More than 2.2 million deaths occur worldwide each year due to diarrheal disease, mostly in children under five years of age, making it a problem of great public health significance. In developing countries, improving water at the household or point-of-use level has decreased the spread of diarrhea-related illnesses more than treatment of water at the source. Additionally, improving the quality of water has been shown to be as important in interrupting disease transmission pathways as increasing the quantity of water and improving general sanitation. Therefore, new technologies are being promoted for use in developing countries as low-cost methods of disease prevention. The current paper reviews interventions designed for water improvement at the household level, paying particular attention to related reductions in diarrhea as a primary disease outcome. Once shown to be effective at reducing disease in field or laboratory trials, the technology must then be promoted among and accepted by its intended users. Drawing upon the principles of community based participatory research, a framework is given for health professionals wishing to implement any novel technology or water quality intervention in a community setting.

Public health has moved away from its original mission to address and promote health on a societal level towards an individually focused, victim-blaming paradigm. In particular, research regarding womens reproductive health is heavily reliant on the biomedical paradigm to document and explain existing health trends related to womens fertility. This research often targets behavior in isolation of its social context. In order to promote the integration of a population health perspective into the current medically dominated realm of womens reproductive health, this dissertation highlights the issue of unintended pregnancy (UIP). The United States (US) continues to have the highest rate of UIP of all industrialized countries. These UIPs, and their negative health consequences, are disproportionately experienced in the high-risk populations of low-income, young and minority women. In efforts to foster greater understanding of UIP and of these disparities, this dissertation encompasses three distinct manuscripts. Based on a review of public health and womens health literature, the first manuscript argues for the adoption of a broadened perspective that focuses on external factors that impact womens reproductive behavior. Manuscript 2 discusses the first component of a mixed-methods research study involving surveys of women at high-risk for UIP who sought pregnancy tests in Pittsburgh, which reveal that assessing womens pregnancy intentions prior to pregnancy testing is feasible and may provide a more accurate portrayal of womens intentions to become pregnant than existing retrospective measures. The third manuscript, which highlights qualitative interviews with ten women from the above sample, presents evidence for the influence of external factors on womens experience of UIP. This dissertation challenges current individually focused paradigms for understanding UIP among US women. The public health significance of this dissertation lies in the findings of the research presented, which demonstrate that a reciprocal relationship exists between the social context of womens lives and their UIP experiences and which emphasize the need to broaden the perspective of current UIP research. Future research, programs, and policy should integrate the perspective and findings highlighted in this dissertation in order to reduce negative health consequences of UIP and promote population-level healthy pregnancy outcomes.

The purpose of this thesis is to propose the use of a program planning model that will address the lack of respite care, or in other words, the lack of a specific place for recuperation after an illness or injury available for homeless people in Allegheny County. This proposal will incorporate a program planning design of a potential respite program in Allegheny County. This respite care intervention is designed to be part of a county wide effort to eliminate homelessness in Allegheny County led by the Allegheny County Homeless Alliance. This proposal will incorporate the Mobilizing for Action through Planning and Partnerships (MAPP) program model for the intervention design. This is a six-phase process that emphasizes community collaboration and assessment as the driving forces for the creation of an intervention. The six phases of the MAPP model are 1) Organizing for Success/Partnership Development; 2) Visioning; 3) The Four MAPP Assessments; 4) Identify Strategic Issues; 5) Formulate Goals and Strategies; 6) The Action Cycle. This proposal will describe how the Allegheny County Homeless Alliance can conduct the phases of the MAPP model using information previously collected as well as ways they can obtain additional information. The proposal will describe a respite care intervention that is an example of a possible respite care program in Allegheny County. The goals of the program are to improve the health of the homeless as well as to create social support for this population and an opportunity to transition into permanent housing. The public health significance of this proposal is that it will create an intervention for the homeless population of Allegheny County that will allow them to achieve better health status through respite and follow-up care, greater social support and, most importantly, the opportunity to obtain permanent housing in a more direct way than what is the norm.

BACKGROUND: Social marginalization and homophobia often foster the production of syndemics and health disparities among MSM populations. Despite findings of the overlap between intimate partner violence (IPV) and HIV in various other populations, research among gay and bisexual men(GBM) and MSM continues to be limited. The small set of literature that does exist suggests excess burden of disease in MSM populations, thereby revealing the public health importance of this problem. A systematic literature review was conducted with the primary objectives of synthesizing relevant literature addressing the intersection of HIV and IPV among MSM, summarizing and critiquing this existing set of published literature, and discussing the implications for future research and practice. METHODS: A comprehensive literature search of HIV and IPV among MSM and/or GBM resulted in the synthesis of 19 studies in the U.S.. Articles were considered for full review if they met with previously established inclusion criteria. The final set of literature was analyzed for general content and for matters related to research design and methodology. RESULTS: Overall, rates of MSM-specific IPV ranged from 12% to 56%. Findings indicated that partner abuse is associated with risky sexual behavior, thereby placing MSM and GBM at greater risk for HIV. Also, prevalence of various forms of IPV among HIV positive persons was revealed. Age, race, and childhood abuse were identified as correlates in the intersection of these two epidemics. In addition, several studies also noted the co-occurrence of substance abuse, partner violence, and HIV as a trend among MSM. CONCLUSION: Several recommendations are made to strengthen the newly emerging arena of HIV and IPV syndemic research. Suggestions for policy and practice are also discussed in light of these dual epidemics found among MSM. Sound research design, measurement, and community-based participatory approaches are ultimately required for the development of MSM-specific interventions and prevention programs that tackle and stunt these mutually reinforcing epidemics.

Community health workers (CHWs) are community natural helpers who serve as bridges between the health care system and their community, empowering individuals through access to information and social support that, in turn, enhances access to primary health services. This qualitative study sought to determine whether implementing a CHW program at a local healthcare provider, would be a feasible and desirable solution to address the unique health needs of immigrants and refugees living in Pittsburgh, PA. The study identifies the public health significance of community health workers as a means to improve immigrants and refugees access to health services, enhance understanding of community needs and assets and increase community participation in defining appropriate solutions. This study conducted open-ended interviews with key staff from twelve agencies serving immigrants and refugees. Four national providers with established CHW programs participated in the study as well as key staff from eight Pittsburgh-based providers. While national providers gave insights into CHW logistics, local providers assessed their organizational capacity in responding to immigrant and refugee needs and stated their interest in CHW programming. The data was analyzed with qualitative data analysis tools. Study findings confirmed the positive impact of community-based advocacy efforts, such as CHW programs, resulting in stronger social networks and empowered immigrant and refugee community. However, CHW programs are resource-intensive initiatives that require continued community engagement in all stages of program planning and implementation as well as adequate compensation and professional development opportunities for CHWs. Pittsubrgh-based providers do not have the necessary resources of time, staff and funding to create their own CHW programs or to engage in collaborative community-based health advocacy programming. Although creating a CHW program might not be possible due to capacity constraints, Pittsburgh-based agencies should lay the groundwork for future community-based collaborations by engaging in information-sharing to learn from each others experiences. By involving communities in these conversations, and adopting a strengths-based approach that identifies organizational and community-based resources, such a collaboration will pave the way to an optimization of service provision that maximizes the use of available resources and engages the consumers in addressing their own health needs.

Background: Successful strategies for addressing inequalities in cancer care are greatly needed as critical racial/ethnic and socioeconomic cancer burden disparities persist in the United States. Patient navigation programs are a promising approach to reducing cancer care disparities. Methods: A mixed-methods evaluation was conducted to systematically collect, analyze and share information about the context, activities, and early impacts of the University of Pittsburgh Medical Center (UPMC) Cancer Centers Minority Outreach Pilot Program (MOPP), a newly implemented cancer patient navigator intervention. The dissertation applies and integrates two evaluation frameworks: 1) the Centers for Disease Control and Prevention (CDC) Framework for Program Evaluation, which provides an organizing structure and standards for conducting sound public health program evaluation, and 2) the RE-AIM framework, which helps to focus the evaluation on issues that are both relevant to stakeholders and critical to assessing the public health impact and generalizability of interventions. The evaluation employs a case study design that includes qualitative (e.g., program document review and informal and semi-structured interviews) and quantitative (e.g., descriptive statistical analysis of program database) methods to examine MOPP development and implementation. Results: The MOPP evaluation provided valuable qualitative and quantitative data related to program implementation achievements and challenges. Additionally, the evaluation produced useful products (e.g., logic model and data reporting templates) and led to immediate small-scale enhancements (e.g., database modifications). Results from the program evaluation suggest that MOPP is generally being implemented as planned. However, findings also called attention to key issues that should be monitored closely within the MOPP program, and, perhaps, within the larger patient navigation movement. These key issues include: the challenges of effectively navigating patients with substance abuse and the need to address the emotional burden of patient navigator work. Conclusion: The public health significance of the evaluation lies in its potential to strengthen MOPPs impact on reducing cancer care disparities in the UPMC patient population. In addition, publication of the evaluation research will contribute to the growing evidence base for cancer patient navigator interventions and address the need to develop the literature on patient navigation.

Sickle Cell Disease (SCD) is an inherited blood disorder that affects 80,000 individuals in the United States. SCD is of public health significance as individuals with this disease are at risk of early mortality, morbidity, and disability. These conditions arise as a result inadequate clinical treatment and improper self-care management, which are potentially modifiable with optimum disease management. The Theory of Self-Care Management for Sickle Cell Disease proposes that self-care management resources have the ability to improve poor health outcomes; however, previous studies indicate that individuals with SCD and their caregivers lack appropriate resources. Consequently, this study was designed to qualitatively assess where caregivers receive self-care management resources; determine what type(s) of information has already been acquired; learn about the type(s) of self-care management resources that intended audiences need; and explore the most appropriate media and channels to disseminate self-care management resources. A focus group was conducted with ten caregivers of children with SCD to facilitate a discussion to address these specific questions. Transcripts were analyzed using the questions from the moderators guide to generate a table to identify themes that emerged throughout the discussion. Results revealed that caregivers primarily relied on routine services to provide self-care management resources and sickle cell educational information was found to be the only self-care management resource provided. This resource provided basic information, causing caregivers to seek additional information from alternative sources like the internet and by asking questions. Caregivers did not acknowledge receiving additional resources, nor did they report receiving self-care management resources for their children. Caregivers acknowledged the importance of these resources and suggested that they be disseminated through all available media by obstetrician/gynecologists offices and schools to caregivers based on their individual preferences for receiving the resources all at once or in stages. Furthermore, the caregivers began acknowledging that it may be their responsibility to provide information and education to their communities. Consequently, additional self-care management resources should be created by other caregivers and peers based on their experiences. Further research should be conducted to develop and pretest these self-care management resources and to determine their impact on health outcomes.

The number of individuals with mental illness in the criminal justice system is increasing. These individuals are the most vulnerable and disadvantaged in the public mental health system, yet little national data are available regarding their characteristics and experiences. Upon release from jail or prison, they face barriers to successful transition into the community. Mentally ill offenders can access mental health and addiction services and income support to pay for housing, food, and other necessities through federal entitlement programs. Many jail and prison inmates with mental illness either lose or are never connected with federal entitlements. It follows that without benefits, these individuals face the same challenges that are likely to have contributed to their original arrest. Connecting these individuals with services and support in the community can enhance their health and safety, and the health and safety of the public; hence this issue is of particular public health importance. This paper reviews the literature to explore the following questions: (1) Are individuals with mental illness who receive federal benefits upon release from jail more likely to seek and continue care than those who do not? And (2) what are the consequences of not continuing care for individuals with mental illness upon release from jail? Many policy organizations have released publications in recent years, highlighting the importance of having federal benefits and maintaining these during incarceration to enhance the likelihood of receiving care once released. A review of the academic literature reveals that there are major gaps in our knowledge and that there is little to substantiate the hypothesis that having federal benefits increases the likelihood of receiving services in the community. There is a need for data-based empirical studies, yet conducting these may be difficult. This issue is complex and it is likely that federal benefit enrollment is only one component of the problem and that facilitating enrollment will not necessarily enhance care. Programs that use an integrated approach to connect these individuals with community-based services are recommended.

Background: Parental sex communication and parental monitoring are associated with reduced adverse adolescent sexual health outcomes. Little is known about cultural nuances of these parenting skills within the African American community. Also, few studies have examined how non-parent adults function as sex educators and monitors of adolescent activity. Objective: To examine the process, barriers, and facilitators of sex education and monitoring by adults within African American adolescents social networks as part of a larger study to develop a parent-targeted intervention to improve these parenting skills. Methods: We conducted 21 focus groups between December 2007- March 2008 with African American parents from Allegheny County Pennsylvania and their adolescents aged 15-17. Participants were recruited through community organizations, health centers and media advertisements. We used a directed approach to content analysis. Results: Parents felt community monitoring of children occurs less than when they were children. Parents expressed the need for more communication between parents and members of their childrens social networks regarding the monitoring of their adolescents. Mothers often act as confidants for their children's friends but struggle over whether to disclose information revealed during these discussions to another child's parents. Fathers advise and role model expected social and sexual behaviors to their children and their friends informally as the children are hanging out. Parents work together using parent networks to monitor youth in the community. Conclusions: African American parents feel their communities and social networks could play a greater role in monitoring children's social and sexual development. Parent-targeted interventions should be tailored to address the different styles mothers and fathers use to communicate with and monitor their children. Public Health Significance: Further understanding of how non-parent adults within the African American community influence adolescent sexual behavior will enable public health professionals to appropriately incorporate non-parent adults into intervention design, therefore increasing the likelihood of decreasing adverse sexual health outcomes among African American adolescents.

Alcohol abuse has been described as the biggest health problem on college campuses today. This single statement illustrates the public health relevance of addressing college student alcohol use. College student alcohol use affects everyone on a college campus, not only the student who uses or abuses alcohol. The author of this paper is currently an employee of the University of Pittsburgh's Student Health Services. As a graduate student assistant, she has facilitated the Personal Education Assistance and Referral (PEAR) program to over 250 students. The goals of this paper are to provide an understanding of background information surrounding college student alcohol use, to critically examine three major reports and two ongoing studies and to specifically elaborate on the goals created by the Surgeon Generals Call to Action to Prevent and Reduce Underage Drinking. This paper concludes with recommendations consisting of prevention and intervention strategies as well as environmental changes that are evidence-based.