Georgia State University’s Institute of Public Health along with the Georgia Department of Public Health’s Chemical Hazards Program conducted a needs assessment survey to learn more about the concerns of environmental advocates and other community leaders in Georgia regarding exposure to toxic chemicals. The purpose of the Georgia Environmental Advocacy Groups Health Education Needs Assessment was to better understand community concerns, to identify hazardous waste sites that might warrant some degree of public health evaluation, to find community leaders and personnel interested in assisting the Chemical Hazards Program in implementing public health interventions, to inform the community about the services offered to the public by the Georgia Department of Public Health and to better understand the best methods for distributing health education material. This is the first time the Chemical Hazards Program has conducted an environmental advocacy group leader needs assessment. The results of this pilot study will help the development of future needs assessments conducted by the CHP. Survey development began in August of 2011 and Georgia State University Institutional Review Board approval was granted January 2012. Participants were selected due to their current leadership role of a Georgia environmental advocacy group/organization. Contact information was found for 137 environmental group leaders. Depending on available contact information, potential participants either received the survey through the mail or electronically via email. Surveys were distributed on January 13, 2012 and had to be returned by February 20, 2012. Twenty-one Georgia environmental advocacy group leaders participated in the survey. A majority of participants cited protect/restore natural habitats as the main purpose of their organization, but the survey did reveal 10 environmental groups that focused on protecting human health. Seven of participants that were dedicated to protecting human health expressed interest in working further with the GDPH to develop or implement public health interventions. The survey was also successful in informing participants about the Chemical Hazards Program. Prior to the needs assessment, more than 80% of participants were not aware of the program. Many pertinent suggestions were also made to aid in the development of the brochure aimed at educating community members about the services offered by the CHP. Although a variety of environmental health concerns were cited by the participants, water quality was most often mentioned. More participants reported they were very concerned about drinking water than any other environment. Ninety percent also reported being either concerned or very concerned about contamination in oceans, lakes and streams. A section of the survey also addressed hazards found within the home, unclean drinking water was selected by far the most often as being of greatest concern compared to all other indoor hazards. Many participants listed specific waste or industrial sites that are of concern among members of their community as a source of contaminants. A few contaminated environments were also listed including specific rivers and lakes. Though many did not list specific sources, the majority of participants cited water contamination as being a chemical contamination issue that has the greatest impact on human health. The survey helped reveal specific community concerns regarding potential chemical contaminants and sites that may lead to the CHP conducting public health assessments/consultations and exposure investigations. The survey also revealed the need for general environmental health education and intervention activities based on concerns of the participants as well as the lack of concern by many. The survey was also successful in identifying individuals that may help the CHP gain future partnerships and identifying creative methods for distributing health education material. The CHP plans to follow-up with many of the participants and the survey will be further developed and used to survey other leaders, community members, and public health workers etc. to further investigate the needs and concerns of communities across Georgia.

Research on exposure to animals and risk of type 1 diabetes (T1D) has had conflicting results with some researchers finding that animal exposure reduces the risk of T1D and others finding no association between animal exposure and T1D. Previously conducted studies on the association between animal exposure and T1D are case-control studies that have been limited by recall bias. The purpose of this study is to investigate the association between early life animal exposure and the risk of persistent, confirmed islet autoantibodies (IA) and T1D diagnosis among an eligible cohort of genetically high T1D risk participants enrolled in the international prospective cohort study, The Environmental Determinants of Diabetes in the Young (TEDDY). It is hypothesized that children who are exposed to animals in early life will have a lower risk of developing IA and T1D than children who are not exposed to animals in early life. A total of 7,432 TEDDY participants were included in the study. The associations between early life animal exposure and the outcomes of interest were explored using Cox proportional hazards models. In order to control for confounding, a propensity score analysis was applied by three different methods: adjustment for the propensity score variable in the Cox proportional hazards model, stratification on propensity score groups, and propensity score pair matching. Early life animal exposure was not associated with diabetes autoimmunity or T1D onset in this genetically high T1D risk population. These findings were consistent across all three propensity score analysis methods and when directly adjusting for HLA type. The hypothesis that children who are exposed to animals in early life will have a lower risk of developing IA and T1D than children who are not exposed to animals in early life is not supported by this study. The results of this study suggest that there is no association between early life animal exposure and development of T1D. Performing this analysis again after longer follow-up has been completed for the study population is recommended as it may elucidate the effect of animal exposure on T1D and IA risk. Further studies are also needed on animal exposure and T1D in different types of environments (e.g., high residential density) and the effect of different types of animal exposures (e.g., species, duration) on T1D and IA risk. Additionally, studies on differences in perceptions of pets across countries could also aid the interpretation of studies on animal exposure and health outcomes.

Occupational skin and respiratory symptoms, and disease, are common problems. Workers can develop new disease or aggravate existing disease as a result of exposures at work. Many workers are exposed to chemicals that can cause both respiratory and skin responses and there is evidence that some workers experience symptoms in both systems. There is also evidence that skin exposure may lead to sensitization and the development of respiratory disease. There is very little research that has examined both airborne and skin exposures together with lung and skin outcomes. The purpose of this thesis was to further investigate the relationships between occupational exposures, skin symptoms and disease, and respiratory symptoms and disease. Four studies were undertaken to improve our understanding of these complex relationships. Results from a study of clinical patch test data determined that seven of the ten most common occupational contact allergens are also capable of causing occupational asthma and that these common occupational exposures may not be recognized as sensitizers in common reference materials. Exposure-response relationships for skin symptoms were modeled in bakery workers and auto body shop workers using historical data; significant exposure-response relationships were found for auto body workers. In two separate studies of concurrent skin and respiratory symptoms, workers did report concurrent skin and respiratory symptoms. In predictive models, subjects reporting a history of eczema were more likely to report concurrent skin and respiratory symptoms. Overall, the results from this thesis provide more evidence that the skin and respiratory systems are associated. This body of work suggests that: (1) several common occupational exposures can cause disease in both the skin and respiratory system; (2) a portion of workers report both skin and respiratory symptoms; and (3) exposure-response relationships do exist for skin symptoms, both work-related and non-work-related. Future studies need to gather detailed information about exposure and response in both systems in order to better determine the role of exposure(s) in the development of skin and respiratory symptoms. Improved understanding of these relationships will allow for more targeted and effective exposure prevention strategies and will ultimately reduce the burden of occupational disease.

<p>Frailty, generally characterized as a clinical state of increased vulnerability resulting from age-related decline in reserve and function across multiple physiologic systems, has been gaining attention in recent years due to its high correlates with a number of poor health outcomes including falls, hospitalization, and mortality. Although policy makers, health practitioners, and researchers have acknowledged that frailty is a major public health issue, few have investigated the life course predictors of this devastating and costly syndrome. The purpose of this dissertation is (1) to identify the early and later-life predictors of initial frailty and frailty growth over time among older US adults, (2) to examine if childhood exposures influence frailty directly and/or indirectly through adult risks and resources, and (3) to examine the role that social relationships play in frailty trajectories among older adults. Drawing from cumulative inequality theory, this dissertation uses longitudinal data from the Health and Retirement Study (HRS) to examine the effects of childhood exposures, adult risks/resources, and social relationships on frailty trajectories among adults 65 and older. The empirical investigation is presented in two main chapters.</p> <p>The first study investigates the life course predictors of frailty prevalence and further examines how childhood exposures may be directly and indirectly associated with frailty through adult risks and resources. The second study builds on the findings of the first by examining the predictors of frailty growth over time and investigating how social relationships in later life may shape that growth. Findings reveal each childhood exposure domain influences frailty either directly or indirectly through adult factors and experiences. Specifically, analyses reveal that childhood chronic disease, impairments, and risky adolescent behaviors directly influence frailty in later life. Additionally, results reveal that poor childhood SES was one of the most consistent predictors of adult frailty—but much of the effect was due to its influence on adult risks and resources. Few adult risk factors influence frailty trajectories over time. Among adult resources, socioeconomic status (particularly education) slows frailty growth over time. Finally, findings reveal that both social support and more social roles mediate the relationship between childhood exposures and frailty, and that the effect of more social roles continues over time. </p> <p>This dissertation highlights a number of life course predictors of frailty and identifies areas for potential interventions—particularly those aimed at providing equal access to higher education and quality social relationships over the life course. Most importantly, this dissertation demonstrates that frailty prevention should not be a task delegated exclusively to older adults. Effective prevention of this often devastating and costly syndrome should begin early in life.</p>

Work-related musculoskeletal disorders (WSMDs) are an important health concern in the workplace.  Accurately quantifying the level of physical exposures (i.e., kinematics and kinetics) is essential for risk assessments, developing and/or testing interventions, and improving estimates of exposure-response relationships.  Such exposures ideally should be quantified in situ, while workers interact with the actual work environment to complete their tasks.  However, in practice, relatively crude and/or time-consuming methods are often used, including self-reports, observational methods, and simple instrumentation, since directly assessing physical exposures is challenging in the workplace, and typically resource prohibitive. Inertial motion capture (IMC) and in-shoe pressure measurement (IPM) systems are emerging wearable technologies, and they can, respectively, facilitate monitoring of body kinematics and external forces on the body in the workplace.  Thus, this research examined the potential of such technologies in exposure assessments, and evaluated them in comparison to mature laboratory systems (i.e., optical motion capture system and force platform) or direct observation.  Performance of an IMC system was evaluated during several manual material handling (MMH) tasks, in terms of estimated body kinematics and kinetics at selected body parts.  A practical issue, regarding calibrating the IPM system in the field, was addressed by defining an ad hoc global coordinate system using a force platform.  Several regression models were developed for estimating center-of-pressure location and ground reaction forces.  Given that outputs from the IMC and the IPM systems are numerically fine-grained, but generally lack contextual information about a given job, task classification approaches were explored to automatically identify task types and their time proportions in a job. Overall, the outcomes from these studies demonstrated the potential of the IMC and the IPM systems for measuring physical exposures in the workplace.  However, estimation of physical exposures using these systems requires further improvements in some cases.  This research provided groundwork for future rapid and direct assessments of physical exposures in the workplace, and which needs to be expanded and validated in future efforts. / Ph. D.

Causal inference methods have been applied in various fields where researchers want to establish causal effects between different phenomena. The goal of causal inference is to estimate treatment effects by comparing outcomes had units received treatment versus outcomes had units not received treatment. We focus on estimating treatment effects in three different projects. We first proposed linear unbiased estimators (LUEs) for general causal effects under the assumption that treatment effects are additive. Under the assumption of additivity, the set of estimands considered grows as contrasts in exposures are now equivalent. Furthermore, we identified a subset of LUEs that forms an affine basis for LUEs, and we characterized LUEs with minimum integrated variance through defining conditions on the support of the estimator. We also estimated the effect of drug-induced homicide (DIH) prosecutions reported by the media on unintentional drug overdose deaths, which have never been empirically assessed, using various models. Using a difference-in-differences-like logistic generalized additive model (GAM) with smoothed time effects where we assumed a constant treatment effect, we found that DIH prosecutions reported by the media were associated with a potential harmful effect (risk ratio: 1.064; 95% CI: (1.012, 1.118)) on drug overdose deaths. Upon further research, however, there are potential issues using a constant treatment effect model in a setting where treatment is staggered and treatment effects are heterogeneous. Therefore, we also used a GAM with a linear link function where we assumed that treatment effects may depend on the treatment duration. With this second model, we estimated a risk ratio for having any DIH prosecutions reported by the media of 0.956 (95% CI: (0.824, 1.110)) and a risk ratio of 0.986 (95% CI: (0.973, 0.999)) for the effect of being exposed to DIH prosecutions reported by the media for each additional six months. Despite being statistically significant, the effects were not practically significant. However, the results call for further research on the effect of DIH prosecutions on drug overdose deaths. Lastly, we shift our focus to Structural Nested Mean Models (SNMMs). We extended SNMMs to a new class of estimators which estimate treatment effects of different treatment regimes in the risk ratio scale---the Structural Nested Risk Ratio Model (SNRRM). We further generalized previous work on SNMMs by estimating treatment effects by modeling a function of treatment, which we choose to be any function that can be modeled by generalized linear models, as opposed to just a model for treatment initiation. We applied SNRRMs to estimate the effect of DIH prosecutions reported by the media on drug overdose deaths.

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Objective: Resistance is a therapeutic process variable that can play an important role in treatment. The present study examined whether observer-rated parental resistance during parent-only sessions of cognitive-behavioral therapy (CBT) for anxious youth predicted the number of parent-reported between-session exposures completed, posttreatment outcome, and 36-week follow-up. Method: Participants (N = 272) were parents or adult caregivers of youth (age 7 to 17 years old) who received CBT for an anxiety disorder as participants in the Child/Adolescent Anxiety Multimodal study (CAMS). Parent-only therapy sessions were rated for resistance by observers. Measures of anxiety and overall symptom severity were completed at posttreatment and 36-week follow-up. Mediation analyses examined the indirect effect of the number of parent-reported exposures completed on the relationship between parent in-session resistance and therapy outcomes at posttreatment and 36-week follow-up. Additionally, resistance levels in participants in the CBT-only condition of CAMS were compared with resistance levels for participants in the CBT plus sertraline condition. Results: Analyses demonstrated that there was no significant difference in mean resistance scores between the CBT-only group and the CBT plus sertraline group. None of the 12 mediation tests found statistically significant indirect effects of the number of parent-reported exposures completed on the relationship between parent in-session resistance and therapy outcomes at posttreatment and 36-week follow-up. A significant relationship was found, however, between number of exposures completed and posttreatment Pediatric Anxiety Rating Scale (PARS) total scores, indicating a significant relationship between number of parent-reported exposures and posttreatment therapy outcomes. Conclusions: Parental resistance is not associated with outcomes for youth receiving CBT for anxiety. Number of exposures was significantly associated with one measure of posttreatment therapy outcomes. / Psychology