<p>Patient nonadherence to physicians? prescribed therapeutic regimen is the greatest challenge in the effective treatment of patients with diabetes worldwide. Scientific evidence has revealed that nonadherence to prescribed medication could result in diabetic complications such as cardiovascular disease, retinopathy, nephropathy, and neuropathic diabetic foot ulcers. The purpose of this study was to explore predictive relationships between levels of adherence to antidiabetic medications, patient HbA1c levels, and diabetic complications among Jamaicans, an understudied population. The research question that guided this study was: Do the patient level of adherence and HbA1c levels have any predictive relationship with the severity of diabetic complications (cardiovascular disease, retinopathy, nephropathy and neuropathic foot ulcer) among Jamaicans after controlling for age and gender? The theory of planned behavior was used to guide the study. Data regarding diabetic complications were collected from 119 records during a cross-sectional review of patient dockets. Level of adherence was determined from an interviewer-administered Morisky 8-item adherence scale. A multiple regression analysis revealed that lower levels of patient adherence to treatment and higher HbA1c levels predicted greater severity of cardiovascular disease (p = .000; p = .000), retinopathy (p = .009; p =.090), nephropathy (p =.007; p =.001) and diabetic neuropathic foot ulcers (p =.027; p =.001). Findings from this study will contribute to the knowledge base on diabetic medication nonadherence and may encourage health care professionals to advocate for better medication adherence strategies among people with diabetes.

<p> Alzheimer&rsquo;s disease (AD) is associated with substantial healthcare utilization costs, resulting in a public health priority. In this study, the relationship between the demographic characteristics of age, gender, and type of health insurance; the presence of comorbidities of older Puerto Rican residents diagnosed with AD; and their healthcare utilization patterns (i.e., medical office and emergency room visits and hospital admissions) was examined using Andersen&rsquo;s behavioral model. Data from the 2013 Puerto Rico Health Study was used in this retrospective cohort design study. All AD cases aged &ge; 60 years were extracted using systematic random sampling. One-way ANOVA-WELCH, Mann-Whitney U test, and negative binomial regressions determined if there was a relationship between independent and dependent variables. Results indicated a statistically significant relationship between age, gender, health insurance type, and presence of comorbidities factors and healthcare utilization patterns among older Puerto Ricans with AD. From the results, opportunities were identified for further research and changes in professional practices in order to initiate discussions and action plans to improve services coordination for older Puerto Ricans with AD. Findings might impact social change by inspiring modifications to the public health infrastructure. These modifications may lead to enhanced disease management support, promoted social justice, and increased resources to improve healthcare access and quality of care, and overall enhancement of health outcomes, for Puerto Ricans living with AD.</p><p>

<p> Malaria has long been a major public health concern, with historic roots dating back thousands of years. This febrile disease is caused by a parasite that is transmitted among vertebrates by mosquitoes. Over the past century, global eradication programs have focused on minimizing populations of the insect vectors, and administering treatments to people infected, especially young children and pregnant women, as they are the most vulnerable to suffering severe complications. Overall, these programs have decreased the geographic distribution and global disease burden; however, malaria remains a major problem in regions where these efforts have been unsuccessful. In 2015, there were an estimated 214 million cases throughout the world, resulting in approximately 438,000 deaths; however, over 3 billion people are living at risk of becoming infected with malaria. Widespread use of the few available effective insecticides and anti-malarial drugs has conferred resistance in both parasitic and mosquito species, decreasing the effectiveness of current interventions. As anti-malarial resistance and insecticide resistance spread, the need for novel malaria interventions becomes more urgent.</p><p> One novel approach to combatting malaria was pilot-tested by researchers in the Department of Microbiology, Immunology and Pathology at Colorado State University. The Repeated Ivermectin Mass Drug Administration to control Malaria, or the RIMDAMAL study, evaluated the safety and effectiveness of repeated village-wide administrations of an anti-parasitic drug to prevent malaria in children &le; 5 years old. The RIMDAMAL study was a randomized trial carried out in Burkina Faso, a small tropical country in West Africa. Ivermectin (IVM) is a common anti-parasitic used around the world to prevent and treat parasitic diseases. Recent evidence has demonstrated that IVM is toxic to malaria-transmitting mosquitoes, and can inhibit the propagation of some life stages of malaria parasites. Initial analyses of the RIMDAMAL data found significantly fewer childhood malaria cases in intervention villages that received repeated IVM administrations, compared to control villages. </p><p> This study is a geospatial analysis of the RIMDAMAL data to provide further insight as to how this intervention could be implemented. There were two study aims for this research: 1) identify significant clustering of high and low childhood malaria incidence within each study village; and 2) identify significant clustering of high and low childhood malaria incidence throughout the entire study region. In total, eight villages were enrolled in the study, four of which served as controls, while the other four received the intervention. Residents of each village live in concessions, or compounds of extended family. Geospatial coordinates were collected for each concession within a study village, along with data on the participants within each concession. Using this data, incidence density of malaria among children 5 years old or younger was calculated at the concession level. Concessions were mapped, and spatial clustering of incidence density values was evaluated using the Getis-Ord Gi* (G-I-star) spatial autocorrelation statistic. To evaluate within village clustering, each of the eight study villages were analyzed individually, and between village clustering was evaluated by analyzing the entire study region.</p><p> Within each village, several &ldquo;hot spots,&rdquo; or statistically significant clusters of high malaria incidence density values were recognized during analyses with max clustering, at the 95% confidence level. Statistically significant clusters of low incidence density were identified in one study village during the analysis with max clustering. The proportion of concessions identified as significant clusters varied by village, ranging from 12% to 91.3%. There seems to be no trend in clustering patterns seen within each village; some villages had randomly distributed hot or cold spots, while others appeared more clustered.</p><p> The spatial clustering patterns in the whole study region are more telling. Max clustering occurs in a bimodal pattern with two peaks; at 2,100 meters and 10,000 meters. The clustering patterns that occur indicate regions of similar malaria incidence. The proximity and locations of these villages may imply the RIMDAMAL protocol has regional impacts. Additional research is needed to evaluate how to most effectively implement this intervention to protect against malaria.</p><p>

<p> <b>Objectives:</b> The purpose of this study was to assess the relationship between two Mediterranean diet indices and to evaluate the proportion of participants who were ranked into identical tertiles of accordance with the Alternate Mediterranean Diet (aMed) and MedDietScore (MDS) tools when applied to an American samples.</p><p> <b>Methods:</b> In this secondary analysis, participants from four samples were pooled into two groups &ndash; one in which respondents completed the web-based VioScreen&trade; (n=200) food frequency questionnaire (FFQ) and the second, those who completed a paper-based Brief Block 2000 FFQ (n=827). Mediterranean diet scores were calculated based on the sex-specific median intakes of nine aMed components as well as meeting target frequency per week of the MDS components. Participants were categorized into a <i>priori </i> tertiles for each score.</p><p> <b>Results:</b> Scores for aMed and MDS were moderately correlated in the VioScreen&trade; (rho= 0.546, p&lt;0.001) and Brief Block (rho=0.627, p&lt;0.001) samples. The greatest proportion of participants was classified into Tertile 2 for VioScreen&trade; each scoring paradigm (40% for aMed and 71% for MDS). In the Brief Block sample, 47% of participants were assigned to Tertile 1 for aMed and for MDS 52% into Tertile 2. Only 47% of VioScreen&trade; and 60.3% of Brief Block participants were ranked into identical tertiles for aMed and MDS. Classification agreement between aMed and MDS was fair for VioScreen&trade; (weighted &kgr; = 0.223, p&lt;0.001) and Brief Block samples (weighted &kgr; = 0.384, p&lt;0.001).</p><p> <b>Conclusions:</b> Agreement between aMed and MDS was no more than fair for either FFQ, indicating that the scoring paradigms are not interchangeable in measuring accordance to the Mediterranean diet. Further investigation into the effects of FFQ selection on aMed and MDS scoring in addition to factor analysis of the variability between aMed and MDS is warranted in American samples.</p><p>

<p> Greater awareness regarding healthcare-associated infections (HAIs) has drawn in a great deal of attention from the government at the local, state, and federal level as well as from the general public and medical insurance companies such as Medicaid and Medicare. This level of attention is the product of heightened interest in the quality of healthcare and the realization that most HAIs can be averted. Healthcare organizations and medical providers worldwide continue to observe exceptional developments in the comprehension of the physiology of uncommon or disease-causing agents and increased transmission of multidrug-resistant organisms in healthcare facilities both nationally and internationally. Such circumstances have prompted the re-examination of fundamental infection prevention processes in healthcare facilities. Evidence-based research has linked hand hygiene compliance to decreased nosocomial infections. With the World Health Organization (WHO) leadership and guidelines on hand hygiene in healthcare and patient safety initiatives, healthcare facilities must focus on compliance in hand hygiene practices. It is inexpensive, simple and it can save many lives.</p><p>

Smoking during pregnancy is one of the most important modifiable behaviors to affect pregnancy outcome. Smoking patterns vary widely among U.S. Hispanic women according to country of origin, and Puerto Rican women have the highest rates of smoking during pregnancy compared to Mexican women and Hispanics from other countries. Therefore, it is important to examine the attributes of women who quit smoking at pregnancy onset as well as the maternal and fetal outcomes associated with continued smoking among Puerto Rican women. The first study of this dissertation examined the attributes of women who quit smoking at pregnancy onset in a population of predominantly Puerto Rican prenatal care patients. Among women who smoked prior to pregnancy, non-Puerto Rican Hispanic ethnicity, being born outside the U.S., and having a family history of type 2 diabetes were significantly associated with quitting smoking at pregnancy onset, while pre pregnancy daily marijuana use, heavy smoking, having a prior birth, and a high stress score were inversely associated with quitting smoking. Findings may be used to tailor cessation messages and target women at risk of continued smoking during pregnancy. The second study of this dissertation examined the association between smoking and risk of gestational diabetes (GDM) and abnormal glucose tolerance (AGT). This study adds to sparse literature on smoking and abnormal glucose tolerance. Smoking in pre, early or mid pregnancy was not associated with risk of GDM but confidence intervals were wide due to small number of cases. Smoking was associated with a suggestion of decreased risk of AGT, although not significant in multivariate models. Additional research is needed to better understand the effect of smoking on plasma glucose levels and risk of AGT during pregnancy. The third study of this dissertation evaluated the association between smoking during pregnancy and risk of preterm birth and small-for-gestational-age (SGA). The strengths of this study included the assessment of smoking at two time points in pregnancy and the evaluation of preterm birth subtypes. Results supported prior findings in largely non-Hispanic white populations that smoking during pregnancy increases the risk of preterm birth and SGA.

Premenstrual syndrome (PMS) is characterized by the presence of physical and psychological symptoms restricted to the late luteal phase of the menstrual cycle and associated with substantial impairment in life activities. In the U.S. about 8 to 15% of women of reproductive age suffer from PMS. Many micronutrients are potentially involved in the development of this disorder due to their role in the synthesis of neurotransmitters and hormones or in their regulation, but few previous studies have evaluated the effects of micronutrients on PMS. The first study examined the association between B vitamin intakes, and PMS development among women participating in the Nurses' Health Study 2 (NHS2). We found that high thiamin and high riboflavin intake from food sources were associated with lower risk of PMS. There were not significant associations between niacin, vitamin B6, folate, and vitamin B12 dietary intake and incident PMS. Intakes of B vitamins from supplements were not associated with lower risk of PMS. The second study evaluated the association between selected mineral intakes and PMS development in the NHS2. In this study, high iron intakes were associated with lower risk of PMS. Although there was no association between zinc and PMS risk, high intake of zinc relative to copper was associated with lower risk of PMS. There were no associations between of magnesium, copper, and manganese intakes and PMS. We observed a significantly higher risk of PMS in women with high intakes of potassium from food sources. The third study focused on the association between dietary intakes of B vitamins, zinc, magnesium, iron, potassium, and sodium and some biomarkers and PMS prevalence among younger women. In this study, we found an association between zinc intake and lower prevalence of PMS. Each 1 mg/d increase in vitamin B6 from foods was associated with a lower PMS symptom score. Blood magnesium levels were higher in women with PMS compared to women without PMS. We observed that intakes of some micronutrients were associated with lower risk of PMS, but further studies should be conducted. This dissertation contributes to the research on modifiable risk factors for PMS.

Prolonged second stage of labor, excessive gestational weight gain and cesarean delivery has been associated with adverse maternal and fetal outcomes. Physical activity during pregnancy is a modifiable risk factor which has never been studied among Hispanic women. Gestational weight gain, another modifiable risk factor has only been evaluated as a risk factor for cesarean delivery in two studies among women induced for labor. To date, no study has examined the effect of duration of second stage of labor on intra-ventricular hemorrhage in very preterm births. We examined these maternal risk factors for prolonged second stage of labor, rate of cesarean delivery and fetal outcomes. The first study evaluated the association between physical activity and duration of second stage of labor. Prior studies regarding physical activity and duration of second stage of labor have been conflicting and none have examined the Hispanic population. During pregnancy, activities such as household chores, childcare, sports and women's occupation constitute a significant proportion of physical activity but have not been considered in prior studies. We examined the association between total physical activity (occupational, sport/exercise, household/care giving, and active living) during pre, early and mid-pregnancy and duration of second stage of labor in a prospective cohort of 1,231 Hispanic participants. Physical activity was quantified using the Kaiser Physical Activity Survey administered during pregnancy. Using multivariate linear regression we did not find statistically significant association between pre, early and mid-pregnancy physical activity and duration of second stage of labor. The second study focused on the effect of gestational weight gain on the cesarean delivery rate after induction of labor. The rate of induction of labor (IOL) has more than doubled from 9.5% in 1990 to 22.5% in 2006. Cesarean delivery usually follows a failed IOL and is associated with maternal and fetal morbidity. One of the two studies evaluating the effect of gestational weight gain on the rate of cesarean section in patients undergoing IOL was restricted to women with normal Body Mass Index (BMI) and the other was subjected to bias because more than half of the patients were missing BMI data. Therefore, we evaluated the effect of gestational weight gain on the rate of cesarean delivery after labor induction. In a retrospective cohort study design, using data from May 2005 to June 2008 and a multivariate logistic regression we found a 13% increase in risk of cesarean delivery with 5 kg increase in gestational weight gain. Finally, we evaluated the effect of mode of delivery and duration of second stage of labor on intra-ventricular hemorrhage (IVH) among early preterm births. IVH is a serious complication associated with preterm birth and important predictors of cerebral palsy and neurodevelopmental delays. Prior studies on this relationship in early preterm births are sparse. In a retrospective cohort study of newborns born less than 30 weeks or less than 1500 g between May 2003 and August 2008, we found an increase in risk of IVH after vaginal delivery. However, duration of second stage of labor had no significant effect on risk of IVH.

<p> The purpose of this study was to characterize sexual harassment in public, or &lsquo;eve teasing&rsquo;, in rural India, develop a measurement tool, and to estimate its prevalence and association with common mental disorders (CMD) and suicide ideation (SI) among young women. Mixed methods included focus group discussions, direct observation of questionnaire administration, and both qualitative and quantitative data gathering with a novel questionnaire. Females ages 14&ndash;26 were recruited through purposive sampling in nine villages for the initial pretest (N=89). Using the finalized questionnaire, we conducted a cross-sectional survey using a randomized cluster sample of 19 villages and recruited 198 women ages 15-24 using house-to-house probability sampling. Eve teasing was described as staring, stalking, passing comments, or inappropriate physical touch. Most participants perceived significant negative consequences, including tight restrictions on girls&rsquo; mobility, inability to attend school or work, girl&rsquo;s being blamed, and causing family problems. Among those who reported eve teasing victimization, psycho-social responses included feelings of fear (88%), anger (78%), and shame (68%) (N=59). The internal reliability of the questionnaire was high for key measures (Cronbach&rsquo;s alpha: .65 to .84) and principal components analysis suggested two underlying constructs in the eve teasing instrument. Nearly 30% of participants reported ever having been eve teased, 21% screened positive for a CMD, and 27% reported recent suicide ideation (N=198). In multivariate analyses, spending more than 1 hour in public daily was associated with reported eve teasing (OR: 3.1 (CI: 1.26-7.49) p=0.016). The odds of screening positive for CMD were significantly higher if eve teased, but only among participants who reported adverse childhood events (ACEs) (OR: 4.5 (CI: 1.18-11.43) p=0.003). Eve teasing was significantly associated with SI among participants who reported ACEs when CMD were included in the model (OR: 3.1 (CI: 1.119-8.472) p=0.032). This is the first study, to our knowledge, to assess the association between eve teasing victimization and mental health outcomes in a community setting. We found that eve teasing may negatively impact the mental health of young women, especially victims of child abuse, and offer a reliable and valid questionnaire for future research.</p>

<p> Objective: To estimate the risk of preterm birth in patients with an ultrasound or physical exam indicated cervical cerclage based on the results of fetal fibronectin (fFN) and cervical length (CL) screening. </p><p> Methods: Retrospective cohort of patients with a singleton pregnancy and an ultrasound or physical exam indicated Shirodkar cerclage placed by one maternal-fetal medicine practice from November 2005 &ndash; January 2015. Patients routinely underwent serial CL and fFN testing from 22-32 weeks. Based on ROC curve analysis, a short CL was defined as &le;15mm. All fFN and CL results included are from after the cerclage placement. </p><p> Results: 104 patients were included. Seventy eight (75%) patients had an ultrasound-indicated cerclage and 26 (25%) patients had a physical exam-indicated cerclage. A positive fFN was associate with preterm birth &lt;32 weeks (15.6% vs. 4.2%, p=0.043), &lt;35 weeks (37.5% vs. 11.1%, p=0.002), &lt;37 weeks (65.6% vs. 20.8%, p&lt;0.001), and earlier gestational ages at delivery (35.2+/-3.9 vs. 37.4+/-2.9, p=0.001). A short CL was also associated with preterm birth &lt;35 weeks (50.0% vs. 11.9%, p&lt;0.01), preterm birth &lt;37 weeks (55.0% vs. 29.8%, p=0.033), and earlier gestational ages at delivery (34.8+/-4.1 vs. 37.2+/-3.0, p=0.004). The risk of preterm birth &lt;32, &lt;35, and &lt;37 weeks increased significantly with the number of abnormal markers. </p><p> Conclusion: In patients with an ultrasound or physical exam indicated cerclage, a positive fFN and a short CL are both associated with preterm birth. The risk of preterm birth increases with the number of abnormal biomarkers. </p>