Thesis (Ph. D.)--University of Texas at Austin, 1998. / Vita. Includes bibliographical references (leaves 171-182). Available also in a digital version from Dissertation Abstracts.

This thesis explores the implementation of an area-based health improvement initiative in the north west of England called Target Wellbeing. In the decades before Target Wellbeing was commissioned in 2007, health inequalities between people living in different areas of the UK had been widening. ABIs were identified by the Labour Government as a key tool for improving the health and wellbeing of residents in areas of socio-economic disadvantage and addressing inequalities in health. ABIs such as this have been well evaluated but there remains no firm evidence about the ability of such initiatives to improve health or to reduce health inequalities. In addition to the problems associated with evaluation, the processes through which ABIs might be used to influence change are not well understood and the value of using area-based services to improve health has been taken for granted. There is little understanding about the processes through which service provider partnerships might develop and limited knowledge about the processes through which residents might develop relations with providers. The key aim of this research was to examine the social processes through which ABIs develop over time. Using a case study approach, the research examined one Target Wellbeing programme as a social figuration of interdependent people. Ethnographic methods, including documentary analysis, non-participant observation and interviews, were used to explore the processes and networks that mediated the planned public health development. The study also drew on relevant quantitative data to describe changes over time. Ideas from figurational sociology were used as sensitising concepts in the development of a substantive theory about the processes through which ABIs develop. The study developed theoretical insight into processes of joint working that helps to explain why, in the context in which services are commissioned and performance managed, provider co-ordination is unlikely to be implemented as planned. It also provided a more sociologically adequate account of the ways in which relations between residents and providers were influenced by the history of relations in the town. Changes to residents’ relations with other residents and providers in the town influenced a greater sense of control over their circumstances. These findings demonstrate that, in relation to public health policy and practice, ABIs might more usefully be conceptualised as a series of interrelated processes that might be used to establish the preconditions for influencing change among residents. However, the study showed that interventions targeted at a small part of much wider networks of interconnected people are unlikely to influence sustained changes for residents in deprived areas.

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As healthcare costs continue to rise across the country more companies are beginning to look for new strategies to cut costs. The evolving health and wellness industry has been shown to reduce expenditures from costly medical services by improving long term healthy behaviors in the work force, aiming to impact the demand and supply sides of healthcare. This paper looks at the history behind the health and wellness movement and specifically evaluates Healthy Incentives, King County's own health and wellness initiative and the impact such a program has on direct medical expenditures as well as key health risk factors that are affecting millions of working Americans.

Breast cancer is the most prevalent form of cancer and the second leading cause of mortality, affecting 1 in 9 women in the United States. Recent studies have shown that antipsychotic drug use is associated with increased prolactin levels, which, in turn, is associated with increased risk of breast cancer. However, studies of the association between antipsychotic drug use and the risk of breast cancer are sparse and have largely been conducted in homogenous populations. Therefore, we evaluated this relationship in postmenopausal women (N = 119 524) in a diverse population of the Women’s Health Initiative (WHI) cohort. Antipsychotic drug use was self-reported and in situ and invasive breast cancer cases were confirmed by medical records for the WHI clinical trial (CT) and the WHI observational study (OS), from 1993 through 2018. We used Cox proportional hazards regression to model breast cancer risk against antipsychotic drug use while adjusting for dietary and lifestyle factors. Overall, antipsychotic users made up 0.41% of this population. There was no overall association between antipsychotic drug use and postmenopausal breast cancer risk (HR = 1.01, 95% CI = 0.73 – 1.40). Among typical antipsychotic drug users, there was a suggested two-fold increased risk in developing in situ breast cancer (HR = 2.02, 95% CI = 0.84, 4.86). Thus, antipsychotic drug use does not appear to increase breast cancer risk overall, but the potential association between antipsychotics and in situ breast cancer merits further study.

Hypertension is a chronic disease with an estimated prevalence of nearly 50% in US adults. In addition to sociodemographic and lifestyle factors, evidence suggests that in utero and early life exposures may contribute to life-long risk of hypertension. This study aimed to investigate the potential associations between an individual’s birthweight and preterm birth status with their risk for hypertension in the Women’s Health Initiative (WHI) cohort. WHI is a large, multi-racial cohort of postmenopausal women. At study entry, birthweight and preterm birth status were self-reported by category (< 6 lbs., 6-7 lbs. 15 oz., 8-9 lbs. 15 oz., or ≥ 10 lbs.; ≥ 4 weeks premature or full term). Baseline and incident hypertension status were self-reported; mean systolic blood pressure, diastolic blood pressure, and 30-second pulse were also recorded at baseline by trained study staff. Linear, logistic, and Cox-proportional hazards regression models were used to generate crude and adjusted beta estimates, odds ratios, and hazards ratios, respectively. After adjusting for demographic and lifestyle factors, we found that participants born at a low birthweight had a higher mean systolic blood pressure than participants born at a normal birthweight and were at increased risk for both baseline and incident hypertension. Women born at a higher birthweight had a lower mean systolic blood pressure and were at lower risk for baseline and incident hypertension. When compared to participants born full term, participants born preterm were at increased risk for baseline and incident hypertension. These results support current research on early life exposures and health risks later in life. Long term follow-up or targeted counseling may be required for individuals born prematurely or at low birthweights to prevent and treat hypertension and associated cardiovascular outcomes.

The research reported in this dissertation examines the dissemination of heart health promotion within the Ontario public health system. It contributes to a relatively new research agenda to understand how to enhance implementation of the new public health; to apply knowledge of effective community- and population-based prevention. Three studies are reported, which extend research conducted in Ontario from 1994 to 1998 as part of the Canadian Heart Health Initiative Ontario Project (CHHIOP). Study one combined diffusion and social ecological theories to examine the dissemination process at the level of the public health system and over a ten year period. Studies two and three examined the implementation stage in more depth, with a view to understand variability across Ontario communities. Study two was a quantitative path analysis to identify determinants of 1997 levels of implementation, and study three was a comparative case study to understand change in implementation from 1994 to 1996. Main data sources were quantitative and qualitative data from CHHIOP. Findings reinforce the need for a systems view of dissemination; that dissemination is a long-term, iterative process; and that organizational capacity building is a vital part of the dissemination process, especially when new practices represent a significant departure from traditional concepts and ways of doing business. The research demonstrates that the interplay of internal organizational factors (e.g. champions, leadership, organizational structure) and external system factors (e.g. research, political priorities, experiences of other jurisdictions, partnerships) helps to explain movement within and across dissemination stages. Findings suggest promising areas for dissemination research, including replicating similar research in other public health systems. Findings also suggest promising strategies to accelerate the dissemination of effective health promotion, including specific strategies to further enhance heart health promotion in Ontario. / Thesis / Doctor of Philosophy (PhD)

Colorectal cancer is the third most common cancer among U.S. women; 63,610 new cases were estimated to have occurred in 2015. Prior studies found a reduced risk of colorectal cancer among antidepressant (AD) users, however, none adjusted for depression, which is itself linked to increased colorectal cancer risk and could confound this relationship. We assessed the relationship between ADs and AD drug classes with risk of colorectal cancer in a prospective cohort of 145,190 women between the ages of 50-79 without a previous history of cancer at enrollment. Current AD use was assessed at baseline. Over an average follow-up of 14 years, there were 5,280 incident cases of colorectal cancer cases. Cox proportional hazard ratios, adjusted for potential confounders including depressive symptoms, were used to estimate hazard ratios. Of all AD users, 51.1% used selective serotonin reuptake inhibitors (SSRIs), 40.7% used tricyclic antidepressants (TCAs), and 15.1% used other ADs. No association was observed between total AD use, SSRI use, and/or other ADs and risk of colorectal cancer. We observed a reduced risk of colorectal cancer among TCA users, which was significant for colon cancer specifically (HR 0.68, 95% CI: 0.48-0.96). Although a reduced risk of colon cancer was observed for TCAs use for less than two years (HR 0.39, 95%: CI 0.19-0.82), no association was observed for TCA use for two or more years (HR 0.85, 95%CI: 0.57-1.26). Our data suggests a protective association between TCA use and risk of colorectal cancer, however more research is needed to verify these findings.

As a result of the recent findings of the Women's Health Initiative (WHI), many women who have been on hormone replacement therapies (HRT) have begun to renegotiate their understandings and strategies of this stage of their lives. The WHI findings suggested that the risks of HRT outweighed the benefits for healthy menopausal women. This study examined women's emerging sensemaking regarding HRT and menopause in light of the WHI findings. Seven women in the Tampa Bay area, who were in various stages of menopause, participated in three focus group sessions and two one-on-one interviews to discuss their lives in menopause. Based upon the women's conversations, I constructed individual stories about each of the women. I included my voice in each step of the process, both participating in the focus group and interview discussions and inserting my voice in the women's stories as an interview and focus group participant. I analyzed the stories to determine categories in the w omen's emerging sensemaking. A theme of change emerged in terms of loss, decay, and decline. The women talked about change while discussing personal issues such as children, their bodies, aging, health concerns, and sex. Throughout their discussions, the women spoke about the contradictions and dilemmas they faced as they tried to sort through the conflicting and sometimes contradictory information they have been receiving about the effects of menopause and HRT on their bodies. Emily Martin's medical metaphors, Michel Foucault's ideas on discourse, and Watzlawick, Weakland, and Fisch's theory of change helped me understand the women's sensemaking. Many of the women framed their sensemaking within the biomedical model of health care, using what Martin called the body-as-machine metaphor, thereby making a first-order change, even though they changed from one HRT formula to another, from "synthetic" to "natural" HRT, or stopped taking HRT entirely. One woman appeared to make a secon d-order change. Overall, the women felt they had little to guide them as they determined how to take care of themselves in the menopausal stage of their lives.

Orientador: Lucia Helena Simões da Costa Paiva / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas / Made available in DSpace on 2018-08-06T03:23:51Z (GMT). No. of bitstreams: 1 LazarJunior_Felipe_D.pdf: 154939 bytes, checksum: 9790b7b84c0e5eb21859931d78316ca3 (MD5) Previous issue date: 2006 / Resumo: O objetivo deste estudo foi avaliar o conhecimento e as repercussões sobre a atitude e prática dos médicos ginecologistas três anos após a publicação dos resultados do estudo Women¿s Health Initiative. Sujeitos e Método: Um questionário auto-administrado e anônimo com 19 questões foi enviado aos 6000 ginecologistas da Associação de Obstetrícia e Ginecologia do Estado de São Paulo (SOGESP). Os questionários foram postados em novembro de 2005 com recepção concluída em dezembro de 2005. Resultados: O índice de resposta foi de 24,2% (1453 questionários preenchidos) com erro amostral de 2,23% e intervalo de confiança de 95%. Apesar de 95,9% dos ginecologistas referirem conhecer o estudo WHI, apenas 24,4% tinham conhecimento dos outros estudos (HERS I, HERS II, e Million Women Study) além do WHI. Apesar de 84,6% referirem que os resultados obtidos no estudo WHI não poderiam ser extrapolados para outros tipos de TH, 23,1% e 25,2% abandonaram o uso de EEC ou AMP, 63,7% diminuíram a dose, 55,2% passaram a prescrever drogas como bifosfonatos, tibolona e serms, e 46,3% passaram a utilizar calmantes, isoflavonas e drogas naturais. Além disso, 59,2% concordaram que o tempo ideal de TH deveria ser diminuído para 4-5 anos. Houve queda significativa nas prescrições para todas as indicações de TH (p<0.0001). Para os médicos, a causa mais importante de descontinuação da TH foi o maior risco de câncer de mama (62,3%), no entanto, segundo os médicos, o fator mais importante para as pacientes foi o medo da TH (80,3%) Conclusão: Os ginecologistas têm elevado conhecimento do estudo WHI e seguiram suas recomendações com relação à prevenção de doença cardiovascular, consequentemente, mudaram sua forma de abordar o tratamento das mulheres na pós-menopausa, restringindo as indicações, tempo de uso e dose da TH / Abstract: The objective of this study was to evaluate gynecologists¿ knowledge of the Women¿s Health Initiative study, and its repercussions on their attitudes and practice three years after publication. Design: A self-administered, anonymous questionnaire containing 19 questions was sent to 6000 gynecologists, members of the São Paulo Society of Obstetrics and Gynecology. Results: The response rate was 24.2% (1453 completed questionnaires) with a sample error of 2.23% and confidence level of 95%. Although 95.9% of gynecologists were aware of the WHI study, only 24.4% had knowledge of all the other studies mentioned (HERS I, HERS II and Million Women Study). Although 84.6% stated that the results of the WHI study could not be extrapolated to other forms of HT, 23.1% and 25.2%, respectively, stopped prescribing CEE or MPA, 63.7% decreased the dose, 55.2% opted for drugs such as bisphosphonates, tibolone and SERMS, and 46.3% began to prescribe tranquilizers, isoflavone and other natural medications. Moreover, 59.2% agreed that HT should be used for only 4-5 years. Prescriptions decreased significantly for all indications (p<0.0001). The principal reason for physicians to discontinue HT in a patient was increased risk of breast cancer (62.3%), whereas, according to the physicians, the most important factor for the patients was fear of HT (80.3%). Conclusion: A high percentage of gynecologists in this study knew of the WHI study and followed its recommendations concerning cardiovascular prevention; consequently they changed their management of the treatment of postmenopausal women by restricting indications for HT and decreasing its duration of use and dose / Doutorado / Tocoginecologia / Doutor em Tocoginecologia