In prevention of mother to child HIV transmission programs, nurses are responsible for counseling HIV-infected mothers about infant feeding. Studies of nurses infant feeding counseling in African countries suggest that counseling quality is often poor and may be associated with nursing culture, inadequate training, and health system factors. Few studies, however, have conducted theory-informed process evaluations to assess nurses implementation of an infant feeding counseling protocol. This study conducted the process evaluation of an infant feeding counseling protocol for the Breastfeeding, Antiretroviral and Nutrition BAN) Study, an ongoing clinical trial in Lilongwe, Malawi. Six nurses, trained on World Health Organization recommendations, counseled HIV-infected mothers to exclusively breastfeed for 6 months and stop breastfeeding at 6 months. This study adapted and applied patient-provider communication theoretical concepts to assess nurses counseling behaviors through: 1) direct observation and audio-taping of 123 infant feeding counseling sessions 30 antenatal and 93 postnatal) using a checklist to document nurses adherence to specific protocol items； and 2) in-depth interviews with each nurse to document adherence perceptions and attitudes toward the protocol. Analysis included calculating a percent adherence of checklists and constant comparison techniques and visual display matrices for the observation and interview data. Results indicate that nurses were implementing the protocol at an average adherence level of 90% or above. Adherence to protocol items during the antenatal sessions was 100%. During postnatal sessions, adherence ranged from 92.7% to 97.8%. Nurses implementation inconsistencies occurred when addressing breast health and breastfeeding cessation issues. An unexpected finding was nurses counseling mothers on proper infant formula preparation, although not detailed in the protocol. Interviews revealed a high nurse to mother ratio and additional counseling training on infant formula and complementary feeding preparation as perceived barriers toward complete protocol adherence. Findings illustrate that with minimal training, nurses implemented the BAN Study infant feeding counseling protocol as designed. The process evaluation results will help to interpret the BAN Studys impact and health outcomes related to evaluating mothers feasibility to follow infant feeding recommendations. The implication for HIV/AIDS clinical trials is to conduct process evaluations to identify and address potential implementation inconsistencies and, thereby, improve protocol implementation adherence.

This study determines if the health and physical education teachers in an urban Pennsylvania high school have positive or negative attitudes toward obese individuals and the factors that contribute to obesity. It also uncovers how they feel about the school setting as the primary location for combating obesity through prevention programs. Methodology: Data was collected using three survey instruments: a demographic survey, the Attitudes Toward Obese Persons Scale (ATOP) and the Attitudes Toward Obesity Issues (ATOI) survey. Analysis included descriptive statistics and correlations between factors in the three instruments. Results: The BMIs of majority of the male HPE teachers fell into the category of overweight, while most of the female HPE teachers were categorized as normal weight. The participants responded similarly to most of the ATOI statements, at 81-100% unanimity for agreement or disagreement, with the exception of one statement. Results for statement 14 of the ATOI found forty-nine percent of HPE teachers agree that high school would be the ideal place to address obesity. Twenty-seven percent disagreed and 24 percent were unsure. The mean ATOP score was 66. Thirty-five percent of the respondents received scores indicating negative attitudes toward obese persons, ATOP &lt； 60. The median score was 68. Conclusion: There was no profile discovered for a HPE teacher who would express negative attitudes toward obese adolescents. Urban high school HPE teachers respond similarly to many statements about obesity issues, however they are diverse in their responses about high school being the ideal place to address obesity.

The purpose of this study was to examine the phenomenon of decision-making about exercise from the perspective of the patient with type 2 diabetes. Through the use of participant observation, semi-structured interviews, and the analysis of the Stages of Behavior Change Scale, the Diabetes Empowerment Scale, and the Cooper Clinic Physical Activity Questionnaire, this comparative cross-case analysis explored the social, clinical and contextual factors, as well as the barriers that influence patient decision-making. The relationship between autonomous regulation of exercise behavior and perceived competence to follow through with ones decisions to exercise by patients, and the concept of autonomy support on the part of healthcare practitioners were also established as important components to consider in the development of an effective diabetes patient education curriculum. The analysis of the data is presented in qualitative, narrative form, using the voices of the participants and first-person accounts of the researcher in an effort to portray the challenges and emotion-filled meanings associated with the lived experience of daily decision-making in type 2 diabetes. The major findings of the study suggest that exercise decision-making is a complex process of interplay between a logical, rational, cognitive approach, and a more dynamic, unconscious, affective process of balancing reasons for exercise choices with ones values, beliefs, experiences and meanings about health, diabetes and exercise. There appears to be a relationship between the stage of behavior change and the degree to which one is a cognitive or affective decision-maker in type 2 diabetes. Cognitive factors such as ones perception regarding the threat of diabetes, having and positive exercise schema, and the degree of internal versus external motivation impact exercise decision-making. Social-contextual factors such as exercise group support, family or social support, and having a positive exercise role model or expert leader/teacher influence adoption and adherence to an exercise habit by those with diabetes. Affective factors such as the meaning-making associated with having diabetes, locus of control and coping behavior have an emotional impact on the person with diabetes, and often unconsciously influence decision-making and autonomous behavior. Barriers to following through with exercise decisions include conflicts with time management, patient fatigue that interferes with exercise tolerance, ease of access to exercise equipment or facilities, boredom with the exercise regimen, and interference with leisure-time television viewing. Abstract shortened by UMI.)

Purpose. This study examined two sets of factors that may affect older adults comprehension of common health-related written materials. One set was related to text difficulty: the Flesch Reading Ease index and text cohesion. The other set was related to older adults reading ability: age, education, health conditions, verbal ability measured by AMNART), working memory measured by Digits Forward, Digits Backward, and reading span), and health literacy measured by S-TOFHLA). Method. 200 short passages that described common senior health issues were collected from websites, health education brochures, and magazines. 16 experiment health passages were selected from the 200 passages based on quartile scores of the Flesch Reading Ease index and text cohesion. Text cohesion was indicated by referential cohesion and latent semantic analysis measures retrieved from the Coh-Metrix software. 124 older adults Age: M ＝ 77.6； SD ＝ 6.93； Years of education: M ＝ 15.08； SD ＝ 2.94) completed the study and 98% showed adequate health literacy. Results. Comprehension increased with older adults working memory gamma01 ＝ .18, p &lt； .001) and verbal ability gamma04 ＝ .02, p &lt； .05) but decreased with age gamma06 ＝ -.01, p ＝ .06). Surprisingly, increasing Flesch Reading Ease impaired comprehension in older adults with working limitations gamma11 ＝ .06, p &lt； .05). When text cohesion was high, older adults, especially young-old adults, benefited from increasing Flesch Reading Ease. When the text cohesion was low, older adults, especially high verbal older adults and young-old adults, benefited from reducing Flesch Reading Ease gamma 34 ＝ .007, p &lt； .05； gamma36 ＝ -.006, p &lt； .05, respectively). Conclusion. Increasing Flesch Reading Ease by using short words or short sentences may result in leaving out connections among ideas and impair older adults comprehension. Increasing text cohesion by repeating similar words and ideas through out the text may reduce the challenges created by using short words and sentences alone. In a text low in cohesion, the use of long sentences may clarify relationships among ideas or concepts, making the text more comprehensible than one using short sentences. Text cohesion should be included in addition to readability formulas to evaluate text difficulty for older adults.

The purpose of the research was to explore and describe the current school nutrition environment in North Carolinas public schools. Current practices to increase the availability of healthful foods and beverages in the school breakfast and lunch programs were analyzed. Barriers that limit the availability of healthful foods and beverages in school meals programs were identified and strategies to overcome the barriers were described. A survey instrument was administered to all Child Nutrition Directors and Supervisors in North Carolina. Of 239 instruments distributed, 211 were returned resulting in an 88.3% response rate. The research found that Child Nutrition Directors and Supervisors were keenly aware of the serious public health problems posed by the epidemic of childhood overweight and recognized that poor food and beverage choices and inadequate physical activity contribute to weight gain among children and adolescents. While healthful foods and beverages were available to students in the school breakfast and lunch programs, competitive foods, which undermined the nutritional and financial integrity of the school meals programs, were also available in approximately one-fourth of elementary schools, half of middle schools and three-fourths of high schools. The leading barrier that limited the availability of more healthful foods and beverages in school meals programs was school finances； financial goals for the programs outweighed nutritional goals for students. Other barriers included lack of support from school administrators and local Boards of Education, principals, teachers and parents. Student taste preferences for foods high in fat, sugar and calories was also a barrier. Other barriers included too little nutrition education in the classroom to influence students food choices, conflicting nutrition messages on school campuses, limited time and space for school meals and the perception that school meals were not a valued part of the instructional day. Multiple strategies were recommended to overcome and/or minimize the barriers.

The purpose of this study was to examine the attitudes of small businesses towards association health plans, a proposed legislation aimed at providing affordable, quality health care through the small business entity. This study addressed the question of small business participation in Association Health Plans AHP) by breaking small firms those with 50 or fewer employees) into 4 categories: firms that currently offer health coverage and support joining AHP Coverage/AHP) n＝79)； firms that currently do not offer coverage and support joining AHP No coverage/AHP) n＝39)； firms that offer coverage and do not support joining AHP Coverage/AHP) n＝21)； and firms that do not offer coverage and are against joining AHP No coverage/No AHP) n＝27). Three Midwestern communities were sampled using local Chamber of Commerce memberships: one representing a rural community with little industry n＝31, 12.4%)； one as an example of a medium sized city with a predominantly manufacturing industry n＝65, 26%)； and the last community represents a medium sized city with diverse industries n＝96, 10.9%). Random samples of 250 firms were selected for the first two communities. The final community served as the pilot study, and involved the total membership of 850 firms. The survey instrument was adapted from the Kaiser Foundations Employer Based Insurance Survey 2002). Additional questions were added involving awareness of AHP, and intent to join an AHP. Several major results were found: 1) there was no significant difference in firm size in those who indicated intent to join an AHP. 2) Coverage/No AHP firms offered a higher range of benefits than other firms. 3) No coverage/No AHP were motivated primarily by cost concerns for initial and future premiums. 4) the relationship between intent to join an AHP and quality of physician services offered by plans, and cost concerns, respectively, was statistically significant. The results suggest that business response will not be homogeneous, signaling the need for further research, such as a price sensitivity analysis to have a better understanding of firm and employee reactions to costs, a key concern for all firms in the current study.

Sourcing food locally at the institutional level supports sustainable farming by bringing wholesome, nutritious food to local communities. Schools, in particular, can benefit from this arrangement in efforts to address childhood obesity. Chapter I reviews previous studies on the subject, which agree that farm-to-school benefits the local economy and increases access to fresh/nutritious food but that there is insufficient infrastructure and financial support for processing and central distribution. The objectives of this study were to examine the perceived benefits and barriers in buying locally, and generate solutions to commonly encountered issues in California. Chapter II describes web-based surveys conducted with twenty-seven-food service directors (FSDs), approximately half of whom bought locally. Follow-up interviews were conducted with eighteen food service directors and ten farmers. FSDs were motivated to buy locally to access fresher food (n＝18, 67%) and support the local economy/community (n＝17, 63%). Barriers were inconvenience of multiple invoicing (n＝14, 52%) and seasonal availability (n＝13, 48%). Processing equipment and staffing were primary requirements for a more coordinated approach to regional produce distribution. School food service directors also consistently requested a list of local suppliers and products to make local food purchasing decisions. Chapter III describes the development and potential use of a web-based directory to support and expand farm-to-school programs in California. Feedback from seven food service directors and six Cooperative Extension advisors indicate the website may be useful at a county level to support development of farm-to-school programs but additional resources are needed to process and deliver products. Chapter IV describes the ability of federal legislation to address needs reported by food service directors. Budgetary constraints and dependence upon the commodity food program were the main barriers to food quality improvement. Future legislation would have a positive nutritional impact by decreasing energy-dense, nutrient-poor foods, on school campuses and increasing the amount of whole, unprocessed plant-based foods offered through the commodity program. Farm-to-school programs hold the potential to substantially improve nutritional status of children and financial stability of farmers, though it is clear that institutional support is needed for systemic transition to this purchasing method.

In 2002, educational interventions mother-to-mother support groups), food-based interventions including a porridge enrichment program), and a microcredit program were implemented in Ghanas Savelugu-Nanton District. One of the aims of the interventions was to improve childrens vitamin A consumption. We jointly model the probability of mothers awareness of the interventions with the probability of participation conditional on awareness. Principles of epidemiology inform a model of how a mother becomes aware of an intervention. Mothers who were economically engaged； in the ethnic majority, or not on traditional childbirth visit were more likely to be aware of the interventions. Lack of awareness of the interventions was the main barrier to mothers participation. Once awareness of the interventions is controlled for, no other variables in the model have substantial associations with mothers participation. We use three approaches to assess the influences of the interventions on mothers vitamin A knowledge and childrens vitamin A consumption. First, we measure the impacts of different combinations of the interventions being present in a community using regression and ordered probit analyses. Second, we measure the impacts of mothers participation in the interventions accounting for the endogeneity of participation. Third, we use propensity score matching to estimate the impacts of participation in the interventions. Participation in the mother-to-mother support groups is associated with children consuming egg and red palm oil more frequently, higher total frequency of consumption of vitamin A rich foods, and children consuming more vitamin A from foods emphasized in the interventions. Participation in the porridge enrichment component of the food based interventions is associated with greater maternal vitamin A knowledge and more frequent egg consumption among children. Participation in the microcredit intervention is associated with children consuming egg more frequently and consuming more vitamin A from emphasized foods. Other determinants of childrens consumption of vitamin A rich foods include the childs age, mothers vitamin A knowledge, education, ethnicity, and whether or not she is on traditional childbirth visit, household expenditures, and household cultivated land area. Other determinants of mothers vitamin A knowledge include household access to radio and household expenditures.

The major objective of this dissertation was to develop and evaluate the “Nutrition Competencies for Californias Children, Pre-Kindergarten through Grade 12″ document, which provides comprehensive and sequential nutrition content standards for student instruction. Comparative analysis conducted with national and state health and nutrition documents was used to develop the themes of the Nutrition Competencies document； the document was expanded to include links between its grade level expectations and the California content standards for English-language arts, mathematics, physical education, history-social science, and science. The document was reviewed by nutrition and education experts and submitted to the Internal Review Team of the California Department of Education. Subsequently a facilitated “Expert Panel Meeting,” including nutrition and education faculty, UC Cooperative Extension advisors, teachers, principals, health and education agency staff, and food service representatives, was held to review the Nutrition Competencies document. The final step in this review process was a survey conducted with California public school teachers N＝250) to assess teachers attitudes towards school-based nutrition education and the Nutrition Competencies document. Results showed that most teachers believe that school-based nutrition education should begin in Pre-Kindergarten 60.9%) and Kindergarten 21.9%). Most teachers agreed or strongly agreed that incorporating nutrition lessons into the curricula of health 100%), home economics ＞81%), physical education ＞70%) and science ＞70%) is a good use of school time. The majority of teachers found the Nutrition Competencies document to be well structured 84.9%), user-friendly 89.8%), and appropriate for the grade level they teach 95.6%). Teachers agreed or strongly agreed that lack of time 81%), resources 69.5%), and an established school nutrition policy 72%) are barriers to using the Nutrition Competencies document. The majority of teachers 72.9%) agreed or strongly agreed that they would use the Nutrition Competencies document to plan nutrition lessons. In conclusion, teachers support school-based nutrition education and view the Nutrition Competencies document as an appropriate tool to successfully incorporate nutrition education into the school curriculum. The state of California recently passed a mandate for Health Education Standards and a newly formed “Health Education Standards Panel” will use the Nutrition Competencies document to develop content areas for nutrition.

The purpose of this study was to determine the health behavior lifestyles of college students and describe the characteristics of the differing lifestyles. The study used the leading indicators of health described by Healthy People 2010 to group college students into health lifestyle clusters. The clustering technique revealed three prominent groupings of students, named for the relative degree of risk indicated by their health-compromising behaviors: low risk, moderate risk, and high risk clusters. Differences in personal and environmental factors were found among the clusters. Notably, the high risk cluster members tended to be upperclassmen, live off campus, have more safety issues and lower GPAs than the members of the other clusters. The moderate cluster members tended to exhibit less risky behaviors, with the exception of a higher likelihood of engaging in risky sexual encounters. The low risk cluster members were more likely to live on campus or with their parents, tended to be younger and have higher GPAs. The ability to profile college students based upon known variables provides an avenue for identifying at-risk students and tailoring health promotion messages specifically for them. Because student behaviors can be linked to environmental and personal factors, there may also be implications for either policy change or adoption connected with health promotion efforts. Differences were also found in the perceived norms of the three clusters, with more extreme norms associated with students with higher risk behaviors. The patterns of these differences indicate more support for the introduction of use of the constructs of the Social Cognitive Theory for explaining and predicting health behaviors based upon personal and environmental factors. The use of these known factors can help identify and augment health promotion efforts at the college level.