Doctor of Philosophy (PhD) / Exercise and physical activity have many benefits for adults with cystic fibrosis (CF), including the potential to aid mucus clearance, improve lung function, exercise capacity and quality of life. Despite the recommendations from consensus documents for CF adults to engage in regular physical activity, exercise participation amongst this population is often very low. No in-depth study has been undertaken to explore the determinants of exercise participation for this group and no studies have examined the benefits of habitual physical activity on the health status and quality of life of CF adults. As well, the current methods to quantify physical activity are problematic. The series of studies, involving CF adults, in this thesis was therefore undertaken in order to examine the physiological rationale for the use of exercise as an airway clearance technique, to understand the decision making process to engage in exercise, to determine if health status and quality of life were affected by exercise participation, and to establish the accuracy of a recently-developed objective measure of physical activity. The study in Chapter 2 provided some physiological rationale for choosing treadmill exercise to aid airway clearance in CF. The main findings were that a single bout of moderate intensity exercise increased the subjective ease of expectoration, most likely due to the increased ventilation with exercise, and that sputum viscoelasticity was favourably decreased immediately following treadmill exercise compared to cycle exercise and control. The studies in Chapters 3 and 4 identified the main beliefs regarding exercise for CF adults and highlighted that the main predictors of exercise intention and participation for this group were aspects of perceived and actual control to exercise, namely self-efficacy or confidence to exercise, feeling healthy, receiving encouragement to exercise, and rating exercise as a high priority treatment. Positive ratings of these aspects of control either increased exercise participation directly, indirectly by increasing intention, or strengthened the conversion of exercise intention to participation. Strategies aimed at targeting these aspects of control are therefore likely to be effective in increasing exercise participation for CF adults. The study in Chapter 5 demonstrated that CF adults, who reportedly performed at least 90 minutes of moderate to strenuous exercise per week, had significantly higher quality of life and fewer days in hospital over the following year than their peers, who exercised less. The difference in hospitalisation between the CF adults, who reportedly exercised more than 90 minutes per week and those who did not, was independent of baseline lung function, and the females who reportedly performed less than 90 minutes of exercise per week had three times as many days in hospital than their high-activity peers. The study in Chapter 6 showed that the SenseWear Pro3 Armband activity monitor provided a reasonable estimate of energy expenditure and step count. Also, its accuracy was not affected by diagnosis with CF, despite the potential for the high salt content in the sweat to interfere with the device’s physiological sensors placed on the skin. Overall, this series of studies adds to the growing evidence of the physical and psychological benefits from exercise participation for CF adults, as well as providing some empirical evidence upon which to base strategies to improve exercise participation for this group and support for an objective measure of physical activity.

Studies have shown that health outcomes are disproportionately worse for homeless individuals as compared with individuals with stable housing (Brickner, Scanlan, and Conanan 1986); however, the unique coping mechanisms that they employ to protect their health have been largely understudied. Better understanding of attitudes and behaviors that individuals adopt to maintain their health, collectively termed “self-care” is imperative to the design and implementation of effective public health interventions for this population. The purpose of this thesis is to better understand both the barriers and coping strategies of transient populations. The two research questions guiding this thesis are: What barriers to health do transient residents in high-risk neighborhoods experience, and how do they mitigate the perceived or existing barriers? Findings from this analysis indicate that the most salient barriers for transient populations are lack of transportation, lack of health insurance, beliefs about health, and mental illness. The agency exercised by participants to improve their own health outcomes has important implications for the efficacy of health promotion campaigns and health policy aimed at high-risk populations.

Background: there is limited research to show that a social intervention such as increasing income improves health, especially as this relates to older people. It is known that poverty is a real problem for many older people in Northern Ireland. One reason for this is that older people often do not claim the financial benefits for which they are entitled. This is a randomised controlled study that sought to investigate the health effects of an increased uptake of social security benefits. Methods: The aims of this study were to find out if an increase in income through the take up of unclaimed financial benefits lead to a significant improvement in the health status of older people and discover if this was maintained over a reasonable period of time. This was a randomised control trial based in the community. Patients were recruited from 11 general practices in South Down, Craigavon, Fermanagh and Tyrone. The intervention consisted of a benefit assessment followed by assistance completing the benefit application. The control group received the assessment but were not give assistance with the application. Instead they were given a list of agencies where help with the application could be found. A range of health, psycho-social and financial outcome was measured. Results: Of the 2180 patients who were sent invitation letters 300 agreed to a benefits assessment. 189 enrolled in the study and 149 were followed up at six months. A total of 89 patients received additional weekly benefits amounting to approximately £3277.19 per annum (£63 per week). A further 13 patients received one off payments totaling £5,731.01. All but two patients received their benefits within three months of assessment. While analysis showed trends suggesting greater improvements in social support and depression scores for the intervention group when compared with the controls the difference were not statistically significant. This is probably due to the following factors. The sample size in this study was small because of problems with the recruitment and screening of patients. More patients in the control group claimed benefits than had been anticipated and as a result it was difficult to detect differences between the two groups. Discussion: Valuable lessons have been leant and modifications to the study methodology have been suggested that will be of use to other researchers attempting to undertake similar studies in the UK.

Alloparenting has played a pivotal role in every society throughout human history in ensuring the survival and healthy development of children. A large amount of theory (e.g. kin-selection) and evidence exists to support this claim, and though alloparenting is certainly not unique to humans, it is difficult to suggest that any other species benefits from it more, and certainly not one as ubiquitous as Homo sapiens. However, there is a surprising dearth of empirical research examining the causes of individual variation in the amount and type of alloparental behavior that a child receives, and what effect this variation has on previously validated measures of child well-being. We propose how different measures of familial relatedness and the spatial distribution of relatives might be used to predict the amount and type of alloparental care a child receives, and how these variables may interact to affect a child’s health. We employed a variety of different methods; genealogical modeling, genetic analysis, geospatial mapping, ethological behavioral observations, and anthropometric measurements in order to generate objective data to test these predictions. As members of a relatively isolated native people in Sonora, Mexico, our study population (the Comca'ac) is uniquely suited to help us test our hypotheses. From just this pilot study, we have made many methodological developments and found strong support for many of our hypotheses. There are many new questions to answer as well, which together suggest the future directions for an intensive study of a broader sample of this population, and alloparental behavior in humans in general.

Background: Parental substance use puts children at risk for poor outcomes. Estimates indicate that 66% of substantiated cases of maltreatment are of parents with substance use disorders (SUD). Some parents with SUD have the opportunity to be treated through two accountability courts including Drug Courts (DC) and family treatment courts (FTC). Purpose: Little is known about the children of parents who participate in treatment through DC’s via the criminal justice system. This study examined differences in parents and their children who receive treatment through FTC’s and DC’s with the notion that DC’s could serve as an important treatment venue for improving child outcomes, which is a major focus of FTCs. Methods: The data used for these analyses are the baseline data of a quasi-experimental study involving two DC’s and two FTC’s across Georgia. The intervention included the implementation of evidence-based parenting and trauma services at one drug court and at one family treatment court, while the other courts served as controls. At each court, participants, one other caregiver, and one child were invited to participate in the project by completing an annual assessment. This included computerized surveys and a videotaped play and talking activity with each adult with the child. Measures included demographics, parenting behaviors, mental health measures, social support, and child mental health measures. All data used in the analyses were collected at baseline and thus prior to intervention. Participants were 80 DC triads and 25 FTC triads (DCP, another caregiver, and child). Results: Compared to DC, FTC clients were more likely to be female (p = p = p =.014). They also had younger children (p = .05) and were more likely to have custody of those children (p =.0015). Parents in FTCs compared to those in DC reported greater social support (p =.05) and better family functioning (p =.03). Parents in DCs reported poorer parental involvement and poorer monitoring of children than FTCs, but no differences in positive parenting (p =.13), inconsistent discipline (p =.27), or child abuse potential (total risk > 9, p =.42; total risk >12, p =.37). Regarding mental health, DC clients reported a greater number of symptoms or poor mental health than FTC. No differences were found for education level (p =.96), parent-child communication skills (p =.38), post-traumatic stress symptom severity (p =.62), or child behavior problems. Conclusion: These data show some differences between FTC participants and DC participants that can affect child outcomes. FTC parents were more involved in their children’s lives and DC parents had greater mental health problems that could interfere with parenting. Interventions are needed, especially for DC client to strengthen the parent-child relationship and improve parenting outcomes.

Diabetes self-management, an essential component of diabetes care, includes weight control practices and requires guidance from providers. Minorities are likely to have less access to quality health care than White non-Hispanics (WNH) (American College of Physicians-American Society of Internal Medicine, 2000). Medical advice received and understood may differ by race/ethnicity as a consequence of the patient-provider communication process; and, may affect diabetes self-management. This study examined the relationships among participants’ report of: 1) medical advice given; 2) diabetes self-management, and; 3) health outcomes for Mexican-Americans (MA) and Black non-Hispanics (BNH) as compared to WNH (reference group) using data available through the National Health and Nutrition Examination Survey (NHANES) for the years 2007-2008. This study was a secondary, single point analysis. Approximately 30 datasets were merged; and, the quality and integrity was assured by analysis of frequency, range and quartiles. The subjects were extracted based on the following inclusion criteria: belonging to either the MA, BNH or WNH categories; 21 years or older; responded yes to being diagnosed with diabetes. A final sample size of 654 adults [MA (131); BNH (223); WNH (300)] was used for the analyses.The findings revealed significant statistical differences in medical advice reported given. BNH [OR = 1.83 (1.16, 2.88), p = 0.013] were more likely than WNH to report being told to reduce fat or calories. Similarly, BNH [OR = 2.84 (1.45, 5.59), p = 0.005] were more likely than WNH to report that they were told to increase their physical activity. Mexican-Americans were less likely to self-monitor their blood glucose than WNH [OR = 2.70 (1.66, 4.38), pThese findings indicate a need for patient-provider communication and care to be assessed for effectiveness and, the importance of ongoing diabetes education for persons with diabetes.

Parkinson disease (PD) is the second most common neurodegenerative disease worldwide, with estimates suggesting that PD prevalence and incidence will increase with aging populations. Therapeutic options and clinical guidelines for PD have significantly changed over the past 15 years; however, pharmacoepidemiology data in PD are lacking, especially regarding adverse effects of non-ergot dopamine agonists (DAs) and outcomes associated with anticholinergic burden. The objectives of this doctoral research are threefold: 1) examine patterns of antiparkinson drug use in relation to clinical guideline publication, drug availability, and emerging safety concerns; 2) determine whether PD patients treated with non-ergot DAs are at increased risk of adverse cardiovascular or cerebrovascular outcomes; and 3) determine whether anticholinergic burden is associated with adverse outcomes in PD. Specific research questions were investigated using epidemiological methods and electronic health data from Cerner Health Facts®, an electronic medical record database that stores time-stamped patient records for more than 300 Cerner subscribing facilities across the United States. Findings from this work are reported in a series of manuscripts, all of which have been published. Key findings include: 1) DA use began declining in 2007, from 34% to 27% in 2012. The decline followed publication of the American Academy of Neurology’s practice parameter refuting levodopa toxicity, pergolide withdrawal, and pramipexole label revisions; 2) heart failure was the only adverse cardiovascular or cerebrovascular outcome that demonstrated a significant association with non-ergot DA use, mainly pramipexole; and 3) anticholinergic burden in PD was associated with the diagnosis of fracture and delirium, and significantly increased the risk of emergency department visit and readmission post inpatient discharge. Reported antiparkinson prescribing trends suggest that safety and best practice information may be communicated effectively in PD. Although findings warrant replication, individuals with PD and independent risk factors for or a history of heart failure may benefit from limited use of pramipexole. Similarly, individuals with PD may benefit from substituting non-PD medications with anticholinergic effects for equally effective non-anticholinergic agents. Additional pharmacovigilance studies are needed to better understand health risks and the impact of population health interventions in PD.

The current study empirically tested four models of type II diabetic patient adherence, including wellness, screening, medication, and treatment adherence. Four mediators were proposed patient understanding, agreement, trust, and motivation were tested for each model. The current study is grounded in patient-centered communication, responding to Street’s (2013) call to model pathways between communication and patient health outcomes. Moreover, the study argues that adherence, for type II diabetic patients should be conceptualized as four distinct clusters of behavior (wellness, screening, medication, and treatment). A sample of (n=817) type II diabetes patients from the U.S. under the care of a medical provider and taking medication for their type II diabetes were surveyed. Findings from the present study indicate that the relationship between patient-centered communication and patient-health outcomes is mediated by proximal outcomes. The results contribute to our understanding or patient-centered communication, patient understanding, agreement, trust, and motivation, and adherence behaviors. Resulted indicated that while three of the four proposed hypotheses were supported, the most commonly studied type of adherence (medication), the relationship between patient-centered communication and medication adherence was not mediated. The current study ends with a discussion and implication of the findings as well as directions for future research

Research has documented the adverse health outcomes that may result from experiences of sexual trauma and medical mistrust. Stigmatization as a result of sexual trauma experience(s) may also cause significant distress. The current study examined the effect of sexual trauma stigma and the potential mediating role of medical mistrust on health. Resiliency was examined as a potential moderator, as it may buffer sexual trauma stigma’s effects on medical mistrust and health outcomes. A sample of 482 women with a sexual trauma history completed questionnaires regarding health and sexual trauma stigma. Study data was analyzed in SPSS v.25 and included correlations and moderated-mediational analyses. Results demonstrated that sexual trauma stigma and medical mistrust independently predicted somatic symptom burden but not BMI. Medical mistrust and resiliency did not emerge as significant mediators/moderators. Limitations include a homogenous sample and possible measurement error. Future research of other maintaining mechanisms is warranted.

<p>Obesity is a major public health problem globally and in the United States (U.S.). Amongst adults in the U.S., prevalence estimates of obesity reached 42.4% in 2017-2018 [1]. Obesity is both a contributor and outcome of chronic disease development including type 2 diabetes and metabolic syndrome [2,3]. Underlying modifiable risk factors for these chronic conditions include lifestyle habits such as dietary intake and physical activity. </p><p>Much of nutrition research investigating the relationship of dietary intake to health outcomes has taken a reductionist approach with a focus on single nutrients and food groups; however, the complexity of the overall diet with all its constituents is being increasingly recognized. Dietary patterns examine the quantities, frequencies, and combinations of food and beverages consumed allowing a more comprehensive investigation of the diet-health relationship [4], yet, the concept and creation of patterns have not considered elements beyond nutrients and food, such as time of eating, which could be an important aspect of dietary patterns. Moreover, most physical activity research has focused on the effect of intensity or counts of activity on health [5–8], while studies investigating daily physical activity patterns have focused on distinct time periods i.e., type of day (weekday vs. weekend) or seasonality [9,10]. Nevertheless, connecting these patterns to health outcomes through the integration of time across an entire day has received little attention.</p><p>Studies that have incorporated time to the concept of dietary patterns focus on behaviors such as breakfast skipping and late meal consumption and show associations with health [11–14]. For instance, compared to early lunch eaters, late lunch eaters lost less weight and had reduced glucose tolerance [15,16]. In contrast, studies that have investigated timing of exercise focused on early vs. evening exercise [17–19]. For example, exercise performed in the morning vs. evening has been associated with a greater reduction in weight and odds of obesity [17,18]. Furthermore, several studies have investigated links between timing of exercise relative to a single meal or over a single day with health [20–24] and revealed a potential benefit to modulating time of these behaviors on postprandial metabolic response. Together, these studies establish the importance of timing of these behaviors in terms of links to health; however, studies are limited by a focus on single time spans or blocks of time in a day. Consideration of the patterns of dietary intake and activity throughout a day, or “temporal dietary and physical activity patterns”, are a novel concept that may provide insight to the behavioral patterns related to health outcomes. Notably, one of the challenges in this work is utilizing methods that will characterize dietary and physical activity patterns as an exposure by integrating timing and other characteristics of these patterns in relation to health. </p> To our knowledge, there are no published reviews that have emphasized joint consideration of the time of eating and exercise, with a focus on the time of day of these events and association with health outcomes. Therefore, Chapter 1 focuses on summarizing current literature that has integrated both of these concepts by answering the question, how does the timing of exercise relative to eating throughout the day effect postprandial response in adults? Moreover, Chapters 2 and 3, include primary research in which a novel distance measure, based on dynamic time warping, is used to develop independent temporal dietary and physical activity patterns over a 24-hour period using data from the National Health and Nutrition Examination Survey and examine their association with short- and long-term health outcomes.