Background: Public health interventions are any activity with the objective of improving human health such as preventing or curing disease, reducing the severity or duration of a disease, or assisting in regaining function after a disease or injury. These interventions are known to be impactful; however, those living with the highest burden of disease such as individuals in low- and middle-income countries have limited money and resources to successfully implement these interventions. Southeast Asian countries are among some of the middle-income countries effected by the lack of affordable interventions. The aims of this study were to assess cost saving and resource limited interventions and understand how sociodemographic and housing characteristics predict knowledge and attitudes of health and social issues. Methods: A scoping review was completed to synthesize literature regarding cost saving and resource limited global public health interventions following the PRISMA ScR guidelines. Data from the Demographic and Health Survey were used to conduct multivariable linear and logistic regression to assess the association of knowledge and attitudes of different health outcomes. Lastly, a pre- post- intervention analysis was conducted to assess the effectiveness of a solar light distribution program in a rural area of the Philippines. Results: The results from the scoping literature review highlighted the importance of handwashing as a cost saving and resource limited Water and Sanitation Hygiene intervention and that more researched should be conducted on interventions associated with access to light and women’s safety. The Demographic and Health Survey study found that there were statistically significant differences in people’s attitudes and knowledge chronic and infectious disease, water and sanitation hygiene and women’s safety based on their sociographic and housing characteristics. Finally, while the study sample size was too small to determine statistical significance of the overall program, participants did report improved outcomes after the solar light intervention in the Philippines. Implications: The findings from these studies highlight the need for additional cost saving and resource limited interventions in Southeast Asia. Continued research needs to be conducted to advance public health in underserved countries and communities.

Despite the well-recognized benefits of exercise, Americans are gaining weight in astounding proportions and levels of physical activity are on the decline. The purpose of this study was to investigate a relationship between physical fitness, self-concept and sexual health. There is a dearth of knowledge on this relationship specifically in the context of sex-negative curricula, which is the dominate discourse in the United States. One hundred and thirty-three participants between the ages of 18 - 50 volunteered for fitness testing and data collection. Physical fitness was assessed through body fat, resting metabolic rate, cardiovascular endurance, muscular strength, muscular endurance and flexibility. Self-reported exercise was measured using the International Physical Activity Questionnaire. Self-concept was measured by the Six Factor Self-Concept Scale, which presented a total self-concept score and as six individual concepts of self (likability, morality, task accomplishment, giftedness, power and vulnerability). Additionally, sexual function was measured by Derogatis Interview for Sexual Functioning and presented as both an aggregate score and five separate constructs of sexual functioning (fantasy/cognition, arousal, orgasm, behavior/experience, and drive/desire). Questions pertaining to sexual partners, sex education, and demographic information were also included. The results of the General Linear Model indicated significant relationships between physical fitness, self-concept and total sexual functioning. The sexual behavior/experience of men was predicted by body fat percentage and flexibility. In women, behavior/experience was predicted by body fat percentage and arousal was predicted by cardiovascular endurance. Total self-concept was related to muscular endurance. When men were isolated in the analysis, likability was positively related to sexual behavior/experience, and task accomplishment was inversely related to sexual behavior/experience. In women, giftedness was related to cognition/fantasy, arousal, orgasm and total sexual functioning. No relationships were found between physical fitness and the number of sexual partners in men; however, both muscular strength and the power self-concept were significantly related to number of sexual partners in women. As a result of these findings, women may be inclined to exercise to improve arousal and sexual functioning. Furthermore, educators should note the findings of a positive relationship between physical and psychological health and sexual well-being because they provide support for the development and adoption of sex-positive curricula that incorporate potential benefits of sexual activity.

Health literacy among the elderly Hispanics is a problem for 44% who read at the lowest level due to issues with recognition, cognition, or vision. The purpose of this study was to determine the extent that elderly Hispanics have problems with medication adherence due to health literacy. The social cognitive theory was the framework for this study. Inclusion criteria consisted of being 65-75 years of age, and speaking and/or reading English and/or Spanish. Questionnaires from 156 individuals were completed in Cobb County/Atlanta GA and analyzed using multiple regression to determine the relationship between health literacy and medication usage. Medication adherence was the dependent variable and independent variables were gender, age, Hispanic origin, education, income, income means, health insurance, health literacy, and medication usage. Statistical significance was noted in medication adherence, health literacy, and working full-time. Results were based on the correct answers from health literacy questions, which showed an association between medication adherence and health literacy and a reduction in medication adherence problems among elderly Hispanics who worked full-time. These findings showed a significant association between medication adherence and health literacy level among elderly Hispanics. No medication adherence problems were noted among participants who had good health literacy, unlike participants with poor health literacy. A larger ethnic group may show a variation of problems in future studies. Implications for social change could include recommendations for the use of Spanish language hotlines and reading materials to provide care, knowledge, and medication information assistance.

Obesity is becoming an increasing health concern for young adults. There have been numerous studies on the potential predictors of obesity. However, few studies have researched the predictors of obesity in young adults. Guided by the health belief model, this quantitative cross sectional study investigated the potential predictors of obesity in young adults. The 2011 Behavioral Risk Factor Surveillance System was used to gather data on the potential predictors of obesity, including physical activity, health care coverage, excessive alcohol consumption, and demographic characteristics on 1,511 young adults, aged 18-34 years, who were living in New York State. Data were analyzed using a combination Pearson correlation and multiple regression analyses. The findings on physical activity were statistically significant and revealed that physical activity had the strongest association to young adult obesity. The study provides information for public health professionals that can be used to develop more effective obesity interventions targeting young adults. The implications for positive social change include improving young adult health through the reduction of obesity rates and the promotion of physical activity.

The purpose of this phenomenological study was to investigate, from the perspective of teachers, the possible effect of school violence on teacher resiliency. School violence has been studied with respect to student behavior and academic success, as well as socioeconomic influences, but not with respect to teacher resiliency, as expressed by teachers themselves. Resiliency theory was the conceptual framework. Participants were all teachers of Grades 2-8 at an elementary/middle school in the Midwest. Twelve in-depth interviews were transcribed into text data and analyzed for common themes. Using NVivo, Version 10, I was able to more easily manage the volumes of text data. Reoccurring themes and meanings were triangulated with a resiliency questionnaire, school climate surveys, and field notes. The overarching themes that emerged were that teacher resiliency at the target school was lowered when its teachers were exposed to a school climate which allowed for excessive violence, especially fights. A second overarching theme was that there were inconsistencies in the support offered by the school administration, which negatively impacted teacher resiliency. A third overarching theme was that there was a significant lack of parental and community support, which also negatively affected teacher resiliency at the target school. Overarching themes that emerged can now be used to support the need for more effective teacher training about school violence. The outcomes may also help generate improved school violence policies at the local, state, and national levels.

Cardiovascular disease (CVD) is a major public health problem and a primary cause of morbidity and mortality in the United States. Regular physical activity is recommended for prevention and management of CVD. Despite the cardiovascular health benefits of physical activity most adults are physically inactive. Therefore, the aim of this dissertation was to examine the factors associated with adherence to physical activity among individuals with or without CVD. The first paper is a report of a study conducted to examine which baseline demographic (age, gender, marital status, socioeconomic status, and place of residency), psychosocial (social support, depression, anxiety, and fatalism), and clinical (past history of exercising, comorbidity, and health literacy) variables predicted successful adoption of the active lifestyle recommendation of increasing moderate-to-vigorous physical activity by an accumulated 15 minutes or more each day following a CVD risk reduction intervention and 2) to identify which of those same factors predicted dropout from the CVD risk reduction intervention among at-risk individuals in rural America. The study sample consisted of 399 rural Americans. The results revealed that a higher anxiety level was a predictor of active lifestyle modification following a CVD risk reduction intervention. In contrast, younger age and low health literacy were predictors of dropout from a CVD risk reduction intervention. The second paper is a literature review of studies investigating the factors that affected enrollment in cardiac rehabilitation in patients with heart failure (HF). The aims of this review were to: (a) describe enrollment rates of patients with HF in cardiac rehabilitation programs, (b) review the literature on factors affecting enrollment of patients with HF, and (c) identify areas for future research. It is difficult to draw conclusion about enrollment rates because the period of time after hospital discharge that enrollment was measured varied across studies. A wide array of demographic, psychosocial, and clinical variables have been identified as potential barriers of enrollment in cardiac rehabilitation programs. Additional research including patients with HF is needed. The third paper is a report of a cross-sectional study of 279 patients with HF. The aims were to determine 1) the amount of variance in the functional status predicted by depressive symptoms, perceived control, self-rated health, HF self-care maintenance behaviors, and serum N-terminal pro-B-type natriuretic peptide ( NT-pro-BNP) biomarker of cardiac dysfunction in patients with HF and 2) whether NT-pro-BNP mediated the relationship between self-care maintenance behaviors and functional status. Depressive symptoms, poor self-rated health, non-adherence to physical activity, and greater serum NT-pro-BNP levels were independently associated with worse perceptions of functional status. Serum NT-pro-BNP levels partially mediated the association between adherence to physical activity and perception of functional status. The findings from this dissertation provided further evidence of the importance of adherence to physical activity and identify key variables that promote participation in interventions to promote heart healthy lifestyles and adherence to physical activity.

The Nature and Perceived Influence of Lifestyle Discussions with Older Adults in Primary Care Rationale: A healthy diet and physical activity help with disease prevention and disease management and can promote quality of life regardless of the age at which an individual begins engaging in these behaviors. Despite the value of these health behaviors, many older adults do not follow lifestyle recommendations. Given that older adults frequently interact with the healthcare system, primary care providers are well situated to counsel older adults to improve their health behaviors. Unfortunately, we do not know how to most effectively engage in this counseling. The purpose of this dissertation is to better understand whether and how providers discuss diet and physical activity with their older patients and how patients perceive their providers’ communication regarding diet and physical activity. Method: One hundred and four older adults, ranging in age from 65 to 95, consented to have their routine primary care visits recorded and immediately following their visits engaged in semi-structured interviews regarding current health behaviors and perceptions of their providers’ diet and physical activity recommendations. Clinical visits were selectively transcribed and analyzed using qualitative description. Interviews were transcribed verbatim, coded, and analyzed through a process of constant comparison. Findings: Discussions of diet and physical activity occurred in over two thirds of visits; recommendations for diet and physical activity occurred in less than half of these discussions. The majority of patients correctly recalled whether or not discussions of diet or physical activity had taken place. Patients reported that the likelihood of engaging in healthy diet and physical activity related to personal motivation and perceived confidence in the ability to make effective changes, both of which could be influenced by providers’ recommendations. When providers did not discuss diet or physical activity, or mentioned these topics only briefly, patients often perceived the message that they should continue with their current behaviors. Implications: These findings support an integrated theoretical framework, highlighting the role of autonomy and confidence, for understanding how providers can promote patients’ health behaviors. Implications for providers’ training and the healthcare system are discussed.

According to popular and academic sources, home cooking is in decline. Nutrition and public health scholars concern that a loss of cooking abilities may diminish individuals' control over their food choices, thus contributing to poor health outcomes. Yet, there are still many unanswered questions. What skills, strategies, and knowledge sets are required to cook a meal on any given occasion? What capacity separates those who cook with ease from those who struggle to incorporate cooking into their daily routines? I propose that this difference is determined by an individual's capacity to employ a range of cognitive and technical skills related to meal preparation. I call this capacity 'food agency'. Drawing upon discourses of human agency developed in the social sciences, this food-specific theory considers how a home cook employs cognitive skills and sensory perceptions, while navigating'and shaping'various societal structures (e.g., schedule, budget, transportation, etc.) in the course of preparing a meal. Thus, to have food agency is to be empowered to act throughout the course of planning and preparing meals. To better understand the form and function of food agency in everyday contexts, this thesis has pursued two ethnographic explorations. The first study explored food agency from the vantage of routine performance by looking at the everyday practices of twenty-seven home cooks in the Northeastern United States. Data was collected through videotaping and observing the home cooks as they prepared typical dinnertime meals, followed-up with semi-structured interviews. The data has revealed a working model of the interrelated components seen as essential to consistent cooking practice, and thus to food agency'a conglomeration of skills, techniques, and strategies; structural and sensory guidelines; confidence and self-efficacy. All the home cooks were found to possess a basic scaffolding for food agency, yet the degree to which each had developed fluency in any given area was contingent upon personal experience. This supports the view that food agency is an actively acquired and dynamic capacity best understood as fluid rather than dichotomous. The second study explored food agency through guided progression, by following a cohort of eight college students at the University of Vermont as they learned how to cook during a semester-long food and culture course. Data was collected through videotaping the students as they cooked, and by interviewing them about their food behaviors and experiences at the beginning and end of the semester. The findings outlined the students' various trajectories as they progressed in many of the component areas involved in food agency'for example, skills, techniques, organizational strategies, sensory engagement, and a sense of individual and collective efficacy around meal preparation. While the longitudinal scope of this study was limited, these results suggest a need to develop similar curricula for hands-on cooking interventions that can be offered in a more diverse range of settings and contexts.

From Dar es Salaam to Dartmouth: A Case Study of the Experiences of Fogarty AIDS International Training and Research Program Fellows at Dartmouth Lisa Purvis, EdD Candidate, MPH, MBA Background The United States (US) is a major host nation to international college students and scholars who study a variety of disciplines (Farrugia & Bhandari, 2014). Beginning in the last decade, the demand for global health training has risen (Kanter, 2008; Kerry, Ndung'u, Walensky, Lees, Kayanjas, & Bangsberg, 2011). Since 2000, Geisel School of Medicine at Dartmouth has been one of 26 US universities participating in a global health training program, funded by the National Institutes of Health, Fogarty International Center's AIDS International Training and Research Program (AITRP). The Fogarty AITRP annually trains scholars (Fogarty Fellows) and focuses on building HIV/AIDS research and medical capacity in low- and middle-income countries through advanced training. Along with the economic, social, and cultural assets that international students bring, are key challenges in students' transition, assimilation, and acculturation. It has been observed that many of the Dartmouth Fogarty Fellows have experienced issues in matriculating at Dartmouth. Purpose of Research Little data exists on the experiences of international students studying global health in the US. Using a case study of the Fogarty Fellows at Dartmouth, this qualitative research project sought to examine their unique transition and assimilation experiences as international graduate students. A secondary purpose of the case study was to identify ways to improve students' experiences. Berry's theory of acculturation provided the theoretical framework for the project (Berry, 1997). Research Approach A qualitative approach was used, guided by Action Research methodology. Action Research focuses on problem-solving and it is typically defined as a reflective process of progressive problem-solving led by an individual(s), who is part of the community of practice, to address issues and solve problems (Bargal, 2008). Research Methods To gain a fuller understanding of the issues and to identify solutions to problems of acculturation that may already exist, in-depth interviews took place with 22 participants: 1) 10 alumni of the Fogarty Program at Dartmouth College; 2) 5 MPH faculty at Dartmouth; 3) 2 MPH administrators; 4) 4 Dartmouth Fogarty Program administrators; and 5) the Fogarty International Fellows Program Officer at NIH. Field research also took place in Tanzania, the home country of the Fogarty Fellows at Dartmouth, to understand the Tanzanian context. Findings Recommendations for program improvement included formalizing the program at several milestones; providing comprehensive pre-matriculation information; using technology to orient Fellows to their new environment; formal mentoring and networking; cross-cultural training with students; and orienting the faculty to the program and the needs of international students. Colleges and universities need to understand the unique experiences and the student support needs of the international student. Future research at the 25 Fogarty AITRP US-based sites is recommended before implementing any of the Dartmouth-based recommendations.

Background: Peer-to-peer (P2P) support programs have the potential to assist ESRD patients in managing their disease and improve outcomes. Yet, there is little research examining P2P programs’ impact on psychosocial outcomes and disease management behaviors. Methods: A 4-month P2P mentoring intervention was designed and piloted in a facility serving 249 in-center hemodialysis patients in Lynchburg, Virginia. Preceded by a social marketing effort, which included a program naming contest and participant recruitment, the intervention included: (1) mentor training, (2) pairing of mentees and mentors, (3) kick-off social mixers, (4) ongoing meetings between mentees and mentors, (5) mentor training booster, and (6) a final celebration. A single arm quasi-experimental study with repeated measurements at three time points was used with data collection over four months. The hypotheses that the intervention would result in improvements for both mentees and mentors (i.e., self-efficacy, knowledge, perceived social support, dialysis social support (i.e., support from peers within the dialysis setting), and self-management behaviors) were tested using repeated measures ANOVA or the Friedman’s test for nonparametric data. Results: Mentees experienced increases in self-efficacy, F(2,22)=8.15, p<.01; knowledge, F(2,44)=6.62, p<.01; perceived social support, F(2,22)=7.30, p<.01; and dialysis social support, F(2,44)=4.79, p=.01. Mentors experienced increases in knowledge, F(2,22)=11.88, p<.01; dialysis social support, F(2,42)=3.19, p=.05; and dialysis self-management, χ2(2) = 7.65, p =.02. Conclusion: A P2P mentoring program for in-center hemodialysis patients can be beneficial for both mentees and mentors. Future research should focus on larger groups of patients using more rigorous research designs.