INTRO: In Tobago, HIV rates continue to increase (prevalence rate =5%). Women and youth are increasingly being infected, and heterosexual transmission accounts for most HIV infections. If these trends continue, Tobago's economic and social structure will be in jeopardy. This study has public health significance because it identifies and makes recommendations for incorporating relevant social and cultural factors into HIV prevention programs in Tobago. METHODS: Qualitative methods (participant observations, ethnographic and in-depth interviews) were utilized to unearth (a) pre- and post-HIV infection experiences of People Living With HIV/AIDS (PLWHAs), (b) relevant cultural and social 'influencer' of HIV/AIDS rates, (c) how these factors influence community norms and individual behavior, and (d) appropriate methods/model for incorporating relevant factors into HIV/AIDS prevention programs. PLWHAs, health professionals, community members and leaders were interviewed. RESULTS: 14 PLWHAs, 10 health professionals, 15 community leaders and 25 community members were interviewed. Participant observations occurred in homes, businesses, entertainment events, HIV-related organizations and health facilities. 206 PLWHAs are currently being treated in Tobago (HIV-related medications free to Trinidad and Tobago citizens). Infidelity, sex-in-exchange for resources, abuse and economic need increased PLWHAs' HIV risk. Lack of confidentiality is an issue, and stigma and discrimination are prevalent. There is lack of information about the causes, prevention and treatment of HIV in the general population. Sex is not openly discussed, however youth sexual behavior is common. Serial monogamy coupled with multiple sexual partnering increases general community risk. Consistent and correct condom use is not common, and purchasing or requesting condom use is difficult for women, youth, and married individuals. HIV testing is not common, and pre- and post-test counseling is inadequate. Current HIV prevention programs focus on abstaining, being faithful and using condoms, which do not take into account the complexities surrounding sexual decision making. There is a need for comprehensive HIV prevention programs. RECOMMENDATIONS: A client-centered, risk-reduction model of HIV prevention is recommended. Using the socio-cultural theory of learning, this study highlights the zone of proximal development, the knowledge-in-waiting, knowledge-in-use, agents of change, needed resources, and social environment needed to improve HIV prevention strategies in Tobago.

The United States has an increasing rate of homelessness due to unemployment, an absence or low availability of affordable housing, high rates of mental illness, and physical ailments that prevent productive employment. Due to economics, these homeless tend to only receive medical care through the emergency department (ED). Since the ED is not equipped to handle social issues such as housing, these individuals are often discharged directly onto the street or to shelters. As a result, these inappropriate discharges increase re-hospitalization and poorer health outcomes among this population. The purpose of our study is to explore the issue of hospitals discharging patients to emergency homeless shelters in Allegheny County. Researchers sent mailings to all of the 16 emergency homeless shelters in Allegheny County for recruitment. As a result, 22 shelter administrators and staffs from 12 of the 16 shelters (response rate=75%) participated in a face-to-face, semi-structured interview conducted at their facility. Participants shared the number of discharges they received from hospitals in the past 12 months, the appropriateness of these discharges, and possible solutions to the problem of "inappropriate discharges." Shelter administrators reported receiving 415 discharges from hospitals; they deemed 91 (22%) of the discharges as inappropriate, meaning the patients needs exceeded the resources of the shelter. Even though a majority of participants reported that their shelter was equipped to handle the medical/psychiatric care of their population, their facilities lacked the means to treat those who needed extensive medical and/or psychiatric care. To address this issue of inappropriate discharges, participants suggested that better communication between hospitals and shelters as well as the development of a medical/psychiatric respite for the homeless population (50% of participants stressed the former and 32% the latter) would alleviate this problem. Shelters, aware that this issue is a multi-faceted one, recognize the need for multiple interventions at the individual, community, and government levels to successfully combat this problem. This is a significant public health problem because by addressing the medical and psychiatric needs of the homeless population both prior to and after hospital discharge may eventually reduce re-hospitalizations and improve the health outcomes of this population.

Few studies have been carried out that examine the effects aging has on the health of older LGBT individuals. This is a matter that warrants further research, for approximately half a million gay men and lesbians turn fifty each year. As the number of aging LGBT persons grows, so does the need for competent clinical care that addresses the unique health and psychosocial issues of this population. It has been shown that discrimination against LGBT persons exists in the medical setting. Additionally, the literature suggests that medical students do not receive sufficient training regarding sexual minorities. Educating primary care physicians, medical students and other health professionals on how to communicate more effectively with aging LGBT patients can lead to improved health outcomes. This is a goal of public health. The IRB-approved study described in this thesis aimed to provide the Allegheny County Area Agency on Aging (A.C.A.A.A.) with information about the health and psychosocial issues of older ( ≥ 50) LGBT individuals living in the Pittsburgh area. Over a two-month period in 2006, a comprehensive survey was dissemintated at a variety of locations frequented by LGBT persons. The survey included questions about demographics, quality of received health care, openess about sexual orientation with one’s primary care physician, end-of-life and legal issues, and questions that addressed pertinent LGBT health and psychosocial issues. Results of the survey indicated that the majority of the sample’s respondents (N=79) reported being in good health, receiving competent health care from primary care physicians, being open with their doctors about sexual orientation, and experiencing minimal discrimination from health care providers due to sexual orientation. These positive findings differ from the somewhat discouraging information presented in the literature review. Despite this, the survey results may inspire more rigorous studies to be carried out in the future that address the health and psychosocial issues of older LGBT persons. Further studies may also bring about positive changes in medical schools’ curricula, not to mention changes in public health policies that address the nations aging population as a whole.

Community Based Participatory Research (CBPR) is becoming popular in the field of public health. While many studies focus on including adults in the CBPR process, far fewer have utilized the input and expertise of children and adolescents. Successful CBPR projects are important to the field of public health due to their ability to open the doorway to the health needs and experiences of youth. This review paper first provides relevant background information regarding the health of youth living in the United States, the importance of adopting a life course approach to public health interventions, and the field of Community Based Participatory Research. It then explains the review methodology utilized and presents the results of the literature review. Specific attention is paid to summarizing CBPR work conducted with youth and the key issues related to such work. This review concludes by providing suggestions for future successful applications of CBPR with youth populations, and discusses the benefits and challenges of conducting this type of research. Results from this review contribute to a better understanding of the importance of utilizing ideas and insights of young people in order to create programming and policy changes that effectively address their needs.

Substance abuse is related to many other health problems, thus making the topic of great public health significance. The scope of this study is the results of focus groups conducted with physicians across the state of Pennsylvania; specifically Harrisburg, Pittsburgh, and Philadelphia. The purpose was to ascertain the barriers to identifying problem alcohol and drug use in patients by practicing physicians. Physicians statewide acknowledged key barriers to screening; time, access to treatment and financial reasons, both patient financial issues or problems and reimbursement from insurers or commercial payers. Additional barriers that were identified as a result of the focus groups included stigmatizing attitude toward substance use, physicians lack of self-efficacy in managing substance use disorders, and lack of knowledge in this area, among others. The study discusses the results of the focus groups and explores the education that could be offered to physicians in order to increase their knowledge in the area of screening and the identification of problem drug or alcohol use.

BACKGROUND: The Latino population of greater Pittsburgh is considered invisible because it is not concentrated within one geographic area. This is of great public health significance, because such dispersion is a major barrier for Latinos seeking quality health care and social services. In the last ten years, this population has grown over 44%, and many of the estimated 20,000 Latinos in the Pittsburgh area do not have medical insurance. Across the nation, research has shown that Latinos often suffer from higher incidence of diseases and accidental deaths. Latinos also frequently experience limited access to health care and social services, and the level of social integration experienced by population members is directly related to this diverse communitys quality of life. METHODS: This study is based on qualitative interviews with a small, purposive sample of young adult Hispanic immigrants, a group likely to experience barriers to accessing services. A free clinic, staffed by bilingual volunteers, was the initial access point to reach uninsured population members. Interviews with participants were recorded, transcribed, and studied to discover which health care and social service needs the community feels they lack, and how their level of social integration was related to their access to services. RESULTS: The most frequently mentioned service needs were dental services, health insurance, bilingual health service providers and/or translation services, and English language classes. Social isolation, lack of legal documentation, fear, racial discrimination, and lack of cultural competence on behalf of institutional employees were frequently cited as major barriers to accessing services. The length of respondents stay in Pittsburgh did not appear to have a significant effect on improving respondents access to needed services. Access to services was related more to the size and extent of ones social network, which usually consisted of family members who had lived in Pittsburgh before the respondent arrived, or which grew slowly over the time the respondent lived in Pittsburgh. CONCLUSIONS: Pittsburghs Latino population would benefit from increased outreach efforts and increased community mobilization strategies. As a new growth community, Pittsburgh service providers are not fully prepared to reach the needs of the population. Additional research, qualitative in nature, will help to increase awareness and understanding of the challenges faced by this community as it seeks to access much needed services and health care.

Minorities suffer disproportionately from tobacco smoke-related morbidity and mortality nationwide. Tobacco-related illnesses are responsible for approximately 47,000 deaths of African Americans annually. Furthermore, greater tobacco- related health disparities exist among African American women in the state of Pennsylvania and the city of Pittsburgh; as the local and state maternal smoke rates exceed the national average. Additionally, low birth weight and infant mortality rates linked to maternal smoking has been disproportionately elevated among African American women in this geographical area. African American mothers who quit smoking generally have higher relapse rates than their Caucasian counterparts. Research limitations in understanding the smoking cessation, self- quitting and relapse prevention among African American women particularly in Pittsburgh, PA; serves as a foundation for this study. Thus, two focus groups were conducted with a sample of 13 African American maternal smokers in the Pittsburgh area to assess their smoking and quitting experiences as well as their unmet needs for cessation treatment. A brief survey was administered to ascertain the participants socio demographic characteristics. The data collected mirror previous research as nicotine addiction, stress and poor social surroundings act as barriers to successful quitting. The women identified willpower as the key to permanent smoking cessation but lack the self-efficacy to quit. Recommendations for advanced investigations and cessation programs for this population are provided. The findings from this exploratory study are significant to public health research as they provide a guide for future research and offer valuable insight for modifying and creating effective smoking cessation interventions for African American women; which can produce long term effects by decreasing the maternal smoking rate disparity in Pittsburgh, Pennsylvania.

Background: Over the past two decades, obesity among women has significantly increased, with women having the highest prevalence in the United States. Obesity prevention programs and interventions focusing on women have traditionally included individual-level approaches although obesity is a multi-level problem. The research literature has cited numerous factors that contribute to obesitybehavioral, personal, psychological, sociodemographic, environmental, biological, and childbearing. As a result, recent public health efforts have shifted away from individual approaches to those that handle multiple factors. Methods: While multiple factors have been associated with obesity among women, the degree and variability of the factors have not been determined in the literature. These three studies seek to explore the effects of the multiple factors on BMI in U.S. women using the International Classification of Functioning, Disability and Health (ICF) Core Sets for Obesity, developed by the World Health Organization and data from the National Health and Nutrition Examination Survey (NHANES). Linear regression was used in the analyses. Results: Significant factors of obesity were sociodemographic information (age, income, and race), body weight perceptions, coexisting health conditions, physical functioning, and engaging in physical activity and proper nutritional practices. Conclusions: Obesity prevention and treatment programs for U.S. women should focus on the most significant factors identified in these studies to decrease obesity incidence and prevalence. Public Health Relevance: The information garnered from this study can be used to further identify the most important characteristics needed for future obesity prevention programs for women.

This thesis describes and assesses existing services for homeless persons with mental illness and suggests improvements. The topic of services for homeless persons with mental illness is of public health significance since the problem has been getting worse in the past few years, with people unable or unwilling to access appropriate services Mental illness in the homeless population is looked at from a social-ecological perspective, including individual, community and policy levels. Current national programs are discussed including Medicaid, SSI, HUD, SAMHSA and ACT. The McKinney Act is discussed as one of the most important pieces of homeless policy. A more in-depth discussion of Allegheny County community capacity and services for homeless persons with mental illness is included. Housing First/Harm reduction, Operation Safety Net, Community Human Services Corporation, Health Care for the Homeless, Mental Health Courts and Police Training are discussed. Key informant interviews reveal frustrations with funding streams, lack of affordable housing and lack of appropriate job opportunities, specific to Allegheny County. An extension of this thesis to include focus groups and interviews with homeless individuals and shelter staff would reveal a more comprehensive view of homeless persons with mental illness. Suggestions for improvements in providing mental health services include, following the housing first/harm reduction model, improving quality of life through increased social supports of this population, advocacy of homeless persons with mental illness, an increase of funding streams that promote collaboration among community agencies, more street outreach for the chronic homeless population and overall more collaboration among different agencies in Allegheny County including, government, social services, education, police and emergency services.

Amyotrophic lateral sclerosis (ALS), an incurable neuromuscular disease, causes progressive paralysis resulting in respiratory failure and ultimately death. Although there are only 30,000 people nationwide living with ALS, this population is of significant public health concern as those afflicted with ALS suffer from progressive symptoms of disability, making them a particularly vulnerable population in need of public health advocacy for improved access to medications and care. As the symptoms of disability become increasing acute in the final months of life, achieving the best quality of life possible is of paramount importance. To achieve this, a number of medications exist to both treat the direct and indirect symptoms of ALS. The purpose of this thesis is to examine barriers terminal ALS patients experience in accessing medications, medication trends as ALS patients near death, and the effect of medications on quality of life for ALS patients in the terminal phase of the disease. Literature pertaining to the terminal phase of ALS was reviewed and an analysis of secondary data was performed. The data analyzed for this thesis was from the National Institute of Mental Health grant funded Living with ALS study, which collected medication data in the preceding months before death from terminal ALS patients. For the purposes of this analysis, patient medications were categorized into four domains: ALS treatment medications, palliative medications, mood medications, and other medications. The correlation between the medication domains and sociodemographic and quality of life indicators were investigated. Changes in medications over time were also investigated. Results of the analysis revealed that those with higher incomes and educational attainment were taking significantly fewer palliative medications. Additionally, those on Medicaid were on significantly fewer other medications. Finally, across all medication domains, medication use declined significantly as patients approached imminent death. These findings suggest that the medications used to treat the symptoms of ALS do little to improve symptoms and even less to improve quality of life. Future research recommendations include exploring patients motivations for discontinuing medications, improving symptom management medications, and improving ALS patients access to both pharmacological and non-pharmacological interventions to improve overall quality of life.