Background: Chronic venous insufficiency (CVI) is prevalent in the United States. The negative impact of CVI on patient quality of life (QoL) has been established, and compression stocking therapy (CST) has been used as a treatment modality. Even though compression therapy has been shown to help, poor adherence is often caused by a lack of knowledge. Best practices include patient education to increase knowledge of CVI, including prevention, symptoms, awareness of compression therapy, and appropriate lifestyle habits. Studies have shown that compression stocking education can help patients learn more about CVI and CST, which can help ease the symptoms of CVI and improve patient QoL. Objectives: This quality improvement project sought to determine whether an intervention including a compression stocking education brochure with in-person simulation affected QoL for patients with chronic venous insufficiency. Methods: A pre-and post-test design over five weeks was used. A convenience sample of 24 patients aged 18 years or older with CVI was recruited from a vascular surgery outpatient clinic. The CIVIQ-20-item questionnaire was used to assess participants' QoL, and a CST questionnaire was used to assess CST knowledge before and after the intervention. Results: Participants experienced improvement in their CIVIQ-20 score after the intervention (M = 54.00, SD = 14.24 pre-intervention, M = 40.50, SD = 10.39 post-intervention, Wilcoxon signed rank test p< .001). Lower CIVIQ-20 scores are more favorable. The perceived knowledge score increased after the intervention (M = 1.35, SD = .62 pre-intervention, M = 2.71, SD = .55 post-intervention, Wilcoxon signed rank p < .001). The actual knowledge scores improved after the intervention (M = 4.38, SD = 2.28 pre-intervention, M = 6.58, SD = .97 post-intervention, Wilcoxon signed rank p <.001). For the knowledge scores, higher scores are more favorable. Conclusion: The key findings of this study demonstrated a statistically significant increase in patients' QoL and CST knowledge following the implementation of a CST educational brochure and in-person simulation.

Health effects at work from exposures to biological, chemical, physical, mechanical, and psychosocial hazards have often been subjects of company safety programs. Nutrition contributes to health, well-being, and productivity at work. Eating a well-balanced diet allows for the body to process nutrients and to maximize them for optimal energy. Poor dietary habits lead to fatigue, decreased mental ineffectiveness, and decreased the ability to perform the job effectively. Nutrition is a function of dietary behaviors and physiological processes that are influenced by the environment, including the work environment. Effects of work on dietary behaviors have been studied in a limited number of occupations, for example, professional drivers and airport personnel. Each individual industry deals with its work environment having different food options that can influence eating behaviors. Characteristics of work such as shift work, have also been studied and shown to influence the attainment of nutritional goals.

A cross-sectional, descriptive, pilot study was conducted to explore work in relation to patterns of eating and nutritional intake. The aim was to explore work characteristics (hours worked, work setting and job category) in relationship to when, where, and with whom workers ate and to determine whether this was associated with nutritional guideline targets. It was hypothesized that work characteristics would be associated with when, where, and with whom workers ate, and this would influence the attainment of nutritional guideline targets. The goal was to gather information that could provide guidance to employers about work characteristics that facilitate nutritional adequacy and also guide nutrition education for workers to equip them to achieve healthy nutrition.

This explorative, descriptive, pilot study utilized a research data set obtained from 51 healthy, employed men. Work characteristics (hours worked per week, work setting, and the North American Industry Classification System (NAICS) code were collected by a self-report questionnaire. Dietary behaviors were self-reported and categorized as the place food was purchased and consumed (for example, purchased at the supermarket, restaurant, cafeteria, eaten at work, home or car), when meals were eaten (breakfast, lunch, dinner or snack), and whether meals were eaten alone or with others. Nutritional analysis was conducted using the National Institutes of Health (NIH) ASA24, Automated Self-Administered 24-Hour Dietary Assessment Tool. Statistical analysis was conducted using STATA version 16.

Associations were found between several occupational characteristics and dietary patterns. Time as total hours worked per day was inversely correlated with meeting the nutritional goal for grains (r= -0.37, p= 0.01), and remained significant after controlling for total nutrient intake, p = 0.001. Construction workers (n= 4) were 2.4 times more likely and information technology workers (n= 2) were 3.2 times more likely to purchase their dinner meals at a restaurant compared to professional workers. Other dietary patterns were noted for this population of employed men. Participants did not meet the nutritional guidelines for at least one or more food groups: 90.2% did not meet caloric intake goal, 86.3% were below the grain intake, 94.1% and 82.4% were below the dairy and total fiber intake. Workers eating breakfast somewhere other than home and work were 1.6 times more likely to be under the calorie target. Eating breakfast alone had a correlation with not meeting the dairy targets (X2 [4, N= 44] = 9.47, p= 0.05). The pilot study characterized work in different ways from previous studies and dietary behaviors were studied in great detail using different methods of characterization. With the information learned from this small pilot study, a larger study can be built to focus on high-risk occupations in order to develop ways to help workers meet the nutritional guidelines, and helping achieve the Total Worker Health™ goal.

Purpose: The potential role of work place bias (WPB) and shiftwork in relationship to diabesity has not been studied in African American (AA) female nurses. Shiftwork (SW) has been shown to be associated with weight gain but this has not been studied in AA women in relationship to diabesity or WPB. The primary aim of this pilot study was to examine the relationship between WPB and diabesity in AA women. A sub-aim was to evaluate the potential mediating effects of chronic stress and moderating effects of SW.

Conceptual Framework: This study is based on three theoretical frameworks: the theory of allostatic load; intersectionality; and ecosocial epidemiology.

Methods: This was a cross sectional correlational study (n= 96) that examined the associations between WPB, SW, chronic stress and diabesity in AA registered nurses. Data acquisition was by self-report questionnaires, blood and saliva biomarkers of chronic stress and anthropometric measures.

Results: Institutional WPB was associated with diabetes in the population of AA nurses, X2 (2) = 7.21, p = .03, and BMI, r = 0.25, p =.02. Institutional WPB was associated with Waist to Hip Ratio (WHR), r= 0.21, p = .02, as was interpersonal work place bias, r= 0.21, p = .02.

WHR was also associated with HbA1C, F (1,89) = 7.38, p = .01.

More than half of the study population were shift workers. Although SW was not associated with diabetes or obesity in this population, it was associated with WHR, X2 (1) = 5.59, p = .02. Job strain was associated with institutional WPB r= -1.32, p = .032 and ERI was associated withboth institutional and interpersonal WPB r = .142, p = .001 and r = .149, p= .002 respectively. Allostatic load was not related to WPB but was associated with length of employment, r = 0.25, p = .02.

Conclusions: We found a significant relationship between interpersonal WPB and WHR, a proxy for visceral adiposity, suggesting WPB may have role in the onset of diabetes. This was not a function of socioeconomic status in this population of AA nurses, 70 % earned an annual salary of $75,000-$150,000 per year. Additional findings for this population of AA nurses suggest that body mass index is associated with institutional WPB but not associated with interpersonal WPB. When shiftwork was found to moderate the relationship suggesting there is a combined effect of SW and WPB on BMI. In this population, we did not find a clear indication of allostatic load based on the biomarkers used; however, we did find a significant relationship between job strain, effort reward imbalance and institutional WPB. This relationship suggests this population is experiencing stress from WPB and warrants further study.

Objective. Work provides personal satisfaction, meaningfulness, and financial stability to adolescent and young adult (AYA) cancer survivors. However, progressive health changes because of cancer and its treatments, may compromise safety and diminish ability to work. Workplace regulations and processes also influence productivity and employment sustainability for AYA cancer survivors. This dissertation explored interactions, and factors influencing interactions, among employed AYA cancer survivors, five years or more after treatment, and occupational and environmental health professionals (OEHPs) within the workplace.

Methods. Data were collected and analyzed using constructivist grounded theory. Individual interviews generated data from twelve AYA cancer survivors (age 15-39 at diagnosis). The sample of AYA cancer survivors (n = 12) was obtained from the California

Surveillance Program in Los Angeles. During interviews, AYA cancer survivors identified OEHPs they encountered in the workplace. Then, twelve OEHPs were interviewed based upon the specified professional categories. Qualitative analysis developed theoretical frameworks based upon the narratives of the participants.

Results. Data revealed the complexity of employment issues surrounding AYA cancer survivors during a career. Disclosure of a cancer survivor identity was central to the frameworks. Four processes were identified: Weighing the risks of revealing the survivor-self, sustaining work ability, weighing advocacy, and accessing or providing support. Additionally, employment challenges were organized into themes: Evading the cancer card, working around limitations, and powering-through for AYA survivors. On the other side of legal protection, OEHPs were becoming agents of change by discovering AYA cancer survivors, navigating systems to provide support, and identifying changes needed.

Conclusion. This dissertation illuminated the unique experiences of AYA cancer survivors and OEHPs in the workplace. Availability of services provided by OEHPs facilitated AYA cancer survivors’ work ability if services were available, known to survivors, and if survivors were willing to reveal needs. Education about OEHP services by employers would improve interactivity and provide a supportive work environment for survivors. Education for workers is needed to enhance sensitivity and improve communication with employees who have a history of cancer. Legislation is needed to promote long-term work ability among AYA cancer survivors by protecting confidential communication to promote greater utilization of OEHP services.

Background: Code Stroke Teams in hospitals provide emergency deployment of stroke clinical care experts for treatment of an acute stroke. Code Stroke Teams monitor their effectiveness using standards for stroke patient outcomes provided by the American Heart Association (AHA) and American Stroke Association (ASA) Stroke measures. This project was conducted in a Southern California suburban hospital where changes in leadership and high turnover rates had led to Code Stroke Team members experiencing decreased motivation, job satisfaction and low morale leading to substandard stroke patient outcomes.

Aim: This quality improvement project aimed to empower staff, improve performance and stroke outcomes by giving monthly presentations of successful Code Stroke cases to the Stroke Performance Improvement Committee leaders and stroke team staff.

Methods: Stroke Performance Improvement Committee leaders and stroke team staff participated monthly in an empowerment intervention through presentation of a stroke case on a “Code Stroke Spotlight” handout (Educational Empowerment Tool) over a 3 month period. Using a repeated measures, pre- post design, staff empowerment (measured by the Psychological Empowerment Instrument) and American Heart Association (AHA) Core Emergency Department Stroke Measures were collected prior to the intervention at baseline and post empowerment intervention following monthly implementation over 3 months.

Results: Results showed statistically significant improvement in all items on the Psychological Empowerment (PE) Instrument using Wilcoxon signed-rank test (p<0.05) (N = 32). Door to neuro MD (neurologic expertise consult) <15 minutes showed significant improvement post intervention (z =-2.285, p = 0.023). Door to PT/INR result <45 minutes showed statistical significance (z =-2.931, p = 0.003). Door to CT film <20 minutes showed no change (z=0.000, p = 1.000). For the remaining goals there was improvement in right direction, demonstrating decreased door to activation times, though these did not reach statistical significance.

Discussion: Implementation of the ‘Code Stroke Empowerment Spotlight’ intervention effectively improved staff empowerment and performance on American Heart Association (AHA) and American Stroke Association (ASA) Stroke core measures. Future studies are needed to evaluate positive reinforcement, meaningful recognition, and empowerment specific to those caring for stroke patients.

Background: More than half of women return to the workforce within one year following the birth of their child. To continue offering breast milk to their infants and follow AAP and WHO recommendations for breastfeeding, these women often need to express breast milk in the workplace. Registered Nurses who work in bedside roles do not traditionally have access to private office spaces or personal control over their work schedule, making them uniquely susceptible to workplace barriers for expression of breast milk. Currently, the CDC recommends cleaning a breast pump with soap and water and leaving it to air dry after each use. It is unknown what the current knowledge and adherence levels to these recommendations are within a working population or how knowledge and adherence may affect breastfeeding practice outcomes.Objectives: The study was conducted: 1) To determine relationships between employee perceptions of workplace support for expression of breast milk in the workplace (EBMW) and duration of breastfeeding, duration of EBMW, and other infant feeding practices, 2) To describe knowledge of CDC recommendations for cleaning of a breast pump across Registered Nurse (RN), Nurse Manager (NM), and Hospital Representative (HR) groups, 3) To determine if RN knowledge was associated with RN adherence to CDC recommendations for cleaning of a breast pump, 4) To describe relationships between RN breastfeeding practices and: RN knowledge and adherence, NM knowledge, and HR Knowledge, and 5) To learn about the experiences of working RNs who have expressed breast milk in the workplace and provide recommendations to employers for improving employee lactation experiences. Methods: This was a cross sectional research study. Registered Nurse participants who had given birth within the past three years (n=199), Nurse Managers (n = 36), and Hospital Representatives (n = 6) were recruited from 10 hospitals within the county of Los Angeles. Registered Nurses completed four questionnaires online: The Employee Perceptions of Breastfeeding Support Questionnaire (EPBS-Q); the Duration of Breastfeeding, Duration of EBMW, and Infant Feeding Practices Questionnaire (BEIF-Q); the Knowledge of CDC Recommendations for Use and Cleaning of a Breast Pump Questionnaire (KBP-Q); and the Adherence for Use and Cleaning of a Breast Pump according to CDC Recommendations Questionnaire (ABP-Q). Nurse Managers completed two online questionnaires: The Managers' Attitude Toward Breastfeeding Support Questionnaire (MATBS-Q) and the Knowledge of CDC Recommendations for Use and Cleaning of a Breast Pump Questionnaire (KBP-Q). Hospital Representatives completed two online questionnaires: Company Support for Breastfeeding Questionnaire (CBS-Q) and Knowledge of CDC Recommendations for Use and Cleaning of a Breast Pump Questionnaire (KBP-Q). Demographic information was collected from all participants via an online questionnaire. Pearson’s correlation coefficient was used to determine significant associations. Linear regression models were used to determine the relationships between workplace breastfeeding support constructs and breastfeeding and infant practice outcomes; and to explain relationships between knowledge of and adherence to CDC guidelines and breastfeeding and infant feeding practices. Qualitative responses from the open-ended question of the EPBS-Q were analyzed for categories using Strauss and Corbin’s Grounded Theory approach. Open coding, axial coding, and selective coding was used to develop the underlying codes and a conceptual description. Workplace recommendations were then created based upon the analysis. Results: Using the EPBS-Q, increased perceived time and frequency of lactation breaks was associated with an increased duration of feeding solids and breastmilk to the infant, and a decreased duration of solids and formula. Increased communication among coworkers was associated with a decrease in the duration of feeding solids, breastmilk, and formula combined. Among RNs knowledge scores of CDC recommendations for cleaning a breast pump were high, but adherence scores to those recommendations was not as high. There was an association between increased RN adherence to CDC recommendations for cleaning a pump and an increase in the duration of feeding solids and formula to an infant. At the manager level among the hospitals, there was an increase in duration of solids and formula with increased manager knowledge of CDC recommendations for cleaning a pump. Qualitative responses to the open-ended question of the EPBS-Q showed that experiences demonstrating a lack of support for EBMW continue to exist among RNs who expressed breast milk upon return to work.

Neurocysticercosis (NCC), a parasitic infection of the human central nervous system with the organism Taenia solium is an important, yet neglected, global public health problem causing preventable disability such as seizure and stroke in those infected. NCC symptoms vary widely, based upon the number and location of lesions, and can be difficult to identify and diagnose. NCC is a reportable disease in Los Angeles County. However, there is limited understanding of NCC disease burden in Los Angeles County due to reporting barriers.

This dissertation is presented in three papers. The first paper examines case reporting and demographics of probable NCC cases identified in a Los Angeles community hospital through review of computerized tomography (CT) brain scan reports performed during 2012 that describe evidence of lesions highly suggestive of NCC infection. The study identified 303 probable NCC cases and found that 7 of the 11 cases reported to Los Angeles County Department of Public Health in 2012 were from the study site.

The second paper describes the presenting symptoms and mortality data of identified probable NCC cases. The study found that 3.9% of cases presented with seizure upon admission to the hospital and that death occurred in 3.9% of cases. The most common presenting symptom was headache (24.7%).

The third paper analyzes the rate of prior and acute stroke in the 303 probable NCC cases. The study found that 28.3% had evidence of prior stroke and 13.2% had evidence of acute stroke on CT brain scan performed during their admission to the hospital. NCC infection was also shown to be statistically significant as an independent risk factor for acute stroke when other known stroke risk factors were controlled for. The odds of acute stroke for probable NCC-infected persons were nearly 25 times that of noninfected NCC persons in this study.

The research presented here improves the understanding of NCC disease burden in Los Angeles County, demonstrates differences in NCC presenting symptoms, and demonstrates that NCC infection is an independent risk factor for acute stroke.

The goal of this research was to test the hypothesis that a brief workplace training session on control of early morning flexion (bending – and other spine-loading activities) can significantly reduce back pain incidence, claims, disability and the associated costs. Back pain is the leading cost driver for workers’ compensation claims, globally the leading cause of days lived with disability, and one of the leading reasons people seek medical care outside of workers’ compensation. Diagnostic methods, including imaging, have not proven to result in improved outcomes. Treatments by health care professionals, regardless of specialty, have been shown to be equally effective, and comparable to education-only results. In this context, self-care approaches have garnered attention. One such approach that has shown promise for chronic low back pain sufferers is the control of early morning flexion. The current study tested this intervention in a workplace setting through a training session to control spine-loading activities within the first two hours of rising from sleep in a prospective cluster-randomized partial cross-over controlled intervention. 157 of 290 eligible university custodial services workers’ completed a baseline questionnaire and were randomly assigned (by supervisor group) into treatment and sham groups then given either treatment (bending) or sham training (lifting technique training known to have no significant impact on back pain). The questionnaire contained demographic, back pain history, workplace, activity, and exercise questions. After one year, the questionnaire was completed again and all subjects were then given the treatment training. After one more year, the questionnaire was completed again. Analysis of the baseline data revealed that when time between rising from sleep and leaving for work were less than two hours, LBP risk increased by 119%, and sciatica risk increased 152%. Bending, sitting, and lifting (objects over 10 pounds) during the first two hours after rising performed “Nearly All the Time” were associated with a 47-fold increased risk of very severe pain and 39 more days with LBP within a 6-month period. Moderate exercise after waking appeared to be somewhat protective. Mixed effects analyses with corresponding predicted values were used to assess the impact of the intervention prospectively. A pattern of greater reduction in odds and incident rate ratios for most back pain measures was observed for the treatment training as well as for the treatment. The greatest decreases for treatment training were for total days of back pain (50% reduction of incident rate ratio) and medication use for back pain (47% reduced odds). Workers should limit spine-loading activities within the first two hours after waking, although exercise may be helpful. Employers should avoid scheduling spine-loading tasks such as sitting, bending, or lifting at the beginning of work shifts. Clinicians may recommend to limit spine-loading activities within two hours after waking from sleep both at home and at work.

Black hair-salon workers face serious health hazards from the products they use on

themselves, products they use on clients, and other health hazards in their work

setting. Currently there is a significant research gap in understanding the prevalence of workplace related exposures and health outcomes. The primary objective of this study was to gather data on workplace exposures and health outcomes of hair care professionals in South Los Angeles. The goal was to determine the workplace exposures, assess hair care services provided, investigate prevalence of personal protective equipment and ventilation use in salons, and to obtain data on potential interest in health and safety education programs. The results suggest the need for proper health and safety training within the salon worker community, specifically around chemical hair services. The results also suggest ergonomic workstation assessments and recommendations for hair care professionals would be beneficial to reduce musculoskeletal disorders. Willingness of stylists to learn more about workplace hazards and how to mitigate their risks was high. It is recommended that a training program be developed to educate stylists on creating safer salons.

Background: Oseltamivir treatment for influenza should begin within 48 hours of symptom onset; however, there is no significant benefit or data supporting the use of Oseltamivir beyond the 48-hour window in otherwise healthy adults. There are many reasons for inappropriate usage of antiviral prescriptions, including providers’ lack of knowledge regarding guideline recommendations for antiviral use for influenza, the belief that prescribing medications may have some benefit, and the need to satisfy patient wants by prescribing a medication for a viral illness other than influenza. The most commonly prescribed antiviral for influenza in urgent care settings is Oseltamivir. The problem is that providers are prescribing Oseltamivir when it is not appropriate and not in accordance with the Centers for Disease Control and Prevention (CDC) prescribing guidelines, which can impact antiviral resistance. Objective: The purpose of this study was to determine whether urgent care providers’ knowledge about Oseltamivir, Oseltamivir resistance, and current CDC prescribing recommendations would increase after implementation of a short, one-on-one educational intervention. Methods: This quality improvement (QI) project enrolled providers working in urgent care clinics. Pre-intervention questionnaires collected baseline knowledge about Oseltamivir, followed by a 15-minute, one-on-one educational presentation on Oseltamivir. Post-intervention questionnaires were collected four weeks after the educational intervention. Statistical analysis consisted of Wilcoxon signed-rank tests. Results: The pre-intervention knowledge scores had a mean of 35.8%, whereas the post-intervention knowledge scores revealed a mean score of 65%, p=0.012 Conclusion: The project was feasible and essential in identifying the gaps in healthcare providers’ knowledge about Oseltamivir and appropriate prescription usage of Oseltamivir for influenza. The end goal was for prescribers to be aware of best practices and CDC guidelines to improve patient’s health and well-being.