Text messaging, also known as short message services (SMS), is a burgeoning innovation area showing promise in eliciting health behavior changes. This dissertation details two intervention trials that each comparatively tests the efficacy of different text message sets intended to improve behaviors. In light of pervasive road traffic injuries amongst young men in Tanzania, the first intervention tested messaging strategies aimed at increasing helmet wearing amongst commercial motorcycle taxi drivers. Participants (N=391) were randomized to receive either: 1) social norming messages emphasizing society’s positive stance on helmets; 2) fear appeal messages emphasizing the dangers of riding without helmets, or 3) control messages. After 6-weeks, the odds of drivers reporting wearing their helmet “on every trip” was 1.58 times higher in the social norming group than amongst controls, though this difference was not significant after accounting for multiple hypothesis testing. There was little difference between fear appeal recipients and controls. In light of China’s excessive caesarean section rate of up to 54.9%, the second trial tested messaging strategies aimed at reducing unnecessary caesareans. This quasi-randomized trial assigned pregnant women (N= 4,375) to receive one of four message sets: 1) Limited “Basic” messages, 2) A set primarily regarding Care-Seeking, 3) A set primarily regarding good prenatal Home Practices, or 4) All Texts. Amongst women that acknowledged receiving program texts, care-seeking messages alone were associated with reduced odds of caesarean delivery (OR=0.71, p=.045). Assignment to receive All Texts was associated with strongly reduced odds (OR = 0.65, p=0.008). Last, an observational study utilizing the Xi’an data investigated the association newborns being born small for gestational age (SGA) and women’s levels of family support. Adjusted logistic regression found that high support was associated with reduced odds of SGA (OR =0.681 p=.013). Mediation analysis suggested this association was at least partially mediated by better nutrition supplementation and more moderate exercise. These results suggest SMS interventions may be useful tools in eliciting behavior change surrounding helmet wearing and mode of delivery. Some message types may outperform others, and family support may be a useful leverage point. Further investigation is warranted.

This dissertation focused on childhood obesity among preschool aged children in the United States, using data from the Early Childhood Longitudinal Study Birth Cohort. Chapter 1 examined racial/ethnic differences in preschool-aged children’s weight trajectories and identified sensitive periods at which disparities emerge, using mixed growth models and nonparametric LOESS curves. Racial/ethnic disparities in US children’s weight-status and growth trajectories emerge at different ages for different racial groups, but they are generally well established by kindergarten age. Our findings indicate that interventions designed to prevent early childhood overweight/obesity should be implemented early in the life-course. Chapter 2 assessed the contribution of behavioral and environmental risk factors to racial/ethnic disparities in preschool children’s weight status, using decomposition analyses to estimate the percent of disparity explained by individual obesity risk factors. Gaps in the prevalence of socio-economic-status (SES) accounted for a substantial part (ranging from 24.4% to 63.3%) of the explained disparities in BMI z-scores between racial/ethnic minority children and their white peers. Apart from SES and its correlates, infant weight gain during the first 9-months of life, lack of breastfeeding, early introduction of solids, and sugar sweetened beverage consumption were additional factors that played important roles in explaining racial/ethnic differences. Interventions implemented early in the life-course that target these key contributory risk factors could potentially help reduce the magnitude of racial/ethnic disparities in early childhood obesity Chapter 3 examined the effect of attending childcare on children’s BMI z-scores, employing OLS regression, as well as two quasi-experimental approaches designed to minimize the effect of selection bias and unmeasured confounding. In linear regression models, compared to children in parental care, children in non-parental childcare at 24 months had higher BMI z-scores at kindergarten entry. However, both quasi-experimental approaches revealed no significant effect of childcare attendance on children’s BMI z-score, suggesting that the link between non-parental childcare and obesity may not be causal. Previously reported associations may be confounded by unobserved family circumstances resulting in selection into different types of childcare arrangement.

Childhood engagement in physical activity improves health and contributes to the sustainment of physical activity in adulthood. My dissertation research broadens scholarship by disentangling the effects of sports- vs. non-sports-focused summer camps on children’s physical activity and identifying modifiable activity characteristics contributing to physical activity enjoyment, an important predictor of physical activity sustainment. My work also challenges current discourse by presenting the analytical argument for bringing enjoyment research to the forefront of public health. In Chapter 1, I hypothesize that children attending a sports camp spend more time in moderate-to-vigorous physical activity (MVPA) compared to children attending general day camps. Multivariable linear regression models estimated differences in percent of accelerometer-monitored time spent in MVPA. Children in the sports camp spent significantly more time in MVPA compared to children in a non-sports-oriented camp. This is the first study of its kind to use real data to document physical activity differences between sports and non-sports camps. In Chapter 2, I investigate whether children in a sports camp experience higher enjoyment when the activity 1) is competitive, 2) has an active line or no line, 3) involves active coaches, 4) poses challenge, or 5) requires skill. Enjoyment scores were higher for competitive vs. non-competitive activities and those with higher perceived challenge and skill. Integrating challenging, competitive, and skill-building activities into sports camps is relatively simple, yet may have broad effects on children’s physical activity behavior. Chapter 3 presents rationales for bringing enjoyment to the forefront of public health dialogue and action to increase physical activity in children. I outline five challenges that have limited physical activity enjoyment research and offer strategies for addressing them. While other fields have linked physical activity enjoyment with physical activity maintenance, the public health field rarely measures or incorporates enjoyment in epidemiologic, intervention, or theory research. Increasing physical activity in childhood should be prioritized in public health. The findings and lessons from these chapters not only contribute new scientific evidence, but also have the potential to inform policies and programs that improve children’s relationship with and experiences of physical activity during childhood and across the life course.

Chronic stress associated with living in societies with high income inequality may increase risk for cardiovascular disease (CVD) and mental illness. Research has also linked social capital, including trust of other people, to mental health outcomes. South Africa has one of the highest levels of income inequality recorded worldwide and is experiencing a growing burden of non-communicable diseases. Data additionally suggest that levels of trust in South Africa are low. Using longitudinal data from adults interviewed in Waves 1 to 3 (2008-2012) of the National Income Dynamics Study, this dissertation examined whether district-level income inequality calculated from census and survey data was associated with several physical and behavioral risk factors for CVD (Paper 1) and with depressive symptoms (Paper 2), as well as whether trust at the individual and district levels was associated with depressive symptoms (Paper 3). Income inequality, measured using Gini coefficients, and prevalence of most CVD risk factors increased during the study time period, while depressive symptoms, measured using the Center for Epidemiological Studies of Depression Short Form (CES-D-10), decreased. In pooled cross-sectional regression models, higher district inequality was associated with lower BMI and waist circumference. In longitudinal fixed-effects models, Gini coefficients were not significantly associated with any CVD risk factors. District-level Gini coefficients were not significantly associated with CES-D-10 scores or with high depressive symptoms (scores of 10 or higher) in either cross-sectional or longitudinal fixed-effects models. Low generalized and personalized trust at the individual level were associated with lower CES-D-10 scores and reduced risk of high depressive symptoms in pooled cross-sectional and longitudinal fixed-effects models. Neither district-level generalized nor personalized trust was associated with depressive symptoms. However, a cross-level interaction was observed suggesting that lower levels of trust are associated with reduced depressive symptoms when districts have low percentages of highly trusting individuals but not when district-level distrust is low. In conclusion, the results of this dissertation do not support the income inequality hypothesis in relation to CVD risk factors or depressive symptoms in South Africa. Moreover, findings suggest that trust may not be beneficial for depressive symptoms for all individuals or in all contexts.

Objectives: Unintended pregnancy is endemic in the United States. Primary care physicians (PCPs) are optimally positioned within the health care system to improve the prevention and management of unintended pregnancy by offering comprehensive contraception and abortion care. Factors at the individual, health center, health systems, and policy levels may influence whether PCPs offer these services. Current practice, knowledge, and attitudes about contraception and abortion among PCPs are poorly understood. This investigation fills these gaps using original quantitative and qualitative data. Methods: This mixed-methods investigation included: 1) a quantitative survey querying a national probability sample of practicing PCPs about contraception, abortion, and other sexual and reproductive health services; 2) a qualitative investigation of determinants of provision of long-acting reversible contraception (LARC) in community health centers (CHCs) through focus group discussions. We applied case weights to survey responses and generated population estimates of current and lifetime abortion provision and current provision of contraceptive methods. Logistic regression modeling identified factors associated with abortion and LARC provision. Qualitative data were coded inductively by multiple investigators using an iterative consensus-based method. Results: Factors at the health systems and health center levels influence provision of abortion and contraception in primary care. In the survey data, the strongest correlate of having received training in, endorsing training in, or reporting current provision of abortion and all contraceptive methods was residency training in family medicine, as compared to general internal medicine or other residency. PCPs generally support residency training in abortion and contraception. The primary reported barriers to abortion provision were lack of training and resources. Prior training, practice type, and health systems-level factors were associated with provision of abortion and contraception; most physician demographics were not. In the qualitative investigation, insurance issues, device stocking, and scheduling of LARC method placement emerged as primary influences on the pathway to care for women seeking these methods. Conclusions: PCPs are receptive to contraception and abortion training and service provision. Efforts to support delivery of these services could include enhanced clinical training and interventions at the health center and health systems levels to ensure access to requisite resources.

Tuberculosis (TB) recently surpassed HIV as the world’s leading infectious killer. Because antibiotic therapy forms the cornerstone of TB control, prevention, and treatment, it is important to apply TB drugs in a way that maximizes their potential benefits while minimizing the risks of resistance. Here, I present three modeling analyses intended to explore these tensions inherent in the use of TB drugs. Preventive therapy involves the use of antimicrobials in asymptomatic and noninfectious individuals, and has been applied to diseases ranging from TB to HIV to malaria. In my first paper, I outline how population use of preventive therapy could increase, decrease, or have non-monotonic effects on the prevalence of drug resistance, depending on the relative contributions of resistance acquired as a result of preventive therapy, resistance acquired as a result of treatment for active disease, and transmitted resistance. In my second paper, I consider the specific use of isoniazid preventive therapy (IPT) to prevent active TB among people living with HIV. Previous models have suggested that widespread IPT use could increase the prevalence of drug resistant TB by providing a selective pressure in favor of resistant strains. In this paper, I show that the impact of IPT on drug resistance is highly dependent on the projected TB/HIV epidemic trends, and that the risks of resistance are likely to remain low for even lifelong IPT durations as long as transmission is already declining. Finally, in my third paper, I present a decision analytic model to determine the optimal targeting of the new TB drug bedaquiline for patients with pre-existing resistance to other available drugs. The optimal use strategy for this new drug depends on the outcome being considered; whereas more liberal strategies would likely decrease resistance to existing drugs as well as onward transmission, more restrictive strategies would decrease resistance to bedaquiline. More research is needed to confirm that more liberal bedaquiline use strategies would improve life expectancy. Overall, these papers illustrate the complexity of the decisions surrounding optimal TB drug use. Thoughtful antibiotic policies, coupled with continued innovation, are needed to effectively combat the global burden of TB.

40 years of public health research on buildings has identified the indoor environmental drivers of health and productivity. Concurrently, increased environmental awareness spurred the green building movement with the goal of encouraging more sustainable buildings. The question remains as to whether green buildings are also healthy buildings. The objective of this dissertation is to investigate the impact of green buildings on health and cognitive function in both laboratory and real-world settings, and furthermore quantify these impacts in comparison to the potential environmental and economic costs. First, 24 participants spent 6 work days in a controlled office environment. On different days, they were exposed to conditions representative of Conventional (high volatile organic compound (VOC) concentration), Green (low VOC concentration), and Green+ (low VOC concentration and increased ventilation) office buildings. Additional conditions tested artificially elevated carbon dioxide (CO2) levels. On average, cognitive scores were 61% higher on the Green building day and 101% higher on the Green+ building days than on the Conventional building day (p<0.0001). VOCs and CO2 were independently associated with cognitive scores. Second, based on the finding of improved cognitive scores in buildings with enhanced ventilation, the productivity benefits were compared to the environmental and economic costs of doubling ventilation rates. The costs were less than $40 per person per year in all climate zones investigated, while the benefits in terms of productivity exceeded $6,500 per person per year. The environmental impacts could be mitigated through the implementation of energy recovery ventilators (ERVs). Lastly, we conducted building assessments of 10 high-performing buildings (i.e. buildings surpassing the ASHRAE 62.1-2010 ventilation requirement and with low VOC concentrations) in 5 cities around the U.S. while tracking the health and productivity of office workers in those buildings. Even among high-performing buildings, workers in green certified buildings scored 26.4% higher on cognitive function tests than those in non-certified buildings. Sleep Quality scores were 6.4% higher in green certified buildings, suggesting an impact of the building on sleep quality. We show significant benefits to cognitive function and health in green buildings through multiple experimental approaches, driven by factors consistent with the public health literature.

<p> Globally, the implementation of environmental change strategies, such as smoke-free policies, has been found to reduce exposure to secondhand smoke (SHS) among women and children (Faber, Been, Reiss, Mackenbach, &amp; Sheikh, 2016). However, implementation of such strategies in Nigeria must first be supported by data indicative of need and feasibility within the local community. In this cross-sectional descriptive study, the self-efficacy construct was used as a theoretical framework to explore the self-efficacy and support for environmental change strategies among pregnant and non-pregnant women living in Kaura Namoda, Nigeria. A self-administered questionnaire survey was adapted and completed by 300 women (age 18 &ndash; 67 years) in August 2016. Descriptive statistical analyses and logistic regression were performed. The non-pregnant respondents (47%) reported greater self-efficacy in reducing children&rsquo;s exposure to SHS than the pregnant respondents (53%). Among the pregnant respondents, higher self-efficacy was predictive of the support for the following environmental change strategies: smoke-free cars (OR = 4.18, 95% CI [2.25, 7.77]), smoke-free homes (OR = 1.69, 95% CI [1.14, 2.52]), smoke-free indoor public places (OR = 2.40, 95% CI [1.53, 3.76]), and smoke-free outdoor public places (OR = 1.60, 95% CI [1.09, 2.34]). However, self-efficacy was only significantly different on the demographic variable of the decision maker at home (F (2, 246) = 10.87, <i>p</i> &lt; 0.001). These findings support the promotion of self-efficacy among pregnant women and the implementation of smoke-free policies in Nigeria. More research is also needed to fully understand the contextual factors that promote self-efficacy in reducing exposure to SHS in Nigeria.</p><p>

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Natives in Canada suffer from high rates of morbidity and mortality in comparison to the Canadian population. Investigation of this inequity has been hampered by a lack of valid health statistics on native populations. This thesis assesses native mortality through a study of three potential sources of native mortality statistics using routinely collected data. Objectives were to: (1) Measure mortality indicators using a computerized record linkage of government Indian administrative records with the Canada Mortality Database. (2) Compare native mortality indicators based on the linked files, on-reserve deaths, and Medical Services Branch native client files. (3) Relate mortality amongst natives with respect to the Canadian population. (4) Determine if there is a contribution of "rural" living to native mortality. The record linkage includes deaths recorded with DIAND as occurring in 1981. The average annual mortality rate for the two other native files and comparison populations are derived from 1979-1983 records. (Abstract shortened by UMI.)