Zambia has one of the highest HIV seroprevalence rates in the world, estimated in 1995 at 17%. Rural Monze district in the Southern province, the site of the study, has high rates of HIV, estimated at 10-12% in 1991. During the study, the district was affected not only by AIDS but also by the 1991-92 drought and by a bovine epidemic of East Coast Fever. This study documents the impact of HIV and AIDS on the health services and on the district economy, and draws some long term implications for the national economy. At the district hospital, approximately 44% of inpatients and 30% of outpatients were HIV seropositive as were 18% of rural health centre patients. Tuberculosis, other respiratory infections, and diarrhoea accounted for the majority of days in hospital. The HIV epidemic was found to be affecting the hospital staff as well, with mortality at Monze and neighbouring Choma hospitals rising from 2 per 1,000 nurse years in 1980 to 27 in 1991 - a 13-fold increase. Measures to increase supply, reduce losses, and make better use of existing staff are proposed. The household survey found that while patients were better off overall than the district population, there was no appreciable difference in wealth between patients with HIV infection and those without. HIV-positive patients were younger than HIV-negative patients, and had fewer children. The loss of a member with HIV would cause a rise in the average household's dependency ratio of 16-17%. Production was affected by HIV disease, with an average of 94 days' loss of labour (patients plus carers) in the final year of life. Implications for policy include the need to decentralize care of patients with HIV disease to health centres, and to protect and make better use of the health human resources. The impact of HIV/AIDS on rural production, with approximately 1 in 3 district households having a member with AIDS, combined with external factors such as removal of subsidies, changes in marketing processes under structural adjustment, and long term drought, makes it increasingly difficult to eke out a living from farming. Combined with the lure of apparent employment opportunities in urban areas created by deaths due to AIDS, these factors may contribute to increased urbanization, making it difficult for Zambia to replace declining copper revenues with increased yields from agricultural production.

TB, a major public health problem in India since the 1900s, has a current prevalence of 14 million and an estimated annual mortality of 500,000 persons. Nation-wide government sponsored anti-TB public health measures introduced in 1948, developed into the National TB Programme in 1962. Despite gains, implementation gaps between programme goals and performance, over 35 years, have been of a magnitude sufficient to cause concern. This study aimed to understand explanatory factors underlying the implementation gap. A policy analysis approach was adopted, focusing on the policy process and specifically on implementation, at national, state, district and local levels. It undertook a historical review with a two-tiered framework covering the period 1947-97. In the first tier the historical narrative is woven around a framework of context, content, process and actors. The nature of the problem and policy relevant technical dimensions of intervention measures are discussed, as are effects of pharmaceutical policies and financial resource flows on TB policy. The second tier applies a framework of implementation factors to national policy development and implementation at state and district level. Interviews were conducted with TB patients, elected representatives, front-line health workers, doctors, district and state staff, national programme managers, researchers and representatives from international agencies. Documents were reviewed. Thus the study incorporated an integrative bottom-up cum top-down approach. Findings highlight that interests of patients, medical and allied professionals, pharmaceutical and diagnostic industries and the state are interdependent, but often conflictual. Unequal societal relations affect not only the development and transmission of TB, but also the implementation of control programmes, particularly for the impoverished, among whom high levels of indebtedness due to the disease and difficulties accessing private services were noted. Techno-managerial approaches to TB control often mask societal and policy process factors accounting for the implementation gap. The importance of leadership, institutional development, capacity at the patient provider interface and accountability and need for sustained policies were noted, within an affirmative framework embodying social justice and safeguarding the interests of the majority of patients.

<p> This research examines three factors &ndash; macroeconomic conditions, the Deficit Reduction Act of 2005, and <i>inter-vivos</i> transfers &ndash; that influence both the availability of long-term care services and the use of these services. The first essay explores how changes in the macroeconomy, specifically the 2007-2009 &ldquo;Great Recession,&rdquo; affect the utilization of paid and unpaid long-term care services. It is theoretically unclear how long-term care use should be affected by such downturns, as an individual&rsquo;s health status, wealth, insurance coverage and access to care are all likely to change during a significant downturn such as the &ldquo;Great Recession.&rdquo; Using data from the 1998-2012 waves of the Health and Retirement Study, a survey that follows Americans over the age of 50 as they begin to transition into retirement, we estimate the effects of changes in the unemployment rate at both the national and county levels on long-term care use. We find consistent evidence that overall care use declines significantly during downturns, with additional results suggesting that these results may be driven by reductions in individual wealth and improvements in individual health status. The second essay examines how the implementation of the Deficit Reduction Act of 2005, a policy that imposed stricter regulations about how individuals could &ldquo;spend down&rdquo; their assets to become Medicaid eligible, impacts both asset transfers and long-term care use among the elderly. Using data from the 1998-2010 waves of the Health and Retirement Study, I estimate the effects of this policy using a difference-in-difference framework. Overall, individuals seem to substitute from making inter-vivos transfers to holding assets in trusts in response to the enactment of the Deficit Reduction Act. With regard to care use, individuals seem to substitute from in-home long-term care to more visits to both doctors and adult day care facilities following the DRA, an effect primarily driven by the wealthiest and youngest individuals. The third essay investigates the relationship between parent-to-child inter-vivos asset transfers and future informal care provision by that child. Using data from the 1998 &ndash; 2010 waves of the Health and Retirement Study, I am able to use the timing of the transfers and the care use to describe this relationship. The results suggest that the receipt of an inter-vivos transfer during the previous two years is strongly positively correlated with that child&rsquo;s likelihood of providing care during the previous month. In addition, I confirm a previous finding in the literature that child&rsquo;s gender, relationship to the parent and geographical proximity to the parent all significantly influence the child&rsquo;s decision to provide care.</p>

<p>Objectives Past research has shown that low socioeconomic status (SES) and perceived discrimination are related to hypertension in African Americans. Past studies have used the Reserve Capacity Model (RCM; Gallo & Matthews, 2003; 2005; 2011) to understand these relationships which posits that stress can be mitigated by psychosocial resources which lead to healthy lifestyle behaviors predictive of cardiac health. However, few studies have examined the RCM resources to predict hypertension in African Americans and none have included discrimination as a stressor in the model. Methods We examined the mediational effects of RCM resources after low SES and discrimination experiences to predict health behavior (exercise) and hypertension in 1202 middle to older aged African Americans using structural equation modeling. Results Both low SES and perceived racial discrimination predicted a diagnosis of hypertension indirectly through levels of reserve capacity and exercise. Conclusions These findings provide support for the RCM as an explanatory framework for how social stressors affect health through modifiable psychosocial resources and health behaviors in middle to older aged African Americans.

<p> Baby boomers are a large population rapidly transitioning into older adulthood. As the proportion of older adults will be higher in the coming decade than at any previous point in history, the aging of the population has placed successful aging at the forefront of public health and health care efforts. Baby boomers have disproportionately low rates of successful aging and physical activity, even though physical activity is known to contribute to successful aging. Existing exercise programs are ineffective as evidenced by the widespread access to but poor participation in exercise programs. Archery exercise is a relatively unexplored, yet promising, physical activity intervention for baby boomers. This exploratory and qualitative case study was the first to explore the role of archery exercise in promoting successful aging through physical activity among baby boomers. A purposeful sample of 12 non-institutionalized baby boomers living in a Midwest community were enrolled in a six-week archery exercise program. A total of 8 females and 3 males with varying physical activity levels completed the program. Information from post-program, semi-structured interviews were triangulated with findings from a literature review. Key themes emerging from the interpretive analysis included physical benefits, mental benefits, positive social experience, appropriateness and benefit for older adults, and motivation to continue. Physical benefits included upper body strength, balance, and improvement to individual limitations. Mental benefits included concentration, movement control, confidence, and relief from individual mental challenges. Participants believed archery exercise is appropriate and beneficial for older adults because of the enjoyment, low intensity, rewarding, shareable, individualized, and multiple component aspects. The study demonstrates archery exercise is a promising physical activity intervention for baby boomers in this community. Future research is needed to explore the impact of archery exercise in other communities and among other older adult populations. Awareness about what constitutes physical activity is needed to encourage participation in exercise programs. Collaboration between public health, sporting, and community stakeholders is needed to deliver additional community-based, multiple component exercise programs to baby boomers. Archery exercise may be an effective physical activity intervention to address population aging concerns, although more research is needed to justify this claim.</p>

There are 17,571 homeless women in Vrindavan, a major pilgrimage town in North India (State Government Report, 2012). The town is spread across 4.56 square kilometers and the number of homeless women is increasing continually (NCW, 2010). The living conditions are inadequate and the majority live below the poverty line (Rai, 2010). In the last two decades, various attempts have been made by the government and non government organizations to build physical amenities, but psychological well being remains ignored (Rana & Misra, 2010). In literature, these women have often been portrayed as the victims of various tragedies, presenting only the vulnerable side. The present thesis attempts to explore the thriving side of these women, along with the vulnerable one. This thesis aims to study the changes, following various adversities, which homeless women of Vrindavan have faced in their lifetime. The study takes a critical stance of the medical model of negative changes following adversities, and endorses the understanding offered by positive psychology. Within positive psychology, the present thesis rejects the use of the term ‘Posttraumatic Growth’ because of the medical and universal implications that the term “trauma” brings, ignoring the cultural differences. Therefore, ‘Changes Following Adversities’ is used as the preferred term. Amongst various factors affecting changes following adversity, religious coping is one of the factors. Its significance has been studied less often than other factors such as social support, personal strengths, personality and optimism. The western perspective is still sceptical about the role of religion in changes following adversity, both methodologically and theoretically. Interestingly, with the population under study, the influence of religion was speculated to be large, because of the religious significance that Vrindavan has. Therefore, to capture the complexity of the experiences, grounded in the culture, a narrative approach was used. Thirty four life narratives were transcribed and translated for the analysis. Thematic analysis was employed to understand the changes across different participants. Overall, the thematic analysis indicated three major themes – adversities, coping strategies and changes following adversities. There were multiple adversities faced by the participants which were based in communal riots, poverty and patriarchal subjugation. Amongst all the coping strategies, emotion focused coping, particularly religious coping, emerged as one of the dominant themes. Ideographically, there were mixed findings on adversity related changes experienced by the participants. Changes in self and philosophy were the two major positive changes reported by the participants. Mental suffering in the form of worries, grief, somatic complaints and depressogenic thoughts were found as negative changes following adversities. A model was derived from the analyses to consolidate the findings, elaborating on the cognitive and emotional processing, leading to changes following adversities. The research has three fold implications-theoretical, methodological and practical. Theoretically, the study has implications for broadening the term trauma and post traumatic growth; using narrative to foster growth; and integrating religion in psychotherapy. Methodologically, the study has implications for cultural nuances faced while studying culturally variant populations, such as translations, and sample characteristics. The practical implications of the study indicate future interventions directed more towards wellbeing than welfare for the population under study.

<p> Human trafficking is a global problem and a multi-billion dollar industry. Most victims are women and girls and more than half are children. In the United States, many at risk youth continue to attend school with school nurses on the frontlines. Using the Peace and Power Conceptual Model, a mixed methods study was conducted to explore their awareness, attitudes, and role perceptions in prevention of commercial sexual exploitation of children (CSEC). Two factors related to increased awareness, and positive attitudes and role perceptions to prevent of CSEC included prior exposure to working with vulnerable students, and prior education about CSEC. Two factors that inhibited identification of CSEC included an uncertainty in identifying CSEC, and a lack of collaboration with colleagues in schools. Four sub-themes were identified; &lsquo;exposure/knowledge, &lsquo;collaboration&rsquo;, &lsquo;role boundaries&rsquo;, and &lsquo;creating respite space&rsquo;. Future research should target the multidisciplinary school team. Simultaneous policy efforts should focus on improving practice conditions for school nurses to support their role in identification and intervention to prevent CSEC among at risk youth.</p>

Background: After the collapse of the Soviet Union in 1990, fifteen former Soviet Union countries (fSU) have been undergoing transition. The Belarusian rate of transition has been slower than the others, and population health is likely to have been affected differently. Aims: This study aimed to explore changes in population health in Belarus between 1990 and 2010, and to analyse and describe changes in the health status of Belarusians between 2001 and 2010. Methods: A mixed-method study was conducted, comprising: (i) a review of the published literature, (ii) an analysis of routine health-related statistics, (iii) a review of the national public health reforms, (iv) a secondary analysis of data from two population surveys conducted in Belarus in 2001 and 2010, and (v) a statistical analysis of data from a new Health Category Response Scale (HRCS) survey. Results: Population health initially deteriorated as living standards fell in the early 1990's. An increase in morbidity and mortality from the major non-communicable diseases, and a decrease in life expectancy, followed patterns of increasing hyperinflation and rising unemployment. Around 1994, the economic situation reversed. Major public health reforms were implemented from 1999. Around 2000, mortality indicators for some diseases improved, but not all, while morbidity continued to increase. The secondary analysis of the cross-sectional data (2001 and 2010) and the HCRS survey conducted in Belarus in 2010 showed that Belarusians perceived their health to be better in 2010 than in 2001. Conclusions: In the early 1990's, population health in Belarus deteriorated. Around 2000, some mortality health indicators showed improvement, but by 2010, they had not yet reached their 1990 levels. In contrast, morbidity health indicators continued to deteriorate throughout 1990 to 2010.

<p> Despite decades of the implementation of the directly observed therapy short-course (DOTS), Sierra Leone is ranked among the 30 highest TB-burdened countries. Several factors account for unfavorable treatment outcomes, among which are patient characteristics. Previous studies have only focused on treatment compliance without any consideration for the factors that lead to noncompliance to treatment. The purpose of this study was to investigate patient characteristics that are associated with treatment noncompliance (treatment not completed) among TB patients undergoing the DOTS program in Sierra Leone. A retrospective longitudinal quantitative design was used to analyze secondary data from the completed records of 1,633 TB patients, using the Andersen&rsquo;s behavioral model of health services utilization as a theoretical framework work. Descriptive statistics and bivariate and multivariate logistic regressions were used to analyze the data. The results show that there was no significant association between treatment completion and age, gender, and TB-case category. On the other hand, being HIV-positive decreases the odds of treatment completion. Also, the educational level, geographic location, and year of treatment were significantly associated with treatment completion. Overall, program performance improved as the number of dropouts decreased significantly between 2013 and 2015. The social change implication of this study was that it identified HIV-positive patients and rural communities as areas needing specific attention such as the assignment of case managers to ensure compliance thereby improve DOTS program performance, thereby reducing the incidence and transmission of TB. </p>

Master of Public Health / Department of Diagnostic Medicine and Pathobiology / Robert L. Larson / Variant H1N1 influenza (vH1N1) virus is an issue both in swine production medicine and in the arena of public health. Influenza viruses can infect but not always produce disease in avian, humans and swine. Swine are unique among the three previously mentioned species in that their respiratory epithelium possesses three receptor sites for the virus types common to each of the three mentioned species. Swine influenza virus (SI) is common and widespread in nearly all Midwestern swine herds and can be transmitted by both direct contact and aerosolization. All of the three previously mentioned species have the potential to re-assort (produce virons containing genetic material of different virons to produce a unique influenza virus (IV). Because of their three specific receptor sites, swine have the greatest re-assortment capability. This re-assortment has the potential is a low mortality/high morbidity disease that is a substantial cost to the swine industry due to its negative effect on production parameters such as average daily gain (ADG) and feed efficiency (FE). It is a public health concern due to its potential to produce different virus types which may have increased mortality/morbidity in humans. Avian are the IV reservoir and have the ability to introduce virus types that are foreign to specific populations in all venues on the planet. It is in the mutual best interest of public health and swine production to mitigate the introduction of different virus types in swine and to control existing infections in swine populations with a goal of establishing SI-free herds. Mitigation for swine populations can occur through vaccination, diagnosis/isolation, and Biosecurity procedures designed to reduce/eliminate IV introduction into swine production facilities. In addition, preventing the interaction of infected humans with swine is another component of swine population Biosecurity.