In the United States, African-American residents are an underserved population with evidence of higher health disparities than those associated with any other race, contributing to escalating health care costs. Despite the absence of health promotion and wellness training, pastors in predominately Black churches accept the responsibility for addressing more than the spiritual needs of their church members. The purpose of this qualitative grounded theory research study was to explore the perspectives of African-American Christian pastors on giving health guidance and their lived experiences as health promotion advocates. A total of 10 African-American Christian pastors were voluntarily recruited from 3 southern U.S. states using both purposeful and theoretical sampling strategies. Interviewing was the main data collection method. Social cognitive theory along with grounded theory were used to examine the interactions based on participants' points of view, and inductive analysis was also used. The results indicated that pastors have knowledge of their congregational members' health challenges and goals and have achieved positive health outcomes. The pastors also agreed that seminary should incorporate more information on health and wellness into the curriculum. These findings suggest that pastors, who are faith-based resources outside of health care systems, need to be educated, equipped, guided, and groomed as health leaders to assist efforts to reduce or eliminate health care disparities. Members of the clergy, their church members, and surrounding community residents would all benefit from the knowledge, understanding, and development of skills to change their unhealthy lifestyle habits and effective self- management of chronic diseases to achieve positive health outcomes.

Obesity, as defined as BMI at or above the 95th percentile on the Centers for Disease Control and Prevention’s growth charts, has increased almost 3-fold among children in the United States since 1980. Overweight in adolescence has been associated with increased fat retention and high blood pressure in adulthood, among other symptoms of metabolic syndrome. However, normative patterns of weight change in childhood have not been developed. Groups of children may follow different trajectory patterns of BMI change over time. If common trajectory patterns could be identified, and their risk factors and outcomes understood, more nuanced intervention with families and children at risk for obesity could be developed. This study used a national dataset of 1,364 children whose weight and length was measured 12 times from birth through 15 ½ years. Testing both latent class growth analysis and growth mixture modeling identified four distinct subgroups, or classes, of BMI growth trajectory from 24 months – 8th grade. These classes were compared on numerous demographic, biological, and psychosocial risk factors identified in previous research as related to obesity. Classes were differentiated primarily on the child’s BMI at 15 months, the mother’s BMI at 15 months, birth weight for age, and percent increase in birth weight. Being male, Black, and lower SES were also related to membership in the higher-BMI trajectory classes. Of the psychosocial factors, maternal sensitivity, maternal depression, and attachment classification were also related to BMI class. Membership in these trajectories strongly predicted weight-related and blood-pressure outcomes at 15 ½ years over and above individual risk factors, demonstrating that patterns of change themselves are highly influential. The best-fitting models of weight-related outcomes at 15 ½ years included change trajectory in combination with biological, psychosocial, and SES risk factors from 0-24 months, with R² ranging from .31 = .50. Characteristics predicting adolescent overweight can be identified in the first years of life and should trigger the development and implementation of early intervention protocols in obstetrics and pediatrics. / text

Family caregivers encounter immense negative consequences including decreased quality of life and increased rates of morbidity and mortality that stem from physical burdens, emotional distress, depression, social isolation, and loss of financial security. Although communication is an important aspect of caregiving, communication tasks are reportedly difficult for end-of-life family caregivers. The goal of this study was to explore the variety of communication stressors experienced by end-of-life family caregivers to gain insight into the communication tasks caregivers perceive as most difficult and the reasons why. Qualitative data was achieved through in-depth, face-to-face interviews with 40 caregivers currently providing care for a family member diagnosed with Alzheimer’s disease and related dementias (n=20; ADRD) and Glioblastoma (n=20; brain tumor [GBM]). A grounded theory approach was employed to gain insight into end-of-life family caregiver communication experiences. The results revealed that communication is perceived as a burden for end-of-life family caregivers. Not only does communication burden exist, end-of-life family caregivers experience immense tension and stress regarding a variety of relational contexts when communicating with the care recipient, others (family, friends), and clinicians. The results further revealed that communication burden stems from the caregiver’s attempt to negotiate between two opposing extremes: a desire to protect the patient and others versus a need to protect oneself. Thus, internal tension occurs when end-of-life family caregivers contemplate whether and how to engage in difficult conversations, and then again when following through. The presence of these contradictory tensions induced the emergence of barriers and therefore communication burden within various aspects of the end-of-life caregiver experience. Added insight into communication burden was achieved through a supplementary scale development study in a sample of ADRD and oncology end-of-life caregivers (N=263), which revealed communication burden as significantly associated with caregiver burden and quality of life. Implications for the advancement of interpersonal and health communication theory as well as practical tailored interventions targeting end-of-life family caregivers are discussed.

Research is necessary to uncover ways to improve adolescent nutrition and reduce obesity rates, particularly in the Appalachian region, which has high rates of food insecurity and adolescent obesity. The current study examines rural cultural norms about food, memorable messages adolescents received about nutrition, and the sources of identified memorable messages. Adolescents shared memorable messages during comprehensive, semi-structured, small group interviews in which participants revealed their individual experiences. Thematic framework analysis is used to present the range and nature of memorable messages about nutrition and to develop strategies for future health campaigns and interventions. This qualitative method of sequential inductive analysis provides transparency of data and resulting interpretations through thematic identification and indexing. Analysis revealed themes of messages that featured critical pieces of the rule-structure of memorable messages – specifically, adherence and consequence regarding nutritional behaviors. Prominent memorable messages of adherence included topics of balance (e.g., MyPlate), type (e.g., junk food), and timing (e.g., “don’t eat after 7 p.m.”). Messages with elements of consequence included communication of short-term (e.g., “breakfast gets your blood flowing) and long-term consequence (e.g., obesity, etc.). Adolescents identified family members, educators, and media as salient sources of memorable messages.

Researchers consistently conclude that finances and health are the two most significant factors associated with retirement decision-making and a successful retirement experience. Retirement planning is one mechanism by which individuals prepare for the retirement transition; however, retirement planning routinely emphasizes financial concerns, often to the exclusion of health or other significant aspects of retirement. Retirement planning is an increasingly relevant topic at a time when the population is aging, company-sponsored pensions and retiree benefits have diminished significantly, and reform is being sought for the long-standing social programs that have provided support for generations of older Americans. From a financial perspective, few would question the positive benefits associated with retirement planning; however, preparing for a healthy retirement is equally important. If a relationship between retirement planning and health status were to be established, Americans might find increased public and private support for individual retirement planning efforts, particularly among more vulnerable populations such as minorities and women. This dissertation explores the notion that engagement in retirement planning is associated with health status through three studies. Utilizing data from the Health and Retirement Study (HRS), the first article explores prevalence of plans for retirement among worker and retiree respondents, and compares health and other key characteristics associated with planning among the two sub-samples. The second and third articles focus on time order relationships between health status and retirement planning, with article two addressing the question of whether onset of poor health precedes planning for retirement and article three examining health status of planners versus non-planners, over time, to determine whether those who engage in retirement planning are more likely to realize better health outcomes. A brief review of th e health, retirement, and retirement planning literature provides the theoretical framework for these research questions and related hypotheses.This dissertation consists of five chapters. Chapter 1 is an introduction to the retirement planning and health literature, Chapters 2-4 describe the series of three studies conducted, and Chapter 5 discusses the overall conclusions as well as future directions for research.

This thesis used attachment theory and the common sense model of illness as theoretical backgrounds to examine the mechanisms that contribute to the quality of the support seeking behaviour and social interactions between patients with type 2 diabetes and their partners. Specifically, this thesis examined actor and spouse effects of working models of attachment on health outcomes, and illness perceptions on health outcomes for both patients and partners. Furthermore, it determined if support seeking, supportive interactions, and negative interactions mediated between the attachment and health outcomes and illness perception and health outcomes. At study entry, 70 patients with type 2 diabetes and their partners completed measures on attachment, illness perceptions, support seeking, receipt of supportive interactions and of negative interactions, satisfaction with support received, and health outcomes. Health outcomes included psychological distress and physical health for patients and partners, and diabetes well-being for patients only. Six months later, participants again completed measures on supportive and negative interactions, satisfaction with support received, and health outcomes. The data were examined both cross-sectionally (including mediational analyses) and longitudinally. The cross-sectional analyses revealed a number of actor and spouse effects in the relationships between attachment and health outcomes, and illness perceptions and health outcomes. Patients who scored higher on attachment-anxiety experienced higher levels of psychological distress and lower levels of diabetes well-being. Also, the partners of these patients experienced higher levels of psychological well-being. Furthermore, covert support seeking behaviour and negative interactions were found to be significant mediators between patient attachment-anxiety and patient psychological distress and diabetes well-being. In addition, support satisfaction mediated the relationship between patient attachment-anxiety and patient psychological distress. Illness perceptions, specifically timeline cyclical perceptions, were also shown to be related to health outcomes, and receipt of negative interactions. Patients and partners who scored higher on timeline cyclical experienced higher levels of psychological distress. Also receipt of negative interactions mediated the relationship between timeline cyclical and psychological distress. Some significant changes over time found when the data were examined longitudinally. For example, patients who scored higher on attachment-anxiety at study entry experienced higher levels of psychological distress over time, and had a partner who also experienced higher levels of psychological distress over time. In addition, partners who scored higher on personal control and who had a spouse (patient) who scored higher on timeline cyclical at study entry experienced higher levels of psychological distress overt time. Taken together, both the cross-sectional and longitudinal findings emphasize the contribution of the partner and his or her interactions with the patient to patient well-being. In the same manner, the results also highlight the effect of the patient’s illness on the partner’s well-being. These findings have important practical implications, especially for practitioners who aim to design intervention to help patients and their partners better adapt to the patient’s illness.

Conducting representative surveys of older people is challenging. This thesis aims to analyze a) the characteristics of individuals at risk of being underrepresented in surveys of older people, b) the systematic errors likely to occur as a result of these selections, and c) whether these systematic errors can be minimized by weighting adjustments.   In Study I, we investigated a) who would be missing from a survey that excluded those living in institutions and that did not use indirect interviews, b) how prevalence rates would be affected by these exclusions, and c) whether post-stratifying the data by sex and age (weighting adjustment) would correct for any systematic measurement error. In Study II, we compared mortality and hospitalization rates in those who responded to a postal questionnaire with rates in the target population. In addition, we tested whether a weighting variable created with a number of auxiliary variables could correct for the differences.   In Study III, we followed a longitudinal cohort sample for 43 years. By recalculating baseline characteristics at each follow-up, we investigated how the sample changed after a) selective mortality and b) survey non-participation. In Study IV, we investigated whether the systematic non-participation that is likely to occur in surveys of older people affects the association between education and health. In sum, the results of these four studies show that people in the oldest age groups, women, those of low socioeconomic position, and those with the poorest health tend to be underrepresented in surveys of older people. This systematic underrepresentation might lead to an underestimation of poor health and function, a bias that is unlikely to be corrected by weighting adjustments, and to an underestimation of health inequality between educational groups. The results also show that the selective mortality that occurs in longitudinal samples might be compounded by selective non-participation among the most disadvantaged groups. / <p>At the time of the doctoral defense, the following papers were unpublished and had a status as follows: Paper 1: Manuscript. Paper 2: Manuscript.</p>

The understanding that Attention Deficit/ Hyperactivity Disorder (ADHD) commonly persists into adulthood has not been widely accepted until recently. Accordingly, less is known about diagnostic and treatment prevalence or health and social outcomes of ADHD in adulthood. The objectives of this study were to: determine lifetime prevalence of ADHD diagnosis and treatment for Manitoba young adults, investigate whether a socioeconomic gradient exists within Manitoba young adults with a lifetime diagnosis of ADHD, and investigate the relationship between ADHD in Manitoba young adults and health service utilization. Using the Manitoba Population Health Research Data Repository, this cross-sectional analysis used 24 years of data (1984/85-2008/09) and included all Manitoba adults aged 18-29 during 2007/08-2008/09 with a lifetime diagnosis of ADHD. Crude prevalence was calculated for ADHD diagnosis and psychostimulant prescriptions, in addition to several demographic variables. The presence of a socioeconomic gradient in lifetime ADHD diagnosis was investigated using Poisson and negative binomial regression. Relationships between young adults with lifetime ADHD diagnosis and health service utilization for several health and social outcome variables were explored using a matched cohort design with two comparison groups and GEE regression models. In relation to previous Manitoba research on childhood ADHD, the socioeconomic gradient for ADHD diagnosis was found to dissipate into young adulthood. However, when region of residence was accounted for, a small inverse gradient in the urban population and a direct gradient in the rural population were evident. Individuals from the highest income quintile were significantly less likely to be diagnosed before age 18 than all other income quintiles. Depression, anxiety, personality disorders, conduct disorder, substance abuse, multiple types of injuries, receipt of income assistance, and reduced high school graduation were significantly correlated with lifetime ADHD diagnosis. Given the high lifetime prevalence of ADHD in Manitoba young adults, significant socioeconomic correlates for diagnosis, and multitude of adverse health and social outcomes in this population, further investigation into the trajectory of this relatively unexplored population is recommended. Furthermore, continued measurement of the provision and success of additional resources will ultimately be necessary for enhancing the health status of all Canadian adults living with ADHD.

The understanding that Attention Deficit/ Hyperactivity Disorder (ADHD) commonly persists into adulthood has not been widely accepted until recently. Accordingly, less is known about diagnostic and treatment prevalence or health and social outcomes of ADHD in adulthood. The objectives of this study were to: determine lifetime prevalence of ADHD diagnosis and treatment for Manitoba young adults, investigate whether a socioeconomic gradient exists within Manitoba young adults with a lifetime diagnosis of ADHD, and investigate the relationship between ADHD in Manitoba young adults and health service utilization. Using the Manitoba Population Health Research Data Repository, this cross-sectional analysis used 24 years of data (1984/85-2008/09) and included all Manitoba adults aged 18-29 during 2007/08-2008/09 with a lifetime diagnosis of ADHD. Crude prevalence was calculated for ADHD diagnosis and psychostimulant prescriptions, in addition to several demographic variables. The presence of a socioeconomic gradient in lifetime ADHD diagnosis was investigated using Poisson and negative binomial regression. Relationships between young adults with lifetime ADHD diagnosis and health service utilization for several health and social outcome variables were explored using a matched cohort design with two comparison groups and GEE regression models. In relation to previous Manitoba research on childhood ADHD, the socioeconomic gradient for ADHD diagnosis was found to dissipate into young adulthood. However, when region of residence was accounted for, a small inverse gradient in the urban population and a direct gradient in the rural population were evident. Individuals from the highest income quintile were significantly less likely to be diagnosed before age 18 than all other income quintiles. Depression, anxiety, personality disorders, conduct disorder, substance abuse, multiple types of injuries, receipt of income assistance, and reduced high school graduation were significantly correlated with lifetime ADHD diagnosis. Given the high lifetime prevalence of ADHD in Manitoba young adults, significant socioeconomic correlates for diagnosis, and multitude of adverse health and social outcomes in this population, further investigation into the trajectory of this relatively unexplored population is recommended. Furthermore, continued measurement of the provision and success of additional resources will ultimately be necessary for enhancing the health status of all Canadian adults living with ADHD.

Health outcomes fulfill a number of roles in the health sector. Economists, clinicians, researchers and managers use health outcomes in a range of different contexts for distinct purposes. New management approaches that use contracts as the basis for health service accountability have attempted to take health outcomes from their clinical role into a management setting. In particular, the purchasers and managers of some health services expect that service providers should demonstrate that they improve the health outcomes of their patients to justify their on-going funding. However, a number of organisations have experienced barriers to the application of the outcomes approach to health service management and there has been no systematic evaluation of the approach. Nor has there been an investigation into why purchasing organisations have difficulty introducing health outcomes into purchasing contracts. The result is that managers and purchasers continue to assign resources to the pursuit of health outcomes as an accountability tool. This thesis addresses two research questions around the use of health outcomes in community and allied health service accountability. The first is the barriers to the application of health outcomes to health services accountability. The second question examines the conditions that must be met before health outcomes can be used as an accountability tool in purchasing contracts for allied health. The research questions are addressed through the analysis of case studies that explore systematically the approach taken by two organisations, the Department of Veterans� Affairs and ACT Community Care, in their attempts to identify health outcomes that could be used in purchasing contracts for community and allied health services. The case study analysis uses a health services research approach that draws on multidisciplinary techniques including epidemiology, health services management and anthropology. The thesis describes the accountability interactions within the purchaser-provider model. Accountability is not a uniform construct. It consists of many domains, levels and interactions. In health service delivery, there are a number of different actors and a wide range of interactions for which they are accountable. Two important interactions are identified: professional accountability, which describes the accountability of the health service professional to their patient; and contractual accountability, which is the obligation of the health service provider (or providing organisation) to the purchaser through their contractual agreement. I conclude that health outcomes are not an appropriate domain of contractual accountability but they are an important component of professional accountability and I discuss the implications of these finding for theory and practice.