The health effects of silica and the connection to occupational exposure has been known for years. In March of 2016, the Occupational Safety and Health Administration (OSHA) of the Department of Labor (DOL) published a new standard meant to reduce workers’ exposure to silica. The standard update was set forth to further protect workers; OSHA estimates this revision will prevent more than 600 silica-related deaths each year. A key feature of the updated OSHA standard emphasizes the use of engineering controls and work practices in certain industries. Material handling of industrial sand is a known cause of silica overexposure in many industries. A novel sand coating technology designed as an engineering control has been tested to reduce worker exposure to airborne silica. This study looked at whether the airborne silica concentrations could be reduced by applying this technology. Area air samples were collected for baseline samples along with coated samples, which were analyzed for respirable dust. The percent reduction was calculated to determine if the coating was able to reduce the airborne silica concentration. This study found that the application of the coating was able to reduce the airborne silica concentration, but the reduction did not meet the benchmark of 80% as set forth for the study. Additional studies to refine application and dosage of the sand coating may result in meeting this benchmark in future studies. Study limitations include small sample size and the truncated sampling time period for some of the samples collected, along with meteorological and site conditions.

The design of the decentralized co-operative governance system, conditioned and regulated by the South African constitution is of critical importance for policy design and implementation. The division of powers falls within a unitary form of government. This study, which is about the processes, mechanisms and modalities of public policies design and implementation uses the public finance and health sectors, as a case study or lens through which policy design and implementation is examined within a decentralized cooperative governance system. The study is per se not about the public health system, but rather a review and an analysis about how the decentralization and cooperative governance nature, practice and dynamic of government system, influences and condition the policy processes and practice on finance and health, separately and collectively within the public health system. In its attempt to unbundle the health function, but also reform the public health system, central and provincial governments have introduced a number of reforms. These reforms were ostensibly driven by different policies and programmes originating either from the public finance or public health sectors with significant consequences for the provinces. Moreover, these different policies also outlined structural and functional responsibilities and authority among the central and provincial government departments. The implementation of these policies was at times based on different interpretations of policy design and implementation responsibilities and authority between the central and provincial governments within co-operative governance system. The argument of this study is that despite intentions implicit to public policy, co-operative governance system is contested at a central government level within the public health system, as well as between levels of government and the public health and finance sectors. This dissertation explores the nature of the relationship between the central and provincial governments by exploring co-operative governance in the health sector on policy and financing processes and mechanisms. The central question is how does decentralized co-operative governance really work in the public health system? A case study method was used to conduct this research. Data was collected over a four and half year period using a variety of data collection methods, including semi-structured in-depth interviews; documents and reports analyses; policy content review and analyses; and revenue and expenditure reviews and analyses. The study’s findings are: a) the functional and structural decentralization of policy-making and implementation within the co-operative governance system contributes to undermining the cooperative governance relationship between the public finance and health sector and central and provincial governments; b) the central government is using its overriding powers to “impose co-ordinated solutions” to problems within the co-operative governance system, leading to situations where ‘imposed co-ordination’ is considered as ‘co-operative governance’; c) the theory provides a classical distinction between state control, supervision and interference models. This dissertation shows that, depending on the policy context and circumstances, the uniqueness of South Africa’s co-operative governance system allows the central government to mobilize any of these models to achieve its policy intentions, whether written or unwritten; and d) the classical arguments of decentralization, particularly within a devolved system of co-operative governance where greater autonomy and authority are given to subnational governments, are found wanting within the South African governance system, given both the policy-making and fiscal resource strength of the central government relative to the provinces. This dissertation leads me to conclude that the South African practice of co-operative governance in the health system is actually imposed co-ordination and that provinces are de facto administration outposts of central government policies, programmes and service delivery responsibilities. Therefore in reality there is no autonomy and independence of the provinces from the central government as envisaged in the Constitution of the Republic of South Africa. In fact, provinces only exist, in terms of their constitutional competencies as far the central government allows it to exist given its plenipotentiary powers over both micro and macro matters affecting institutions, fiscus and social policies.

OBJECTIVE: Parental depression is considered amongst the greatest risk factors for the diagnosis of depression in children and adolescents. Less is known about how and to what extent parental depression influences their depressed children’s depression treatment. Building on Bronfenbrenner’s ecological model and Andersen’s model, this study aimed to assess the impact of parental depression on depressed children and adolescents’ depression treatment. DATA/STUDY POPULATION: Children and adolescents aged 3 to 17 diagnosed with depression in MarketScan Claims and Encounters Database (2010–2014) METHOD: Psychotherapy, pharmacotherapy, and combination treatment were examined. Study covariates were described. Chi-square tests with Bonferroni correction were conducted to examine the difference in study covariates between types of depression treatment. Generalized estimating equation models were used to examine the effect of parental depression on the likelihood of receiving depression treatment, controlling for study covariates, while accounting for the clustering of children and adolescents in the same household. RESULT: Children and adolescents with depressive parents were less likely to use psychotherapy (aOR: 0.80, 95% CI: (0.74, 0.86)), and more likely to use antidepressant (aOR: 1.41, 95% CI: (1.28, 1.56)) and combination treatment (aOR: 1.55, 95%CI: (1.43, 1.68)), compared to those without. Depressed children and adolescents living with depressed siblings in the same family were significantly less likely to use any depression treatment (aOR: 0.47, 95% CI: (0.41, 0.55)). CONCLUSION: The significant relationship between parental depression and their depressed children and adolescents’ treatment indicates that consideration should be given to parents’ decision-making and engagement in the treatment.

BACKGROUND: This dissertation presents an initial, mixed-methods case study of a hospital-based multidisciplinary care team (MCT) program designed to reduce hospital readmissions and emergency department (ED) revisits among patients with high hospital utilization without restrictions in a large, not-for-profit, non-teaching, community hospital system. METHODS: High utilizers were defined by either ≥10 ED visits or ≥4 inpatient stays within the past 12 months on a rolling basis. Electronic medical records and retrospective patient-level surveys completed by MCT staff provided insight into program reach and implementation, as well as initial impacts on hospital-based outcomes, non-hospital based outcomes, and staff-perceived impacts of MCT services on patients. Interviews with MCT patients, program staff, hospital administrators, community partners, and field experts were analyzed to understand the key challenges, best practices, and lessons learned to help inform transferability and sustainability of this type of program. RESULTS: Of the 1,680 patients who were identified as eligible high utilizers, about half received ≥2 telephone calls or face-to-face visits with the MCT. There were significant delays to patients receiving MCT services, especially for patients who met eligibility criteria within the first few months of the program initiation. Data reflected the high number of MCT encounters and breadth of services provided to MCT participants. On average, changes in post-period ED revisit and inpatient readmission rates were not significantly different from pre-period rates for MCT participants overall, or when broken down by initial classification as an inpatient or ED high utilizer. MCT staff reported improvements in housing stability, usual source of care, and substance use treatment or recovery for MCT participants. Staff perceived positive overall and specific impacts of MCT services for a large portion of patients, with greater perceived positive impacts on all outcomes with increasing program duration. Salient themes from the qualitative data analysis included the heterogeneity of the high utilizer population, internal communication and support, community integration, and financing. CONCLUSION: This initial study, conducted prior to the conclusion of the full MCT program, provided insight into the strengths, challenges, and early lessons learned from a hospital-based multidisciplinary care team program designed to reduce high readmission and revisit rates among high utilizers. This study also lays the groundwork for a full post-program evaluation in the future. / 2019-11-08T00:00:00Z

Iran is among the countries with the highest rates of opioid and heroin consumption in the world. Smoking opium among the Iranian population has historical and traditional roots; however the rising rate of injection drug use is a relatively new phenomenon. This project was designed as a retrospective case-comparison study, aiming to identify the social and behavioral factors that are associated with initiating injection drug use among a population of 948 male drug users, who sought addiction treatment at a methadone clinic in western Iran between February 1, 2004 and August 31, 2005. Logistic regression was employed to assess the statistically significant social and behavioral risk factors for injection drug use initiation. The study population included 177 injecting drug users, constituting 18.67% of the total participants, and 771 non-injecting drug users. The initial crude analysis of the data indicated that drug users who were younger, more educated, unemployed, addicted at a younger age, lived in an urban area, were not married and had no children, initiated smoking before the age of 20, had one addicted blood-relative, used drugs four times or more per day, ceased drug use while in prison or began with or used other drugs like buprenorphine, heroin, or marijuana were more likely to turn to injection drug use. However, after adjustment for confounding effects through logistic regression analysis only younger age, buprenorphine use, high daily frequency of drug use, and history of drug use cessation in prison camps, remained associated with initiating injection. Interestingly, the impact of the associated risk factors was considerably different between the participants who indicated their onset date of drug use as after versus prior to the year 2000, coinciding with the ban on poppy production in neighboring Afghanistan, which is the primary source of opiate import into Iran. Most notably, the subjects who initiated injection after 2000 were more likely to be highly educated, receiving at least a high school diploma or higher, whereas the group that initiated drug use prior to the year 2000 were shown to have a significantly higher rate of imprisonment and attempts at quitting in law-enforced rehabilitation facilities. It was also demonstrated that the population who began drug use after the year 2000 had an increased shift towards using buprenorphine, which is highly associated with increasing the drive towards injection, and increasing the prevalence of the associated infections such as human immunodeficiency virus (HIV), Hepatitis C Virus (HCV), and other injection-associated adverse health outcomes. This analysis elucidated that changes in policy and governmental control measures could indirectly influence the choices and behaviors of drug users, demonstrating the interplay between social and behavioral factors. Therefore, in order to minimize detrimental effects of policy changes, harm reduction interventions must be dynamic and cater to the needs of target populations who are at risk of opting for drug use behaviors that could be more harmful to their long-term health. Factors such as date of addiction initiation may indirectly affect the risk of injection initiation, and information on these factors can guide us to identify and assess other contextual factors that may have an impact on the significance of risk factors that could lead to injection initiation. This observation is especially significant in the context of addiction in a country such as Iran, with a constantly changing economy. Caution must therefore be applied to not group drug using populations in a single category when designing public policy, health interventions, or treatment measures. Therefore, identifying the risk factors for injection initiation in the context of environmental and societal changes is of utmost importance in order to provide appropriate harm reduction solutions for those who have yet to inject and are at highest risk for injecting.

High-risk alcohol use by U.S. undergraduates has been a widely studied topic over the past 25 years, and there are numerous individual- and environmental-level strategies being implemented at colleges and universities nationwide. Nonetheless, high-risk alcohol use by college students remains a pervasive and seemingly intractable challenge for health practitioners employed at institutions of higher education, one that they have made a priority due to the severe consequences that undergraduates can experience during a sensitive time in their physical, cognitive, and emotional development. This dissertation uses a case study approach to develop a chronology of the alcohol prevention efforts implemented at a small, private, urban research university in the Northeast between 1996 and 2016 and a rich, thick description of the historical alcohol-related events and contextual conditions that occurred during that time. The study’s primary aim is to identify the factors that have sustained positive gains from the University’s alcohol prevention programs. This is a mixed-methods study, predominantly qualitative but also including an additional quantitative approach. Qualitative methods included intensive interviews of current University employees with knowledge of the prevention efforts implemented during the study period, plus a review of internal and publicly available documents and reports, newspapers and other publications, and online media content from University and local community sources. Existing annual survey data collected between 1997 and 2016 were examined to assess the relationship between the chronology of prevention efforts and the trends and fluctuations observed in student alcohol use and its negative consequences over time. The data and lessons learned from this case study informed a framework for how health practitioners in higher education can assess: 1) the degree to which their institution is implementing a comprehensive mix of evidence-based prevention efforts – which collectively operate at all levels of the Social-Ecological Model – to reduce high-risk alcohol use by undergraduates; and 2) the presence of factors that can increase their institution’s capacity to sustain positive gains from these efforts over time.

The incidence of obesity has risen significantly over the past decades, reaching epidemic levels in many countries around the world. More alarming is the increasing number of overweight and obese children. Obesity is associated with an increased risk for physical and psychological health problems. While the impact of obesity is well documented, less is known about its effect on tooth development. Several studies have found evidence supporting a correlation between the incidence of dental caries and obesity. However, the correlation between obesity and tooth development is unclear because of the scarce information and few studies on the topic. To address this issue, a systemic review of the correlation between obesity and tooth development in children and adolescents has been conducted. High fat content affects growth and hormonal metabolism that indicates that obese children have accelerated linear growth. Therefore, the hormonal changes produced as a result of obesity may also modify tooth eruption in children and adolescents. Various studies have shown that most obese children consume copious amounts of snacks—particularly high-calorie snacks that contain high amounts of sugar. As a result, these children surpass the ideal weight for their age. Furthermore, obesity results from the imbalance between energy expenditure and calorie intake, which in turn leads to an abnormal buildup of fat in the body. Few studies have explored whether childhood obesity affects tooth development. One study found that obese children tend to have more erupted teeth than non-obese children, and their teeth tend to erupt earlier than those of non-obese children as well, after adjusting for weight, gender, age, and race. In particular, obese children have about four more erupted teeth compared to thin children. Tooth eruption is a development stage that influences body weight. Therefore, interfering with the timing of the tooth eruption consequently impairs the emerging teeth and further prolongs the treatment of teeth. Moreover, if tooth eruption is left undiagnosed and untreated, those individuals are more vulnerable to other dental problems, such as crowding, poor oral hygiene, and malocclusion. Delayed treatment may also result in the need for additional treatment as the child grows. Research shows that obese children tend to mature faster and develop permanent teeth earlier than children with a normal body mass index. One study posited that dental development progresses with rises in body mass index. This explains why dental development is relatively higher among obese adolescents, compared to normal-weight adolescents of the same age. It also suggests that obese adolescents are predisposed to dental health problems such as malocclusion.

Unnecessary prescribing of antibiotics for viral respiratory tract infections is common and contributes to emerging antibiotic resistance and patient morbidity and mortality. Interventions aimed at promoting judicious use of antibiotics, such as prescribing guidelines, are often ineffective. Approaching the problem of overprescribing from new perspectives is key to making progress towards more effective antimicrobial stewardship. Exploring characteristics shared between patients and providers, attitudes of new antibiotic stewards, and the role of prescribing on subsequent use offer opportunities to better understand antibiotic stewardship and overprescribing at a time when new perspectives are needed to inform better interventions. This dissertation contains three studies that incorporate novel perspectives to investigate the patient, provider, and practice factors that promote judicious use of antibiotics and solicit a better understanding of the current state of stewardship from future antibiotic stewards. Study 1. A Qualitative Study of the Knowledge and Attitudes of Infectious Disease Fellows, sought to understand the attitudes and beliefs of infectious disease fellows on the front line of antibiotic stewardship. Fellows highlighted the importance of formal and informal education, explained the challenges faced when practicing stewardship, and suggested improvements to fellowship programs to encourage better antibiotic stewardship training. Study 2. Patient-Provider Race and Sex Concordance in Prescribing, explored how race and sex concordance between patients and providers predicted overprescribing. Results showed that racial concordance was one of the most important predictors of overprescribing, suggesting that concordance can be more important to the prescribing outcome than some clinical indicators and that improving cross-cultural communication may be a way to combat overprescribing. Study 3. Early Prescribing Behavior as a Predictor of Future Antibiotic Exposure and Resource Utilization, described how the decision whether or not to prescribe antibiotics at a child’s first acute bronchitis visit affected that child’s likelihood of returning for an additional acute bronchitis complaint and being prescribed an antibiotic. The results of this study suggested that the prescribing behavior of providers can affect future visits and subsequent prescribing. / 2019-03-11T00:00:00Z

BACKGROUND: The increasing rates of opioid use disorder and resulting overdose deaths are a public health emergency, yet only a fraction of individuals in need receive treatment. This thesis aims to describe the implementation of and participants’ experiences with a novel police-led addiction treatment referral program. METHODS: Follow-up telephone calls to participants in the Gloucester Police Department’s Angel Program from June 2015–May 2016. Open-ended survey questionnaires assessed individuals’ program participation experience, confirmed police-reported placement, and queried self-reported substance use and treatment outcomes. RESULTS: Surveys were completed by 198 of 367 individuals (54% response rate) who participated 214 times. Reasons for participation included: positive program publicity, belief that treatment placement would be obtained, poor prior treatment system experience, and external pressure to seek treatment. The majority of participants reported positive experiences citing the welcoming, nonjudgmental services. In 75% of encounters, participants confirmed they entered referral placement. Participants expressed frustration when they did not meet program entry requirements and had difficulty finding sustained treatment following initial program placement. CONCLUSIONS: A police-led referral program was feasible to implement and acceptable to participants. The program was effective in finding initial access to treatment, primarily through short-term detoxification services. However, the fragmented treatment system remains a barrier to long-term recovery. / 2019-11-08T00:00:00Z

In the past three decades prevalence of obesity has increased substantively in the US and has reached epidemic proportions both among adults and among children. Childhood obesity is of significant concern because it is associated with childhood morbidity, adverse social outcomes and may be associated with life-long implications. In recent years, there has been an increased interest in understanding the possible role of local food environment in shaping individual's behavior in ways that may encourage food consumption and affect weight status. This study examines whether fast food availability at the residential neighborhood may explain children's risk for obesity. Data from the Fragile Families and Child Wellbeing study, a population-based panel data of urban children and their families, were linked to locations of fast food outlets. Using both cross-sectional and longitudinal analytic techniques and numerous robustness checks, I find no discernible effect of exposure to fast food at the residential neighborhood on children's weight. Policies designed to reduce accessibility to fast food in children's residential neighborhood may not be effective in the effort to fight the childhood obesity epidemic.