggest that a different formulation of a multistage model should be tried for arsenic-associated lung cancer mortality. Others have suggested that the lung retention time is important, and if this is true, it may help explain the continued rise in lung cancer rates despite the cessation of exposure. vi

Lumbar disc disease, specifically herniated lumbar disc, is responsible for considerable activity limitation, disability and impairment. Biomechanical and experimental studies have shown various compression loads and torsional forces to be related to herniated disc; however, epidemiologic studies of risk factors for herniated disc are limited, focusing primarily on occupational activities. This research examines the role of non-occupational activities as potential risk factors for herniated disc, as one component of a larger multi-center matched case-control study of risk factors for herniated disc. New cases of herniated disc were identified and matched to controls by age, sex and source of access. Study participants were interviewed to ascertain data pertaining to risk factors. Data were analyzed using conditional multiple logistic regression analysis to obtain odds ratios and 95% confidence intervals for associations between non-occupational activities and herniated disc among 276 case-control pairs. The major study findings indicated that lifting 25 or more pounds off the job, and the various aspects of the lift, such as position while lifting (knees straight, back bent), starting the lift with arms extended more than half the time, twisting while lifting, and lifting from and to waist level were associated with herniated disc, each compared to no lifting; the strength of the association was greater among confirmed cases of herniated disc. Repeated bending compared to no bending was also shown to be associated with herniated disc, particularly among confirmed cases. Associations were also evident for lifting 10-24 and 25 or more pound children with knees straight and back bent. Sports activities in general were negatively associated with herniated disc; playing golf or racquet sports frequently were strongly associated in the negative direction, compared to not participating in these sports. Bowling showed a slight positive association with herniated disc. No associations were found for pregnancy history, use of free weights or weight lifting equipment. Results are consistent with findings on risks of occupational activities, and with biomechanical studies.