was a cluster-randomized trial to evaluate a cross-peer school-based obesity prevention program in Southern Appalachia. Undergraduate students from the disciplines of Kinesiology, Nutrition, and Public Health were trained as peer facilitators to deliver an 8-week curriculum in high school classes. The focus of the curriculum was on improving diet and physical activity with an additional emphasis on enhancing leadership and communication skills. Control group participants received their regularly scheduled curriculum. The current article is about the experiences of an undergraduate kinesiology student participating as a peer-facilitator in the trial. A brief overview of the program and peer facilitator training is followed by this students reflections on both personal development and student outcomes.

This dissertation consists of three essays that study the role of information acquisition and processing in health decision-making. Each chapter underscores the ways in which new information shapes the choices of health providers and consumers. Understanding these responses sheds light on critical health policy problems, including the potential overuse of low-value health services, gaps between medical evidence and practice, and inequitable access to high-value health services. The first essay studies the role of a consumer’s family network in the formation of their risk perceptions. I assess whether people correctly interpret new risk information communicated through household health events and analyze how these responses impact household welfare. Individuals respond to new diagnoses in ways most consistent with individual reevaluations of health risk rather than other possible explanations. To assess welfare implications, I estimate a structural model of health choices in which individuals learn about risk after health events reveal information. I find that consumers over-respond to recent, salient health events by over-weighting their risks ex-post. This leads to individual and social welfare losses, and suggests that aiding consumers in interpreting health risk information should be an important aim of health literacy policies. The second essay explores how health providers respond to information about innovations in mental health treatments, paying particular attention to the heterogeneous adoption costs of different practices. I compare the impact of continuing education on takeup across innovations that incur learning costs (psychotherapy) and those that do not (psychopharmacology). I use a novel extension of an estimator proposed by Calvi et al. (2021) to estimate a dynamic treatment effect in the presence of classification error. Therapists respond more to education when learning costs are negligent, being about three percentage points more likely to write new prescriptions following a conference. The third essay assesses the tradeoff between adopting novel medical technologies and achieving health equity. I study the adoption of transcatheter valve replacement surgeries in Medicare patients; these surgeries disrupted the supply of medical interventions from cardiothoracic surgeons to interventional cardiologists. This transition led providers to adjust practice styles along two margins: medium-risk patients became more likely to receive surgery, and low-risk patients received fewer medical interventions overall. I incorporate these findings into a model of physician decision-making, showing that both the expansion of high-intensity intervention and the crowd-out of low-intensity treatment can be rationalized by the presence of technological spillovers. The model further highlights that crowd-out may be inequitably distributed across the patient population when treatment appropriateness is not directly observed. I validate these predictions in my setting, showing that technology adoption resulted in disproportionately high barriers to care for low-income patients.

BACKGROUND: Individuals with serious mental illness face a significant burden of disease, yet experience lower quality care across a range of services (1). Hospital readmission within 30 days of discharge is an important, if imperfect, proxy for quality of care. Factors contributing to readmission are well documented (2–5), yet successful interventions to decrease readmissions have been slow to take shape (6–9). To effectively develop and incorporate evidence-based interventions to reduce 30-day psychiatric readmissions into large, geographically diverse inpatient systems; there is a need to conduct in-depth implementation analyses to better understand the relationship between patient-, hospital-, health system-, and community-level factors and their net impact on readmissions. This research addresses this need. METHODS: Using a modified Consolidated Framework for Implementation Research (CFIR), two state-based case studies were conducted within a large U.S. hospital system. Two hospitals per state were selected-- one with a high and one with a lower readmission rate. We conducted document reviews and semi-structured interviews (N=52) with corporate, clinical and community stakeholders, using the CFIR to identify key themes within each construct. We scored and compared hospitals with lower vs. higher readmission rates. An analysis of EMR data from the hospital system contextualized case study findings. RESULTS: In one state a complex interplay of factors at all levels contributed to readmission rates in both hospitals. In the second, constructs within the inner hospital setting contribute to differences in hospital readmission rates. Facilities with high readmission rates scored lowest among CFIR constructs “Patient Needs and Resources in the Community” and “External Policies and Incentives.” CONCLUSIONS: Ours is the first known study to explore a broad range of factors that influence readmission rates among patients with serious mental illness and a range of comorbidities. Findings from two state-based case studies indicate that readmission rates are determined by multiple, interrelated factors which vary in importance based on hospital and community context and political environment. To be effective, systemic interventions to reduce readmissions must be tailored to the specific context at targeted hospitals.

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No description available.

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A particularly unhealthy and high-risk group of individuals at the intersection of the criminal justice and public health systems often cycle between arrest, jail, prison, public hospitals, emergency departments, homeless shelters, and similar institutions over time. This population, while relatively small, represents disproportionate public spending and complex, multidimensional needs. The overarching goal of the current study is to gain a deeper understanding of the patterns and dimensions of frequent cross-system involvement, or repeat cycling between the criminal justice and public health systems. Specifically, the overlap of arrest by police and contact with the ED was examined. A secondary goal was to illuminate what factors work together to encourage or differentiate between various patterns of cross-system cycling. Group-based trajectory modeling was used to determine patterns of arrest and ED contact among adults that accessed these systems in Camden, NJ between 2010 and 2014. These groups were then brought together to determine patterns of cross-system involvement with a focus on patterns representative of frequent cycling between arrest and the ED. These joint groups were then described in detail using descriptive and predictive methods. By comparing across different patterns of frequent cycling, it is clear that cross-system involved individual do not represent a homogenous group; nor is mental illness and substance abuse the only factors driving this overlap. The most frequent joint trajectory groups exhibited significantly more ED visits to address injuries including skull-related injuries, chronic physical health conditions, dental and skin issues, anxiety, depression, suicide attempts, substance abuse and co- and multimorbidity measured as chronic conditions experienced with behavioral health concerns and drug/alcohol abuse. Arrests for disorderly, drug and prostitution offenses were also significantly more prevalent among frequent cross-system cyclers when compared to groups with fewer system contacts. Many of these same factors were also more prevalent among a subsample of young adults aged 18 in 2010 with repeat contacts with both systems. These steps, together with qualitative interviews with service providers in the Camden community, illuminated important factors associated with more frequent arrest and ED contact. These are important contributions to criminological research as discussion is often restricted to behavioral health and is less often concerned with physical health, co- and multi-morbidity. This is also among the first research studies to dig deeper into specific diagnoses associated with frequent arrest and frequent cross-system cycling, among adults and young adults. Healthcare provider interviews were able to confirm that certain issues like dental and skin conditions, depression, anxiety and suicide attempts/ideation tend to increase in prevalence as system contacts accumulate. These are factors that could be targeted earlier in the lifecourse in order to reduce cross-system cycling – an important form of concentrated disadvantage and vulnerability on which to focus attention and resources. / Criminal Justice

Doctor of Philosophy / Department of Horticulture, Forestry, and Recreation Resources / Richard H. Mattson / Subjects of this research were 64 adolescents receiving treatment at two behavioral health service institutions located in an urban mid-western city. Both institutions provided horticultural therapy and non-horticultural therapy programs. Research subjects were adolescents with diverse treatment needs and their responses on research questions were inconsistent compared to other related studies with general population. Current research assessed the adolescents with horticultural therapy treatment and without horticultural therapy treatment in three aspects. First, the levels of psychological aspects of adolescents were assessed with the Rosenberg Self-Esteem Scale and Nowicki-Strickland Locus of Control Scale for Children. The levels of self-esteem and locus of control of adolescents with horticultural therapy treatment were not significantly different from those of adolescents without horticultural therapy treatment at both institutions. Based on the different level of worthiness and competence factors, it is recommended to design horticultural therapy programs focused on improving the worthiness factor of self-esteem. Second, the pastoralism disposition of the Children's Environmental Response Inventory was used to assess the level of environmental attitude of the adolescents with and without horticultural therapy treatment. Horticultural experience and environmental attitude had a positive relationship with most subjects. At one institution, the level of environmental attitude of the adolescents with horticultural therapy treatment was significantly higher than the adolescents without horticultural therapy treatment. The adolescents at the horticultural therapy program which was scheduled more frequently showed higher environmental attitude scores. To improve environmental attitude of adolescents, horticultural therapy program should provide diversity and abundant opportunities of horticultural experiences. Third, basic horticultural knowledge was tested with the Basic Horticultural Knowledge Questionnaire. Vegetable/fruit consumption and preference were described with the Vegetable and Fruit Preference and Consumption Survey. Basic horticultural knowledge scores of the horticultural therapy group were significantly higher than that of the non-horticultural therapy group at one institution, but the scores were similar between the two groups at the other institution. Basic horticultural knowledge of subjects was significantly correlated to their vegetable and fruit consumption. To increase vegetable/fruit consumption, horticultural therapy programs should set goals to incorporate nutrition education.

Recent research shows that 7.7% of individuals who use indoor tanning beds do so in private homes,1 but little is known about this group. This study evaluated the tanning practices, reasons for tanning, and association with tanning addiction of adults who use tanning beds in private residences.

The objective of this study was to compare the accuracy of self-reported skin cancer risk outcome measures proposed as standards by prevention experts to aggregated estimates of behavior from weekly diaries. Weekly electronic diaries of ultraviolet radiation (UVR) behaviors, initially validated by comparison with daily electronic diaries, were used to assess the accuracy of commonly used end-of-summer self-reported measures among 250 adults. Results revealed low biases, and good correspondence between simple open-ended self-reported estimates of days outside, hours outside, sunbathing days and hours, and days outside when not protected by either sunscreen, long-sleeved shirts, hats, or shade. Rating scale measures commonly used in the current literature and those recently recommended as standards by a workshop of experts showed evidence of being non-interval and lacking precision for more frequent behavior (e.g., >1 h sun exposure daily). These data indicated that open-ended frequency self-reports of skin cancer risk behaviors that follow procedures designed to increase accuracy were reliable over a summer-long period.