Local Health Departments (LHD) that aim to address the public health needs of growing populations require qualified professionals with management competencies. In Arizona, the majority of public health services are delivered by the county health departments, which are charged with assisting community members and monitoring and improving community health. These activities are funded with federal, state and local money, which varies across counties. This study provides a comprehensive understanding of the local public health system in Arizona, the distribution of public health services across counties and examines the association between health outcomes data and funding patterns for each county. National Association of City and County Health Officials (NACCHO) data from their 2008 survey was used to examine the activities performed at the local level. The majority of the activities in which the LHDs focus fall within the assurance function of public health. Interviews with all Arizona county health department directors (N=15) were conducted. Discussion focused on LHD activities, county and state political/policy climate and partnerships that contribute to LHDs activities. Responses varied significantly across the state due to differences in demographic and financial characteristics of the counties. Many political, socioeconomic and environmental barriers to provision of services were identified as well as the need for developing a stronger public health infrastructure.Finally, associations between several health outcomes and funding, workforce and demographic data of the 15 local health departments in Arizona were examined by conducting correlation analysis and linear regressions. This study found strong positive associations between LHD revenues, LHD expenditures, population size and number of LHD employees and HIV/AIDS incidence, low birth weight births and infant mortality rate. Positive associations were also found between revenues and number of women who received prenatal care and HIV/AIDS mortality rate as well as between number of LHD employees and diabetes mortality rate. This study represents a small step in better understanding the local public health system in Arizona, the distribution of public health services across counties and the political, financial and policy constraints faced by county health department directors.

<p>Over the last three decades, there has been a precipitous rise in curiosity regarding the clinical use of mindfulness meditation for the self-management of a broad range of chronic health conditions. Despite the ever-growing body of evidence supporting the use of mindfulness-based therapies for both medical and psychological concerns, data on the active ingredients of these mind-body interventions are relatively scarce. Regular engagement in formal mindfulness practice is considered by many to be requisite for generating therapeutic change; however, previous investigations of at-home practice in MBIs have produced mixed results. The equivocal nature of these findings has been attributed to significant methodological limitations, including the lack of standardized, systematic practice monitoring tools, and a singular focus on practice time, with little attention paid to the nature and quality of one’s practice. The present study used a prospective, observational design to assess the effects of home-based practice on dispositional mindfulness, self-compassion, and psychological functioning in twenty-eight people enrolled in an MBSR or MBCT program. To address some of the aforementioned limitations, the present study collected detailed weekly accounts of participants’ home-based practice engagement, including information about practice time (i.e., frequency and duration), exercise type, perceived effort and barriers to participation, and practice quality. Hierarchical multiple regression was used to examine the relative contribution of practice time and practice quality on treatment outcomes, and to explore possible predictors of adherence to at-home practice recommendations. As anticipated, practice quality and perceived effort improved with time; however, rather unexpectedly, practice quality was not a significant predictor of treatment-related improvements in psychological health. Home practice engagement, however, was predictive of change in dispositional mindfulness, in the expected direction. Results of our secondary analyses demonstrated that employment status was predictive of home practice engagement, with those who were unemployed completing more at-home practice on average. Mindfulness self-efficacy at baseline and previous experience with meditation or other contemplative practices were independently predictive of mean practice quality. The results of this study suggest that home practice helps generate meaningful change in dispositional mindfulness, which is purportedly a key mechanism of action in mindfulness-based interventions.</p> / Dissertation

Philosophiae Doctor - PhD / This thesis purposes to examine the impact of financial development on health outcomes, health care expenditure and financial protection in health in 46 selected sub-Saharan African (SSA) countries from 1995 to 2014. It also estimates the impact of health care expenditure on health outcomes. The thesis is premised on the hypothesis that health care expenditure is a critical transmission mechanism through which financial development leads to better health outcomes. The health care expenditure channel is conspicuously absent in the literature on financial development and health outcomes; hence the need for this study to fill the gap in the literature. The thesis explores the effects of both depth and access dimensions of financial development on health outcomes, expenditure and financial protection. Throughout the study, financial access is measured by the number of automated teller machines (ATMs) and commercial bank branches per 100 000 people, while financial depth is measured by the proportion of broad money and bank credit to the private sector, to Gross Domestic Product (GDP). The study uses fixed and random effects and the Two-Stage Least Squares estimation approaches. The Generalised Method of Moments (GMM) is also used to estimate the impact of health care expenditure and health outcomes given the absence of valid instrumental variables. The results of the regression analyses show that financial development leads to increased health care expenditure and health outcomes. The analysis also shows that health care expenditure leads to better health outcomes. Additionally, the study indicates that financial development leads to financial protection in health care by reducing out-of-pocket health care expenditure. Well-developed financial systems provide financial protection from the risk of catastrophic health care expenditure and impoverishment resulting from illness. The study shows that health care systems financed through prepaid mechanisms reduce neonatal, infant and under-five mortality rates and increase life expectancy, while those relying on out-of-pocket expenditure have adverse effects on health outcomes.

Background: Stroke is the second leading cause of disability and mortality in the U.K., therefore research investigating stroke has been highlighted by the National Stroke Strategy to develop studies which are longitudinal and focus on outcome. A comprehensive systematic review (Study One) was undertaken to investigate the role of psychological factors on stroke recovery. This informed the development of the research study (Study Two). The aim of this study was to investigate the role of psychological and cognitive factors on psychological and physical recovery from acute stroke, in a longitudinal study as directed by the National Stroke Strategy. The current study additionally incorporates cognitive neuropsychological elements along with measures of mood, personality and coping. This is the first study to the authors’ knowledge which has investigated repressive coping and Type D personality with stroke. Method: Longitudinal data collection was conducted in two NHS hospitals, with a clinical sample at Time 1 (0-6 weeks post stroke), followed up at Time 2 (3 months post stroke) and Time 3 (6 months post stroke), in the participants’ homes or in nursing homes. Measures used to test independent variables were: Centre for Epidemiologic Studies Short Depression Scale (CES-D 10), Perceived Stress Scale (PSS), Multidimensional Scale of Perceived Social Support (MPSS), Standard Assessment of Negative Affectivity, Social Inhibition, and Type D Personality (DS 14, Type D personality), Marlowe-Crowne Form B & 6 Item STAI (for repressive coping), 3 item Sense of Coherence (SoC) scale, line bi-section & Bells cancellation task (visual neglect), forward digit span (verbal short term memory), Rivermead Behavioural Memory Test (visual short term memory) and the colour word Stroop test (executive function), along with demographic data, stroke markers and health behaviours. Dependent variables were: Quality of life (measured by the SF-36) and physical recovery (modified Rankin Scale). Results: The main analysis used hierarchical multiple regression analyses and mediation analysis to test a series of hypotheses. Physical recovery outcome was predicted by stroke severity, age, stress, repressive coping, social support and visual neglect at different time points. Depression and visual memory were reported as mediators at Time 2. Quality of life outcome was predicted by stroke severity, age, stress, social support, depression and visual neglect at different time points. Conclusions: The results of this study indicate that psychological factors do have an impact on both physical and psychological outcome from stroke. Stress, repressive coping and visual neglect were the most consistent predictors of outcome. Depression and social support played a smaller role, whereas Type D personality was nonsignificant across analyses.

Chronic health problems are hypothesised to be a risk factor to child and adolescent mental health, due the consistent and continuing stress these health problems pose to normative patterns of development. However, this theory remains to be substantiated by empirical research. Moreover, a systematic review conducted as part of this research indicated that the empirical body is not one on which the validity of this theory can be adequately tested. The major question posed is whether the lack of high quality epidemiological data in the field is obscuring a true psychiatric risk associated with chronic illness in childhood and adolescence, or whether, in contrast, the theory of chronic health problems as a particular risk factor to child and adolescent mental health, is based on false premises. In order to provide a stronger insight into the association of chronic health problems to mental ill-health across the late childhood and adolescent period, this study used data from a large, representative British sample (the Avon Longitudinal Study of Parents and Children (ALSPAC)) and sensitive measures of mental health outcomes. Mediating factors in these associations were also identified, and a model of the association of chronic health problems to poor mental health outcomes in early adolescence was developed. In order to ensure that all findings were applicable across chronic health conditions, outcomes over this period for children with chronic illness more generally were compared to outcomes for children with asthma diagnoses. Children with chronic health problems presented with a disproportionate rate of psychiatric illness at 10 years, and these chronic health problems continued to be associated with poor mental health outcomes across the early to mid-adolescent period. The outcomes at 10 and 13 years were suggested to be mediated by factors non-specific to any diagnosis, specifically peer victimisation and health-related school absenteeism. Limitations to external validity in the research, and implications for public health and future research are discussed.

Introduction Vitamin D status is an important public health issue due to the high prevalence of vitamin D insufficiency and deficiency, especially in high latitude areas. Furthermore, it has been reported to be associated with a number of diseases. In a previous umbrella review of meta-analyses of randomized clinical trials (RCTs) and of observational studies, it was found that plasma/ serum 25-hydroxyvitamin D (25(OH)D) or supplemental vitamin D has been linked to more than 130 unique health outcomes. However, the majority of the studies yielded conflicting results and no association was convincing. Aim and Objectives The aim of my PhD was to comprehensively explore the association between vitamin D and multiple outcomes. The specific objectives were to: 1) update the umbrella review of meta-analysis of observational studies or randomized controlled trials on associations between vitamin D and health outcomes published between 2014 and 2018; 2) conduct a systematic literature review of previous Mendelian Randomization studies on causal associations between vitamin D and all outcomes; 3) conduct a systematic literature review of published phenome wide association studies, summarizing the methods, results and predictors; 4) create a polygenic risk score of vitamin D related genetic variants, weighted by their effect estimates from the most recent genome wide association study; 5) encode phenotype groups based on electronic medical records of participants; 6) study the associations between vitamin D related SNPs and the whole spectrum of health outcomes, defined by electronic medical records utilising the UK Biobank study; 7) explore the causal effect of 25- hydroxyvitamin D level on health outcomes by applying novel instrumental variable methods. Methods First I updated the vitamin D umbrella review published in 2015, by summarizing the evidence from meta-analyses of observational studies and meta-analyses of RCTs published between 2014 and 2018. I also performed a systematic literature review of all previous Mendelian Randomizations studies on the effect of vitamin D on all health outcomes, as well as a systematic review of all published PheWAS studies and the methodology they applied. Then I conducted original data analysis in a large prospective population-based cohort, the UK Biobank, which includes more than 500,000 participants. A 25(OH)D genetic risk score (weighted sum score of 6 serum 25(OH)D-related SNPs: rs3755967, rs12785878, rs10741657, rs17216707, rs10745742 and rs8018720, as identified by the largest genome wide association study of 25(OH)D levels) was constructed to be used as the instrumental variable. I used a phenotyping algorithm to code the electronic medical records (EMR) of UK Biobank participants into 1853 distinct disease categories and I then ran the PheWAS analysis to test the associations between the 25(OH)D genetic risk score and 950 disease outcome groups (i.e. outcomes with more than 200 cases). For phenotypes found to show a statistically significant association with 25(OH)D levels in the PheWAS or phenotypes which were found to be convincing or highly suggestive in previous studies, I developed an extended case definition by incorporating self-reported data collected by UK Biobank baseline questionnaire and interview. The possible causal effect of vitamin D on those outcomes was then explored by the MR two-stage method, inverse variance weighted MR and Egger's regression, followed by sensitivity analyses. Results In the updated systematic literature review of meta-analyses of observational studies or RCTs, only studies on new outcomes which had not been covered by the previous umbrella review were included. A total of 95 meta-analyses met the inclusion criteria. Among the included studies there were 66 meta-analyses of observational studies, and 29 meta-analyses of RCTs. Eighty-five new outcomes were explored by meta-analyses of observational studies, and 59 new outcomes were covered by meta-analyses of RCTs. In the systematic review of published Mendelian Randomization studies on vitamin D, a total of 29 studies were included. A causal role of 25(OH)D level was supported by MR analysis for the following outcomes: type 2 diabetes, total adiponectin, diastolic blood pressure, risk of hypertension, multiple sclerosis, Alzheimer's disease, all-cause mortality, cancer mortality, mortality excluding cancer and cardiovascular events, ovarian cancer, HDL-cholesterol, triglycerides and cognitive functions. For the systematic literature review of published PheWAS studies and their methodology, a total of 45 studies were included. The processes for implementing a PheWAS study include the following steps: sample selection, predictor selection, phenotyping, statistical analysis and result interpretation. One of the main challenges is the definitions of the phenotypes (i.e., the method of binning participants into different phenotype groups). In the phenotyping step, an ICD curated phenotyping was widely used by previous PheWAS, which I also used in my own analysis. By applying the ICD curated phenotyping, 1853 phenotype groups were defined in the participants I used. In PheWAS, only phenotype groups with more than 200 cases were analysed (920 phenotypes). In the PheWAS, only associations between rs17216707 (CYP24A1) and "calculus of ureter" (beta = -0.219, se = 0.045, P = 1.14*10-6), "urinary calculus" (beta = -0.129, se = 0.027, P = 1.31*10-6), "alveolar and parietoalveolar pneumonopathy" (beta = 0.418, se = 0.101, P = 3.53*10-5) survived Bonferroni correction. Nine outcomes, including systolic blood pressure, diastolic blood pressure, body mass index, risk of hypertension, type 2 diabetes, ischemic heart disease, depression, non-vertebral fracture and all-cause mortality were explored in MR analyses. The MR analysis had more than 80% power for detecting a true odds ratio of 1.2 or larger for binary outcomes. None of explored outcomes were statistically significant. Results from multiple MR methods and sensitivity analyses were consistent. Discussion Vitamin D and its association with multiple outcomes has been widely studied. More than 230 outcomes have been linked with vitamin D by meta-analyses of observational studies and RCTs. On the contrary, evidence from Mendelian Randomization studies is lacking. In particular I identified only 20 existing MR studies and only 13 outcomes were suggested to be causally related to vitamin D. In the systematic literature review of previous PheWAS studies, I summarized the applied methods, predictors and results. Although phenotyping based on ICD codes provided good performance and was widely applied by previous PheWAS studies, phenotyping can be improved if lab data, imaging data and medical notes can be incorporated. Alternative algorithms, which takes advantage of deep learning and thus enable high precision phenotyping, needs to be developed. From the PheWAS analysis, the score of vitamin D related genetic variants was not statistically significantly associated with any of the 920 phenotypes tested. In the single variant analysis, only rs17216707 (CYP24A1) was shown to be associated with calculus outcomes statistically significantly. Previous studies reported associations between vitamin D and hypercalcemia, hypercalciuria, nephrolithiasis and nephrocalcinosis, may be due to the role of vitamin D in calcium homeostasis. In the MR analysis, I found no evidence of large to moderate (OR > 1.2) causal associations of vitamin D on a very wide range of health outcomes. These included SBP, DBP, hypertension, T2D, IHD, BMI, depression, non-vertebral fracture and allcause mortality which have previously been proposed to be influenced by low vitamin D levels. Further, even larger studies, probably involving the joint analysis of data from several large biobanks with future IVs that explain a higher proportion of the trait variance, will be required to exclude smaller causal effects which could have public health importance because of the high population prevalence of low vitamin D levels in some populations.

Adverse childhood experiences (ACEs) are events that take place during one’s youth that may be stressful or traumatic (Adverse Childhood Experiences, 2017) and a strong focus within this body of knowledge has been on the experiences of childhood neglect and abuse. Emerging adulthood is a distinct developmental phase of the life course characterized by extensive self-exploration and consideration about the future (Arnett, 2000). Given that identity exploration continues to be important during emerging adulthood, it is important to study ACEs and the effects they have on the emerging adult who is making decisions regarding their future. Much of the literature on ACEs has been dedicated to establishing the relationship between ACEs and negative health outcomes. For instance, research has shown that ACEs have been linked to increased risks for suicide attempt and ideation throughout one’s lifespan (Sachs-Ericsson et. al, 2016) and has also been associated with feelings of anxiety (Briggs & Price, 2009), guilt (Kaess et. al, 2013), and depression (Briggs & Price, 2009). Therefore, ACEs and negative health outcomes have already been strongly confirmed. The positive psychology movement (Seligman & Csikszentmihalyi, 2014) has brought to scholars’ attention the need to expand on conceptualizations of what it means to be doing well. Specifically, it is no longer sufficient to define optimal well-being only in terms of the absence of negative outcomes. In order to assess holistic well-being, consideration must also be given to positive factors. A recent review of the literature yielded no studies that have explored the presence, or absence, of positive well-being factors in conjunction to negative health outcomes among those having experienced ACEs. In order to obtain a true understanding of holistic well-being at critical developmental junctures, the current study moves beyond a sole focus on pathology by also considering how life satisfaction and subjective happiness manifest during emerging adulthood in relation to ACEs. Data on 284 participants were collected and analysis is forthcoming. Participants were recruited through the use of physical flyer postings, social media advertisements, and through Amazon’s Mechanical Turk (mTurk) system. Regression analysis and bivariate assessments will be used to explore the relationship between ACEs and depression, anxiety, life satisfaction, subjective happiness, and survivor’s guilt. Findings will be discussed in terms of broadening our understanding of the impacts to holistic well being for as related to ACEs during a rather critical and busy developmental juncture, emerging adulthood. Moving beyond pathology-focused models will expand on professional practice by utilizing frameworks embedded within a strengths-based approach. Educators, advocates, practitioners, and clinicians can utilize this this knowledge to enhance their work with clients and the services provided.

Thesis (MBA.) -- University of Limpopo, 2015 / The health profiles and outcomes in South Africa are unsatisfactory, not seeming to improve appreciably, amid the robust reform efforts, policies and strategies. These health challenges comprise largely of preventable conditions, as demonstrated by the quadruple burden of disease. Community participation, including the use of community governance structures in improving community health profiles and outcomes, are alluded to be beneficial in improving these communities` health profiles and outcomes. The main aim of this study was to understand the current and the potential future role and the factors at play, of the community governance structures in managing their communities` health profiles and outcomes, in the Zebediela sub-district, Limpopo, South Africa. A qualitative study was conducted, using the Zebediela sub-district as a case study, where from six out of the potential nine governance structures were interviewed and recorded in focus groups, using a pre-determined discussion guide. The recordings were analysed in-depth for themes, using the consistency matrix and the N-vivo data analysis. The results indicate that, the community governance structures are aware of the unsatisfactory health profiles and outcomes in their communities, but are not doing anything specific towards intervening to improve the situation. However, they are keen and willing to participate in improving the situation and are able to identify the potential role they can play, the skills and resources in themselves and in the communities, including the factors that facilitate and those that impede, their participation together with the recommendations of what can facilitate their participation and efficiency in improving their communities` health profiles and outcomes. The community governance structures represent a good opportunity to improve community health profiles and outcomes, through a specific strategic focus that would empower, support, motivate, strengthen and reinforce their current level of skills, functioning and participation.

Precision medicine has allowed for the development of monoclonal antibodies that unmask the anti-tumor immune response. These agents have provided some patients durable clinical benefit. However, PD-1 and PD-L1 inhibitor therapies are effective in a small group (10-20%) of non-small cell lung cancer (NSCLC) patients when used as single-agent therapy. The approved companion diagnostic is expression of the immune cell surface molecule, programmed death ligand 1 (PD-L1), on tumors measured by immunohistochemistry (IHC). Studies in tumor biology and immune surveillance dictate that PD-1 inhibitor efficacy should depend on the level of PD-L1 expression; however, the literature has not followed with convincing evidence. The limitations of this test include timing of tissue acquisition, tumor heterogeneity, and timing of therapy relative to the expression of PD-L1. In addition, the requirement of analyzing tumor tissue biopsy samples from a patient is cumbersome. Thus, a peripheral blood biomarker that predicts efficacy of PD-1/PD-L1 inhibition would be optimal for precise and cost-effective treatment. A history of chronic inflammatory diseases may be advantageous for a cancer patient who is treated with PD-1/PD-L1 inhibitors and may allow them to then mobilize a swift immune response to tumor cells. Specific biological components of this persistent inflammation may predict PD-1 inhibitor response. We have taken a novel approach to leverage national healthcare claims data that couples patient history with response to therapy. We have identified potential peripheral blood biomarkers of response to PD-1/PD-L1 inhibitors using a combination of healthcare outcomes and molecular markers that correlate with therapeutic efficacy.

Childhood sexual assault (CSA) refers to a sexual act that is imposed on a child or adolescent who lacks the emotional capacity, maturity, and cognitive development to understand what they are engaging in, and is incapable or unwilling to give consent. Many individuals who experience CSA also experience adult sexual assault, such as rape. To date, there is limited research that has examined early maladaptive schemas (EMS) and CSA, and no research that examines the relationship between CSA, EMS, and revictimization. The present study examined EMS as mediators of revictimization and mental health outcomes (i.e., depression and PTSD) among 263 college women who experienced CSA. Participants completed the Sexual Experiences Survey (SES-LFV; Koss et al., 2007) which assesses victimization and perpetration of unwanted sexual experiences, the Young Schema Questionnaire (YSQ-SF: Young, 1998) to measure early maladaptive schemas, Posttraumatic Stress Disorder Checklist 5, a brief self-report instrument consisting of 20 items that reflect the symptoms of PTSD outlined in DSM-5, and the Center for Epidemiological Studies Depression Scale (CESD-R; Radloff, 1977) is a brief self-report instrument used to measure symptoms of depression. As hypothesized, CSA was positively correlated with revictimization. CSA was correlated with EMS, specifically, emotional deprivation, mistrust/abuse, social isolation, defectiveness/shame, and self-sacrifice, but not abandonment. Surprisingly, EMS did not mediate the relationship between CSA and revictimization. EMS mediated the relationship between CSA and mental health outcomes, such as, depression and PTSD. EMS social isolation mediated the relationship between CSA and depression symptoms and EMS mistrust/abuse, social isolation, and self-sacrifice mediates the relationship between CSA and PTSD. In conclusion, our findings could be used to further investigate what appropriate early childhood interventions could possibly be used to address and treat early maladaptive schemas.