Lifestyle behaviors, including diet and exercise, may mediate the risk of breast cancer recurrence. Large national and international organizations, including the American Cancer Society, the American Institute for Cancer Research, and the World Research Fund, recommend consuming a diet high in plant-based foods, specifically fruits, vegetables, and whole grains, and low in dietary fat and added sugar for cancer recurrence prevention. In addition, these organizations recommend regular physical activity, typically 30 minutes of moderate to vigorous activity per day. However, many cancer survivors unfortunately fall short of meeting these recommendations. In addition, low-income, and racial/ ethnic minority populations, especially Latinas, are at increased risk of breast cancer recurrence due to a myriad of factors such as limited access to health care. Theory-based, behaviorally-focused, and culturally-tailored nutrition and physical activity education has been shown repeatedly to improve these lifestyle behaviors in other populations. Previous intervention studies by our research group have significantly improved dietary behaviors among Hispanic/ Latina breast cancer survivors. This dissertation consists of a review of the educational literature on diet and physical activity studies among breast cancer survivors, and three studies: (1) a methodological description on the development of a theory-based, behaviorally focused intervention with classroom and online education curricula, (2) an empirical validation study of a survey instrument, and (3) a cross sectional study of women’s diet and physical activity behaviors and theory-based determinants. Taken together, these studies can inform future educational interventions with this population by using our culturally-tailored, theory-based, behaviorally-focused model as a framework and by using our validated assessment tools. These studies can also inform future educational interventions by understanding diet and physical activity behaviors and related potential mediators. These dissertation activities were conducted within the context of a larger, on-going, two-by-two factorial designed National Cancer Institute (NCI) funded educational intervention study, Mi Vida Saludable (My Healthy Life), which aims to change diet and physical activity behaviors of Hispanic/ Latina breast cancer survivors. The main study will examine the separate and synergistic effects of a) online education and b) in-class education. The intervention is based upon nutrition education curricula developed by the non-profit organization Cook for Your Life, which develops recipes and cooking education for cancer patients and survivors in New York City and a previous intervention conducted by this research group, that targeted fruit, vegetable, and dietary fat intake only. The on-going larger study, Mi Vida Saludable, involves cohorts of 30-40 Hispanic/ Latina breast cancer survivors who go through the intervention arms, at intervals of every 4-8 months, depending on recruitment. As of April 2018, two of the five planned cohorts have completed the study, and four of the five cohorts have been randomized. The purpose of the initial comprehensive review of the literature was to inform the development of this Mi Vida Saludable educational intervention. Three areas relevant to the intervention were reviewed. The first area was the varying dietary and physical activity guidelines, both for cancer survivors, and also for common simultaneously occurring lifestyle-related diseases such as heart disease and diabetes. Similarities and differences were examined, and the resulting recommendations were used in the intervention development. The second area of review consisted of dietary and physical activity interventions that specifically targeted breast cancer survivors. Commonalities of successful interventions included the use of Social Cognitive Theory and the Stages of Change construct of the Transtheoretical Model. Finally, the text message literature was reviewed as it pertains to weight management, dietary, and physical activity behaviors, specifically among Hispanic/ Latina populations. Findings indicated that text message interventions were more successful if they decreased in frequency over time, included specific educational advice, and had the ability for two-way communication. The findings from these literature reviews were used to develop the Mi Vida Saludable intervention. (1). The methodological study involved the development of the content of the Mi Vida Saludable group education and electronic (“e-“)-communication programs. These programs were developed using a systematic stepwise theory-based, behaviorally-focused process, the Nutrition Education DESIGN Procedure. Briefly, DESIGN stands for: 1. Decide behaviors; 2. Explore determinants or potential mediators of change; 3. Select theory; 4. Indicate objectives; 5. Generate plans; and 6. Nail down evaluation. DESIGN was applied to help assure the curricula a) enhance motivation and b) facilitate action to change the following behaviors: 1) increase fruit and vegetable intake, specifically focused on non-starchy varieties, 2) decrease dietary fat intake operationalized as less fatty meats, decreased fat added during cooking, and smaller portions of cheese, 3) decrease added sugar intake operationalized as fewer sugar sweetened beverages and less added sugar in processed food and cooking, and 4) increase daily moderate-to-vigorous physical activity. The behavior-change theory applied was the Social Cognitive Theory. The resulting group education program consisted of 4 lessons, 4 hours each in length. Each lesson included a hands-on cooking component and facilitator-led nutrition education and discussion. Two of the four lessons included field trips to the local grocery store and farmers’ market. The resulting e-communication program included 11-months of weekly text messages, biweekly emailed newsletters, and ongoing website access. The content of the online curriculum was developed after the classroom curriculum and mirrored the classroom curriculum so that mode of education would be the key variable tested. (2). A survey instrument was developed to assess two key psychosocial potential mediators of behavior change from Social Cognitive Theory, preferences and self-efficacy, separately for each targeted behavior. This survey was tested for validity and reliability. Expert panel review assessed scale validity by Content and Face Validity. Participants from the target population assessed scale validity and reliability by 1) cognitive interviewing, 2) convergent validity, 3) internal consistency reliability, and 4) test-retest reliability. Content and face validity, and cognitive interviews successfully improved the questionnaire before quantitative analysis. Modifications from content and face validity included the addition of pictures of fruits and vegetables and the addition of examples of different food types high in fat and added sugar. Results from the cognitive interviews indicated primarily that changes should be made in the questionnaire to examples of foods with and without dietary fat and added sugar. Study findings revealed that Cronbach alpha values were sufficient for all Preferences and Self-efficacy scales except for Preferences for Added Sugar Intake. Study findings also revealed that item-total correlations were sufficient for all reduced Preferences and Self-efficacy scales, and that ICC values were sufficient for all Preferences and Self-efficacy reduced scales except for Preferences for Dietary Fat Intake. (3). Psychosocial potential mediators and measures of quality of life were examined in a cross sectional study of Mi Vida Saludable participants as they relate to women’s diet and physical activity behaviors at study entry. Outcome variables included diet, specifically servings of fruits and vegetables (both total and varieties specifically targeted by the intervention), percent dietary fat and added sugar, as well and average minutes of physical activity per week. Our study found that, among Hispanic/ Latina breast cancer survivors, decreased self-efficacy to choose lower sugar foods, increased locus of control of powerful others, and increased stress are related to increased added sugar intake. We also found that increased preferences for foods low in fat are related to decreased fat intake. Finally, we found higher mental health-related quality of life scores are related to increased fruit and vegetable intake, decreased fat intake, and increased physical activity. The results from these three studies will be used to understand behavioral outcomes of the Mi Vida Saludable study, as well as develop future interventions with this and other populations. Advancing our understanding of potential mediators and psychological variables can improve the development and success of interventions, especially among understudied populations such as Hispanic/ Latina breast cancer survivors.

Effective communication is essential for both a satisfying and productive patient-provider relationship. Ineffective communication can lead to many detrimental patient outcomes including a lack of access to care, an inability to navigate the healthcare environment, a decreased adherence to treatment recommendations, and a lack of patient understanding about disease risk factors, prevention, and management. The Healthy People 2010 initiative recognized the importance of communication by including several health communication-related goals in its objectives. A goal of one of these objectives included increasing the percentage of patients who reported that their care providers have satisfactory communication skills. Researchers can gain insight about those barriers that prevent providers from experiencing effective communication by examining the patients' perspectives about communication. The primary aim of this pilot study was to explore urban African American women's perspectives about the communication utilized during clinical encounters with providers via the use of semi-structured interviews. The semi-structured interviews collected data about a variety of topics including participants' breast cancer-related knowledge, attitudes, beliefs, and practices. Data was also collected about participants' clinical encounter experiences, including their comprehension of health information and their communication experiences with medical providers and other types of health care professionals. Any responses that discussed participants' communication experiences with providers, comprehension of health information, or perspectives about factors that could impede or facilitate communication were selected for analysis. In addition to the semi-structured interviews, participants also completed two health literacy assessments in order to gauge their health literacy levels. Women were administered the Rapid Estimate of Adult Literacy in Medicine (REALM), a word recognition assessment, and the Short Test of Functional Health Literacy in Adults (STOFHLA), a comprehension assessment. Eligibility criteria included women who: (1) were aged 50 and older, (2) were English-speaking, (3) able to respond to interview questions without assistance, (4) of African descent, (5) were Harlem residents, and (6) had never received a diagnosis of breast cancer. One hundred women participated in the study. Data about the effectiveness of providers' communication skills, patients' abilities to comprehend health information, patients' communication experiences with various types of health care providers, and preferred sources of health information were collected from the interviews. Open-ended questions were utilized to gather information about factors that women deemed as either impediments or facilitators to effective communication with providers. Collected data from interviews were analyzed qualitatively. In addition to information about participants' health literacy scores from the literacy assessments, final results included demographic information, preferred sources of health information, and information about those factors that women viewed as either impediments or facilitators to effective communication with doctors and with other health care providers both in and outside of the medical appointment. Additionally, findings from the qualitative analysis results were utilized in order to inform the creation of health communication recommendations for providers who treat urban African American female patients.

This dissertation aims to contextualize the normative and structural constraints on women's bodies, health, and wellbeing in rural Tamil Nadu, India. Using theoretical frameworks by R.W. Connell and Michel Foucault, this qualitative study explores the intersection of gender and power at interpersonal-, institutional-, and community-levels. Findings from this research highlight specific manifestations of the local gender regime that women may need to overcome to better care for their bodies and selves.

A grounded theory method was used to investigate the experiences of women who use naturopathic medicine, a system of alternative therapy, for health care during the menopausal transition. Transcripts of 16 in-depth interviews with women who received naturopathic health care during the menopausal transition were analyzed with respect to three research questions: (a) Why do women seek naturopathic health care during the menopausal transition? (b) Do women who use naturopathic treatment for menopausal health care share similar experiences of menopause? and ( c) Are women satisfied with the naturopathic treatment they receive for menopausal health care? Conditions leading to informants' use of naturopathy were represented by two categories: Practicing natural self-care, and Rejecting the conventional medical system Experiences of menopause were represented by three categories: It's not a singular event, Paying attention to changes in and around me, and Information helps. Informants' satisfaction with naturopathy for menopause-related health care was represented by four categories: Naturopathy is consistent with engaging in natural self-care practices, Naturopathy is effective in treating troubling menopausal signs, Naturopathy addresses individual and interrelated aspects of menopause, and Naturopathy provides moral and informational support. Continued analysis of the data revealed a core category, Exchanging infonnation, that provided a foundation for the theoretical model representing the experience of women who use naturopathic health care at menopause. The grounded theory developed in this study may be useful to health professionals by increasing understanding of the naturopathic health care option for menopausal women. Suggestions for further study include quantitative evaluation of components of the theory developed in this study, continued qualitative and quantitative investigation of aspects of information exchange between patients and their conventional and alternative practitioners, application of grounded theory methodology to studies of women's use of hormone replacement therapy, and application of grounded theory methodology to studies of patients' selection of alternative medicine for health matters other than menopause.

Thesis (M.CUR.) --University of Limpopo, 2014 / Indigenous practices (IPs) are experiences generated by people who are living in a specific region context and a specific cultured group. IPs are shaped by cultural traits that are passed from one generation to the next. The practices are rooted and embedded in such a society and, therefore, the practices become part of the people’s lifestyle. It is difficult to try and change these practices, since people have adhered to them throughout their entire lives. The believe system plays a major role in health care seeking behaviour of individuals because they are informed by the IPs that are observed in their environment (Shaik & Hatcher, 2005). IPs are stored in people’s memories and are expressed in songs, dances, beliefs, rituals, cultural values, myths, and healing of diseases by using herbs. During pregnancy, IPs are still applied worldwide. Ayaz and Efe (2008) indicate that it occurs mostly in Turkey and Africa where women’s reassurance is depending on the local context and meaning of pregnancy. THE PURPOSE OF THE STUDY To determine indigenous practices of pregnant women at the Dilokong Hospital in the Greater Tubatse Municipality of the Limpopo Province.This was achieved by the exploring and describing the indigenous practices of pregnant women in the antenatal (ANC) clinic of the maternity ward at the Dilokong Hospital.. DESIGN AND METHOD A qualitative, descriptive, explorative and contextual research design was used for the participants to describe the indigenous practices by pregnant women. Data was collected by means of unstructured one-on-one interviews in maternity unit of the ANC clinic at the Dilokong Hospital of the Greater Tubatse Municipality. Ethical considerations as described by Denosa (2000) were adhered to in order to ensure the v quality of the study. The criteria for trustworthiness were observed as stipulated in Babbie and Mouton (2009).Fifteen pregnant women were interviewed. FINDINGS AND RECOMMENDATIONS Four themes with sub-themes emerged from the data analysis by using Tech’ṡ open coding approach (Creswell 2006, Botma, Greef, Mulaudzi & Wright, 2010). Four themes were emerged namely; indigenous practices based on ancestral knowledge; indigenous practices based on spiritual diviners versus church principles; restricted practices versus instructions followed during pregnancy and labour and indigenous practices during labour and delivery. It is recommended that a national IP strategy needs to be developed to provide a framework and platform to support and promote grass roots IPs into mainstream development in the health care system in relation to midwifery practice. CONCLUSION The study findings indicated that IPs were regarded as an honourable health intervention by THPs, families, and pregnant women. They showed trust in methods used to preserve pregnancy, labour, and delivery, although, the indigenous practices by pregnant women still continue. Indigenous practices such as cords around their waists, are still observed during physical examinations. However, there is a reduction of prescribed potions mixed with cool drinks for use to accelerate labour and to prevent negative consequences because the potential toxicity has been explained during the provision of health education. These findings call for health care professionals to emphasise training and workshops for the THPs church diviners that are the fundamental principle of effective implementation of IPs to enhance improvement in the prevention of complications during pregnancy, labour and delivery. KEYWORDS Pregnant women Indigenous practice Indigenous knowledge

Studies in young women show that rowing exercise is osteogenic at the spine. However, little is known regarding rowing exercise and spine bone mineral density in older women. The aim of this study was to examine differences in spine bone mineral density (BMD) and back strength between premenopausal and postmenopausal competitive female masters rowers (n=28, 45.5 ± 4.7 yrs, n=28, 56.1 ± 5.7 years, respectively) and age-matched non-rowers (n=30, 43.3 ± 4.2 yrs; n=26, 56.8 ± 4.8 years). Competitive rowers were recruited from nine rowing clubs in the local area and compared to controls recruited from the same region who were normally active but not participating in rowing activity. Participating rowers had been engaged in competitive rowing for a minimum of one year. The average years spent rowing for the premenopausal and postmenopausal groups was 7.5 ± 6.6 yrs and 5.9 ± 6.9 yrs, respectively. BMD (g/cm²) of the third lumbar vertebrae (L3) was measured by dual-energy x-ray absorptiometry (DXA) in both the anterior-posterior and lateral views. Back strength was assessed using a standing cable tensiometer. Subjects also completed questionnaires to assess diet, physical activity, medical history and rowing history. Differences in BMD and back strength between groups were determined by analysis of covariance, controlling for lean mass. Compared to controls, postmenopausal rowers had 3.2% higher BMD at the anterior-posterior spine (p=.02) and 4.4% higher lateral spine BMD (p=.04). Furthermore, isometric back strength was 22.6% greater in these rowers than controls (p=.01). In contrast, controls had higher lateral BMD than rowers, with no differences in AP spine BMD or back strength between the premenopausal rowers and controls. Back strength was a significant predictor of AP spine BMD in premenopasual rowers and controls (R²=0.137, p=0.004) and of lateral spine BMD in postmenopausal rowers only (R²=0.153, p=0.04). There were no differences in calcium intake, age, menopausal status, weight, or lean mass between rowers and controls in either the premenopausal or postmenopausal samples. Since both increased BMD and back strength are associated with reductions in vertebral fracture risk, our results suggest that rowing exercise may be an important strategy to promote bone health and reduce vertebral fracture risk in postmenopausal women. However, the forces applied in rowing may not be great enough to alter bone mass before the onset of menopause. Therefore more research is needed examining rowing exercise in these older populations. / Graduation date: 2005

This study was designed to investigate the relationship between retinol intake, bone mineral density, and falls in 101 elderly women aged 72 to 90 years (78.6 yrs. �� 4.3 yrs.). Bone mineral density (BMD) (g/cm��) of the left hip, anterior-posterior lumbar spine (L3), and lateral spine (L3) was measured using dual-energy x-ray absorptiometry. Dietary intake and physical activity were assessed by validated questionnaires (the 100-item Block Food Frequency Questionnaire and the Physical Activity Scale for the Elderly, respectively). Isometric hip abduction strength of the right and left legs was assessed using a hand-held dynamometer. Fall surveillance was collected using a "postcard" system at three-month intervals over a two-year period. Multiple regression analyses were used to show the predictability of retinol, vitamin D, calcium, years past menopause, years on hormone replacement therapy, and physical activity on BMD variables. Together, these variables explained 14% of the variance in total hip BMD at follow-up (R��=0.14, SEE=0.12, p=0.020), 26% of the variance in the anterior-posterior spine BMD at follow-up BMD (R��=0.26, SEE=0.17, p=0.051), and 33% of the variance in lateral spine BMD at follow-up (R��=0.33, SEE=0.10, p=0.009). Two-year changes in hip BMD were poorly predicted using the model with only 5% of total hip BMD variance being explained by the six independent variables (R��=0.05, SEE=0.03, p=0.558). Logistic regression was used to determine whether the likelihood of being a faller vs. a non-faller could be predicted from a model using retinol, vitamin D, average hip strength, and physical activity. It was shown that 11.5% of the variability in fall status could be explained by the model (Cox & Snell's R��=0.115). Using an ROC curve analysis, the model correctly classified 69% of the individuals into the correct "fall category". We conclude that retinol, although not an independent predictor of BMD or fall status, is an important component in the prediction of both BMD and falls. Further interventional research is needed to determine the effects of retinol on BMD and falling. / Graduation date: 2004

The purpose of this study was to determine if a 5-month progressive-resistance exercise program would affect measures of activities of daily living (ADLs) and functional stability in elderly women. All subjects were ambulatory women, 80 to 93 years old, who lived in assisted-care facilities. Eight exercise and 7 control subjects completed the 5-month study. Exercise subjects participated 3 times weekly in progressive resistance of the lower extremities and upper extremities. ADLs were assessed by the Barthel Index, and functional stability was assessed by timed measures of rising from a chair, walking, and standing, feet together, with eyes open and eyes closed. All subjects were tested at 0, 10, and 20 weeks. Using repeated measures analysis of variance, significant differences were seen only in an overall Group effect (p<.0005). The Eyes Open stance (p=.02) and Walk (p=.01) measures contributed most to this effect. The lack of significance in other analyses may have resulted from low sample size, high variation of scores, initial group differences, or perhaps an ineffective treatment program. / Graduation date: 1997

published_or_final_version / History / Doctoral / Doctor of Philosophy

The focus of this study was the exploration of belly dance as a form of female self care. The specific facet of self care explored was female health and well being as impacted on by belly dance. There is a limited amount of existing scholarly studies t hat focus on the value of belly dance in self care. Therefore this study followed a qualitative format which promoted exploration of th is under researched field. This study occurred in a context where women’s lives are busier than ever before as a result of their involvement in both the home and the workplace. Thus there is a need for them to engage in self care activities that effectively restore and replenish body, mind and soul in order to enable them to continue to meet their multiple responsibilities in a functional manner. Facets of self care explored were psychical, mental and social health and well being as impacted on by belly dancing. To achieve this, data collection tools of focus groups and interviews, following a semi-structured format were used. The results showed that belly dance plays a significant and positive role, not only in female self care but in enjoyment as well. Some specific aspects of belly dance found to be useful to female self ca re was its liberating use of the female form, its non-discriminatory aspect that unites all women in enjoyment of the dance, the absence of men, the supportive presence of women, the music, the feminine aspects, a secure environment and the opportunity that belly dance presents for women to pl ay a different role. Conclusions point to women viewing society as androcentric and providing little opportunity for feminine expression. A major conclusion is that women are non-verbally strong, relational beings who are predisposed to the language of dance and music. They are effectively revitalised by dance and music as presented by belly dance. This has implications for social work service delivery to women on multiple levels. / Thesis (M.A.)-University of KwaZulu-Natal, Durban, 2008.