Cardiovascular disease (CVD) is the leading cause of mortality among American women, and event rates are particularly high among African Americans. Recent technologies have facilitated early detection of subclinical vascular changes that precede clinical events. This research project examined the interrelationships of ethnicity, CVD risk factors, socioeconomic status (SES), and psychosocial health with these subclinical CVD changes among women. We examined data from the Study of Womens Health Across the Nation (SWAN) Heart Study (ns=303-536), a prospective epidemiological study of middle-aged African Americans and Caucasians. Coronary artery calcification (CAC), aortic calcification (AC), carotid artery intima-media thickness (IMT), and aortic pulse-wave velocity (PWV) were assessed at two visits, an average of 2.3 years apart. We examined ethnic differences in the associations of traditional CVD risk factors on PWV progression, or arterial stiffening. Systolic blood pressure (SBP) and waist circumference were associated with accelerated PWV progression. The effect of SBP was stronger among African Americans than among Caucasians, and LDL-C, diastolic blood pressure (DBP) and glucose levels were associated with PWV progression only among African Americans. African American women have poorer CVD outcomes but do not consistently have higher subclinical CVD in the literature. We speculated that SES partly explains relationships between ethnicity and subclinical CVD. Our findings indicated that low education was related to AC, after adjustment for ethnicity. African American ethnicity was associated with IMT and PWV after adjustment for education, but not income. A significant interaction between ethnicity and income suggested that low-income African American women were at greatest risk of presenting with high PWV. Finally, we observed that low educational attainment was associated with greater CAC progression among Caucasians but not African Americans. Financial strain partly mediated this relationship. Our findings suggest that certain CVD risk factors are more strongly related to progression among African Americans than among Caucasians. Furthermore, SES may explain some ethnic differences in the extent of subclinical CVD. Lastly, psychosocial indicators explain higher CAC progression among low-SES Caucasian women. This project has public health significance. Clarifying how biological and psychosocial factors contribute to subclinical CVD may reveal targets for prevention of clinical disease.

Maternal functioning in the year following childbirth has exacted inadequate attention in the research literature. The negative effects of postpartum depression on mother and child have been more extensively studied. This deficit in the area of maternal functioning research is of public health significance as functional status may be a more direct measure of deleterious effects on infant development than depression status. Functioning and factors associated with functioning during this critical time period for infant development has been primarily studied by a handful of researchers. Prior to the development of the Barkin Index of Maternal Functioning (BIMF), the Inventory of Functional Status After Childbirth (IFSAC) was the only instrument designed for the express purpose of measuring functional status. However, the IFSAC is less than ideal for measuring this important concept; its rigid definition of functional status makes it difficult for women to achieve full functional status. This precipitated the development of the BIMF. The BIMF was developed through qualitative methods. New mother focus group discussions provided much of the content (and the framework for a new definition of functional status) that is reflected in the BIMF. This method of survey development has many advantages and helps to ensure content validity and a patient-centered product. The BIMF was also critiqued by a panel of experts in relevant fields. This work resulted in a new 20-item self-report measure of maternal functioning. In an initial psychometric analysis, the BIMF exhibited good reliability (and validity), with a Cronbachs Alpha of 0.87. An analysis of factors related to maternal functioning (as measured by the BIMF) in a population of women who screened positive for depressive symptoms revealed an association of functioning with depression and atypical depression. Race and atypical depression were independently associated with the BIMF in a stepwise regression analysis. The BIMF and the Gratification Checklist were also significantly and positively correlated.

MRSA is a dominant hospital pathogen because of its increasing incidence, the cost of treatment, antibiotic resistance, limited antimicrobial armamentarium, and associated increased mortality. Determining risk factors for MRSA acquisition in hospital settings has important public health relevance for defining targets for infection control, reduction in mortality from hospital-acquired infections, and decreasing hospitalization costs. A retrospective matched case-control study was initiated to determine patient-associated risk factors for MRSA acquisition at the Presbyterian University Hospital. It was hypothesized that risk factors for MRSA acquisition could be identified and used to enhance or tailor infection control strategies. Cases and two matched controls were selected among patients admitted to high risk units where MRSA screening was routinely done from January 2001 to December 2008. Cases were subjects who acquired MRSA during hospitalization. Variables collected were potential patient-associated risk factors associated with MRSA acquisition among cases versus controls. The odds of exposure to potential risk factors for MRSA acquisition were compared between cases and controls, using matched univariate conditional logistic regression. A single multivariate conditional logistic regression model identifying patient-specific risk factors significantly associated with MRSA acquisition was generated. The final model included 15 independently significant variables. Seven factors were positively associated with MRSA acquisition: primary diagnosis of respiratory disease, digestive tract disease, or injury/trauma, any diagnosis of pneumonia, cerebrovascular/peripheral vascular disease, intracranial ventricular shunt procedure, and a high risk unit stay prior to index culture. Eight variables were protective and included two beta lactam antibiotic classes (penicillin and cephalosporin), rifamycin, daptomycin/linezolid, proton pump inhibitors, history of transplant, extracorporeal membrane oxygenation, and intravascular stenting/catheterization. As 3 of the 7 factors positively associated with MRSA acquisition were conditions present on admission, they were not modifiable. Of the remaining 4, pneumonia could potentially be reduced by maintaining high compliance with pneumococcal vaccine. Admission to a high risk unit in itself is not modifiable. Although ventricular shunting was a factor, the lack of association with many common bedside or interventional procedures performed in these high risk areas argues for intensified environmental control and strict sterile technique for all procedures performed on patients.

Diabetes self-care plays a vital role in achieving better diabetes outcomes. To enhance diabetes self-care, the strategies of goal setting and barrier identification are widely used to assist people in making behavior change. Depression is a common co-morbidity and a barrier to self-care in people with diabetes. The purpose of this study was to examine the effects of depression and antidepressant use on goal setting and barrier identification in patients with type 2 diabetes. In patients with type 2 diabetes enrolled in the American Association of Diabetes Educators (AADE) Outcomes System as part of their routine diabetes education, 778 patients were included into this analysis. Self-report depression, 7 self-identified behavior change goals, and 13 barriers to diabetes self-care were collected from the Diabetes Self-management Assessment Report Tool (D-SMART®); antidepressant use was determined from the Diabetes Educator Tool (D-ET®). Multiple linear regression was used for the number of goals and the number of barriers with controls for relevant covariates. Patients with and without depression had a similar number of self-identified behavior change goals (P = 0.47), whereas patients with depression had 1.01 barriers to diabetes self-care greater than those without depression (P = 0.0001). In the depressed subgroup, there was no significant difference between those with and without antidepressant use in the number of goals (model 3A, P = 0.18; model 3B, P = 0.35) and in the number of barriers (P = 0.99). Since depression was related to a greater number of barriers to self-care, depression screening is important in patients with diabetes. Although antidepressant use had no association with the number of goals or the number of barriers, antidepressants are still useful in treating depression in patients with diabetes. In addition, collaborative treatment should be integrated to provide maximal benefit to improve both diabetes and depression. These conclusions are of public health significance and can be used to develop behavior change strategies to improve diabetes self-care.

Schistosomiasis is a water-borne parasitic disease that affects most tropical regions. It is caused by infection with parasitic worms of the genus Schistosoma and poses a big public health threat to affected communities and individuals. More than 200 million people are infected worldwide, and 85 percent of the burden is concentrated in sub -Saharan Africa. It is important to recognize the risk factors which favor development of infection and to focus on countries which are at high risk. In this thesis, sub- Saharan African (SSA) countries with high prevalence of schistosomiasis infection (living in endemic areas) were identified. Risk factors were also identified and their association with schistosomiasis prevalence was assessed. The results indicate that high literacy rates are associated with low schistosomiasis infection rates. Such results are of great public health significance because neglected tropical diseases like schistosomiasis could be prevented by increasing literacy in at- risk populations.

Introduction: Occupational injury is recognized as a key attrition factor in nursing with musculoskeletal injury the most common cause. Nurses, nurse aides and orderly injury rates are consistently listed in the top ten US occupations in terms of total numbers of injuries with patient transfer a primary etiologic factor. Patient transfer education for trainees as well as employees remains inconsistent and non-standardized. Legislative and policy efforts have not been effective. Methods: Two methods are combined in this paper to approach the problem: hierarchical task analysis and a simulation educational intervention. Hierarchical task analysis has been used to solve industrial process problems for more than three decades and simulation education methods have been used in aviation since the 1920s. The hierarchical task analysis process is used to develop an optimal task set which was used to frame and implement a healthcare simulationtraining intervention. Results: Performance evaluation tools for patient transfer were developed based on the optimum task set. Transfer of simulation training outcomes to the clinical setting was demonstrated on pilot study intervention and control units. The program was implemented in a community hospital with sustained improvement in transfer skill and reduction of injury rates and lost work days. Conclusion: Because patient safety and improved outcomes are linked to adequate levels of nurse staffing, the public health implications of this project are significant. If nursing injury can be avoided using these methods then true progress can be made in arresting the injury epidemic with resultant reduction of nursing workforce losses with consequent healthcare system benefits.

Exposure to maternal pre- and postnatal depression (PPND) and anxiety (PPNA) symptoms have been linked to a number of adverse outcomes in children. This research used growth mixture modeling (GMM) to examine individual-level PPND and PPNA symptom patterns in a sample of women and adolescents participating in a longitudinal study of maternal health practices. These trajectory groups were then used as exposure states for offspring in a series of analyses that examined whether symptom trajectory exposure was associated with age of onset of any psychiatric illness, the risk for Major Depressive Disorder (MDD), or the risk of Conduct Disorder (CD). Finally, path analysis was used to identify potential mechanisms associated with trajectory exposure and psychiatric illness. The GMM analyses found distinct trajectories of PPND and PPNA symptoms. Two groups of stable PPND symptom patterns were identified: low and high. PPNA exposure had three stable symptom patterns: low, medium, and high. Examination of the co-occurrence of PPND and PPNA found that those in the high PPND trajectory were more likely to be in the medium or high PPNA symptom trajectories, compared to the low PPND individuals. PPND, PPNA, and co-occurring trajectory group exposure were not associated with age of onset of first psychiatric illness or with MDD. The risk of CD onset was not associated with PPND or co-occurring trajectory exposure. However, males exposed to medium and high PPNA trajectories were at an increased risk of CD compared to low PPNA exposed males. Females exposed to medium or high PPNA trajectories were at a decreased risk of CD, compared to their low PPNA counterparts. Results of the path analysis suggested a direct path from PPNA to CD risk, moderated by gender. Furthermore, PPNA exposure predicted higher levels of emotionality, which predicted higher CD risk. CD is responsible for serious morbidity among affected children and places a large burden on society as a result of increased service use and involvement in the juvenile justice system. The public health significance of identifying a strong risk factor for CD in males is that it provides a new potential target for primary prevention.

Physical activity is an accepted intervention for the prevention of diabetes mellitus (DM) and insulin resistance (IR) in the general population. Few studies in HIV-infected persons assessed the role of physical function or physical activity as a contributing factor to glucose disorders. The relationship between self-reported and performance-based measures of physical function in HIV-infected individuals has not been assessed. This dissertation examined associations between self-reported and performance-based measures of physical function, DM, and IR in HIV-uninfected and HIV-infected men. Data from 658 men from the Pitt Men¡¦s Study were analyzed to assess the contribution of self-reported physical function to prevalent DM and IR. Physical function score (AOR 1.5 per 25 unit decrease, p=0.02) was significantly associated with diabetes, but not IR, after adjustment for covariates. Data from 1790 men from the Multicenter AIDS Cohort Study (MACS) were used to assess physical function as a risk factor for incident DM and IR. Cumulative DM incidence was highest among HIV-uninfected and HIV-infected men with low physical function. Low physical function was a risk factor for incident DM in HIV-uninfected men using more stringent (HR 1.31; 95% CI 1.02-1.66) and less stringent (HR 1.29; 95% CI 1.11-1.50) diabetes definitions adjusting for BMI, family history of diabetes and race. Among HIV-infected men, physical function was a risk factor for incident DM using the less stringent diabetes definition. To assess the relationship between self-reported and performance-based measures of physical function, DM and IR, a cross-sectional study of 2079 men from the MACS was conducted. Self-reported physical function and performance-based measures correlated weakly. (HIV-uninfected: â=0.12-0.23, p<0.01; HIV-infected â=0.16-0.24, p<0.01). Self-reported physical function had a stronger association with DM and IR than performance-based measures in HIV-uninfected but not HIV-infected men. There are important public health implications of this dissertation. Low physical function is a risk factor for DM in two cohorts of HIV uninfected and HIV-infected men; therefore interventions to increase physical function may decrease DM risk while simultaneously reducing the risk of further disability and chronic sequelae among HIV-infected individuals already diagnosed with diabetes. This is essential given the national burden of HIV infection and DM.

Each year in the United States more than one-quarter million children suffer a traumatic brain injury. Previously published research has shown that children who survive a TBI event are more likely to exhibit symptoms of emotional and behavioral disorders in the months and years following their injury. This research seeks to add to the field by examining the prevalence of clinically significant symptoms of these outcome disorders and identify factors related to the presence of these disorders. Through a three-manuscript format, this dissertation examines the prevalence of depression, anxiety, Attention-Deficit Hyperactivity Disorder (ADHD), Oppositional Defiant Disorder (ODD), and Conduct Disorder (CD) symptoms in the young injury survivors as well as depression, anxiety, and poor quality of life in their primary caregivers. This study aimed to describe the distribution of the symptoms of these disorders and identify factors related to both the injury and home recovery environment that are associated with their presence. The first manuscript, focusing on depression and anxiety in the injured youth, found a 5.9% prevalence of both depression and anxiety. More severe injury is associated with increased depressive symptoms. Anxiety symptoms in the child are positively correlated with depression symptoms in the caregiver. The second manuscript found a 35.7% prevalence of ADHD in this cohort, a rate higher than expected in the general population. While no factors were significantly associated with ADHD, this is a significant finding because several years had passed since the injury event. No child was reported having symptoms of ODD/CD. Lastly, the third manuscript focused on the primary caregivers of the brain-injured youth. More than half of all caregivers in this study reported symptoms of a low or very low quality of life. This work has public health significance in that the identification of factors associated with worse outcomes can improve public health by identifying patients and families who may need additional follow-up because of their increased risk. Additionally, these measures will help to improve long-term outcomes in survivors of TBI, and identify caregivers who may need additional assistance in their caregiving responsibilities and may face poor outcomes as well.

A hallmark of vascular aging, central arterial stiffness is the primary determinant of hypertension in older adults and an important predictor of cardiovascular events and mortality. Few studies of older adults have evaluated the longitudinal association of arterial stiffness with cognitive and physical declines, two common consequences of vascular disease. We sought to characterize the relationships among aortic pulse wave velocity (PWV), a measure of central arterial stiffness, cognitive and physical declines and mortality risk among community-dwelling older adults participating in the Health, Aging and Body Composition (Health ABC) study. In an analysis of the Health ABC Cognitive Vitality Substudy, poorer performances in several cognitive domains were associated with accelerated gait speed decline, consistent with a shared cerebrovascular pathogenesis underlying cognitive and physical declines in aging. A second analysis of the substudy identified PWV as a predictor of longitudinal decline in psychomotor speed; this domain-specific association may reflect a vulnerability of the deep white matter to cerebral microvascular disease in the presence of aortic stiffness. In an analysis of the full Health ABC cohort, higher PWV was independently associated with slower gait at baseline and throughout the study period in participants with peripheral arterial disease (PAD), suggesting synergistic roles of arterial stiffness and PAD in mobility decline. Finally, in the full cohort rates of decline in the Modified Mini-Mental State Exam (3MS) and gait speed predicted mortality independent of each other, baseline performance and risk factors, demonstrating a prognostic value for repeated assessments of both cognitive and physical performance in initially well-functioning older adults. The public health relevance of these findings is the potentially clinically important influence of central arterial stiffness to both cognitive and physical function, two central facets of successful aging.