Background: Diabetic foot ulcers are the result of multiple complications from hyperglycemia and lead to poor quality of life and high healthcare costs. The annual diabetes foot screening exam (ADFSE) and prevention interventions can reduce DFUs up to 75%. In 2015, 71% of the US population received the ADFSE. Objectives: The main objectives of this dissertation were: 1) to determine the association between adherence to diabetes self-management behaviors and the ADFSE, 2) to determine the association between concordant and discordant comorbidities and the ADFSE and 3) to determine the association between the performance of diabetes preventive care processes, number of office visits for diabetes and the completion of the ADFSE. Methods: Three cross-sectional studies used data from the 2015 Behavioral Risk Factor Surveillance System. Logistic regression models were evaluated to assess the association between the self-management behaviors and the ADFSE. Structural equation modeling (SEM) was used to assess the simultaneous, direct effects of concordant and discordant comorbidity loads on the ADFSE and the performance of diabetes preventive care processes and the number of office visits for diabetes care on the ADFSE. Results: In 2015, between 78.2% and 80.4% of the US population with diabetes received the ADFSE. Performance of the ADFSE was 77% less likely (OR: 0.33, 95%CI: 0.25-0.44) in those who do not perform self-foot inspections and 40% (OR: 0.59, 95%CI: 0.45-0.76) less likely in those who have never received the pneumococcal vaccination. Receiving the ADFSE was 50-80% less likely in patients who do not self-monitor blood glucose at least one time per day, depending on insulin use and receipt of diabetes education. Neither concordant comorbidities (β=0.226, p=0.086) nor discordant comorbidities (β=0.080, p=0.415) had a direct association with the performance of the ADFSE. The collection of preventive care processes demonstrated a 7% (OR: 1.07, 95% CI: 1.05-1.10) increase in the likelihood the ADFSE was performed Conclusions: Performance of the ADFSE may be improved through multiple types of interventions. Patient-based interventions to increase adherence to self-management behaviors is one route. Programs to improve overall diabetes care in the clinical setting may also help to further improve completion of the ADFSE.

Maternal mortality is a critical area of concern globally, despite the availability of accessible preventive measures. The role of sociodemographic and service delivery factors in maternal mortality in the Accra Metropolitan Area of Ghana are important to examine. As part of the United Nations (UN) Millennium Campaign, the UN implemented 8 Millennium Development Goals (MDGs); maternal mortality reduction by 75% between 1990 and 2015 was among the fundamental MDGs to be achieved by 2015. The purpose of this case-control study was to use secondary data to assess the relationships between sociodemographic variables, service delivery factors, and maternal mortality among 8,171 women of reproductive age (15-45 years) living in the Greater Accra metropolitan area in Ghana. The health belief model and social cognitive theory provided the theoretical framework to interpret the study findings. Particularly, income (p = .023), primary (p = .035) and secondary (p = .002) education, and health insurance (p = .008) were significantly associated with maternal-related mortality. However, for survival outcome, health insurance (p = .003), prenatal care (p = .001), and presence of a skilled attendant at delivery (p = .020) were significant factors. These study results provide support for the significant effects of sociodemographic and service delivery factors on maternal mortality and survivorship in the Greater Accra metropolitan area in Ghana. The results of this study could enhance educational and outreach programs designed to lower maternal mortality rate. Further research needs to be done to advance knowledge and practice in health delivery services and public health education with respect to the importance of sociodemographic and service delivery characteristics.