This thesis argues that ethical issues in Ghana and Malawi represent barriers to pandemic influenza management and prevention. The ways in which ethical issues arise and are manifested are poorly understood, in part because there is little knowledge and inadequate Planning for, and Response to, Pandemic Influenza (PRPI). Rather than offering simple answers, this thesis describes how ethical problems emerge in the course of pandemic authorities performing their everyday duties. The central aim is to understand what ethical issues mean to policymakers and how they may be resolved. An extensive review of the experiences of the 1918 influenza pandemic including the epidemiology is examined to illustrate the profound impact of the disease and lessons that can be learnt. The study operates at two distinct but related levels. Firstly there is an investigation of PRPI at a broad level. Secondly, an exploration of the ethical issues that emerges from PRPI within the analytical framework of decision-making models. A qualitative study using semi-structured interviews is used to conduct the study with a “purposive sampling” of forty six policymakers from Malawi (22) and Ghana (24). Utilizing existing normative ethical theories, but acknowledging theoretical and empirical approaches to public health ethics and bioethics, this thesis provides a contextual public health framework to study broad moral problems in particular situations. The findings of the study reveal that normative claims can successfully influence policy if substantiated with empirical evidence. Ethical problems are highly practical and contextual in nature, occurring differently in the context of particular settings, cultures, values and moral judgments. Policymakers interviewed identified ethical problems in relation to four key areas: the extent and role of resources in PRPI, the nature of public health interventions (PHIs), the extent of the impact of PHIs and the extent and process of decision-making, reasoning and justification. Policymakers resolved ethical problems by simply applying rules, work norms and common sense without moral and flexible principle-driven thinking. Policymakers’ technical knowledge of ethics is inadequate for balancing the hard pressed moral tensions that may arise between the demands of civil liberties and public health. These results underscore the need to update overall goals in pandemic operations, training and education. Most importantly, an ethical framework remains an important part of dealing with ethical problems. A process of developing an ethical framework is proposed, but the key to combating any ethical problem lies in understanding the PRPI strategy.

<p>Cardiovascular disease and diabetes are a growing problem around the world and both considered leading causes of death in the United States. Cardiovascular disease is often not diagnosed until it advances to causing serious problems such as heart attacks. Diabetes can greatly increase the risk of cardiovascular disease so diagnoses is important. Metabolic syndrome is a relatively easy way to predict who is at risk of these diseases or to make an early diagnoses. The syndrome is diagnosed in patients that meet 3 or more criteria relating to obesity, blood pressure, triglycerides, cholesterol, and glucose in an individual. Calcium scores, a result of a specific body scan, are a good indicator of cardiovascular disease but are not commonly performed. Metabolic syndrome can be diagnosed using information from a routine physical with blood work. This paper observed the prevalence rate of metabolic syndrome in a cohort of police officers who responded to the September 11th attack at the World Trade Center in New York City. In our study population, the prevalence of metabolic syndrome was 26%. We also found a correlation between calcium scores and the number of metabolic syndrome criteria met; patients meeting all 5 criteria had significantly higher calcium scores with a p-value of .02 and 95% confidence interval of 1.084-2.583.

<p> Heat stress is a recognized occupational hazard present in many work environments. Its effects increase with increasing environmental heat loads. There is good evidence that exertional heat illness is associated with ambient thermal conditions in outdoor environments. Further, there is reason to believe that risk of acute injury may also increase with the ambient environment. For these reasons, the assessment of heat stress, which can be done through the characterization of the wet bulb globe temperature (WBGT), is designed to limit exposures to those that could be sustained for an 8-h day. The ACGIH Threshold Limit Value (TLV) for heat stress was based on limited data from Lind in the 1960s. Because there are practical limitations of using thermal indices, measurement of physiological parameters, such as body temperature and heart rate are used with environmental indices or as their alternative. </p><p> The illness and injury records from the Deepwater Horizon cleanup effort provided an opportunity to examine the effects of ambient thermal conditions on exertional heat illness and acute injury, and also the cumulative effect of the previous day&rsquo;s environmental conditions. The ability of the current WBGT-based occupational exposure limits to discriminate unsustainable heat exposures, and the proposal of alternative occupational limits was performed on data from two progressive heat stress protocol trials performed at USF. The USF studies also provided the opportunity to explore physiological strain indicators (rectal temperature, heart rate, skin temperature and the Physiological Strain Index) to determine the threshold between unsustainable and sustainable heat exposures. Analysis were performed using Poisson models, conditional logistic regressions, logistic regressions, and receiver operator curves (ROC curves).</p><p> It was found that the odds to present an acute event, either exertional heat illness or acute injuries increased significantly with rising environmental conditions above 20 &deg;C (RR 1.40 and RR 1.06, respectively). There was evidence of the cumulative effect from the prior day&rsquo;s temperature and increased risk of exertional heat illness (RRs from 1.0&ndash;10.4). Regarding the accuracy of the current TLV, the results of the present investigation showed that this occupational exposure limit is extremely sensitive to predict cases associated with unsustainable heat exposures, its area under the curve (AUC) was 0.85; however its specificity was very low (specificity=0.05), with a huge percentage of false positives (95%). The suggested alternative models improved the specificity of the occupational exposure limits (specificities from 0.36 to 0.50), maintaining large AUCs (between 0.84 and 0.89). Nevertheless, any decision in trading sensitivity for specificity must be taken with extreme caution because of the steeped increment risk of heat related illness associated with small increments in environmental heat found also in the present study. Physiologic heat strain indices were found as accurate predictors for unsustainable heat stress exposures (AUCs from 0.74 to 0.89), especially when measurements of heart rate and skin temperature are combined (AUC=0.89 with a specificity of 0.56 at a sensitivity=0.95). Their implementation in industrial settings seems to be practical to prevent unsustainable heat stress conditions.</p>

<p> Background and objectives: Early dental visits provide the opportunity to reduce the prevalence of early childhood caries through risk assessment, counseling, and provision of specific preventive measures. Despite the American Academy of Pediatric Dentistry&rsquo;s recommendation that the first dental visit should occur by 1 year of age, many children are not receiving care until much later. Evidence that early dental visits improve dental outcomes is vital to educate parents and health care providers. Hence, this study examined the association between a child&rsquo;s age at the first dental visit and dental outcomes, parents&rsquo; awareness of the recommendation for the first dental visit, and perceived barriers to dental care. A secondary aim examined pediatric dentists&rsquo; perceived barriers to children&rsquo;s early dental care in West Virginia. </p><p> Methods: A cross-sectional survey was used to collect data from parents of children &le; 6 years of age, and under the care of a pediatric dentist. Pearson correlation was used to examine the association between age at first dental visit and age at caries onset. Chi-square analyses were used to test the association between (1) age at first dental visit and history of caries, (2) age at first dental visit and history of an adverse dental outcome, and (3) reason for the first dental visit and history of an adverse dental outcome. A binary logistic regression model was used to evaluate the extent to which age at the first dental visit explained caries history. For the qualitative study component, pediatric dentists responded to questions regarding barriers to the establishment of a dental home for West Virginia children. </p><p> Results: A significant association was noted between a child&rsquo;s age at the first dental visit and age at caries onset, r (29) = 0.65, p &lt;.0001 [95% CI=0.39, 0.82]. No significant association was noted between age at the first dental visit and history of caries, or between age at first visit and history of adverse outcome (p >.05). However, children whose first visit was for a problem with the teeth or mouth were significantly more likely to have had an adverse outcome, &chi;² (1, n = 160) = 7.60, p = .0058. The adjusted odds ratio for age at first dental visit in the logistic regression model predicting caries history was 1.10, [95% CI= 1.04, 1.17], p =.0013. Pediatric dentists perceived the limited dental workforce in West Virginia to be the greatest barrier to early dental visits for children. </p><p> Conclusions: This pilot study demonstrates that parent reported dental outcomes may be useful in studies evaluating the association between early dental visits and dental outcomes. There remains a need to educate parents about the recommended first dental visit by age 1 year.</p>

<p> Background. Norovirus disease is of great public health significance as evidenced by the health and economic burdens each year in the United States. Although norovirus disease afflicts all ages in the general population, vulnerable segments of the population include the young and elderly. Currently there is no norovirus vaccine on the market to prevent norovirus infection nor is there prescribed medical treatment other than supportive care for self-limiting symptoms. </p><p> Methods. Surveillance data on norovirus outbreaks obtained from the Centers for Disease Control National Outbreak Reporting System, school enrollment data obtained from the National Department of Education, healthcare resource utilization data obtained from the Healthcare Cost and Utilization Project, and results from published research findings were used to estimate the health and economic burdens of norovirus disease among the school age population. Decision analysis was used to model the costs and benefits of norovirus vaccination. Cost effectiveness analysis was conducted from the societal and healthcare perspectives in order to determine the incremental cost-effectiveness ratios for the alternative health strategy compared to the current standard health strategy. Univariate and multivariate analyses were conducted in order to examine uncertainty associated with parameters and assess how the uncertainty affects the outputs of the decision model. Probabilistic sensitivity analysis was conducted in order to assess and quantify the impact of varying all parameters at the same time. </p><p> Results. Norovirus results in high numbers of illnesses and high direct medical, direct non-medical and indirect costs among school age children. In terms of health burden, there were a greater number of cases requiring supportive care than any other health outcome. The cost of supportive care is relatively inexpensive until indirect costs are factored in to the total cost of one episode of norovirus illness. </p><p> The results of the present study indicated that when comparing the standard health strategy of no norovirus vaccination to that of the alternative health strategy of norovirus vaccination, vaccination was found to be optimal. The results of probabilistic sensitivity analysis indicated that the alternative health strategy was marginally cost effective. </p><p> Conclusion. The results of the present study represent the first attempt to estimate the health and economic burdens of norovirus disease among the school age population with a focus on norovirus disease spread occurring in closed (schools) environments. The study findings will illustrate the uniqueness of closed environments in perpetuating norovirus spread and the feasibility of norovirus vaccination among school age children. The results of cost-effectiveness analysis indicated vaccination was an optimal strategy but is marginally effective. </p><p> Given the numerous limitations of using passive surveillance data, future research efforts should use higher quality and more accurate sources of data in order to estimate the health and economic burdens of norovirus disease and examine the other hidden costs of norovirus outbreaks such as environmental decontamination, school closure, student and staff absenteeism and other intangible costs. In addition, future research efforts should use the findings from this and other studies that have identified high prevalence of norovirus disease among younger age groups in order to establish priority age groups for vaccination when a vaccine becomes available on the market. Clinical trials are underway and development of a norovirus vaccine is expected within the next few years. </p>

<p> Increasingly, e-cigarettes are being used and claimed to be an effective means of smoking cessation. Clinical studies have been limited to the aspects of use pertaining to chemical dependence, yet little addiction research has examined the psychology of smoking cessation behavior utilizing e-cigarettes. Health behaviors, such as harm reduction in smoking through the use of nicotine replacement therapies, have been previously studied and several dispositional traits have been found to be highly related to these behaviors. These personality factors include Neuroticism and Conscientiousness, Self-Efficacy, Grit, and Hardiness. The present study aimed to determine psychological traits related to successful smoking cessation utilizing e-cigarettes using measures of NEO-FFI-3, GSE, DRS-II, and Grit-S. Results indicated that Self-Efficacy was a noteworthy factor associated with cessation with 6 months or more of e-cigarette use. A majority of the study participants did not concurrently smoke and use e-cigarettes. These findings support the potential of e-cigarettes as a replacement therapy and provide some insight into formulating interventions toward this end; however, smoking cessation attempts appeared to be inhibited from full success as a result of the efficacy of the replacement.</p>

<p> Farmworkers and their families may experience increased levels of agricultural pesticides in their homes due to both (1) take-home/soil track-in on shoes, clothes and skin, and (2) air infiltration from nearby agriculture fields via agricultural pesticide drift in the vapor phase or adhered to resuspended soil particles. This dissertation estimates the relative contributions o the take-home/soil track-in and air infiltration pathways of agricultural pesticides into homes, as well as identifies the risk factors for increased in-home agricultural pesticide levels for farmworkers and their families living near agriculture fields. Samples of outdoor air, yard soil, and house dust from 21 farmworkers' homes in Yuma County, Arizona were collected and analyzed for a suite of agricultural pesticides. To capture household information, such as behaviors, demographics, and housing structure, a participant questionnaire was administered at the time of the sampling. A pesticide transport model was developed, evaluated, and applied to quantify relative contributions of the air infiltration and the take-home/soil track-in pathways of agricultural pesticides into the house dust of the farmworkers&rsquo; homes. To explore a wide-range of potential risk factors for increased agricultural pesticide levels in the homes, traditional statistical methods and Classification and Regression Tree (CART) analyses were used. The results of this study, found that the air infiltration pathway contributes to over 90% of some agricultural pesticides in the house dust found in the farmworkers&rsquo; homes. In addition, among the influential risk factors for increased in-home agricultural pesticide levels was the home being a closer distance to an agricultural field, as well as the home having carpeted floors, more farmworkers per square footage of the home, and less months of heating and cooling the home. It is suggested that future intervention efforts to reduce in-home agricultural pesticide levels put more emphasis on targeting the air infiltration pathway, and take into consideration relevant risk factors for increased pesticide levels in the home.</p>

The Chinese construction industry is China's third biggest industrial killer. Accidents causation analysis revealed that more than 80% of accidents are caused by unsafe human behaviour. The current research was focused on exploring and examining the factors affecting safety rule violations among Chinese construction workers through four main studies in which a combination of qualitative and quantitative methodologies were used. In the first study, on-site observation and organisational document analysis were conducted in fourteen construction companies to familiarise the author with the research settings and to obtain triangulation evidence for the following studies. It was followed by the second study in which interviews and focus groups were conducted among 97 managers, safety officers and workers in order to explore the factors associated with workers' rule violation. Thematic analysis revealed four main categories of factors, i.e., individual factors, managerial factors, sectoral and labour market factors, and national and cultural factors. The qualitative study was followed by questionnaire surveys (n = 700) to test in a larger management sample the qualitative study's results. Survey results complemented the qualitative study's findings. Based on the obtained results, a fourth study using the Delphi method and the modified G1 method was conducted among 17 experts in order to calculate the importance levels of each factor in influencing workers' rule violation. Although managerial factor was ranked as the most influential factor compared with other categories, some extra-organisational factors and situations were ranked at high positions amongst 24 specific factors. The results suggested that workers' behaviour need to be scrutinised not only within the context of organisational safety management, but also from the particular background and characteristics of Chinese migrant workers, Chinese construction sector, as well as the society and the culture.

<p> Sickle cell disease is a disabling chronic autosomal recessive blood disease characterized by abnormal hemoglobin, pain crises, and frequent emergency department visits. Adherence to hydroxyurea therapy has been shown to improve these patient outcomes. Guided by the theory of comfort, the purpose of this project was to determine if an educational intervention would increase adherence to hydroxyurea therapy in pediatric patients between 2 and 17 years of age recruited from an urban university hospital hematology clinic. The RE-AIM model was used to support the translation of evidence and the change process. An educational video produced by AFLAC was viewed by patients&rsquo; parents 4 weeks after enrollment into this pretest/posttest design project. A total of 22 African-American parent participants completed the 8-item Morisky Medication Adherence Scale at baseline and again at 8 weeks to assess hydroxyurea adherence. The Short Test of Functional Health Literacy in Adults tool was used to assess parents&rsquo; health learning needs; all parents met the adequate literacy level at baseline. Using <i>t</i> test statistics, no statistically significant differences were found pretest to posttest on the Morisky Medication Adherence Scale scores, mean corpuscular hemoglobin, and fetal hemoglobin percentages. Wilcoxon Signed Rank tests showed no significant differences in emergency room visits nor number of pain crisis. Although no significant changes emerged in short-term hematologic findings, emergency room visits, and pain crises, social change in the health care setting was promoted by confirming parents were able to understand education and a high level of hydroxyurea adherence was maintained; literature indicated that long-term adherence to hydroxyurea limits severe attacks.</p>

<p> Women and men&rsquo;s preferences for delivery services in rural Ethiopia Nancy Beam Aims: This study aims to determine the combination of facility-based delivery care attributes preferred by women and men; if gender differences exist in attribute preferences; and key demographic factors associated with attribute preferences. </p><p> <b>Background:</b> Despite programs to promote facility-based delivery, which has been shown to decrease maternal and neonatal mortality, 80% of women in rural Ethiopia deliver at home without a skilled birth attendant. </p><p> A review of the Ethiopian literature on factors associated with delivery location revealed several weaknesses in research methods that need to be addressed. First, research participants were almost exclusively women, although male partners often make decisions about delivery location. Second, most quantitative study designs are similar in content to the Ethiopian Demographic Health Survey, limiting the generation of new knowledge. Third, cultural practices identified in qualitative studies as barriers to facility-based delivery have not been included in quantitative studies. This study addressed these weaknesses by using discrete choice experiment methodology to elicit preferences for delivery service attributes, including support persons in the delivery room, staff training and attitude, cost, distance and transportation availability. </p><p> <b>Methods:</b> A cross-sectional, discrete choice experiment was conducted in 109 randomly selected households in rural Ethiopia in September-October 2015. Women, who were pregnant or who had a child &lt; 2 years old, and their male partners were interviewed. After completing a demographic questionnaire, male and female respondents were asked separately to choose between facility-based scenarios that reflected various attributes for delivering their next baby. Data were analyzed using a multilevel mixed-effects logistic regression model. </p><p> <b>Results:</b> Both women and men preferred health facilities where medications and supplies were available, a support person was allowed in the delivery room, cost was low, and doctors performed the delivery. Women also valued free ambulance service, while men favored nearby facilities with friendly providers. Men are disproportionately involved in making household decisions, including decisions about whether their wives seek health care. Yet, men are often unaware of their partners&rsquo; prenatal care attendance. </p><p> <b>Implications:</b> The Ethiopian government and health facilities could increase facility births in rural areas by responding to families&rsquo; delivery service preferences.</p>