The predominately rural state of Mississippi responded to high teenage pregnancy rates by enacting a 2011 law requiring school districts to choose between an abstinence-only and an abstinence-plus program for their high schools. However, there is limited extant research on Mississippi's sex education policies, creating a research gap that inhibits developing successful programs to reduce teenage pregnancy rates. There is specifically a need to compare the two types of allowed programs with a focus on rural areas. This study compared programs by examining students' abstinent sexual attitudes, social norms, self-efficacy, sexual abstinence behaviors, and perceived effectiveness of sexual education and decision making to address whether those variables differed by program and if programs and genders interacted. The study was informed by the health belief model, social cognitive theory, and the theory of reasoned action. The study collected data from 366 students who had taken one of the two programs completed 4 surveys: a demographic survey, the Sexual Risk Behavioral Belief and Self-Efficacy scale, the Sexual Abstinence scale, and the Effectiveness of Sexual Education scale. Students who completed the abstinence-plus program had higher levels of abstinent sexual attitudes, abstinent social norms, abstinent self-efficacy, and sexual decision-making self-efficacy when compared to students who completed the abstinence-only program, with a small effect size for abstinent social norms. Sexual abstinence behavior scores did not differ by program and programs and genders did not interact. Future studies should include a pretest and posttest evaluation. Analyzing these programs facilitates social change by informing the design of effective programs that focus on at-risk youth sexual behaviors.

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Pulmonary Arterial Hypertension (PAH) is a rare incurable condition affecting both the cardiac and respiratory systems. Patients living with PAH face the burden of both intensive medication regimens and debilitating disease symptoms. This study’s primary aim was to identify patients’ medication-taking behaviours and beliefs using a framework derived from the extended health belief model (EHBM), and to use this information to deliver personalised interventions to improve medication-taking behaviours. A mixed-methodology longitudinal study design recorded patients’ parameters over a 12-month period. Thirteen participants from Northern Ireland completed the study. The results showed that the level of high-adherence to PAH medicines, as assessed using the MARS questionnaire was 80%, but this value differed when assessed via pill counting and interview data. There was a trend to improvement in observed and predicted medication adherence over the study duration. Participants’ beliefs showed a non-statistical increase in the specific-necessity beliefs and a reduction in general-overuse belief. This study added to the EHBM new constructs of trust and support in being able to better predict nonadherent behaviours. Key medication-taking themes were self-confidence, perceived ranking of medicines, uncertainty and knowledge. This study developed important learning that can be applied to future research on behavioural health studies. / Heart Trust Fund; Actelion Pharmaceuticals

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Osteoporosis is a disease of the bone and skeletal system which weakens bone structure and results in fractures. The disease has caused a heavy economic burden in the U.S., especially among Americans over the age of 50. According to The Surgeon General's report on bone health in 2004 (U.S. Department of Health and Human Service (USDHHS), 2004), an estimated 10 million Americans over age 50 have osteoporosis, and another 34 million have osteopenia and are at risk of osteoporosis. The projected cost directly associated with osteoporosis is $34.0 billion in 2005 and will rise to more than $41.4 billion in 2025 (Vanness & Tosteson, 2005). Osteoporosis also results in serious and often devastating health problems for affected individuals (Riggs & Melton, 1995) because of the fractures it causes. Riggs and Melton (1995) estimated that each year 1.5 million people suffer an osteoporosis-related fracture. Unlike genetic risk factors that can be nearly impossible to modify, living on a calcium-rich diet is a lifestyle choice. Effective intervention programs can be useful tools to educate people to adopt a calcium-rich diet. Studies have shown that a calcium-rich diet can increase bone mineral density and intervention programs can facilitate the process of the lifestyle change (Wong, Lau, E.M., Lau, W.W., & Lynn, 2004; Lv & Brown, 2011). However, effective intervention programs against osteoporosis are limited for minorities, and specifically, for elderly Chinese women. The prevalence of osteoporosis in Chinese women is high but the knowledge level is low (Babbar et al., 2006; Lau, Woo, Leung, Swaminathan, & Leung, 1992), which provides an opportunity for intervention. A community-based intervention program was designed based on the modified health belief model (HBM). Its content was specifically tailored to the cultural background and the characteristics of the Chinese women living in the Greater Philadelphia area, based on the findings from previous studies. The intervention program was implemented and its effectiveness was evaluated in a 2-group quasi-experimental study. The study recruited eight (8) Chinese community organizations and assigned them to receive either the intervention program or the control program according to the timing of their agreement to participate and the balance of total participants recruited for each study group at the time. A total of 102 Chinese women were enrolled from the three (3) organizations that were assigned to the Intervention Group and 90 from the five (5) organizations that were assigned to the Control Group. Participants in the Intervention Group received a 30-mintue education session delivered in Chinese (Mandarin). The education focused on the Health Belief Model constructs in the context of osteoporosis intervention. It provided information about osteoporosis, including the functions of the bones, prevalence and risk factors. It highlighted participants' susceptibility to osteoporosis, the consequences and severity of the disease, and targeted messages to increase self-efficacy and decrease barriers. The contents were tailored to the study population. The osteoporosis education was delivered in plain language to suit the population's low educational level and used examples relevant to their cultural background. Participants in the Control Group watched a 30-minute video about liver functions and hepatitis B transmission and prevention. The study tested three (3) primary hypotheses that, compared with the Control Group, the Intervention Group at post-intervention would have 1) a higher knowledge level of osteoporosis, 2) a higher self-efficacy for adopting a calcium-rich diet, and 3) a higher intention level to consume more calcium-rich food items. The data were collected at three time points: baseline, post-intervention, and three months after the intervention. The scores of knowledge level and self-efficacy were analyzed by mixed linear regression models with adjustment of the baseline variables and accounted for the correlations among the participants from the same site. The intention stage was analyzed by a multinomial logistic regression model with adjustment of baseline intention stage and the baseline variables. The results for the study were consistent with all three primary hypotheses. The intervention program increased the knowledge level of osteoporosis and perceived self-efficacy in the Intervention Group. At post-intervention, the differences between the two study groups was 0.17 (95% CI: 0.02, 0.32; p-value<0.037) for the knowledge scores, and 0.34 (95% CI: 0.12, 0.56; p-value<0.001) for the self-efficacy scores. The results also suggested that the intervention program moved the participants in the Intervention Group to higher intention stages. The odds ratio (Intervention/Control Group) of being at a higher intention stage was 3.29 (95% CI: 1.23, 8.82; p-value=0.016). The study showed that the community-based and culturally tailored intervention program designed for the elderly Chinese women was effective. It increased the osteoporosis knowledge level and self-efficacy for adopting a calcium-rich diet and moved participants to a higher intention stage of consuming more calcium-rich food items. Additionally, the study showed that more than 50% of the participants had low bone mass. In conclusion, this intervention program reached a hard-to-reach population of elderly Chinese women and provided public health professionals a useful tool to work with. The high provalance of low bone mass in this population provided the public health agencies useful information to aid their decisions on resource allocation. / Public Health

The overall aim of this study was to investigate the knowledge, awareness and practices regarding TB at a selected gold mine in Tanzania in order to enhance the paucity of knowledge in this area of public health. The mining population is considered to be at high risk of tuberculosis infection and illness. However, there is little data available on the knowledge, awareness and practices in the mining population in Tanzania. A quantitative, descriptive study, using the Health Belief Model as the conceptual framework, was conducted among 100 workers in order to give a detailed description of the knowledge and awareness of tuberculosis. The study confirms the role of the media, particularly radio broadcasting, health workers, teachers, and the community in promoting information and education on TB. Fever as a symptom was a problem. The study area is a malaria endemic area where fever is the commonest presentation hence every fever is regarded as malaria. This complicated picking up and identifying other causes of fever. Despite feeling compassion for and wanting to help TB sufferers, most avoided them, which emphasised people’s general fear of TB. This indicated the general isolation and stigmatisation of TB sufferers. The findings highlighted the need for on-going education about TB and its treatment, especially early diagnosis and adherence to treatment. / Health Studies / M.A. (Public Health)

The purpose of the study was to explore factors that influenced safer sex practices in Malawi. A quantitative, explorative, descriptive study was conducted to determine why the prevalence of new HIV infections was still high in Malawi despite. Questionnaires were used to collect data. Sexually active men, women, boys and girls that participated in the Centre for Human Rights and Rehabilitation community awareness activities participated in this study. The study found that demographic, socio-economic and knowledge-related factors influence safer sex practices in Malawi. Various modifying factors played a role in influencing the individuals’ perception of susceptibility, severity, barriers and benefits of practising safer sex. The findings indicated that individuals generally had a broad knowledge of the spread and prevention of HIV. The Health Belief Model was used as theoretical framework for the study / Health Studies

This study investigated the implementation of the roll back malaria (RBM) programme at household and at health post levels and examined factors that negatively impact on malaria prevention and control activities. Quantitative, descriptive, analytic crosssectional research, guided by the conceptual framework of the Health Belief Model, was conducted. Structured interviews were conducted with 857 women (for the household survey in phase 1) and 53 health extension workers (HEWs) in phase 2 of the study, in nine malaria endemic districts of Sidama Zone, southern Ethiopia. Data were analysed using SPSS version 20. The study’s findings indicate that 53.3% (n=457) of the household respondents and 24.5% (n=13) of the HEWs had low levels of overall malaria-related knowledge. Household respondents aged 25-34 years, (p<0.01); regularly received malaria-related information, (p<0.001) and the less poor women (p<0.001) had good levels of knowledge. Of the households, 38.9% (n=333) reported poor RBM practices. Wealth, knowledge, perceived threat of malaria and perceived benefits of implementing malaria preventive measures were positively associated with good RBM practices. Indoor residual spraying (63.6%; 422 out of 664), consistent use of insecticide treated bed nets (51.6%; 368 out of 713), and environmental sanitation (38.6%; 331 out of 857) were the most commonly implemented malaria prevention strategies in the study area. Out of the 252 reported malaria cases, 53.6% (n=135) occurred among children under five years of age who also comprised 50.0% (n=16) of 32 reported malaria-related deaths. The RBM practices were poorly implemented in the study area despite malaria prevention and control efforts. Slow progress in behavioural changes among household members, lack of transportation services for referring malaria patients, lack of support given to HEWs and lack of feedback and supervision from higher level health care facilities were identified as potential challenges facing RBM implementation in the study area. Future efforts need to focus on effective behavioural changes based on intervention studies and regular monitoring of the RBM programme. The workloads of the HEWs should also be reconsidered and lay health educators should be used more effectively. Health posts should always have sufficient anti-malaria drugs and other resource such as rapid diagnostic kits. / Health Studies / D. Litt. et Phil. (Health Studies)

Rheumatoid arthritis (RA) is a chronic, progressive autoimmune disease causing inflammation of the synovium resulting in severe pain, joint disfigurement and disability as well as malaise, fatigue and a depressed immune system. Treatment consists of three broad phases; firstly, following diagnosis treatment is focussed on rapid reduction of pain and inflammation. Secondly, maintenance of quiescence is sought through medication. Finally, if disease activity remains high despite medication, escalation to anti-TNF α therapy is required to prevent permanent joint damage and disability. The primary course of treatment is prescription of disease modifying anti-rheumatic drugs (DMARDs) within 3 months of onset of symptoms. However, DMARDs can take 8-12 weeks to exhibit a noticeable benefit whereas unpleasant side effects can occur shortly after initiation. Also, DMARDs do not alleviate pain; therefore it is difficult for patients to attribute recovery to this medication. For these reasons, although it is imperative for future health and functioning to take DMARDs as prescribed, non-adherence is common at 30-50%. Non-adherence to treatment can be intentional, where a decision is made not to conform to the prescription, or unintentional which is often due to forgetting. To measure intentional non-adherence, a validated measure of adherence for rheumatoid arthritis was reduced through exploratory factor analysis from 19 items to 5 items by removing items that did not add to the explained variance of adherence. The CQR5 explained 53% of the variance in adherence and was shown to have a good fit to the data through confirmatory factor analysis. A discriminant function equation was generated that correctly identifies 88.5% of patients as high or low adherers and has high clinical utility due to the brevity for patients and unidimensionality for easy interpretation. The CQR5 was used throughout the programme of research to measure intentional non-adherence along with a separate measure of unintentional non-adherence. Four commonly used social cognition models of illness were measured in 227 RA patients to determine which had the best utility for predicting non-adherence to DMARDs. Patients were recruited to represent the three stages of illness including newly diagnosed, established on DMARD therapy and established with concurrent anti-TNF α therapy. Logistic regression analysis showed that the Self Regulatory Model best predicted intentional non-adherence as patients with perceptions of worse consequences of RA and longer disease duration were more likely to be highly adherent to DMARDs in cross-sectional analysis. In contrast, the Theory of Planned Behaviour better predicted patients who self-reported forgetting their DMARDs with patients with more confidence in being able to take their medications (Perceived Behavioural Control) being less likely to forget. 171 patients were successfully followed-up six months after baseline recruitment. The longitudinal results showed that the social cognition models differed for patients at different stages of the illness suggesting that their experience of living with rheumatoid arthritis influenced perceptions of their illness and medications. Newly diagnosed patients scored lower on factors measuring perceptions of disease chronicity and seriousness whereas patients that had escalated to anti-TNF α therapy scored higher on these factors. The newly diagnosed patients also showed more variability in the social cognition scores whereas the more established patients demonstrated stable models of illness. This supports Leventhal’s (1992) theory that illness representations will be regulated through integration of knowledge and experience of an illness. Structural equation modelling was used to establish the best predictors of intentional non-adherence at six month follow-up. In support of research in other chronic illnesses (Horne & Weinman, 2002; Niklas, Dunbar & Wild, 2010), the effect of perceptions of the consequences and chronicity of the illness on adherence are mediated by perceptions of the necessity of the medication. In addition, the impact of the emotional reaction to the illness on adherence to DMARDs is mediated by concerns about the medication. In addition, this study incorporated factors from the Theory of Planned Behaviour to explain medication adherence and found that the influence of friends and family impacts on the patient’s confidence to follow the prescription accurately which in turn as an effect on adherence to DMARDs. This large longitudinal study found that by combining factors from a number of social cognition models, it is possible to explain and predict intentional non-adherence and provides some evidence for best ways to intervene to improve adherence and prognosis. To provide a more comprehensive and clinically useful picture of non-adherence, a Cost of Illness study was carried which found that patients self-reporting low adherence to DMARDs also had significantly higher costs for this medication. This was caused by an increased incidence of Leflunamide prescribing for patients who often forget their medication and was maintained longitudinally. This association has not been previously reported in the literature and provides some evidence that non-adherence to DMARDs is having a concrete effect on the clinical management of patients. Finally, an SMS text message based reminder service designed to remind patients who self-report forgetting their medications was tested through a simulation study for the cost and likely benefit in health related quality of life using the health economic analysis of the longitudinal study and the results of a survey establishing the feasibility of implementing such a service in the rheumatology clinic. A sensitivity analysis testing the number of messages sent and the cost per message found that a reminder service for the sample of patients in this programme of research would cost between £1387.00 and £142.27 per year. This would equate to a cost per Quality Adjusted Life Year (QALY) gain of between £2889.58 and £296.40 by enabling patients to adhere more rigorously to their DMARD regimen. This programme of research is the first to test four commonly used social cognition models to predict adherence to DMARDs in a large, multi-centre longitudinal study of rheumatoid arthritis patients. Perceptions of the likely duration and consequences of the illness, as measured by the Illness Perceptions Questionnaire and the necessity of medications (measured by the Beliefs about Medications Questionnaire) along with self-efficacy (measured by the Theory of Planned Behaviour) explained 24% of the variance in intentional adherence over six months. The results show the importance of considering intentional and unintentional non-adherence separately as they appear to have different underlying mechanisms as well as patients in different phases of the illness as their experience influences their social cognition models of illness. A simple SMS based reminder service could act as a cue to action to reduce unintentional non-adherence whereas addressing issues surrounding maladaptive perceptions about the illness and the treatment could improve intentional non-adherence which has the potential to improve the prognosis and quality of life for patients as well as safe costs for the NHS.