Purpose: To examine likelihood of parental acceptance of human papillomavirus (HPV) vaccination for young adolescent girls, together with reasons for acceptance and non-acceptance. The ultimate goal of this research is to inform policy decisions and educational planning in this area.

Methods: A random-digit-dial telephone survey of parents in California households was conducted, yielding 522 parents with an eligible daughter. Cross tabulations and odds ratios were employed to analyze likelihood of vaccination acceptability. Reasons provided for acceptance or non-acceptance were analyzed qualitatively.

Results: Overall, 75% of the sample reported that they would be likely to vaccinate a daughter before age 13. Hispanic parents were more likely to accept vaccination than were non-Hispanic parents, while African-American and Asian-American parents were less likely. Other subgroups less likely to accept vaccination were identified. Five clusters of reasons by non-accepting parents emerged: pragmatic concerns about effects on sexual behavior, specific HPV vaccine concerns, moral concerns about sexual behavior, general vaccine concerns, and denial of need. A sixth group of interest comprised those who would vaccinate before age 16 but not age 13. Conclusions: Consistent with previous studies on this topic, a large majority of California parents endorsed HPV vaccination for daughters by the recommend age. Although important subgroup disparities were found, majorities of all subgroups supported vaccination. This information, together with the identified clusters of cognitive decision factors for non-acceptance, has implications for policy decisions and educational planning in this area. Suggestions for further research on subgroup disparities and on cognitive factors involved in parents’ decisions arise from these findings.

Obesity as a social and health problem is well recognized in the public's consciousness, and as a result, numerous food-related policies and programs have been conceived to encourage healthful dietary changes in individuals. In response to the high caloric content of fast food, menu labeling laws, which strive to reduce consumers' consumption of unhealthful foods, have become a popular approach to address obesity. These laws and other policies aimed at changing individual's consumption practices exist within a context where many factors may shape food choices. By considering the literature on food choice, which has remained largely independent of public health research on obesity and food policy, questions are raised about the extent to which individuals can and will prioritize their health when making food choice decisions. This qualitative interview study examined the food choices of 20 working class African American women - those considered among the highest at risk for obesity - to consider to what extent food-related policies may be effective in changing their consumption practices.

The following compendium presents three papers resulting from analyses of in-depth interviews with women. The first paper, "Conflicting discourses in qualitative research: The search for divergent data within cases," is a methodological piece that considers the important role of examining conflicting discourses within women's narratives to uncover more meaningful and holistic accounts of respondent's lives. The second paper, "A transdisciplinary perspective of food choice for working class African American women," presents a transdisciplinary model of food choice that shaped the study design and helped to reveal the multi-dimensional nature of food choice for women. Finally, the third paper, "Embodying both stigma and satisfaction: Messages for obesity prevention targeting young African American women," introduces an important emergent theme about body image that was uncovered with this project. Each of these three papers is unified not only by the simple fact that they resulted from the same research project but also by demonstrating the meaning and importance of contradictions - or inherent thematic conflicts - that are revealed through qualitative data analyses.

It is widely agreed that sexuality is an important aspect of adolescent development, and the combination of developmental transitions can leave adolescents vulnerable to negative sexual health outcomes. Sexuality education has the potential to positively support sexuality development and influence sexual health outcomes. However, evidence suggests that current approaches to sexuality education are not adequately meeting adolescent sexual health and development needs. The incorporation of a more clearly defined developmentally-appropriate approach may be one way to strengthen these programs.

Through this dissertation, I aim to inform future directions for sexuality education by assessing and analyzing current understandings of the construct of developmentally-appropriate sexuality education and highlighting where gaps exist between the scientific knowledge base on adolescent development and current practice in sexuality education.

In the first paper, "Developmentally appropriate sexuality education: Implications of adolescent development research," I broadly review the research pertaining to adolescent development, adolescent sexuality development specifically, and adolescent motivation, and note the limitations of this research. Finally, I discuss the implications of this research for sexuality education, including determining developmentally appropriate content and educational strategies, and making accommodations for developmental diversity.

In the second paper, "Conceptualizing developmentally appropriate sexuality education: Perspectives from the field," I report on findings from 18 in-depth interviews with sexuality educators and sexuality education materials developers. Four aspects of developmentally appropriate sexuality education that emerged consistently across interviews are discussed: (1) addressing developmentally relevant topics, (2) adapting content to cognitive development, (3) accommodating developmental diversity, and (4) facilitating the internalization of sexual health messages. In addition, challenges and barriers to the institutionalization of a more comprehensive and integrated approach to developmentally appropriate sexuality education are described.

And finally, in the third paper, "Is current sexuality education developmentally appropriate? A content analysis of popular curricula," I identify the extent to which 5 popular sexuality education curricula, designated for middle and high school aged adolescents, use developmentally appropriate educational strategies according to the criteria discussed in papers 1 and 2.

As a whole, this dissertation highlights the need for further attention to the concept of developmental appropriateness and its application to sexuality education.

There are large gaps in information currently about the way evaluations of multi-level interventions are conceptualized and implemented in public health practice. Existing evaluation literature provides little guidance to evaluators as they attempt to design and implement comprehensive evaluations of such interventions. Multi-level interventions that attempt to create change or impact at two or more levels are being developed and implemented with increasing frequency in several fields, including public health. However, these interventions are often not comprehensively evaluated. If evaluation is conducted, it is often piece-meal, and important elements such as data collection on all levels intervened are often lacking. The reasons behind this disconnect between the comprehensiveness of the intervention and evaluation is not clear.

This dissertation was conducted to fill a current gap in the fields of evaluation and public health. This study expands knowledge by having assessed current multi-level projects and their context, in order to better understand contextual elements described as influencing the comprehensiveness of their evaluations.

The author reviewed literature and current evaluation practice around multi-level evaluations and developed a Framework for Comprehensive Evaluation of Multi-Level Interventions (Framework). A multiple case study was conducted with four projects evaluating multi-level interventions in tobacco control and childhood obesity to further understand contextual elements influencing their evaluation. Analysis of case data took place individually for each project, across projects within the same field, and across the fields of tobacco control and childhood obesity. Case data were later compared with the Framework, to assess how contextual elements influenced evaluations of projects studied.

Cases studied provided information on strengths and challenges of their evaluations, sources of information used in the development of their evaluations, and contextual elements that influenced their evaluations.

Great overlap was found between cases and across the fields studied. These projects developed their evaluations using similar sources of information and expertise. Also, many similar elements were described as influencing the comprehensiveness of their evaluations. While the original Framework and hypotheses developed early in the study were not fully supported, case data provided valuable information on nuance around contextual elements, such as how different elements influenced evaluation development versus evaluation comprehensiveness.

Ultimately, the combination of having strong internal capacity for evaluation, access to external evaluation expertise, adequate and consistent funding for the evaluation, a logic model and other sources of information to guide the evaluation, and flexibility to modify the evaluation as needed, were found as key factors for the success and comprehensiveness of projects studied. This pattern was found across the cases and across both fields.

Field itself may not be a particularly distinguishing factor for cases studied in evaluation development, comprehensiveness, or contextual elements influencing these areas. Projects studied may be providing guidance to others based on their successes around evaluation comprehensiveness, expertise, and amount of time they have been funded and evaluating their programs, rather than their field. And it may be that childhood obesity as a newer field for multi-level interventions, and with large amounts of new funding, is looking to others, especially other programs with many years of multi-level intervention and evaluation experience for more guidance at this time.

Recommendations were developed to address challenges identified, promote promising strategies, and provide considerations for future work. Recommendations were developed to address areas including: capturing synergy, determining "who gets credit", funding issues, access to evaluators and improved training of evaluators, reporting and communication, building an evidence base, use of logic models, inclusion of external evaluation experts, building internal capacity, and flexibility to modify evaluations as needed.

Information gathered through this dissertation can be used by multiple audiences to improve evaluations of multi-level interventions in the future. Multi-level projects, such as those studied, are not carried out quickly or simply, so having multiple suggestions for improvement, to help with the development, comprehensiveness and other areas of the evaluation, can be quite helpful. The ultimate goal of this dissertation was to provide the fields of evaluation and public health with information to increase comprehensiveness and quality of evaluations for multi-level interventions in the future.

Future work beyond this dissertation can go in several directions, including advancing recommendations provided, further study of elements within the Framework, or studying contextual elements beyond those in the Framework, which may also influence evaluation comprehensiveness. Additionally, future studies could look at other cases within these fields, or fields beyond tobacco control and childhood obesity, that are carrying out multi-level interventions, to see if similar patterns are found.

For more than a century, the question of how adolescents should be taught about their emerging sexuality and sexual health has been debated in schools, within communities, and across the public sphere. Today, most efforts to provide formal sexuality education fall under two models: abstinence-only programs, which promote the benefits of restraint from sexual activity, or abstinence-plus programs, which encourage abstinence and offer lessons on safer sexual practices. The lack of consistent, compelling evidence for these widely used approaches has reinforced the need, among some leaders in the field, to reconsider the paradigm as a whole. They advocate for a shift from a narrow emphasis on reducing the risks of adolescent sexual activity toward a positive, holistic emphasis on the healthy sexual development of young people. The term "rights-based" has become increasingly linked to this concept of a more comprehensive approach to sexuality education.

Discussions of a rights-based approach to sexuality education have become increasingly common in both international and U.S. contexts over the past decade. Among a small but growing group of program developers, funders, health educators, and scholars, the idea of addressing contextual factors such as gender norms, power differentials, and sexual rights within sexuality education has gained enthusiastic backing. While preliminary evidence from basic science and theoretical guidance lend support to this interest, there is little direct evidence for concluding that that this new approach is preferable to existing models. This dissertation was developed to offer a critical exploration of this new paradigm for sexuality education.

In the first paper, "A Rights-Based Approach to Sexuality Education: Conceptualization, Clarification and Challenges," I present a conceptual definition for a rights-based approach to sexuality education that is consistent with and gives structure for understanding the guidelines, curricula, research, and theory that have been cited as informing the approach. Based on in-depth qualitative interviews with experts, I propose a rights-based approach as the intersection of four elements: 1) an underlying principle guiding the provision of sexuality education to youth as holders of sexual rights and responsibilities; 2) an expansion of programmatic goals beyond reducing unintended pregnancy and sexually transmitted infections; 3) a broadening of curriculum content to include issues such as gender norms, sexual orientation, sexual expression and pleasure, violence, and individual rights and responsibilities in relationships; and 4) a participatory teaching strategy that engages youth in critical thinking about their sexuality and sexual choices.

In the second and third papers, I focus on one construct - adolescents' underlying attitudes about their sexual rights in relationships - of particular importance for the development, implementation, and evaluation of future rights-based sexuality education programs. In "Adolescents' Attitudes about Rights in Sexual Relationships: Measure Development and Psychometric Assessment," I describe the development of self-report survey measures that address adolescents' attitudes about their rights in steady and casual sexual relationships, and assess their psychometric properties using both classical test theory (CTT) and item response modeling (IRM) approaches. The final measures show evidence of psychometric soundness, including reliability and validity, which encourages their use in both epidemiological studies of adolescent sexual behavior and evaluations of rights-based sexuality education programs.

In the third paper, "Understanding Adolescents' Attitudes about Rights in Sexual Relationships," I examine how adolescents' attitudes about their sexual relationship rights vary by demographic and behavioral characteristics, in contexts with a steady or casual sexual partner, and across the different dimensions of sexual relationship rights. Adolescents report strong support for sexual relationship rights across complex hypothetical situations, with some notable differences by individual characteristics and relationship contexts. I also investigate a theorized causal connection between attitudes about their sexual relationship rights and communication with sexual partners using a series of regression models. These analyses support a causal relationship between attitudes about rights to express sexual engagement needs and partner communication, net of plausible alternative explanations and partially mediated by comfort communicating with sexual partners. In contrast, there was no evidence to support an association between adolescents' attitudes about their rights to refuse sexual activity or rights to establish relationship autonomy and their communication with sexual partners.

As a whole, this dissertation provides a critical examination of the rights-based approach to sexuality education, asking research questions not previously addressed in the literature and suggesting a number of avenues for future sexual health promotion efforts.