Background: Integration of social services (e.g., civil registration, community mobilization) with public health and primary care has been recommended as a key strategy by practitioners, researchers and policy-makers to solve the multifactorial determinants of chronic diseases. Despite efforts to increase service integration in the past 50 years, there is limited evidence on effective approaches to integrating myriad services. This study investigated the influence of individual- and organizational-level factors, and job characteristics on service integration using 262 providers from the Estratégia Saúde da Famí­lia teams. Brazil's Sistema Úšnico de Saúde is acknowledged worldwide as a model for studying integration as FHS transdisciplinary teams, which comprise of Community Health Agents (in Portuguese, Agentes Comunitário de Saudi or ACS), nurses, and physicians, are mandated to integrate services. Methods: Cross sectional data were collected from 168 ACS, 62 nurses and 32 physicians in Mesquita and Santa Luzia. Service integration was measured by three services: HIV prevention, community mobilization, and civil registration. HIV prevention refers to biomedical interventions that prevent the spread of HIV by blocking infection (e.g., condoms), decreasing infectiousness (e.g., antiretroviral therapy), or reducing acquisition/infection risk (e.g., medical male circumcision). Community mobilization is the participation of citizens in activities, such as community walks, geared towards understanding their sociopolitical environment. Civil registration is the documentation of deaths, births and household information. Multiple logistic regression analysis and Structural Equation Modeling (SEM) were used to identify salient job characteristics, individual- and organizational-level factors associated with the three measures of service integration and service integration in itself. Individual factors were measured by providers' confidence, knowledge and skills, community familiarity, perseverance, and efficacy of the FHS team. Job characteristics were measured by transdisciplinary collaboration, provider's autonomy in making decisions, skill variety (ability to use a set of diverse skills); and consumer-input. Organizational factors were measured by work conditions and resources. Results: Majority of participants were ACS (64%); 24% nurses; and 12% physicians. Of the sample, 82% were females (n =214). The highest proportion of participants identified as pardo (multiracial; n= 123; 46%); 82 (31%) as white; and 54 (21%) as black or Afro-descent. The mean age was 34 (SD = 10); ranging from 20 to 70 years. Results from the multiple logistic regression indicated that pardo providers, ACS, providers with a caseload of more than 500 usuária (service consumers), reported greater perseverance, and less work methods autonomy had greater odds of offering HIV prevention services. Providers with higher levels of knowledge and skills, greater confidence and skill variety had greater odds of engaging in civil registration. Providers who identified as pardo, had less than 5 years or 5 years of work experience with the FHS, reported higher levels of knowledge and skills and greater skill variety had greater odds of mobilizing communities. Providers with experience of 5 years or more reported more service integration. After accounting for all variables, community mobilization, HIV prevention, and civil registration were strongly correlated. The following variables positively influenced service integration: higher levels of knowledge and skills; greater discretion by the job to use a variety of skills, confidence, and perseverance. Greater work-methods autonomy and decision-making autonomy were negatively associated with service integration. No organizational-level factors influenced service integration. Conclusions: This dissertation initiates a conversation in the literature on a framework to studying service integration. Provider trainings globally should incorporate activities that enhance providers' confidence, perseverance, knowledge and skills, and ability to make decisions on the spot use diverse skills while integrating services. While Brazil's FHS program endorses transdisciplinary collaboration as a process for providers to integrate services, transdisciplinary collaboration was not significant predictor. Greater research needs to be designed and implemented in collaboration with providers to assess their perceptions of transdisciplinary collaboration. Research going forward also needs to be conducted on how organizational level factors impact service integration.

For many American adolescents, the decision to delay pregnancy is a manifestation of attitudes and behaviors which increase their ability to avoid unplanned pregnancies. Poor self-perception and external locus of control, in turn, are considered to be major determinants of the quality of decisions that many adolescents make. Research informs us that many factors: family, environmental and psychological, come together to motivate the adolescent's self-perception and perception of the risks of pregnancy and childbearing. To motivate the freshmen at an inner city high school, a three phase program of interventions using professional staff from a nearby hospital was developed. Built into this program was a research component based on the classic experimental design. The sixty students in the experimental group met once weekly for eight weeks in small groups of 10-12 each, to learn social interaction, communication, and decision-making skills as well as family planning and male/female sexual responsibility. Additionally, condoms were distributed free of charge along with encouragement to use them whenever a decision was made to have sex. The six week career mentorship component of the program made it possible for these students to try out a possible life career by spending time with a professional person in a chosen area of health care. The students then returned to their groups for a six week termination phase. Pretesting, based on the Nowicki-Strickland test and the Rosenberg scales showed no differences between the control and experimental groups, and incremental improvement after treatment which was not statistically significant, however, posttests results show a significant increase in the use of contraception amongst sexually active program participants. In addition, frequency of sexual activity decreased by more than one half after treatment. Students who completed the program participated in a graduation ceremony and were given certificates. These young men and women gave very positive evaluations to the program. More significantly, many of them have returned as volunteers and peer mentors to work with a new group who have just started the new program cycle.

This dissertation employs qualitative and quantitative methods to examine the relationship between religion and sexual HIV risk among 1,342 male migrant workers from Kyrgyzstan, Tajikistan, Uzbekistan, and Kazakhstan, employed in Baraholka Market, located in Almaty, Kazakhstan. Drawing on a conceptual theoretical framework which incorporates decision-making, social support, and gender and power theories, research questions examine how religion contributes to engagement in or avoidance of sexual HIV risks through the mechanisms of decision-making, social supports, and gendered norms; whether affiliation and religiosity are associated with sexual HIV risks; and whether changes in religiosity over time are associated with sexual HIV risks. Study findings identified that most men were Muslim and religious norms contributed to their understanding of sexual relationships. Some associations with protective behavior were found for men who were Muslim, men with higher levels of religiosity, and men who maintained higher than average religiosity over time. Men with higher than average religiosity were more likely to consider themselves protected from acquiring HIV. Study findings have a number of implications for HIV prevention efforts in Central Asia.

Parents are central to adolescents’ lives and extensive research shows that parents can influence adolescent and young adults’ sexual decision-making in positive ways. However, the ability of interventions to help parents influence their children’s sexual health has been modest. In many cases, interventions for parents have not been guided by theory or strong research and many interventions for parents are based on only a general sense that more communication between parents and their children on topics related to sexuality is helpful. Currently, millions of dollars in public funding in the United States are designated for programs to reduce teen pregnancy and prevent sexually transmitted diseases. In addition, many foundations and individuals contribute significant funds to organizations that implement programs that strive to improve adolescent sexual health. Increasingly, there is an interest in including program components for parents in order to help them to positively influence their teens’ sexual decision-making. At this time, few interventions for parents related to influencing their teens sexual decision-making and behavior have been developed that have resulted in positive outcomes, with the notable exceptions of Families Talking Together and Get Real: Comprehensive Sex Education that Works, which have both been added to the United States Department of Health and Human Services list of evidence-based programs in the last 18 months. In order to develop additional interventions of benefit to parents and adolescents and to ensure that policy and practice are strengthened, up-to-date information from large, diverse samples about the frequency and content of family communication about sexuality currently taking place between parents and teens is critical. Few studies have allowed for direct comparison of African American, Hispanic and White families in terms of communication about sexuality and parental monitoring of adolescents. Understanding both similarities and differences can help with tailoring interventions to have more positive effects on teen sexual decision-making and behavior. One challenge to better understanding the influence of parental communication on adolescent sexual health is the wide variety of measures used in research, with some studies relying only on single item measures of communication. Without consistent measurement of communication and its many facets, it is difficult to ascertain which aspects of communication may be the drivers of behavior or to compare results across studies. Scales with strong psychometric properties are needed to strengthen the consistency and quality of research on parent-child communication about sexuality. Further, these scales must be tested with samples that include participants that are racially and ethnically diverse and samples that include fathers and mothers, as well as teen males and females to allow for scales to be validated by gender and race/ethnicity and for both parents and teens. The current study resulted in the development of three new scales with strong psychometric properties, which can now be used in research on parent-child communication about sexuality. This study also allowed for an examination of current barriers to communication about sexuality including the ways that those barriers differ and influence communication for African American, Latino and White parents and teens. Further, understanding the role that monitoring can play in promoting teens’ sexual health also merits up to date exploration as well as greater understanding of whether monitoring practices vary in diverse families or for teen males compared to females is needed to increase awareness of opportunities for positive influence on young people’s sexual development. The current study is particularly valuable given that many data sets do not allow for direct comparisons of African American, Latino and White teens and parents. The extent to which family communication or monitoring practices differ may suggest ways that interventions should be tailored for various populations or may suggest positive practices that can be promoted across groups. In addition, a current understanding of how communication and monitoring may vary with sons compared to daughters can provide awareness and insight to both parents and program developers about the types of parenting behaviors that might be addressed by programs and improved in order to make a difference in the lives of young people. The papers in this dissertation utilize data collected from 1,663 parent-child dyads in July, 2014 by Gfk, Inc. Gfk, Inc. has constructed a large, diverse panel of adults in the United States. They recruit their panel using a combination of random digit dial phone techniques and address-based sampling. More information on the construction of the overall Gfk, Inc. panel is available at: http://www.gfk.com/us/Pages/default.aspx. For this study, parents were sampled from the broader Gfk, Inc. panel using e-mail invitations and were asked to consent on behalf of themselves and one of their children between the ages of 9 and 21. For non-Latino White parents, a random selection of parents were invited. All Latino and African American parents in the panel were invited to participate. An algorithm was used to request which of the parent’s children to invite when a parent had more than one child in the eligible age group which was age 9-21. The organization requesting the data had a particular interest in 15-19 year olds and the algorithm was constructed accordingly. Within a household, when there was more than 1 child in the 9-21 year old age range, 15-19 year olds were selected at a 3:1 ratio (e.g. when there was a 15-19 year old and a 9-14 year old or a 20-21 year old in the same household, for every three times a 15-19 year old was selected, a non-15-19 year old was selected one time). The final sample included 749 teens ages 14 and younger, 740 teens ages 15-19, and 174 teens ages 20-21. In addition to parental consent, teens assented for their participation in the study. The parent questionnaire contained 91 items and the teen questionnaire contained 46 items. The median completion time was 17 minutes. Seven hundred eleven Whites, 300 African Americans and 652 Latino dyads completed the surveys. One thousand eighty one mothers and 582 fathers completed the surveys and 801 girls and 862 boys completed the surveys. Surveys for parents were customized using the name of the child that parents stated would take the survey and teen surveys were customized to include the term father or mother based on which parent had completed the survey. I completed a preliminary analysis of the demographics of the study sample compared to available nationally representative data prior to beginning the research for the dissertation. That analysis immediately follows this introduction. The three papers follow. Paper 1 is a confirmatory factor analysis on five potential scales for measuring parent-child communication about sexuality and barriers to communication. Paper 2 explores parent-child communication about sexuality related topics including differences in communication by race/ethnicity, gender and age and whether communication is associated with changes in the likelihood of adolescents’ ever having engaged in any sexual behavior, ever having engaged in oral sex, ever having engaged in vaginal sex, consistency of condom use in the past 3 months and/or consistency of birth control use (other than condoms) in the past 3 months. Paper 3 examines parent and teen reports of parental monitoring and the association between monitoring and sexual behavior outcomes as well as differences in monitoring among African American, Latino and White families and of sons compared to daughters. Conclusions and implications follow the third paper.

In the context of decreasing or plateauing HIV incidence among multiple risk groups in United States, new HIV infections among gay, bisexual, and other men who have sex with men (MSM) continue to rise. Syndemic theory has become a well-established framework for the explanation of how individual experiences and social conditions influence both an individual’s disease experience and the distribution of disease across populations. This framework is currently defined as “a set of enmeshed and mutually enhancing health problems that, working together in a context of deleterious social and physical conditions that increase vulnerability, [and] significantly affect the overall disease status of a population.”1 An important and robust body of literature has been amassed investigating syndemic burden and its association with HIV status, HIV incidence, HIV-related sexual risk behaviors, and more recently, antiretroviral (ART) medication adherence and viral suppression among HIV-positive MSM. Many of the studies that comprise this literature have several things in common. They are mostly focused on enmeshed individual-level risk factors; that is, this literature largely focuses on co-occurrence of these health problems and the increased vulnerability to HIV that may develop as a result. Even more importantly, most of these studies focused on a small subset of these risk factors: childhood sexual abuse, depression, intimate partner violence, polydrug use. These studies also largely ignore the synergy (defined as biological interaction on the additive scale or deviations from additivity) implied in the mutually enhancing language of this framework. Finally, this literature is also unable to account for the “deleterious social and physical conditions” that give context to the individual-level burden. Taken together, the body of studies present an important but not fully realized use of this framework. This dissertation seeks to investigate all three major facets of the syndemic framework: the individual-level co-occurring syndemic factors, the implied synergy, and the social and physical conditions that surround and influence the individual. It will do so in three steps, broadly defined by a systematic literature review followed by two analytic papers. The literature review will serve as a guide to the syndemics literature among MSM, and will identify the constellation of experiences that have been identified as syndemic factors. The identified experiences will be used to guide the first analytic paper, which will incorporate those experiences into syndemic burden, which will then be modeled using latent class modeling (LCA) to investigate if there are any patterns of syndemic burden that may be important to intervention development. This first analytic paper will also explicitly investigate synergy by calculating the attributable proportion due to interaction (AP). Finally, the second analytic paper will incorporate the “deleterious social and physical conditions” using multilevel latent class modeling (MLCA).

The dearth of public health leadership and lack of leadership development in higher education for public health, reported by the Institute of Medicine Committee for the Study of the Future of Public Health, prompted this study of leadership perspectives in schools of public health and the practices and behaviors of contemporary public health leaders and their followers. Ambiguity between management and leadership was evident. Academic responders identified transactional leadership roles and relationships more often than those of transformational leadership. Leader and follower ratings of leader performance were most often 'moderate' indicating that leaders sometimes or fairly often exhibit exemplary leadership practices and behaviors. Variances between academic and practice findings suggest that, although many graduates do become leaders in public health, this may not be an outcome of the educational experience. Content and comparative analyses identify twelve concepts of transformational leadership which form a framework for course content in leadership development for public health.

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