Common use of Conclusions Clause in Contracts

Conclusions. BMI appeared to have a stronger influence on young adult SBP and pre-hypertension / hypertension than all measures of SES, but significant moderation and mediation was observed between BMI and various measures of SES. Further research is needed into the role of BMI as a mediator or moderator on SES and young adult blood pressure, and to investigate whether individual components of SES may predict young adult blood pressure. Influence of Socioeconomic Status and Body Composition on Young Adult Blood Pressure: The Birth to Twenty Cohort By Chloe W. Eng B.S. Northeastern University 2014 Thesis Committee Chair: Xxxxx X. Xxxxx, PhD A thesis submitted to the Faculty of the Xxxxxxx School of Public Health of Emory University in partial fulfillment of the requirements for the degree of Master of Science in Public Health in Epidemiology 2016 I would like to extend my sincerest thanks and appreciation to: Xxxxx X. Xxxxx, for allowing me this learning opportunity, as well as his insight, support, and ongoing patience whenever I veer off topic. Xxxxx Xxxxxx, PhD, study staff and researchers at DPHRU, and University of the Witwatersrand, for their efforts towards the continuation of Birth to Twenty, for allowing me the ability to learn from them through the practicum experience, and the hospitality that has continued past the culmination of my practicum. The Global Field Experience (GFE) Committee, for providing me with the funding that allowed me to help clean and analyze this data in the context in which it was collected. Xxxx Xxxxxx, for your company in South Africa, your indispensable advice, and for letting me rely on you for cell phone access and transportation while abroad. My friends and fellow Xxxxxxx classmates, for the laughter, levity, and late nights that made these past years immensely enjoyable. And finally, my parents, for being my ever present anchors and for allowing me the opportunities to learn and grow so many miles away from home for the past six years. Chapter I: Literature Review 1 Chapter II: Manuscript 15 Abstract 15 Introduction 16 Methods 18 Results 26 Discussion 31 Chapter III: Summary, Future Directions, & Public Health Implications 36 Tables and Figures. 37 References. 50 Chapter I: Literature Review Introduction Globally, non-communicable disease (NCD) has begun to replace communicable, or infectious, disease as the major contributor to mortality.1 One example of this epidemiologic shift seen in South Africa, a middle-income country that exhibits rates of chronic diseases such as hypertension as high as or exceeding those seen in high-income nations. Hypertension is now regarded as one of South Africa and Sub-Saharan Africa’s greatest health challenges after the HIV/AIDs crisis.2 Nationally representative World Health Organization (WHO) data from 2007 to 2010 showed a hypertension prevalence of 77.9% [95% confidence interval (CI): 76.4 – 79.4] in South African adults over age 50, the highest rate reported in this age group of any nation in the world. After stratifying by gender, hypertension prevalence rates were reported to be as high as 74.7% [95% CI: 72.6 – 76.8] in males and 80.3% [95% CI: 78.6 – 82.0] for females.3 However despite the similarities in hypertension prevalence with high income countries, South Africa and many other Sub-Saharan African nations report significantly lower rates of detection, treatment, and control than high-income nations.2 South Africa reports some of the highest rates of obesity as well, a condition that has shown consistent associations with hypertension. The WHO Study on Global Aging and Adult Health (SAGE) compiled data from the six middle-income countries of China, Ghana, India, Mexico, Russia, and South Africa, and found that age and obesity were consistently significant predictors of hypertension prevalence in all six countries (though significance in South Africa data alone was only significant in the 60 – 79 year age group, with an odds ratio of 38.89 and 95% confidence interval of 5.55 to 272.6). Socioeconomic factors such as insurance status were also found to be significantly correlated with diagnosis of hypertension, and income was found to have a significant association with hypertension treatment status, though it showed no effect on prevalence.4, 5 This thesis uses data from the Birth to Twenty Cohort to investigate the effect of socioeconomic status on blood pressure in young adults from South Africa, an age group that remains underrepresented in the study of hypertension in sub-Saharan Africa. Birth to Twenty is distinctive as the longest running longitudinal birth cohort in Africa and has focused on the early expression of metabolic risk factors and conditions as one of its primary domains.6 Because the presence of risk factors such as obesity and hypertension in childhood are strongly associated with adverse health outcomes in later years, the data from this cohort provides a unique opportunity to examine health and development from youth to early adulthood. This cohort is the first to allow for tracking of health throughout early life in South Africa, and past findings have contributed to nation-wide policies, including regulation of age for school attendance and restrictions on tobacco purchasing.7 Therefore, this research aims to explore blood pressure in the young adult data collection wave, and to assess how the major risk factor of obesity may mediate observed associations in the unique socioeconomic context of post-Apartheid South Africa.

Conclusions. BMI appeared The U.S. needs a national mechanism to have a stronger influence on young adult SBP and pre-hypertension / hypertension than all measures of SES, but significant moderation and mediation was observed between BMI and various measures of SES. Further research is needed into the role of BMI as a mediator or moderator on SES and young adult blood pressure, systematically identify survey reports and to investigate whether individual components standardize measures and reporting for Campus Climate Surveys. FTFI and CASI elicited similar rates of SES may predict young adult blood pressuresexual violence disclosure, suggesting that colleges and universities can conduct robust assessments via CASI. Influence Nonsignificant findings that FTFI elicited more disclosures warrants further study. Colleges and universities need to xxxxxx inclusive campus culture for students while implementing Campus Climate Surveys. Understanding the Disclosure of Socioeconomic Status Sexual Violence among College Women By Xxxxxxxx Xxxxx Xxxxxx B.A., Xxxxxxxx College, 2006 X.Xx. London School of Hygiene and Body Composition on Young Adult Blood PressureTropical Medicine, 2009 Advisor: The Birth to Twenty Cohort By Chloe W. Eng B.S. Northeastern University 2014 Thesis Committee Chair: Xxxxx Xxxxxxx X. Xxxxx, PhD Ph.D. A thesis dissertation submitted to the Faculty of the Xxxxxxx Xxxxx X. Xxxxx School of Public Health Graduate Studies of Emory University in partial fulfillment of the requirements for the degree of Master Doctor of Science Philosophy in Public Behavioral Sciences and Health Education 2018 Acknowledgements There are many people to whom I’m grateful for supporting me in Epidemiology 2016 I would like this work. Thank you to extend my sincerest thanks and appreciation to: Xxxxx X. Xxxxx, for allowing me this learning opportunity, as well as his insight, support, and ongoing patience whenever I veer off topiccommittee. Xxxxx Xxxxxxx Xxxxxx, PhD, study staff and researchers at DPHRU, and University of the Witwatersrand, thank you for their efforts towards the continuation of Birth to Twenty, for allowing helping me the ability to learn from them expand this idea into a dissertation through the practicum experienceproposal development class and for guiding me through the directed study on psychometric measurement. Xxxxxx Xxxxxxxxxx, and thank you for encouraging me to pursue the hospitality that has continued past the culmination systematic review of my practicum. The Global Field Experience (GFE) CommitteeCampus Climate Surveys, for providing me with the funding that allowed me to help clean and analyze this data a directed study in the context in which it was collected. Xxxx Xxxxxx, for your company in South Africa, your indispensable advicestructural equation modeling, and for letting me rely pop-in to your office on a frequent basis. Xxxxxxx Sales, thank you for cell phone access selecting me to serve as the co-chair of the Campus Climate Survey Subcommittee in 2014, which gave me invaluable insight into these surveys and transportation the practical experience with implementation and communication of results. Thank you for your support throughout my committee work, in figuring out the logistics of this project, and the directed study in screening for experiences of violence, linkages to clinical care, and ethics. Finally, thank you to my advisor, Xxxxxxx Xxxxx. You pushed me to “think big” and prepared me to take on a project of this scope. You encouraged me to work independently while abroadproviding consistent support and guidance, removing barriers as I encountered them. My friends It has been a pleasure to have you as my advisor, chair, and fellow mentor. Thank you to the Department of Behavioral Sciences and Health Education for the excellent training that I have received. Thank you to both Director of Graduate Studies who served during my time; Xxx Xxxxx Xxxxxxx classmatesand Xxxxx Xxxxx. You both served as the anchor for the doctoral students. Thank you to Xxxxxxx XxXxxxx for leading our department into a new era. Thank you to the faculty members who helped me navigate the world of teaching (you all served as wonderful role models); Xxxx Xxxxxx, Xxxxx Xxxx, and Xxxxx Xxxx. Thank you to Xxx Xxxxx Xxxxxxx, Xxxxx XxXxxxxxxx, and Xxxxxxxx Xxxxx for writing letters of support for my F31 grant. Thank you to all of the department faculty, who xxxxxx an environment of scientific rigor and genuine collegiality. It has made for a happy doctoral experience. I would never have completed this step, or any milestone in the program without the support of my doctoral student colleagues. Thank you to my cohort; Xxxxx Xxxxxxxxx, Xxxxx Xxxxx, Xxxxx Xxxxxxx, and Xxxxxx St. Xxxxx Xxxxxxxx; what a joy to have been through it all together. Thank you to my violence prevention colleagues, Xxxxxxxxx Xxxxxxx, Xxxxx Xxxx, Xxxxxx Xxxxxxx, and Xxxxx Xxxxxx; you inspire me each day through your dedication to the movement. Thank you as well to my peer mentor Xxxxxxxx Hayley; you served as an unparalleled example for hard work and generosity. Thank you to my officemates, who are aforementioned, as well as Xxxxx Xxxxxxx, and unofficial officemate Jing Xxxx Xx, for your willingness to let me “run something by you real quick,” and for all the laughter. I have a reason to thank each doctoral student in this department for a different reason; so again, levitythank you to all. Thank you to the department administrative staff; Xxxxxx Xxxxxx, Xxxxxxxx Xxxxx, Xxxxxx Xxxxxx, and late nights Yenawa Xxxxxxxx. Our department would not function without you, and I thank you for making it all happen, from signing me up for classes and helping me manage my funding, to making me countless PDF packages, and planning our social gatherings. Thank you for serving as problem fixers and friends. I cannot wait to see what future opportunities await for my excellent research assistants Xxxxxxxx XxXxxxxxx, Xxxxxxxxx Xxxxxxxx, and Xxxxxxx Xxxxxxx. Your enthusiasm and talent kept me motivated throughout the past three years. You are all stars about to launch into the sky. Thank you. Thank you to the Respect Program; Xxxxx Xxxx, Jamechya Xxxxxx, and Xxxxxxx Passono. I see you as my partners in this work. I cannot help but be excited when we meet or collaborate on projects. Thank you for all that made these past years immensely enjoyableyou have taught me and for all that you do for the Emory campus. And finallyThank you especially, to Xxxxx, who has written me about six different letters of support for me to pursue funding for this work. Thank you to my colleagues at Emory University who have all contributed to making this work a reality: Xxxxxx Xxxx, Xxxxxx Xxxxxx, Xxxxxx Xxxxxx, Xxxxxx Xxxxx, and Xxxxxx Xxxxxxx. Thank you to my funders. Research reported in this dissertation was supported by National Institute of Child Health and Human Development of the National Institutes of Health under award number 1F31HD086964-01A1. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. This work was additionally supported by the Emory Injury Prevention Research Center and Xxxxx Graduate School Professional Development Support funds. Thank you to all of my friends who supported me throughout the applying to graduate school, moving to Atlanta, and finishing this degree. Thank you to my family for your love and support. Thank you to my parents, for Xxxxx and Xxxxx. You have always encouraged me to follow my dreams and you have made achieving them possible by helping me get there. Thank you to my siblings, Xxxxxxx and Xxxxx. Spending a lifetime being my ever present anchors and for allowing known to teachers as “the third Xxxxxx child” provided me the opportunities with an endless motivation to learn and grow so many miles away from home for the past six yearslive up to your brilliance. Chapter I: Literature Review 1 Chapter II: Manuscript 15 Abstract 15 Introduction 16 Methods 18 Results 26 Discussion 31 Chapter III: SummaryThank you also to Bo, Future Directions, & Public Health Implications 36 Tables and Figures. 37 References. 50 Chapter I: Literature Review Introduction Globally, non-communicable disease (NCD) has begun to replace communicable, or infectious, disease as the major contributor to mortality.1 One example of this epidemiologic shift seen in South Africa, a middle-income country that exhibits rates of chronic diseases such as hypertension as high as or exceeding those seen in high-income nations. Hypertension is now regarded as one of South Africa and Sub-Saharan Africa’s greatest health challenges after the HIV/AIDs crisis.2 Nationally representative World Health Organization (WHO) data from 2007 to 2010 showed a hypertension prevalence of 77.9% [95% confidence interval (CI): 76.4 – 79.4] in South African adults over age 50, the highest rate reported in this age group of any nation in the world. After stratifying by gender, hypertension prevalence rates were reported to be as high as 74.7% [95% CI: 72.6 – 76.8] in males and 80.3% [95% CI: 78.6 – 82.0] for females.3 However despite the similarities in hypertension prevalence with high income countries, South Africa and many other Sub-Saharan African nations report significantly lower rates of detection, treatmentMolly, and control than high-income nations.2 South Africa reports some Xxxxx. Thank you to my life partner and future husband, Xxxxxxx. Words fall short of the highest rates of obesity as wellall that you mean to me. Thank you for inspiring me with your heart, a condition that has shown consistent associations with hypertension. The WHO Study on Global Aging and Adult Health (SAGE) compiled data from the six middle-income countries of China, Ghana, India, Mexico, Russiayour mind, and South Africayour cooking. Finally, thank you to my Student Advisory Board, my participants, and found that age and obesity were consistently significant predictors of hypertension prevalence survivors. You make this work worthwhile. I am grateful for your willingness to participate in all six countries (though significance in South Africa data alone was only significant in my study. Many students on campuses across the 60 – 79 year age group, with an odds ratio of 38.89 and 95% confidence interval of 5.55 country act to 272.6). Socioeconomic factors such as insurance status were also found to be significantly correlated with diagnosis of hypertension, and income was found to have a significant association with hypertension treatment status, though it showed no effect on prevalence.4, 5 This thesis uses data from the Birth to Twenty Cohort to investigate the effect of socioeconomic status on blood pressure in young adults from South Africa, an age group that remains underrepresented in the study of hypertension in sub-Saharan Africa. Birth to Twenty is distinctive as the longest running longitudinal birth cohort in Africa and has focused create change on the early expression of metabolic risk factors and conditions as one of its primary domains.6 Because the presence of risk factors such as obesity and hypertension in childhood are strongly associated with adverse health outcomes in later years, the data from this cohort provides a unique opportunity issues that matter to examine health and development from youth to early adulthood. This cohort is the first to allow for tracking of health throughout early life in South Africa, and past findings have contributed to nation-wide policiesthem, including regulation sexual violence. I do this work in honor of age for school attendance and restrictions on tobacco purchasing.7 Therefore, this research aims to explore blood pressure in the young adult data collection wave, and to assess how the major risk factor of obesity may mediate observed associations in the unique socioeconomic context of post-Apartheid South Africayou.

Conclusions. BMI appeared HDP was associated with higher rates of adverse maternal and neonatal outcomes in one hospital with possibly better reporting of maternal complications than other hospitals in Haiti. This finding is comparable to have a stronger influence on young adult SBP studies of HDP conducted in high- income countries. The Associations of Hypertensive Disorders in Pregnancy with Maternal and pre-hypertension / hypertension than all measures Neonatal Outcomes in Haiti By Xxxxxxx Xxxxxxxx Bachelor of SES, but significant moderation and mediation was observed between BMI and various measures of SES. Further research is needed into the role of BMI as a mediator or moderator on SES and young adult blood pressure, and to investigate whether individual components of SES may predict young adult blood pressure. Influence of Socioeconomic Status and Body Composition on Young Adult Blood Pressure: The Birth to Twenty Cohort By Chloe W. Eng B.S. Northeastern Science Clemson University 2014 2011 Thesis Committee Chair: Xxxxx X. XxxxxXxxxxxx Xxxxxx, PhD Ph.D. A thesis submitted to the Faculty of the Xxxxxxx School of Public Health of Emory University in partial fulfillment of the requirements for the degree of Master of Science in Public Health in Global Epidemiology 2016 I would like to thank the Centers for Disease Control and Prevention and the Emergency Response and Recovery Branch, who made this project and experience possible. I would like to extend my sincerest thanks a special thank you to Xx. Xxxxxx Xxxxxxx, who allowed me access to the ePOSS project and appreciation to: Xxxxx X. Haiti data. I would also like to thank Xx. Xxxxxxxx Xxxxx, for allowing me this learning opportunitywhose expertise, as well as his insight, supportguidance, and ongoing patience whenever support allowed me to grow and learn throughout this process. Additionally, I veer off topicwould like to thank Xxxx Xxxxxxx, who was instrumental in helping with data cleaning and management. I sincerely thank Xx. Xxxxxxx Xxxxxx and Xx. Xxxxx XxxxxxXxxxx for the time they put into helping me with this project. I greatly appreciate all their wisdom and feedback, PhD, study staff which challenged me to expand my project and researchers at DPHRU, enhance my scientific writing. I would also like to acknowledge my family and University of the Witwatersrand, for their efforts towards the continuation of Birth to Twenty, for allowing me the ability to learn from them through the practicum experience, and the hospitality that has continued past the culmination of my practicum. The Global Field Experience (GFE) Committee, for providing friends who provided me with the funding that allowed me to help clean and analyze this data in much- needed support throughout the context in which it was collected. Xxxx Xxxxxx, for your company in South Africa, your indispensable advice, and for letting me rely on you for cell phone access and transportation while abroad. My friends and fellow Xxxxxxx classmates, for the laughter, levity, and late nights that made these past years immensely enjoyable. And finally, my parents, for being my ever present anchors and for allowing me the opportunities to learn and grow so many miles away from home for the past six last two years. Glossary i Chapter I: Literature Review 1 Hypertensive Disorders in Pregnancy: A Global Problem 2 HDP Research in the Developed World 4 Health System in Haiti 6 Health Complications Faced by Haitian Women 8 Hypertensive Disorders in Pregnancy Research in Haiti 9 Challenges in Health Statistics in Haiti 11 Conclusion 12 Chapter II: Manuscript 15 13 Abstract 15 13 Introduction 14 Methods 16 Methods 18 Results 26 19 Discussion 31 Chapter III22 Tables 28 Table 1: SummaryPrevalence of hypertensive disorders in pregnancy in 4 hospitals by 6-month intervals 28 Table 2: Comparison of clinical presentation of women at 4 hospitals in Haiti 29 Table 3: Clinical presentation of women with and without stillbirth at HAS, Future Directions, & Public Health Implications 36 Tables by entire cohort and Figures. 37 References. 50 Chapter I: Literature Review Introduction Globally, non-communicable disease (NCD) has begun to replace communicable, or infectious, disease as the major contributor to mortality.1 One example of this epidemiologic shift seen in South Africa, a middle-income country that exhibits rates of chronic diseases such as hypertension as high as or exceeding those seen in high-income nations. Hypertension is now regarded as one of South Africa and Sub-Saharan Africa’s greatest health challenges after the HIV/AIDs crisis.2 Nationally representative World Health Organization (WHO) data from 2007 to 2010 showed a hypertension prevalence of 77.9% [95% confidence interval (CI): 76.4 – 79.4] in South African adults over age 50, the highest rate reported in this age group of any nation in the world. After stratifying by gender, hypertension prevalence rates were reported to be as high as 74.7% [95% CI: 72.6 – 76.8] in males and 80.3% [95% CI: 78.6 – 82.0] for females.3 However despite the similarities in hypertension prevalence with high income countries, South Africa and many other Sub-Saharan African nations report significantly lower rates of detection, treatment, and control than high-income nations.2 South Africa reports some of the highest rates of obesity as well, a condition that has shown consistent associations with hypertension. The WHO Study on Global Aging and Adult Health (SAGE) compiled data from the six middle-income countries of China, Ghana, India, Mexico, Russia, and South Africa, and found that age and obesity were consistently significant predictors of hypertension prevalence in all six countries (though significance in South Africa data alone was HDP mothers only significant in the 60 – 79 year age group, with an odds ratio of 38.89 and 95% confidence interval of 5.55 to 272.6). Socioeconomic factors such as insurance status were also found to be significantly correlated with diagnosis of hypertension, and income was found to have a significant association with hypertension treatment status, though it showed no effect on prevalence.4, 5 This thesis uses data from the Birth to Twenty Cohort to investigate the effect of socioeconomic status on blood pressure in young adults from South Africa, an age group that remains underrepresented in the study of hypertension in sub-Saharan Africa. Birth to Twenty is distinctive as the longest running longitudinal birth cohort in Africa and has focused on the early expression of metabolic risk factors and conditions as one of its primary domains.6 Because the presence of risk factors such as obesity and hypertension in childhood are strongly associated with adverse health outcomes in later years, the data from this cohort provides a unique opportunity to examine health and development from youth to early adulthood. This cohort is the first to allow for tracking of health throughout early life in South Africa, and past findings have contributed to nation-wide policies, including regulation of age for school attendance and restrictions on tobacco purchasing.7 Therefore, this research aims to explore blood pressure in the young adult data collection wave, and to assess how the major risk factor of obesity may mediate observed associations in the unique socioeconomic context of post-Apartheid South Africa.30

Conclusions. BMI appeared Providers and staff highlighted many strengths and gaps in the TIC practices of the TC. We put forth recommendations that build upon center strengths and address the identified barriers to have facilitate the creation of a stronger influence on young adult SBP and pre-hypertension / hypertension than all measures of SES, but significant moderation and mediation was observed between BMI and various measures of SES. Further research is needed multilevel implementation strategy to integrate TIC into the role of BMI HIV services provided. If successfully adapted, the TC could serve as a mediator or moderator on SES HIV-TIC model for other high-volume, resource- constrained HIV clinics. Barriers and young adult blood pressureFacilitators to Providing Trauma Informed Care at a Large Urban HIV Treatment Center in the Southeastern United States: Perceptions from the Clinic Staff and Providers. By Xxxxx X Xxxxxxx BSc, and to investigate whether individual components of SES may predict young adult blood pressure. Influence of Socioeconomic Status and Body Composition on Young Adult Blood Pressure: The Birth to Twenty Cohort By Chloe W. Eng B.S. Northeastern University 2014 Arizona State University, 2016 Thesis Committee Chair: Xxxxx X. XxxxxXxxxxx Kahloke MD, PhD MSc A thesis submitted to the Faculty of the Xxxxxxx School of Public Health of Emory University in partial fulfillment of the requirements for the degree of Master of Science in Public Health in Epidemiology 2016 I would like to extend my sincerest thanks and appreciation to: Xxxxx X. Global Health, 2018 Acknowledgements “Thesis… it’s a marathon. Not a sprint.” – Xxxxxx Xxxxx, MPH Class of 2018 This has been an experience of a lifetime and I have so many people to thank for allowing joining me on this learning opportunityjourney. First and foremost, a special thank you to Xxxxxx Kahloke, who advised this thesis and provided much support and guidance throughout the process. I am grateful to the entire GTICS research team, who provided ample opportunities to learn the ins and outs of conducting implementation research as well as his insightthe knowledge around conducting and analyzing qualitative research. Thank you to our participants and the treatment center who we cannot name but trusted us with the triumphs and tribulations of their work and believe in our ability to assist them in improving patient care at their center. Our work would not be possible without the center staff, supportadministrators, and ongoing patience whenever I veer off topicproviders who candidly shared their experiences and express amazing devotion to the unique patients they serve. Xxxxx XxxxxxThe biggest thank you goes to my accountability team, PhDCharjoi Xxxxxxx and Xxxxxx Xxxxx, study staff who joined me for many Thesis-Sundays* and researchers at DPHRUThesis-cation**, and University who continuously reminded me of my timeline and encouraged me every step of the Witwatersrandway. To my amazing supportive family, for their efforts towards the continuation of Birth who listened to Twentymy stories, for allowing me the ability excitement, complaints and ranting, your support is invaluable and grateful is an understatement! It really took a village to learn from them through the practicum experienceproduce this work, and the hospitality that has continued past the culmination of my practicum. The Global Field Experience (GFE) Committee, for providing me with the funding that allowed me to help clean and analyze this data in the context in which it was collected. Xxxx Xxxxxx, for your company in South Africa, your indispensable advice, and for letting me rely on you for cell phone access and transportation while abroad. My friends and fellow Xxxxxxx classmates, I will be forever grateful for the laughter, levity, opportunity to improve my skills and late nights that made these past years immensely enjoyable. And finally, my parents, for being my ever present anchors and for allowing me the opportunities to learn and grow so many miles away from home for the past six years. Chapter I: Literature Review 1 Chapter II: Manuscript 15 Abstract 15 Introduction 16 Methods 18 Results 26 Discussion 31 Chapter III: Summary, Future Directions, & Public Health Implications 36 Tables and Figures. 37 References. 50 Chapter I: Literature Review Introduction Globally, non-communicable disease (NCD) has begun to replace communicable, or infectious, disease as the major contributor to mortality.1 One example of this epidemiologic shift seen in South Africa, a middle-income country that exhibits rates of chronic diseases such as hypertension as high as or exceeding those seen in high-income nations. Hypertension is now regarded as one of South Africa and Sub-Saharan Africa’s greatest health challenges after the HIV/AIDs crisis.2 Nationally representative World Health Organization (WHO) data from 2007 to 2010 showed a hypertension prevalence of 77.9% [95% confidence interval (CI): 76.4 – 79.4] in South African adults over age 50, the highest rate reported in this age group of any nation in the world. After stratifying by gender, hypertension prevalence rates were reported to be as high as 74.7% [95% CI: 72.6 – 76.8] in males and 80.3% [95% CI: 78.6 – 82.0] for females.3 However despite the similarities in hypertension prevalence with high income countries, South Africa and many other Sub-Saharan African nations report significantly lower rates of detection, treatment, and control than high-income nations.2 South Africa reports some of the highest rates of obesity as well, a condition that has shown consistent associations with hypertension. The WHO Study on Global Aging and Adult Health (SAGE) compiled data from the six middle-income countries of China, Ghana, India, Mexico, Russia, and South Africa, and found that age and obesity were consistently significant predictors of hypertension prevalence in all six countries (though significance in South Africa data alone was only significant in the 60 – 79 year age group, with an odds ratio of 38.89 and 95% confidence interval of 5.55 to 272.6). Socioeconomic factors such as insurance status were also found to be significantly correlated with diagnosis of hypertension, and income was found to have a significant association with hypertension treatment status, though it showed no effect on prevalence.4, 5 This thesis uses data from the Birth to Twenty Cohort to investigate the effect of socioeconomic status on blood pressure in young adults from South Africa, an age group that remains underrepresented in the study of hypertension in sub-Saharan Africa. Birth to Twenty is distinctive as the longest running longitudinal birth cohort in Africa and has focused on the early expression of metabolic risk factors and conditions as one of its primary domains.6 Because the presence of risk factors such as obesity and hypertension in childhood are strongly associated with adverse health outcomes in later years, the data from this cohort provides a unique opportunity to examine health and development from youth to early adulthood. This cohort is the first to allow for tracking of health throughout early life in South Africa, and past findings have contributed to nation-wide policies, including regulation of age for school attendance and restrictions on tobacco purchasing.7 Therefore, this research aims to explore blood pressure in the young adult data collection wave, and to assess how the major risk factor of obesity may mediate observed associations in the unique socioeconomic context of post-Apartheid South Africainspired by so many.

Conclusions. BMI appeared to have a stronger influence on young adult SBP This study finds no evidence indicating an association between nitrosamine exposure from condoms and pre-hypertension / hypertension than all measures incidence of SES, but significant moderation cervical and mediation was observed between BMI colorectal cancer. Condoms provide substantial and various measures of SES. Further research is needed into the role of BMI as a mediator or moderator on SES and young adult blood pressuremeasurable public health benefits, and providers and healthcare organizations should continue to investigate whether individual components recommend and promote them without hesitation. Lack of SES may predict young adult blood pressure. Influence ecological association between state-level cervical and colorectal cancer incidence and nitrosamine exposure from condom use for a cross-sectional study of Socioeconomic Status and Body Composition on Young Adult Blood Pressure: The Birth to Twenty Cohort the United States By Chloe W. Eng B.S. Northeastern University 2014 Xxxxxx XxXxxxxx Bachelor of Arts, Vassar College, 2013 Thesis Committee ChairChairs: Xxxxx X. Xxxxx, PhD PhD, MPH Xxxxx Xxxxxxx, PhD, MHS A thesis submitted to the Faculty of the Xxxxxxx School of Public Health of Emory University in partial fulfillment of the requirements for the degree of Master of Science in Public Health in Global Epidemiology 2016 Acknowledgements I would like to extend express sincere appreciation to my sincerest thanks committee chairs Xxxxx Xxxxxxx and appreciation to: Xxxxx X. Xxxxx, Xxxxx for allowing me agreeing to take on another thesis advisee despite their very busy schedules. Thank you so much for your support and advice during this learning opportunityprocess, as well as his insightyour good humor and very interesting conversations. I would like to thank Xxx X’Xxxxxx at the Emory Center for Digital Scholarship and Xxxxxxx Xxxxxxxx at the Xxxxxxxx Health Science Center Library for their help, supportincluding answering emails at 10pm on a Sunday and agreeing to meet frantic MPH students the very next day. I would also like to thank Xxxxx Xxxxxxx for her expertise and infectious enthusiasm for mapping and GIS, as well as her encyclopedic knowledge in finding (free) data. Finally, all my love and gratitude to my friends and family. To my Xxxxxxx friends, I could not have done it without you all—we’re (almost) done! To everyone else, I’ll stop talking about this and return calls/emails in a timely manner now, I swear. Contents INTRODUCTION 1 Nitrosamines in food and water 5 Occupational exposure to nitrosamines 9 Nitrosamines in rubber products 13 Colorectal cancer 18 Cervical Cancer 19 METHODS 21 Data Sources 21 Spatial Analysis 23 Bivariate association with cancer incidence 24 Multivariable association with cancer incidence 25 RESULTS 27 Colorectal Cancer Incidence 27 Cervical Cancer Incidence 28 DISCUSSION: 29 Conclusions 29 Limitations: 30 Future directions 32 APPENDIX 34 Figure 1 34 Figure 2 35 Figure 3 36 Figure 4 37 Figure 5 38 Figure 6 39 Figure 7 40 Figure 8 41 Table 1 42 Table 2 43 Table 3 44 Table 4 45 Table 5 46 Works Cited 47 Non-printed sources cited 53 Introduction Condoms are one of the most important public health tools in sexual health, playing roles in human immunodeficiency virus (HIV) prevention, prevention of sexually transmitted infections (STIs), and ongoing patience whenever I veer off topicfamily planning. There has been substantial investment by local governments, international health agencies and non- governmental organizations (NGOs) to increase supply and uptake of condoms (Xxxxxx et al., 2016; Xxxxxxx et al., 2008; Xxxxxxx et al., 2016; Xxxxx Xxxxxxet al., PhD2015). Increasing access to condoms and education about STI and HIV prevention has resulted in important gains in condom use, study staff especially among high-risk populations like commercial sex workers (CSW) and researchers at DPHRUmen who have sex with men (MSM) (Xxxxxxx et al., 2008; Xxxxxx & Xxxxx, 2016; Xxxxxxxx et al., 2016; Xxxxxxxxxxx et al., 2013). However, condom usage among CSWs continues to face barriers including client preference for unprotected sex, inconsistent condom supply, and University policies that criminalize sex work (Xxxxxxxx et al., 2016; Xxxx, 2013). Among MSM populations, condom use is mediated by perceptions of risk and condom self-efficacy (Xxxxxx & Xxxxx, 2016; Xxxxxxxxxx et al., 2016; Xxxx, 2013). National rates of condom use in the US vary by race, age, gender, and sex act: 24.7% of men and 21.8% of women report condom use at last vaginal intercourse while 26.5% of insertive male partners, 44.1% of receptive male partners and 10.8% of receptive female partners report condom use at last anal intercourse (Xxxxx et al., 2010). One of the Witwatersrandbarriers to condom usage in low-income countries is negative perception or rumors about condoms (Xxxxxxx et al., for 2004); a study in Tanzania found that negative beliefs about condoms were significant predictors of willingness to use condoms (Xxxxxxx et al., 2012). Perceptions by the public about condom safety and efficacy directly affect their efforts towards use and thus can adversely affect sexual and reproductive health programs (Xxxxx et al., 2014; Xxxxxxx et al., 2012). Negative beliefs about condoms include the continuation belief that condoms cause cancer (Xxxxxxx et al., 2012). This is actually a concern among some condom manufacturers —specifically, the release of Birth to Twentynitrosamines from condoms (ISO/TC 157, for allowing me 2015). Nitrosamines are a class of carcinogenic compounds that can be produced in the ability to learn from them through manufacturing process of rubber products. Formed by the practicum experiencereaction of nitrites with secondary or tertiary amines, nitrosamines can vary in their carcinogenicity, with two potent carcinogens, N‐nitrosodiethylamine (NDEA) and the hospitality that has continued past the culmination N- nitrosodimethylamine (NDMA), often used as indicators of my practicumnitrosamine presence (Xxxxx, 2011). The Global Field Experience (GFE) Committee, for providing me with the funding that allowed me to help clean and analyze this data in the context in which it was collected. Xxxx Xxxxxx, for your company in South Africa, your indispensable advice, and for letting me rely on you for cell phone access and transportation while abroad. My friends and fellow Xxxxxxx classmates, for the laughter, levity, and late nights that made these past years immensely enjoyable. And finally, my parents, for being my ever present anchors and for allowing me the opportunities to learn and grow so many miles away from home for the past six years. Chapter I: Literature Review 1 Chapter II: Manuscript 15 Abstract 15 Introduction 16 Methods 18 Results 26 Discussion 31 Chapter III: Summary, Future Directions, & Public Health Implications 36 Tables and Figures. 37 References. 50 Chapter I: Literature Review Introduction Globally, non-communicable disease (NCD) has begun to replace communicable, or infectious, disease as the major contributor to mortality.1 One example of this epidemiologic shift seen in South Africa, a middle-income country that exhibits rates of chronic diseases such as hypertension as high as or exceeding those seen in high-income nations. Hypertension is now regarded as one of South Africa and Sub-Saharan Africa’s greatest health challenges after the HIV/AIDs crisis.2 Nationally representative World Health Organization (WHO) data from 2007 to 2010 showed a hypertension prevalence of 77.9% [95% confidence interval (CI): 76.4 – 79.4] in South African adults over age 50), the highest rate reported in this age group of any nation in the world. After stratifying by gender, hypertension prevalence rates were reported to be as high as 74.7% [95% CI: 72.6 – 76.8] in males and 80.3% [95% CI: 78.6 – 82.0] for females.3 However despite the similarities in hypertension prevalence with high income countries, South Africa and many other Sub-Saharan African nations report significantly lower rates of detection, treatmentEuropean Union, and control than high-income nations.2 South Africa reports some of the highest rates of obesity US Environmental Protection Agency (EPA) classify NDEA and NDMA as wellprobable or presumed human carcinogens (Xxxxx, a condition that has shown consistent associations with hypertension2011). The WHO Study US Department of Health and Human Services released the 13th Report on Global Aging Carcinogens in 2014, which included 15 listings of nitrosamines classified as “known or reasonably anticipated” carcinogens (NTP, 2014). Nitrosamines are linked with the development of multiple different types of cancer in many different animal models, including colon tumors in male rats, female mice and Adult Health guinea pigs, as well as cervical tumors in female shrews following rectal or oral administration (SAGE) compiled data from the six middle-income countries of ChinaNTP, Ghana2014). Nitrosamines have been found in food, Indiacosmetics, Mexico, Russiatobacco products, and South Africarubber goods such as balloons, pacifiers, baby bottle teats, and found that age and obesity were consistently significant predictors of hypertension prevalence in all six countries also condoms (though significance in South Africa data alone was only significant in the 60 – 79 year age groupNTP, with an odds ratio of 38.89 and 95% confidence interval of 5.55 to 272.62007; Xxxx et al., 2015; Xxxxxxxx et al., 2005; Xxxxxxxx et al., 2015; Xxxxxxxx & Xxxxxxxxxxxx, 2011). Socioeconomic factors such Nitrosamine-related cancer studies in humans are relatively scarce, though they include epidemiological studies of cancer mortality for occupational cohorts, as insurance status were also found to be significantly correlated with diagnosis of hypertensionwell as case-control or ecological studies conducted on dietary exposure (Monarca et al., 2001; de Vocht et al., 2007; NTP, 2014). Subsequent sections will discuss studies and regulations regarding nitrosamine exposure in occupational settings, food and drinking water, as well as rubber products like pacifiers, rubber gloves, and income was found condoms1. The migration of nitrosamines from condoms to mucous membranes like the vagina and rectum, which have higher absorption, is a significant association with hypertension treatment statuspossible risk (Eisenbrand, though it showed no effect on prevalence.4, 5 This thesis uses data from the Birth to Twenty Cohort to investigate the effect of socioeconomic status on blood pressure in young adults from South Africa, an age group that remains underrepresented in the study of hypertension in sub-Saharan Africa. Birth to Twenty is distinctive as the longest running longitudinal birth cohort in Africa and has focused on the early expression of metabolic risk factors and conditions as one of its primary domains.6 Because the presence of risk factors such as obesity and hypertension in childhood are strongly associated with adverse health outcomes in later years, the data from this cohort provides a unique opportunity to examine health and development from youth to early adulthood. This cohort is the first to allow for tracking of health throughout early life in South Africa, and past findings have contributed to nation-wide policies, including regulation of age for school attendance and restrictions on tobacco purchasing.7 Therefore, this research aims to explore blood pressure in the young adult data collection wave, and to assess how the major risk factor of obesity may mediate observed associations in the unique socioeconomic context of post-Apartheid South Africa2005).

Conclusions. BMI appeared While OAT is effective in reducing substance use and improving quality of life, stigma towards opioid dependent individuals is commonly reported. A multisectoral approach to have a stronger influence on young adult SBP reduce stigma and pre-hypertension / hypertension than all measures link individuals to care is recommended. Trajectories of SESstigma among opioid dependent individuals in Ukraine: A comparison between individuals currently receiving opioid agonist treatment and those not in treatment By Xxxxxxx X. Xxxxxxxx B.A., but significant moderation and mediation was observed between BMI and various measures of SES. Further research is needed into the role of BMI as a mediator or moderator on SES and young adult blood pressureXxxxxxxx College, and to investigate whether individual components of SES may predict young adult blood pressure. Influence of Socioeconomic Status and Body Composition on Young Adult Blood Pressure: The Birth to Twenty Cohort By Chloe W. Eng B.S. Northeastern University 2014 2015 Thesis Committee Chair: Xxxxx X. XxxxxXxxxxx xxx Xxx, PhD MD A thesis submitted to the Faculty faculty of the Xxxxxxx School of Public Health of Emory University in partial fulfillment of the requirements for the degree of Master of Science in Public Health in Epidemiology 2016 Global Health 2019 ACKNOWLEDGEMENTS This research could not have been possible without support and encouragement from others. I would like to thank Dr. Xxxxxx xxx Xxx for his support in the development of this research, constructive feedback, and invaluable guidance throughout my graduate career. Xx. Xxxxxxxxx Xxxxxx for welcoming me into his research team, conceptualizing this research, and encouraging me to think critically. Xx. Xxxxxx Xxxxxx for her unwavering encouragement, constructive feedback, and willingness to help. I would like to extend my sincerest thanks and appreciation to: Xxxxx X. Xxxxxto Xxxxxxxxx XxXxxxxx, for allowing me this learning opportunity, as well as his insight, support, and ongoing patience whenever I veer off topic. Xxxxx Xxxxxx, PhDand Xxxxxxxxxx Xxxxxxxxxxx for their support in developing this research, study staff being willing to talk through writing blocks, assisting in translation and researchers at DPHRUsurvey development, and University of the Witwatersrand, their invaluable hospitality while in Ukraine. The support and inspiration from others could not be understated. I am thankful for my family and friends for their efforts towards the continuation of Birth to Twentyoverwhelming support, for allowing me the ability to learn from them through the practicum experiencelove, and the hospitality that has continued past the culmination of advice. For my practicum. The Global Field Experience (GFE) Committeefiancé for his willingness to move with me so I can progress my education, for providing me with the funding that allowed me to help clean and analyze this data in the context in which it was collected. Xxxx Xxxxxx, for your company in South Africa, your indispensable adviceencouragement when times felt difficult, and for letting patience beyond belief. I could not thank you all enough. To my dear friend, who left us to soon. May your struggles fade and mind find peace. Our cherished memories will continue to guide me rely on you for cell phone access and transportation while abroadthrough. My friends and fellow Xxxxxxx classmates, for the laughter, levity, and late nights that made these past years immensely enjoyableTABLE OF CONTENTS CHAPTER I. INTRODUCTION 8 1.1. And finally, my parents, for being my ever present anchors and for allowing me the opportunities to learn and grow so many miles away from home for the past six yearsINTRODUCTION AND RATIONALE 8 1.2. Chapter I: Literature Review 1 Chapter PROBLEM STATEMENT 10 1.3. PURPOSE STATEMENT 11 1.4. RESEARCH QUESTION 11 1.5. SIGNIFICANCE STATEMENT 12 1.6. ACRONYMS AND DEFINITION OF TERMS 13 CHAPTER II: Manuscript 15 Abstract 15 Introduction . LITERATURE REVIEW 14 2.1. HIV IN UKRAINE 14 2.2. INJECTION DRUG USE 16 Methods 2.3. STIGMA 18 Results 26 Discussion 31 Chapter 2.4. LAW ENFORCEMENT 21 2.5. MEDICATION ASSISTED TREATMENT 23 2.6. SUMMARY 25 CHAPTER III: Summary, Future Directions, & Public Health Implications 36 Tables and Figures. 37 References. 50 Chapter I: Literature Review Introduction Globally, non-communicable disease (NCD) has begun to replace communicable, or infectious, disease as the major contributor to mortality.1 One example of this epidemiologic shift seen in South Africa, a middle-income country that exhibits rates of chronic diseases such as hypertension as high as or exceeding those seen in high-income nations. Hypertension is now regarded as one of South Africa and Sub-Saharan Africa’s greatest health challenges after the HIV/AIDs crisis.2 Nationally representative World Health Organization (WHO) data from 2007 to 2010 showed a hypertension prevalence of 77.9% [95% confidence interval (CI): 76.4 – 79.4] in South African adults over age 50, the highest rate reported in this age group of any nation in the world. After stratifying by gender, hypertension prevalence rates were reported to be as high as 74.7% [95% CI: 72.6 – 76.8] in males and 80.3% [95% CI: 78.6 – 82.0] for females.3 However despite the similarities in hypertension prevalence with high income countries, South Africa and many other Sub-Saharan African nations report significantly lower rates of detection, treatment, and control than high-income nations.2 South Africa reports some of the highest rates of obesity as well, a condition that has shown consistent associations with hypertension. The WHO Study on Global Aging and Adult Health (SAGE) compiled data from the six middle-income countries of China, Ghana, India, Mexico, Russia, and South Africa, and found that age and obesity were consistently significant predictors of hypertension prevalence in all six countries (though significance in South Africa data alone was only significant in the 60 – 79 year age group, with an odds ratio of 38.89 and 95% confidence interval of 5.55 to 272.6). Socioeconomic factors such as insurance status were also found to be significantly correlated with diagnosis of hypertension, and income was found to have a significant association with hypertension treatment status, though it showed no effect on prevalence.4, 5 This thesis uses data from the Birth to Twenty Cohort to investigate the effect of socioeconomic status on blood pressure in young adults from South Africa, an age group that remains underrepresented in the study of hypertension in sub-Saharan Africa. Birth to Twenty is distinctive as the longest running longitudinal birth cohort in Africa and has focused on the early expression of metabolic risk factors and conditions as one of its primary domains.6 Because the presence of risk factors such as obesity and hypertension in childhood are strongly associated with adverse health outcomes in later years, the data from this cohort provides a unique opportunity to examine health and development from youth to early adulthood. This cohort is the first to allow for tracking of health throughout early life in South Africa, and past findings have contributed to nation-wide policies, including regulation of age for school attendance and restrictions on tobacco purchasing.7 Therefore, this research aims to explore blood pressure in the young adult data collection wave, and to assess how the major risk factor of obesity may mediate observed associations in the unique socioeconomic context of post-Apartheid South Africa.MANUSCRIPT 27

Conclusions. BMI appeared to have a stronger influence on young adult SBP This study finds no evidence indicating an association between nitrosamine exposure from condoms and pre-hypertension / hypertension than all measures incidence of SES, but significant moderation cervical and mediation was observed between BMI colorectal cancer. Condoms provide substantial and various measures of SES. Further research is needed into the role of BMI as a mediator or moderator on SES and young adult blood pressuremeasurable public health benefits, and providers and healthcare organizations should continue to investigate whether individual components recommend and promote them without hesitation. Lack of SES may predict young adult blood pressure. Influence ecological association between state-level cervical and colorectal cancer incidence and nitrosamine exposure from condom use for a cross-sectional study of Socioeconomic Status and Body Composition on Young Adult Blood Pressure: The Birth to Twenty Cohort the United States By Chloe W. Eng B.S. Northeastern University 2014 Xxxxxx XxXxxxxx Bachelor of Arts, Vassar College, 2013 Thesis Committee ChairChairs: Xxxxx X. XxxxxGuest, PhD PhD, MPH Xxxxx Xxxxxxx, PhD, MHS A thesis submitted to the Faculty of the Xxxxxxx School of Public Health of Emory University in partial fulfillment of the requirements for the degree of Master of Science in Public Health in Global Epidemiology 2016 Acknowledgements I would like to extend express sincere appreciation to my sincerest thanks committee chairs Xxxxx Xxxxxxx and appreciation to: Xxxxx X. Xxxxx, Guest for allowing me agreeing to take on another thesis advisee despite their very busy schedules. Thank you so much for your support and advice during this learning opportunityprocess, as well as his insightyour good humor and very interesting conversations. I would like to thank Xxx X’Xxxxxx at the Emory Center for Digital Scholarship and Xxxxxxx Xxxxxxxx at the Xxxxxxxx Health Science Center Library for their help, supportincluding answering emails at 10pm on a Sunday and agreeing to meet frantic MPH students the very next day. I would also like to thank Xxxxx Xxxxxxx for her expertise and infectious enthusiasm for mapping and GIS, as well as her encyclopedic knowledge in finding (free) data. Finally, all my love and gratitude to my friends and family. To my Xxxxxxx friends, I could not have done it without you all—we’re (almost) done! To everyone else, I’ll stop talking about this and return calls/emails in a timely manner now, I swear. Contents INTRODUCTION 1 Nitrosamines in food and water 5 Occupational exposure to nitrosamines 9 Nitrosamines in rubber products 13 Colorectal cancer 18 Cervical Cancer 19 METHODS 21 Data Sources 21 Spatial Analysis 23 Bivariate association with cancer incidence 24 Multivariable association with cancer incidence 25 RESULTS 27 Colorectal Cancer Incidence 27 Cervical Cancer Incidence 28 DISCUSSION: 29 Conclusions 29 Limitations: 30 Future directions 32 APPENDIX 34 Figure 1 34 Figure 2 35 Figure 3 36 Figure 4 37 Figure 5 38 Figure 6 39 Figure 7 40 Figure 8 41 Table 1 42 Table 2 43 Table 3 44 Table 4 45 Table 5 46 Works Cited 47 Non-printed sources cited 53 Introduction Condoms are one of the most important public health tools in sexual health, playing roles in human immunodeficiency virus (HIV) prevention, prevention of sexually transmitted infections (STIs), and ongoing patience whenever I veer off topicfamily planning. There has been substantial investment by local governments, international health agencies and non- governmental organizations (NGOs) to increase supply and uptake of condoms (Xxxxxx et al., 2016; Xxxxxxx et al., 2008; Pienaar et al., 2016; Xxxxx Xxxxxxet al., PhD2015). Increasing access to condoms and education about STI and HIV prevention has resulted in important gains in condom use, study staff especially among high-risk populations like commercial sex workers (CSW) and researchers at DPHRUmen who have sex with men (MSM) (Xxxxxxx et al., 2008; Xxxxxx & Xxxxx, 2016; Xxxxxxxx et al., 2016; Subramanian et al., 2013). However, condom usage among CSWs continues to face barriers including client preference for unprotected sex, inconsistent condom supply, and University policies that criminalize sex work (Xxxxxxxx et al., 2016; Jung, 2013). Among MSM populations, condom use is mediated by perceptions of risk and condom self-efficacy (Xxxxxx & Xxxxx, 2016; Xxxxxxxxxx et al., 2016; Jung, 2013). National rates of condom use in the US vary by race, age, gender, and sex act: 24.7% of men and 21.8% of women report condom use at last vaginal intercourse while 26.5% of insertive male partners, 44.1% of receptive male partners and 10.8% of receptive female partners report condom use at last anal intercourse (Reece et al., 2010). One of the Witwatersrandbarriers to condom usage in low-income countries is negative perception or rumors about condoms (Xxxxxxx et al., for 2004); a study in Tanzania found that negative beliefs about condoms were significant predictors of willingness to use condoms (Xxxxxxx et al., 2012). Perceptions by the public about condom safety and efficacy directly affect their efforts towards use and thus can adversely affect sexual and reproductive health programs (Xxxxx et al., 2014; Xxxxxxx et al., 2012). Negative beliefs about condoms include the continuation belief that condoms cause cancer (Xxxxxxx et al., 2012). This is actually a concern among some condom manufacturers —specifically, the release of Birth to Twentynitrosamines from condoms (ISO/TC 157, for allowing me 2015). Nitrosamines are a class of carcinogenic compounds that can be produced in the ability to learn from them through manufacturing process of rubber products. Formed by the practicum experiencereaction of nitrites with secondary or tertiary amines, nitrosamines can vary in their carcinogenicity, with two potent carcinogens, N‐nitrosodiethylamine (NDEA) and the hospitality that has continued past the culmination N- nitrosodimethylamine (NDMA), often used as indicators of my practicumnitrosamine presence (Xxxxx, 2011). The Global Field Experience (GFE) Committee, for providing me with the funding that allowed me to help clean and analyze this data in the context in which it was collected. Xxxx Xxxxxx, for your company in South Africa, your indispensable advice, and for letting me rely on you for cell phone access and transportation while abroad. My friends and fellow Xxxxxxx classmates, for the laughter, levity, and late nights that made these past years immensely enjoyable. And finally, my parents, for being my ever present anchors and for allowing me the opportunities to learn and grow so many miles away from home for the past six years. Chapter I: Literature Review 1 Chapter II: Manuscript 15 Abstract 15 Introduction 16 Methods 18 Results 26 Discussion 31 Chapter III: Summary, Future Directions, & Public Health Implications 36 Tables and Figures. 37 References. 50 Chapter I: Literature Review Introduction Globally, non-communicable disease (NCD) has begun to replace communicable, or infectious, disease as the major contributor to mortality.1 One example of this epidemiologic shift seen in South Africa, a middle-income country that exhibits rates of chronic diseases such as hypertension as high as or exceeding those seen in high-income nations. Hypertension is now regarded as one of South Africa and Sub-Saharan Africa’s greatest health challenges after the HIV/AIDs crisis.2 Nationally representative World Health Organization (WHO) data from 2007 to 2010 showed a hypertension prevalence of 77.9% [95% confidence interval (CI): 76.4 – 79.4] in South African adults over age 50), the highest rate reported in this age group of any nation in the world. After stratifying by gender, hypertension prevalence rates were reported to be as high as 74.7% [95% CI: 72.6 – 76.8] in males and 80.3% [95% CI: 78.6 – 82.0] for females.3 However despite the similarities in hypertension prevalence with high income countries, South Africa and many other Sub-Saharan African nations report significantly lower rates of detection, treatmentEuropean Union, and control than high-income nations.2 South Africa reports some of the highest rates of obesity US Environmental Protection Agency (EPA) classify NDEA and NDMA as wellprobable or presumed human carcinogens (Xxxxx, a condition that has shown consistent associations with hypertension2011). The WHO Study US Department of Health and Human Services released the 13th Report on Global Aging Carcinogens in 2014, which included 15 listings of nitrosamines classified as “known or reasonably anticipated” carcinogens (NTP, 2014). Nitrosamines are linked with the development of multiple different types of cancer in many different animal models, including colon tumors in male rats, female mice and Adult Health guinea pigs, as well as cervical tumors in female shrews following rectal or oral administration (SAGE) compiled data from the six middle-income countries of ChinaNTP, Ghana2014). Nitrosamines have been found in food, Indiacosmetics, Mexico, Russiatobacco products, and South Africarubber goods such as balloons, pacifiers, baby bottle teats, and found that age and obesity were consistently significant predictors of hypertension prevalence in all six countries also condoms (though significance in South Africa data alone was only significant in the 60 – 79 year age groupNTP, with an odds ratio of 38.89 and 95% confidence interval of 5.55 to 272.62007; Dong et al., 2015; Altkofer et al., 2005; Fritschi et al., 2015; Xxxxxxxx & Xxxxxxxxxxxx, 2011). Socioeconomic factors such Nitrosamine-related cancer studies in humans are relatively scarce, though they include epidemiological studies of cancer mortality for occupational cohorts, as insurance status were also found to be significantly correlated with diagnosis of hypertensionwell as case-control or ecological studies conducted on dietary exposure (Monarca et al., 2001; de Vocht et al., 2007; NTP, 2014). Subsequent sections will discuss studies and regulations regarding nitrosamine exposure in occupational settings, food and drinking water, as well as rubber products like pacifiers, rubber gloves, and income was found condoms1. The migration of nitrosamines from condoms to mucous membranes like the vagina and rectum, which have higher absorption, is a significant association with hypertension treatment statuspossible risk (Eisenbrand, though it showed no effect on prevalence.4, 5 This thesis uses data from the Birth to Twenty Cohort to investigate the effect of socioeconomic status on blood pressure in young adults from South Africa, an age group that remains underrepresented in the study of hypertension in sub-Saharan Africa. Birth to Twenty is distinctive as the longest running longitudinal birth cohort in Africa and has focused on the early expression of metabolic risk factors and conditions as one of its primary domains.6 Because the presence of risk factors such as obesity and hypertension in childhood are strongly associated with adverse health outcomes in later years, the data from this cohort provides a unique opportunity to examine health and development from youth to early adulthood. This cohort is the first to allow for tracking of health throughout early life in South Africa, and past findings have contributed to nation-wide policies, including regulation of age for school attendance and restrictions on tobacco purchasing.7 Therefore, this research aims to explore blood pressure in the young adult data collection wave, and to assess how the major risk factor of obesity may mediate observed associations in the unique socioeconomic context of post-Apartheid South Africa2005).

Conclusions. BMI appeared The primary analysis did not support the hypothesis that NAFLD has an association with lower BMD. The secondary analysis suggested the possible relationship between NAFLD and lower BMD among people with low to have a stronger influence on young adult SBP normal BMI. Mineral Density -- Results from the Third National Health and pre-hypertension / hypertension than all measures Nutrition Examination Survey (NHANES III) By Xxxxxxxxx Xxxxxxx Bachelor of SESMedicine, but significant moderation and mediation was observed between BMI and various measures the University of SES. Further research is needed into Tokyo, 2007 Doctor of Philosophy (Medicine), the role University of BMI as a mediator or moderator on SES and young adult blood pressureTokyo, and to investigate whether individual components of SES may predict young adult blood pressure. Influence of Socioeconomic Status and Body Composition on Young Adult Blood Pressure: The Birth to Twenty Cohort By Chloe W. Eng B.S. Northeastern University 2014 Thesis Committee Chair: Xxxxx X. XxxxxXxxxxxx XxXxxxxxx, PhD MD, MPH A thesis submitted to the Faculty of the Xxxxxxx School of Public Health of Emory University in partial fulfillment of the requirements for the degree of Master of Science in Public Health in Epidemiology 2016 I would first like to extend thank my sincerest thanks and appreciation to: Xxxxx X. Xxxxx, for allowing thesis adviser Xx. Xxxxxxx XxXxxxxxx of Xxxxxxx School of Public Health at Emory University. He gave me this learning opportunity, as well as his insight, supportimportant advices, and ongoing patience whenever steered me in the right direction. I veer off topicwould also like to thank Xx. Xxxxxx Xxxxx Xxxxxxof Centers for Disease Control and Prevention as the second reader of this thesis. I appreciate his valuable comments on this thesis. Finally, PhDI must express my gratitude to my family. My wife, Xxxx Xxxxxxx, provided me with unfailing support and continuous encouragement throughout my study staff and researchers at DPHRUperiod. I also would like to thank Xxxxxxxx Xxxxxxx, and University of the WitwatersrandXxxxxx Xxxxxxx, for their efforts towards the continuation of Birth to Twenty, for allowing me the ability to learn from them through the practicum experience, and the hospitality that has continued past the culmination of my practicum. The Global Field Experience (GFE) Committee, for providing me with the funding that allowed who supported me to help clean and analyze this data study in the context in which it was collectedUnited States. Xxxx XxxxxxI really appreciate my father, for your company in South AfricaXxxxx Xxxxxxx, your indispensable advice, who endured through difficulties and for letting me rely on you for cell phone access and transportation while abroadraised me. My friends and fellow Xxxxxxx classmates, for the laughter, levity, and late nights that made these past years immensely enjoyableThis accomplishment would not have been possible without them. And finally, my parents, for being my ever present anchors and for allowing me the opportunities to learn and grow so many miles away from home for the past six yearsThank you. Chapter I: Background/Literature Review 1 Chapter II: Manuscript 15 Abstract 15 Introduction 16 Methods 18 7 Results 26 17 Discussion 31 Chapter III: Summary, 22 Future Directions, & Public Health Implications 36 Directions 27 References 28 Tables 37 Figures and Figures. 37 References. Figure Legends 45 Appendices 50 Chapter I: Supporting Information 50 SAS Source Codes 56 Background/Literature Review Introduction GloballyIn this study, non-communicable disease I focused on two chronic health conditions, low bone mineral density and nonalcoholic fatty liver (NCD) has begun to replace communicableNAFLD). These days, or infectiouschronic health conditions have been attracting more attentions in public health, disease as the major contributor population lives longer and ages. Historically communicable diseases or infectious diseases were the main concerns, contributing to mortality.1 One example the mortality and morbidity. After the end of this epidemiologic shift seen 19th century, developing the knowledge and treatments for infectious diseases has contributed to the steep declines in South Africamortality from infectious diseases (1). As a result people live longer but people became suffering from different diseases, a middle-income country that exhibits rates of chronic diseases such as hypertension cancers, heart diseases, diabetes, and dementia (2). Low bone mineral density and NAFLD are not directly related to a life-threatening conditions, and they have not attracted so much attention. However, low bone mineral density can increase the rate of bone fracture, which decrease the patients’ quality of life. The number of people with NAFLD is increasing as obesity is becoming more prevalent. Therefore, these two factors can have a great impact on public health, and considering the association can give us a better strategy for prevention and therapy, and must be beneficial for the future researches. Bone Mineral Density Bone mineral density (BMD) is widely used to diagnose osteoporosis (3). Osteoporosis is a disease “characterized by low bone mass, deterioration of bone tissue and disruption of bone architecture, compromised bone strength and an increase in the risk of fracture.” (3) Xxxxxx reported 10.2 million Americans aged 50 years and older are affected by osteoporosis in 2013 (4). Maintaining BMD level is beneficial to protect against incidents of bone fractures. Prospective cohort studies have demonstrated that people with low bone mineral density of femur (5, 6), lumber spine (5, 7), radius (6, 8) or forearm (9) have higher risk of bone fracture. Meta-analysis reported -1 S.D. BMD people have 1.5 to 2.6 times as high as or exceeding those seen in high-income nationsrisk of bone fracture (10). Hypertension is now regarded as one of South Africa and Sub-Saharan Africa’s greatest health challenges after In the HIV/AIDs crisis.2 Nationally representative World Health Organization (WHO) data from 2007 to 2010 showed a hypertension prevalence of 77.9% [95% confidence interval (CI): 76.4 – 79.4] in South African adults over age 50industrialized countries, the highest rate reported in this age group number of any nation people with osteoporosis or low bone mineral density is increasing, as population is aging. “It is anticipated that the number of fractures will grow proportionally.” (3) “Annually, two million fractures are attributed to osteoporosis, causing more than 432,000 hospital admissions, almost 2.5 million medical office visits and about 180,000 nursing home admissions in the world. After stratifying by genderU.S.” (3) Therefore, hypertension prevalence rates were reported to be as high as 74.7% [95% CI: 72.6 – 76.8] in males and 80.3% [95% CI: 78.6 – 82.0] for females.3 However despite the similarities in hypertension prevalence with high income countries, South Africa and many other Sub-Saharan African nations report significantly lower rates of detection, treatment, and control than high-income nations.2 South Africa reports some of the highest rates of obesity as well, a condition that has shown consistent associations with hypertension. The WHO Study on Global Aging and Adult Health (SAGE) compiled data keeping bone mineral density is also beneficial from the six middle-income countries view of China, Ghana, India, Mexico, Russia, and South Africa, and found that age and obesity were consistently significant predictors of hypertension prevalence in all six countries (though significance in South Africa data alone was only significant in the 60 – 79 year age group, with an odds ratio of 38.89 and 95% confidence interval of 5.55 to 272.6). Socioeconomic factors such as insurance status were also found to be significantly correlated with diagnosis of hypertension, and income was found to have a significant association with hypertension treatment status, though it showed no effect on prevalence.4, 5 This thesis uses data from the Birth to Twenty Cohort to investigate the effect of socioeconomic status on blood pressure in young adults from South Africa, an age group that remains underrepresented in the study of hypertension in sub-Saharan Africa. Birth to Twenty is distinctive as the longest running longitudinal birth cohort in Africa and has focused on the early expression of metabolic risk factors and conditions as one of its primary domains.6 Because the presence of risk factors such as obesity and hypertension in childhood are strongly associated with adverse health outcomes in later years, the data from this cohort provides a unique opportunity to examine public health and development from youth to early adulthood. This cohort is the first to allow for tracking of health throughout early life in South Africa, and past findings have contributed to nation-wide policies, including regulation of age for school attendance and restrictions on tobacco purchasing.7 Therefore, this research aims to explore blood pressure in the young adult data collection wave, and to assess how the major risk factor of obesity may mediate observed associations in the unique socioeconomic context of post-Apartheid South Africahealthcare economy.

Conclusions. BMI appeared These results add to have a stronger influence on young adult SBP the inconsistent findings regarding IPV, relationship power, and pre-hypertension / hypertension than all measures of SES, but significant moderation SRH outcomes. Future research may wish to examine differences in these variables among younger and mediation was observed between BMI older adolescents and various measures of SES. Further research is needed into consider the role of BMI as a mediator or moderator on SES and young adult blood pressuresexual network, and other partner characteristics. High STI rates among those experiencing IPV highlights the need to investigate whether individual components promote prevention methods that women can control, including testing, PrEP, and HPV vaccinations. Additionally, the high rates of SES may predict young adult blood pressureSTIs and low reported condom use overall calls for increased sex education in high schools that stresses STI risk and the importance of health protective behaviors to reduce the spread of STIs among high-risk adolescents including African American emerging adults. Influence of Socioeconomic Status Relationship Power and Body Composition on Young Adult Blood PressureSRH Outcomes: The Birth to Twenty Cohort Mediating Role of Refusal Self-Efficacy and Depression among Emerging Adult African American Females by Recent IPV Exposure By Chloe W. Eng Xxxxxxxxx X. Xxxxxxx B.S. Northeastern University 2014 Neuroscience Hobart and Xxxxxxx Xxxxx Colleges 2012 Thesis Committee Chair: Xxxxx X. XxxxxXxxxxxx XxXxxxxxx Sales, PhD PhD, MA A thesis submitted to the Faculty of the Xxxxxxx School of Public Health of Emory University in partial fulfillment of the requirements for the degree of Master of Science in Public Health in Epidemiology 2016 Behavioral Science and Health Education 2018 Acknowledgements I would like to extend thank everyone who supported me throughout this process. I am particularly grateful to my sincerest thanks and appreciation to: Xxxxx X. thesis chair, Dr. Xxxxxxx Xxxxx, and committee member, Xx. Xxxxxxxxx Xxxxxx, for allowing me this learning opportunity, their time as well as his insightfor their guidance and encouragement both in relation to this thesis and throughout my time at Xxxxxxx. I feel so lucky to have such wonderful women doing incredible public health work to look up to. Additionally, supportthank you to my family and friends, near and far, who listened to all my excitement, disappointment, and ongoing patience whenever I veer off topicrandom thesis thoughts over the past year. Xxxxx Xxxxxx, PhD, study staff and researchers at DPHRU, and University of the Witwatersrand, for their efforts towards the continuation of Birth to Twenty, for allowing me the ability to learn from them through the practicum experience, and the hospitality that has continued past the culmination of my practicum. The Global Field Experience (GFE) Committee, for providing me with the funding that allowed me to help clean and analyze this data Whether it came in the context in which it was collected. Xxxx Xxxxxxform of phone calls, for your company in South Africatexts, chats, or coffee, your indispensable adviceencouragement was much appreciated. Lastly, thank you to all the young women who participated in this study. Without their openness to research and for letting me rely on you for cell phone access engagement in the intervention none of this would have been possible. Table of Contents Chapter 1: Introduction Background and transportation while abroad. My friends Significance 1 Risk Behaviors 4 Relationship Power 5 Current Interventions 5 Purpose and fellow Xxxxxxx classmates, for the laughter, levity, and late nights that made these past years immensely enjoyable. And finally, my parents, for being my ever present anchors and for allowing me the opportunities to learn and grow so many miles away from home for the past six years. Research Questions 7 Theoretical Basis 10 Chapter I2: Literature Review 1 Chapter II: Manuscript 15 Abstract 15 Introduction 16 Methods 18 Results 26 Discussion 31 Chapter III: Summary14 Personal, Future Directions, & Public Health Implications 36 Tables and Figures. 37 References. 50 Chapter I: Literature Review Introduction Globally, non-communicable disease (NCD) has begun to replace communicable, or infectious, disease as the major contributor to mortality.1 One example of this epidemiologic shift seen in South Africa, a middle-income country that exhibits rates of chronic diseases such as hypertension as high as or exceeding those seen in high-income nations. Hypertension is now regarded as one of South Africa and Sub-Saharan Africa’s greatest health challenges after the HIV/AIDs crisis.2 Nationally representative World Health Organization (WHO) data from 2007 to 2010 showed a hypertension prevalence of 77.9% [95% confidence interval (CI): 76.4 – 79.4] in South African adults over age 50, the highest rate reported in this age group of any nation in the world. After stratifying by gender, hypertension prevalence rates were reported to be as high as 74.7% [95% CI: 72.6 – 76.8] in males and 80.3% [95% CI: 78.6 – 82.0] for females.3 However despite the similarities in hypertension prevalence with high income countries, South Africa and many other Sub-Saharan African nations report significantly lower rates of detection, treatmentBehavioral, and control than high-income nations.2 South Africa reports some of the highest rates of obesity as wellEnvironmental Influences on Condom Use 14 IPV, a condition that has shown consistent associations with hypertension. The WHO Study on Global Aging and Adult Health (SAGE) compiled data from the six middle-income countries of China, Ghana, India, Mexico, RussiaCondom Use, and South Africa, STI Outcomes 16 Relationship Power and found that age Refusal Self-Efficacy 18 Relationship Power and obesity were consistently significant predictors Depression 19 Summary 20 Chapter 3: Methods 22 Participants 22 Procedures 23 Study Design 23 Intervention Methods 23 Measures 24 Background Demographics 24 Stratification Variable 25 Covariates 26 Hypothesized Predictor Variable 27 Hypothesized Mediator Variables 28 Hypothesized Outcome Variables 29 Analysis 30 Chapter 4: Results 32 Background Demographics 32 Independent Variable 35 Covariates 35 Mediators 36 Dependent Variables 36 Bivariate Analysis of hypertension prevalence in all six countries Covariates 37 Mediation Analysis 38 Bivariate Analysis: Independent with Dependent 38 Bivariate Analysis: Independent with Mediators 40 Bivariate Analysis: Mediators with Dependent 41 Mediation Regressions 42 Chapter 5: Discussion 44 Research Question 1 45 Research Question 2 46 Research Question 3 48 Discussion of Covariate Significance 49 Limitations 50 Conclusions 51 Table of Tables TABLE 1 KEY THEORETICAL CONSTRUCTS 13 TABLE 2 PSYCHOMETRIC PROPERTIES OF MEASURES 29 TABLE 3: SAMPLE DEMOGRAPHIC CHARACTERISTICS 33 TABLE 4 COVARIATES BY IPV EXPOSURE 35 TABLE 5: DESCRIPTIVES OF VARIABLES OF INTEREST BY RECENT IPV EXPOSURE 36 TABLE 6 BIVARIATE CORRELATIONS AMONG THOSE WITH IPV EXPOSURE (though significance in South Africa data alone was only significant in the 60 – 79 year age group, with an odds ratio N=96) 37 TABLE 7 BIVARIATE CORRELATIONS AMONG THOSE WITH NO IPV EXPOSURE (N= 375) 38 TABLE 8 BIVARIATE CORRELATIONS AMONG FULL SAMPLE (N=560) 38 TABLE 9: POWER AND MEDIATOR ASSOCIATIONS 41 TABLE 10 BIVARIATE CORRELATIONS OF MEDIATORS WITH OUTCOMES BY IPV EXPOSURE 41 TABLE 11 STI AT BASELINE BY RECENT IPV EXPOSURE 42 Table of 38.89 and 95% confidence interval of 5.55 to 272.6)Figures FIGURE 1 PROPOSED MEDIATION MODEL 10 FIGURE 2 THEORETICAL BASIS: SCT AND TGP 11 FIGURE 3 BINARY REGRESSION BETWEEN RELATIONSHIP POWER AND CONDOM USE BY IPV EXPOSURE. Socioeconomic factors such as insurance status were also found to be significantly correlated with diagnosis of hypertension, and income was found to have a significant association with hypertension treatment status, though it showed no effect on prevalence.4, 39 FIGURE 4 BINARY REGRESSION BETWEEN RELATIONSHIP POWER AND STI STATUS BY IPV EXPOSURE 40 FIGURE 5 This thesis uses data from the Birth to Twenty Cohort to investigate the effect of socioeconomic status on blood pressure in young adults from South Africa, an age group that remains underrepresented in the study of hypertension in sub-Saharan Africa. Birth to Twenty is distinctive as the longest running longitudinal birth cohort in Africa and has focused on the early expression of metabolic risk factors and conditions as one of its primary domains.6 Because the presence of risk factors such as obesity and hypertension in childhood are strongly associated with adverse health outcomes in later years, the data from this cohort provides a unique opportunity to examine health and development from youth to early adulthood. This cohort is the first to allow for tracking of health throughout early life in South Africa, and past findings have contributed to nation-wide policies, including regulation of age for school attendance and restrictions on tobacco purchasing.7 Therefore, this research aims to explore blood pressure in the young adult data collection wave, and to assess how the major risk factor of obesity may mediate observed associations in the unique socioeconomic context of post-Apartheid South Africa.MEDIATION PATHWAY FOR PROPORTIONAL CONDOM USE 43 FIGURE 6 MEDIATION PATHWAY FOR STI STATUS 43

Conclusions. BMI appeared The findings from this study provide insight into variabilities of toxicological endpoints in ATSDR and other governmental databases, which could be useful in public health guidance and risk assessments. Estimating variabilities of toxicological endpoints of concerns to have a stronger influence on young adult SBP the Agency for Toxic Substances and pre-hypertension / hypertension than all measures Disease Registry (ATSDR) By Xxx Xxxxxxxx Bachelor of SES, but significant moderation and mediation was observed between BMI and various measures Science Georgie Institute of SES. Further research is needed into the role of BMI as a mediator or moderator on SES and young adult blood pressure, and to investigate whether individual components of SES may predict young adult blood pressure. Influence of Socioeconomic Status and Body Composition on Young Adult Blood PressureTechnology 2016 Thesis Faculty Adviser: The Birth to Twenty Cohort By Chloe W. Eng B.S. Northeastern University 2014 Thesis Committee Chair: Xxxxx X. Xxxxx, PhD A thesis submitted to the Faculty of the Xxxxxxx School of Public Health of Emory University in partial fulfillment of the requirements for the degree of Master of Science in Public Health in Epidemiology 2016 Biostatistics 2019 Acknowledgements Everything I would like have accomplished so far, I have done so with the great support of my parents and family, especially my late grandfather, Xxxxxxxxxx Xxxxxxx. I am grateful to extend my sincerest thanks family, friends and appreciation to: Xxxxx X. mentors who have supported me through difficult times, always encouraging me to see the light at the end of a tunnel. I am especially indebted to Dr. Xxxx Xxxxxx and Xxx. Xxxxxx Xxxxxxx who steered me towards the world of public health when I was an undergraduate student. I am grateful to my supervisor and mentor Xx. Xxxxxx Xxxxxxx at the Computational Toxicology and Methods Development Lab (CompTox) at ATSDR. I developed interests in statistics and data science while I was training under him during my undergraduate and gap years. His tough style of questioning everything and challenging me to my limits while still being patient and understanding has helped me become a better researcher. He has been a great asset to me for last four years and few sentences here do not fully cover the extent of his influence on my professional/personal growth and development. I will do injustice if I do not express my gratitude to our CompTox Team Lead, Xx. Xxxxxxx Xxxxx, for allowing his continued support of my ORISE fellowship. Additionally, I am extremely thankful to all my CompTox team members, especially Xx. Xxxxxx Xxxxxxx, who has helped me this learning opportunityfrom my first day with the team. I am grateful to Xx. Xxxxxxx Xxxxxxxxxx for agreeing be my thesis adviser even though I was working on a project that was initially unfamiliar to him. His guidance and comments on academic and statistical matters have been of great assistance. Finally, as well as his insight, support, and ongoing patience whenever I veer off topic. Xxxxx Xxxxxx, PhD, study staff and researchers at DPHRU, and University am thankful to all members of the Witwatersrand, for their efforts towards the continuation Xxxxx Xxxxxxx School of Birth to Twenty, for allowing me the ability to learn from them through the practicum experience, and the hospitality that has continued past the culmination of my practicum. The Global Field Experience (GFE) Committee, for providing me with the funding that allowed me to help clean and analyze this data in the context in which it was collected. Xxxx Xxxxxx, for your company in South Africa, your indispensable advice, and for letting me rely on you for cell phone access and transportation while abroad. My friends and fellow Xxxxxxx classmates, for the laughter, levity, and late nights that made these past years immensely enjoyable. And finally, my parents, for being my ever present anchors and for allowing me the opportunities to learn and grow so many miles away from home for the past six years. Chapter I: Literature Review 1 Chapter II: Manuscript 15 Abstract 15 Introduction 16 Methods 18 Results 26 Discussion 31 Chapter III: Summary, Future Directions, & Public Health Implications 36 Department of Biostatistics and Bioinformatics for everything they have done to make my Xxxxxxx experience the one to remembe Table of Contents Introduction 1 Methods 4 Data Compilation 4 Data analysis 8 Results 12 Data description 12 LD50s: 12 L(N)OAELs 13 Data analysis 14 Accessing homogeneity of variances assumption 14 Variance estimation of LD50s 15 Variance estimation of L(N)OAELs 18 Variability versus sample size 23 Derivation of factors based on SDs 24 Discussion 25 Variability of LD50s and comparison to previous studies 25 Variability of L(N)OAELs and comparison to LD50s 26 Scaling factors to derive a lower bound on an endpoint 28 Further study 29 Conclusions 31 References 32 Appendix A: Tables and Figures. 37 References. 50 Chapter Ii Appendix B: Literature Review Introduction Globally, non-communicable disease (NCD) has begun to replace communicable, or infectious, disease as the major contributor to mortality.1 One example of this epidemiologic shift seen in South Africa, a middle-income country that exhibits rates of chronic diseases such as hypertension as high as or exceeding those seen in high-income nations. Hypertension is now regarded as one of South Africa and Sub-Saharan Africa’s greatest health challenges after the HIV/AIDs crisis.2 Nationally representative World Health Organization (WHO) data from 2007 to 2010 showed a hypertension prevalence of 77.9% [95% confidence interval (CI): 76.4 – 79.4] in South African adults over age 50, the highest rate reported in this age group of any nation in the world. After stratifying by gender, hypertension prevalence rates were reported to be as high as 74.7% [95% CI: 72.6 – 76.8] in males and 80.3% [95% CI: 78.6 – 82.0] for females.3 However despite the similarities in hypertension prevalence with high income countries, South Africa and many other Sub-Saharan African nations report significantly lower rates of detection, treatment, and control than high-income nations.2 South Africa reports some of the highest rates of obesity as well, a condition that has shown consistent associations with hypertension. The WHO Study on Global Aging and Adult Health (SAGE) compiled data from the six middle-income countries of China, Ghana, India, Mexico, Russia, and South Africa, and found that age and obesity were consistently significant predictors of hypertension prevalence in all six countries (though significance in South Africa data alone was only significant in the 60 – 79 year age group, with an odds ratio of 38.89 and 95% confidence interval of 5.55 to 272.6). Socioeconomic factors such as insurance status were also found to be significantly correlated with diagnosis of hypertension, and income was found to have a significant association with hypertension treatment status, though it showed no effect on prevalence.4, 5 This thesis uses data from the Birth to Twenty Cohort to investigate the effect of socioeconomic status on blood pressure in young adults from South Africa, an age group that remains underrepresented in the study of hypertension in sub-Saharan Africa. Birth to Twenty is distinctive as the longest running longitudinal birth cohort in Africa and has focused on the early expression of metabolic risk factors and conditions as one of its primary domains.6 Because the presence of risk factors such as obesity and hypertension in childhood are strongly associated with adverse health outcomes in later years, the data from this cohort provides a unique opportunity to examine health and development from youth to early adulthood. This cohort is the first to allow for tracking of health throughout early life in South Africa, and past findings have contributed to nation-wide policies, including regulation of age for school attendance and restrictions on tobacco purchasing.7 Therefore, this research aims to explore blood pressure in the young adult data collection wave, and to assess how the major risk factor of obesity may mediate observed associations in the unique socioeconomic context of post-Apartheid South Africa.Figures xiv

Conclusions. BMI appeared The specificity of QFT-GIT was high and similar to have TST at either cutoff. Test discordance observed in recruits with increased risk may be due to lower TST specificity, lower QFT-GIT sensitivity, or both. Negative QFT-GIT results for recruits born in countries with high–TB prevalence and whose TST is > 15mm suggest that QFT-GIT may be less sensitive than TST. Additional studies are needed to determine the risk of developing TB when TST and QFT-GIT results are discordant. Assessing specificity and discordance between the tuberculin skin test and a stronger influence on young adult SBP and prewhole-hypertension / hypertension than all measures blood interferon-γ release assay for the detection of SESMycobacterium tuberculosis infection among United States Navy recruits. By Xxxxx Xxxxxxx Xxxxx Bachelor of Science in Biology Bachelor of Science in Anthropology University of Utah 2007 Thesis Faculty Advisor: Xxxx X. XxXxxxx, but significant moderation and mediation was observed between BMI and various measures of SES. Further research is needed into the role of BMI as a mediator or moderator on SES and young adult blood pressureXx., and to investigate whether individual components of SES may predict young adult blood pressure. Influence of Socioeconomic Status and Body Composition on Young Adult Blood PressureM.D. Field Advisor: The Birth to Twenty Cohort By Chloe W. Eng B.S. Northeastern University 2014 Thesis Committee Chair: Xxxxx Xxxxxx X. XxxxxXxxxxxx, PhD M.D. A thesis submitted to the Faculty of the Xxxxxxx School of Public Health of Emory University in partial fulfillment of the requirements for the degree of Master of Science in Public Health in Epidemiology 2016 2011 Acknowledgements I would like to extend thank Xx. Xxxxxxx and Xx. XxXxxxx for their efforts in advising and mentoring me through the processes of the thesis and my sincerest thanks professional development while at Emory University and appreciation to: with the CDC; the staff at CDC, DTBE, especially Xxxxx X. Xxxxxxx, Xxxxxx Xxxxx, Kit Xxxxxxxxx, Xxxxxxx Xxxxxxxx and Xxxxx Xxxxxxx, for allowing including me this learning opportunityin the branch’s activities and assisting in innumerable ways with my analysis and manuscript; my professors at the Xxxxxxx School of Public Health, as well as his insightparticularly Xx. Xxxxxxxxx, supportwho provided council on my statistical analyses; also my friends and colleagues at in the Epidemiology and Behavioral Science and Health Education departments, who have helped make my time in Atlanta a rich experience; my parents, Xxxxxx and ongoing patience whenever I veer off topic. Xxxxx Xxxxxx, PhD, study staff and researchers at DPHRU, and University of the WitwatersrandXxxxxxx, for their efforts towards unwavering love and support; and Xxxxxxx Xxxxx, who has endured the continuation hardships of Birth education with me and has given me such support and freedom, that I may never truly repay her gifts and sacrifices. Table of Contents INTRODUCTION 1 CHAPTER I: BACKGROUND 4 EPIDEMIOLOGY OF TUBERCULOSIS 4 PATHOGENESIS OF MYCOBACTERIUM TUBERCULOSIS INFECTION 6 DIAGNOSTICS FOR MYCOBACTERIUM TUBERCULOSIS INFECTION 11 THE TUBERCULIN SKIN TEST 14 INTERFERON-GAMMA RELEASE ASSAYS 19 WHOLE-BLOOD INTERFERON-GAMMA RELEASE ASSAYS 22 DISCORDANCE IN RESULTS FOR THE DETECTION OF M. TUBERCULOSIS INFECTION 29 LIMITATIONS TO INTERFERON-GAMMA RELEASE ASSAYS 36 TUBERCULOSIS AND THE UNITED STATES NAVY 40 LATENT TUBERCULOSIS INFECTION IN MILITARY RECRUITS 45 CHAPTER II: MANUSCRIPT 52 TITLE PAGE 52 INTRODUCTION 53 MATERIALS AND METHODS 58 RESULTS 64 DISCUSSION 70 LIMITATIONS AND STRENGTHS 83 CONCLUSION 87 REFERENCE LIST 89 TABLES 115 FIGURES 122 CHAPTER III: PUBLIC HEALTH IMPLICATIONS 124 SUMMARY 124 APPLICATIONS OF THE QUANTIFERON-TB GOLD IN-TUBE ASSAY 126 FUTURE DIRECTIONS 128 REFERENCES 131 APPENDICES 173 MILITARY HISTORY FORM FROM STUDY PROTOCOL 173 LINK TO XXXXXXX ET AL. – M. TUBERCULOSIS INFECTION IN NAVY RECRUITS, 2007 175 Tables and Figures TABLE 1. CHARACTERISTICS OF US NAVY RECRUITS 115 TABLE 2. OUTCOMES OF THE TUBERCULIN SKIN TEST VERSUS THE QUANTIFERON®-TB GOLD IN-TUBE ASSAY 116 TABLE 3. OUTCOMES OF THE QUANTIFERON®-TB GOLD ASSAY VERSUS THE QUANTIFERON®-TB GOLD IN-TUBE ASSAY 117 TABLE 4. UNIVARIATE ASSOCIATION OF SUBJECT CHARACTERISTICS WITH TUBERCULIN SKIN TEST OR QUANTIFERON®-TB GOLD IN-TUBE ASSAY RESULTS 118 TABLE 5. UNIVARIATE ASSOCIATION OF SUBJECT CHARACTERISTICS WITH DISCORDANT RESULTS BETWEEN THE QUANTIFERON®-TB GOLD IN-TUBE ASSAY AND THE TUBERCULIN SKIN TEST, USING A 10 MM CUTOFF 119 TABLE 6. UNIVARIATE ASSOCIATION OF SUBJECT CHARACTERISTICS WITH DISCORDANT RESULTS BETWEEN THE QUANTIFERON®-TB GOLD IN-TUBE ASSAY AND THE TUBERCULIN SKIN TEST, USING A 15 MM CUTOFF 120 TABLE 7. MULTIVARIATE ANALYSIS EXAMINING DISCORDANCE BETWEEN NEGATIVE QUANTIFERON®-TB GOLD IN-TUBE ASSAY RESULTS AND TUBERCULIN SKIN TEST RESULTS USING A 15 MM OR A 10 MM CUTOFF 121 FIGURE 1. DIAGRAM OF STUDY PARTICIPATION AND TESTING 122 FIGURE 2. COMPARISON OF TUBERCULIN SKIN TEST RESULTS TO INTERFERON-GAMMA RELEASE ASSAY INTERPRETATIONS, STRATIFIED BY RISK OF INFECTION 123 Introduction Tuberculosis (TB) is a leading cause of death and illness worldwide. The causative agent of TB is the Mycobacterium tuberculosis bacillus. Mycobacterium tuberculosis infection (MTBI) occurs in humans, who act as its primary reservoir. Approximately 2 billion people worldwide have quiescent or latent M. tuberculosis infection (LTBI) and are at risk of developing TB (1). Due to Twentyeffective treatment and control measures, for allowing me TB incidence and prevalence rates are declining in the ability United States (US) and most developed regions of the world (2, 3). However, elimination of TB remains elusive, even in high-resource countries because of continued transmission in groups at high risk of MTBI and progression to learn from them through the practicum experienceTB, difficulties in detecting MTBI, and programmatic complacency (4). Around 4% of the hospitality that has US population is thought to have LTBI, and is a constant source for future TB and MTBI transmission (5). There is continued past pressure to improve diagnostic and screening methods for detecting MTBI, including LTBI and infection manifesting as TB (6-8). Identifying and treating LTBI among those at high risk of developing TB is an important component for TB control and elimination in low-TB incidence regions, such as the culmination US and Canada (9, 10). No method exists for accurately detecting LTBI. Historically, the only way to diagnose LTBI was the tuberculin skin test (TST), which involved measuring immunologic delayed hypersensitivity to an intradermal injection of my practicumpurified protein derivatives (PPD) made from M. tuberculosis (tuberculin PPD) (11). The Global Field Experience TST has limitations in detecting LTBI in some settings. For example, where the prevalence of LTBI is low, the positive predictive value (GFEPPV) Committee, for providing me with of TST is hindered by cross reactions induced by sensitization to other mycobacteria (11). The development of interferon-gamma release assays (IGRA) offered an alternative to the funding that allowed me to help clean TST and analyze this data addressed some limitations in the context in TST (12, 13). MTBI typically induces an immune T-lymphocyte response which it was collectedproduces the cytokine interferon gamma (INF-γ) when the T-cells encounter mycobacterial antigens (13). Xxxx XxxxxxWhole-blood IGRAs such as the 2nd generation, for your company in South AfricaQuantiFERON®-TB Gold test (QFT-G) (Cellestis Limited, your indispensable adviceXxxxxxxx, Xxxxxxxx, Australia) measure the amount of INF-γ released when blood is stimulated with specific Mycobacterium antigens (14). In 2007, the US Food and for letting me rely on you for cell phone access and transportation while abroad. My friends and fellow Xxxxxxx classmates, Drug Administration (FDA) approved the 3rd generation of IGRA for the laughterdetection of MTBI, levitythe QuantiFERON®-TB Gold In-Tube test (QFT-GIT) (Cellestis Limited, Xxxxxxxx, Xxxxxxxx, Australia) (15). Like the TST, positive QFT-GIT results are highly associated with factors that historically contribute to MTBI (15, 16). However, QFT-GIT can exhibit discordance when compared to TST results and late nights that made these past years immensely enjoyableother IGRAs (15, 17-19). And finallyAbsence of a “gold standard” to confirm MTBI limits IGRA assessments of accuracy and allows only estimates of sensitivity and specificity (15, my parents16). Approximations of sensitivity have been achieved by comparing the results of diagnostic tests to culture-confirmed cases of TB (15). Previous studies have assessed IGRAs among “assumed negative” populations at low-risk of MTBI, to better approximate specificity, with some consideration of test discordance (20- 22). Further research has been suggested to understand the factors associated with discordant test results (6, 15, 23). In light of the need for being my ever present anchors more research to understand IGRA accuracy and discordance, this study on QFT-GIT is part of a series of IGRA studies (21, 24- 26). This study was conducted to add to the current discourse on the interpretation of LTBI screening results among low-risk populations when considering multiple testing methods. The analysis of cross-sectional data obtained from US Navy recruits in 2004 will quantify QFT-GIT specificity for allowing me a population at low-risk for MTBI. Additionally, this study will identify recruit characteristics and estimate their associations to discordant results between the opportunities QFT-GIT and TST. Results for QFT-GIT will also be compared to learn and grow so many miles away from home for other IGRA results, performed at the past six yearssame time (21). Chapter I: Literature Review 1 Chapter II: Manuscript 15 Abstract 15 Introduction 16 Methods 18 Results 26 Discussion 31 Chapter III: Summary, Future Directions, & Public Health Implications 36 Tables and Figures. 37 References. 50 Chapter I: Literature Review Introduction Globally, non-communicable disease (NCD) has begun to replace communicable, or infectious, disease as the major contributor to mortality.1 One example of this epidemiologic shift seen in South Africa, a middle-income country that exhibits rates of chronic diseases such as hypertension as high as or exceeding those seen in high-income nations. Hypertension is now regarded as one of South Africa and Sub-Saharan Africa’s greatest health challenges after the HIV/AIDs crisis.2 Nationally representative World Health Organization (WHO) data from 2007 to 2010 showed a hypertension prevalence of 77.9% [95% confidence interval (CI): 76.4 – 79.4] in South African adults over age 50, the highest rate reported in this age group of any nation in the world. After stratifying by gender, hypertension prevalence rates were reported to be as high as 74.7% [95% CI: 72.6 – 76.8] in males and 80.3% [95% CI: 78.6 – 82.0] for females.3 However despite the similarities in hypertension prevalence with high income countries, South Africa and many other Sub-Saharan African nations report significantly lower rates of detection, treatment, and control than high-income nations.2 South Africa reports some of the highest rates of obesity as well, a condition that has shown consistent associations with hypertension. The WHO Study on Global Aging and Adult Health (SAGE) compiled data from the six middle-income countries of China, Ghana, India, Mexico, Russia, and South Africa, and found that age and obesity were consistently significant predictors of hypertension prevalence in all six countries (though significance in South Africa data alone was only significant in the 60 – 79 year age group, with an odds ratio of 38.89 and 95% confidence interval of 5.55 to 272.6). Socioeconomic factors such as insurance status were also found to be significantly correlated with diagnosis of hypertension, and income was found to have a significant association with hypertension treatment status, though it showed no effect on prevalence.4, 5 This thesis uses data from the Birth to Twenty Cohort to investigate the effect of socioeconomic status on blood pressure in young adults from South Africa, an age group that remains underrepresented in the study of hypertension in sub-Saharan Africa. Birth to Twenty is distinctive as the longest running longitudinal birth cohort in Africa and has focused on the early expression of metabolic risk factors and conditions as one of its primary domains.6 Because the presence of risk factors such as obesity and hypertension in childhood are strongly associated with adverse health outcomes in later years, the data from this cohort provides a unique opportunity to examine health and development from youth to early adulthood. This cohort is the first to allow for tracking of health throughout early life in South Africa, and past findings have contributed to nation-wide policies, including regulation of age for school attendance and restrictions on tobacco purchasing.7 Therefore, this research aims to explore blood pressure in the young adult data collection wave, and to assess how the major risk factor of obesity may mediate observed associations in the unique socioeconomic context of post-Apartheid South Africa.

Conclusions. BMI appeared This pilot study offers the first regional-level characterization of PLWH proceeding through the early steps of transplantation. PLWH were less likely to have a stronger influence on young adult SBP traverse the steps of kidney transplant compared with those HIV negative, highlighting the need for targeted interventions to improve access to kidney transplant for PLWH. Identifying the barriers and pre-hypertension / hypertension than all measures disparities for referral to kidney transplantation faced by person living with HIV and end stage renal disease By Xxxx X. Xxxxxxxx ScB, Monmouth University, 2009 MD, Xxxxxx Xxxxxxxxxx University School of SESHealth Sciences, but significant moderation and mediation was observed between BMI and various measures of SES. Further research is needed into the role of BMI as a mediator or moderator on SES and young adult blood pressure, and to investigate whether individual components of SES may predict young adult blood pressure. Influence of Socioeconomic Status and Body Composition on Young Adult Blood Pressure2013 Advisor: The Birth to Twenty Cohort By Chloe W. Eng B.S. Northeastern University 2014 Thesis Committee Chair: Xxxxx Xxxxxx X. Xxxxx, PhD MD A thesis submitted to the Faculty of the Xxxxxxx Xxxxx X. Xxxxx School of Public Health Graduate Studies of Emory University in partial fulfillment of the requirements for the degree of Master of Science in Public Health in Epidemiology 2016 Clinical Research 2020 I would like to extend thank Xx. Xxxxxx Xxxxx and Xx. Xxxxxx Xxxxxx for serving as research mentors. Their assistance in honing my sincerest thanks ideas and appreciation to: interests, providing me with the necessary support and guidance to complete my MSCR application, and informative discussions regarding the implications of this work, not only tremendously developed this work, but helped me to grow as a junior investigator. I am thankful for the help of Dr. Zhensheng (AKA Xxxxx) Wang who assisted me with the analysis and served as my reader and additionally and Xx. Xxxxxxxxx for reviewing the drafts of this thesis. I would like to thank Xx. Xxxxxxx Xxxxx X. Xxxxxfor being instrumental in obtaining the data for this project and being so accommodating to additional data requests. I am also appreciative of Dr. Xxxxx Xxxxxxxxx who has been a fearless leader and program director, and the main reason why I applied to the MSCR program. Lastly, I would like to thank my husband Xxxxxx Xxxxxxxxx for allowing me this learning opportunityhis patience, as well as his insightlove, support, and ongoing patience whenever I veer off topicSAS consultations. Xxxxx XxxxxxTABLE OF CONTENTS INTRODUCTION 1 BACKGROUND 3 METHODS 8 RESULTS 19 DISCUSSION 24 CONCLUSIONS 33 REFERENCES 34 INTRODUCTION‌ End-stage renal disease (ESRD) has increased by 1000% in the past 3 decades, PhDproving to be a significant health concern in the United Sates. In 1980, study staff there were 60,000 persons with ESRD though in 2018 there were over 700,000 Americans living with ESRD (1). The expense of Chronic Kidney Disease (CKD) and researchers at DPHRUESRD has a significant impact on the United States economy and in 2018, CKD and ESRD accounted for approximately 7% of Medicare expenditure, equating to $114 billion per year (2,3). It is well established that kidney transplantation is the optimal therapy for ESRD as it provides increased survival, better quality of life, and University is less costly when compared with conventional dialysis (4–7). Since the advent of effective antiretroviral therapy, persons living with HIV (PLWH) are surviving longer and accumulating comorbidities. While HIV specific mortality has decreased, unfortunately, there continues to be a growing HIV epidemic, particularly in the southeastern United States. In 2017, the south accounted for 52% of the Witwatersrand38,739 new HIV diagnoses (8). As the HIV population ages, for ESRD has emerged as a significant cause of morbidity and mortality, with PLWH being three times more likely to develop ESRD compared with the general population and is thought to compromise approximately 1.5% of the dialysis population (9,10). Additionally, compared with HIV- negative counterparts, PLWH experience a lower one- and five- year survival on dialysis (11). Despite this, there is growing evidence that PLWH are less likely to be placed on the organ waitlist and 47% less likely to receive a living donor kidney transplant (12). In order to improve survival and increase transplant rates among PLWH, it is critical to better understand the barriers to achieving a kidney transplant in this high-risk population. The objective of this thesis project was to identify and describe the HIV positive dialysis population in ESRD Network 6, the region with the lowest rates of kidney transplantation in the nation. Additionally, to compare their efforts towards the continuation of Birth to Twenty, for allowing me the ability to learn from them progression through the practicum experienceearly steps (referral, evaluation, and waitlisting) of kidney transplantation to general dialysis population, and highlight patient and dialysis level characteristics that may influence access to kidney transplantation. This was accomplished through creating a novel HIV-ESRD dataset that identifies PLWH as well as those who proceeded through the hospitality that has continued past early steps of transplantation. BACKGROUND‌ PLWH have increasing rates of ESRD. HIV-associated nephropathy (HIVAN) was previously one of the culmination leading causes of my practicumrenal failure among PLWH. The Global Field Experience widespread use of affective antiretroviral therapy (GFEART) Committeehas decreased the prevalence of HIV-associated nephropathies (13,14), for providing me with the funding that allowed me however, PLWH are still developing CKD and ESRD faster than HIV negative counterparts. This is largely due to help clean and analyze this data in the context in which it was collected. Xxxx Xxxxxxco-morbidities (diabetes mellitus, for your company in South Africacardiovascular disease, your indispensable advicehypertension, and for letting me rely on you for cell phone access and transportation while abroad. My friends and fellow Xxxxxxx classmatesmetabolic syndrome), for the laughterco- infection with hepatitis C virus (HCV), levitymedication induced injury, and late nights accelerated aging seeing in chronic HIV infection (9,15,16). PLWH of black race are especially at risk for progression from CKD to ESRD. A study performed in Baltimore, Maryland revealed that made these past years immensely enjoyable. And finallyAfrican-Americans were at an increased risk for incident CKD and developed ESRD markedly faster than white subjects (HR, my parents, for being my ever present anchors and for allowing me the opportunities to learn and grow so many miles away from home for the past six years. Chapter I: Literature Review 1 Chapter II: Manuscript 15 Abstract 15 Introduction 16 Methods 18 Results 26 Discussion 31 Chapter III: Summary, Future Directions, & Public Health Implications 36 Tables and Figures. 37 References. 50 Chapter I: Literature Review Introduction Globally, non-communicable disease (NCD) has begun to replace communicable, or infectious, disease as the major contributor to mortality.1 One example of this epidemiologic shift seen in South Africa, a middle-income country that exhibits rates of chronic diseases such as hypertension as high as or exceeding those seen in high-income nations. Hypertension is now regarded as one of South Africa and Sub-Saharan Africa’s greatest health challenges after the HIV/AIDs crisis.2 Nationally representative World Health Organization (WHO) data from 2007 to 2010 showed a hypertension prevalence of 77.9% 17.7 [95% confidence interval CI 2.5-127.0]) (CI): 76.4 – 79.4] 17). ESRD among PLWH is particularly present in South African adults over age 50the southeast. In 2000, ESRD Network 6 had the 4th highest percentage of PLWH on dialysis at a proportion of 1.9% compared to an national average of 1.5%(10). Unfortunately, the southeastern region of the US continues to have the highest rate reported in this age group burden of any nation in the world. After stratifying by genderCKD and ESRD with Georgia, hypertension prevalence rates were reported to be as high as 74.7% [95% CI: 72.6 – 76.8] in males North Carolina and 80.3% [95% CI: 78.6 – 82.0] for females.3 However despite the similarities in hypertension prevalence South Carolina being states with high income countries, South Africa and many other Sub-Saharan African nations report significantly lower rates of detection, treatment, and control than high-income nations.2 South Africa reports some of the highest rates age-standardized CKD disability-adjusted life years (18,19). This coupled by the ongoing HIV epidemic in the southeast makes ESRD Network 6 a unique region to study the coexistence of obesity as wellESRD and access to kidney transplantation among PLWH. With significant risk of progression from CKD to ESRD, it is imperative to understand access to transplantation among this vulnerable patient population. Renal transplantation is a condition feasible treatment option for PLWH with ESRD. In the 1980’s, HIV infection was considered a contraindication for transplantation and US legal code was amended to make it a federal crime to transplant tissue from HIV positive donors (20). It was theorized that has shown consistent associations the effect of immunosuppression would contribute to progression of HIV disease, lead to more episodes of infection and increased rate of death; making it an inappropriate allocation of an organ. Between 1987 to 1997, there were 32 kidney transplants performed in the US in PLWH (mostly unintentional transplantation), with hypertensionreported 3-year graft survival of 53% and patient survival 83% (21,22). The WHO Study These transplants though were prior to significant improvement in medications used to treat PLWH. In 2003, Stock et al published promising outcomes on Global Aging 14 HIV-positive patients who underwent transplantation. At a mean follow up of 480 days, 10 out of 10 (100%) of patients who received kidney transplants were alive with functioning grafts. There was no evidence of HIV disease progression and Adult Health HIV did not seem to have an impact on graft survival (SAGE) compiled data from 23). Around the six middle-income countries same time, driven out of Chinalack of access to dialysis, Ghana, India, Mexico, Russia, and South Africa, and found that age and obesity were consistently significant predictors of hypertension prevalence in all six countries (though significance colleagues in South Africa data alone performed the first kidney transplants from HIV-positive organ donors to HIV-positive recipients, showing that transplantation among PLWH was only significant safe and feasible (24). With revived interest in transplanting PLWH, there have been a number of single center studies and a large multicenter study of 150 HIV-positive renal transplant recipients which all reported transplant outcomes for PLWH that were similar to the general transplant population 19(25–28). With better HIV care and improved understanding of medication interactions, PLWH in the 60 – 79 year age groupUnited States are not only eligible for HIV-negative organs, with an odds ratio of 38.89 and 95% confidence interval of 5.55 to 272.6)but HIV-positive organs as well. Socioeconomic factors such as insurance status were also found In 2013, the HIV Organ Procurement Equity (HOPE) Act was signed into law, reversing the 1988 amendment, allowing HIV positive organs to be significantly correlated with diagnosis of hypertensiontransplanted into HIV positive recipients. This policy change is estimated to increase the donor pool by 300-500 organs, and income was found to have a significant association with hypertension treatment status, though it showed no effect on prevalence.4, 5 This thesis uses data from the Birth to Twenty Cohort to investigate the effect of socioeconomic status on blood pressure in young adults from South Africa, an age group that remains underrepresented in the study of hypertension in sub-Saharan Africa. Birth to Twenty is distinctive as the longest running longitudinal birth cohort in Africa and has focused on the early expression of metabolic risk factors and conditions as one of its primary domains.6 Because the presence of risk factors such as obesity and hypertension in childhood are strongly associated with adverse health outcomes in later years, the data from this cohort provides providing a unique opportunity to examine health increase utilization of these organs and development from youth increase rates of kidney transplantation in HIV positive individuals 20(29). The transplant evaluation process is a multifaceted and complex process with the southeastern region performing the least transplants. Though it is possible for patients to early adulthoodbe referred for kidney transplant prior to starting dialysis, the majority of ESRD patients start on dialysis before they are referred to a transplant center. Within 60 days of starting dialysis, patients are required by law to be educated on the risks and benefits of transplantation and if eligible, are referred by a dialysis provider to a transplant center. The transplant center then decides on their waitlist candidacy through conducting thorough medical evaluations (often inclusive of multiple studies and specialty evaluations), performing a psychosocial evaluation, assessing their social support network and financial ability to fund kidney transplantation. When this step is completed, the patient can be waitlisted with the eventual hope of receiving a living or deceased donor kidney transplant. To better understand how well dialysis facilities were performing in referring patients to kidney transplant, Xx. Xxxxxx Xxxxxx (co-I; Department of Surgery & Department of Epidemiology) and team reported in 2014 that ESRD Network 6 has the lowest rates of kidney transplantation in the nation, and that Georgia had the lowest of all 50 states (18,30,31) (Figure 1). Factors associated with decreased access to transplant include demographic differences in the southeast, racial disparities, socioeconomic influences, distance to transplant center, provider knowledge and awareness of transplantation (18,32,33). Because no national surveillance data exist on steps prior to waitlisting, the Southeastern Kidney Transplant Coalition developed a novel data registry for referral and evaluation for transplantation among all 9 transplant centers in Xxxxxxx, Xxxxx Xxxxxxxx xxx Xxxxx Xxxxxxxx (X00XX000000, PI: Xxxxxx). They found substantial variability in transplant access at the dialysis facility level where some facilities referred 0% of patients and others referred 76% (34). Dialysis facility variability in transplant rates for HIV patients have not been described because currently no data exists linking HIV and ESRD care within a state or region. Factors influencing referral to kidney transplantation in PLWH have yet to be described in ESRD Network 6 and will direct construction of future interventions. Identifying PLWH who are on dialysis is difficult to do. Since 2005, there are scarce data on the incidence and prevalence of PLWH requiring dialysis. As part of a condition of participation in the ESRD Medicare program, Centers for Medicare and Medicaid Services (CMS) medical evidence form (CMS 2728 form) is completed on every ESRD patient upon initiation of dialysis. CMS funds dialysis for ESRD patient and the surgical procedure and immunosuppressants for those who undergo kidney transplantation. The medical evidence form provides evidence of an ESRD condition, registers patients into a national renal registry, documents medical co-morbidities and other clinical data in dialysis patients, and ensures quality care for ERSD patients (35). In 2005, HIV serostatus was removed as an ESRD-related condition on the medical evidence form due to concerns regarding disclosure of HIV status (36). Presently, in order to identity PLWH on dialysis, HIV status is inferred through pharmacy prescription data (12). This cohort ascertainment method is suboptimal, as it may misclassify patients on pre-exposure prophylaxis as being on ART, may fail to identify PLWH not engaged in HIV care, and lacks patient-level epidemiologic and clinical data. Nonetheless, pharmacy prescription data is the first only currently available method that can be used. In this study, Medicare prescription part D claims data was used to allow for tracking identify PLWH on dialysis. In 2016, there was 81% participation of health throughout Medicare part D among hemodialysis patients, suggestive that majority of the HIV population is captured in this study (37). METHODS‌ Hypothesis: Persons living with HIV in ESRD Network 6 are less likely to traverse through the multistep process of kidney transplantation compared to HIV-negative counterparts in the setting of ESRD. Specific Aims Aim 1: To identify and describe the characteristics of PLWH and ESRD in ESRD Network 6. Aim 2: To describe the distribution and timing of early life in South Africasteps of kidney transplant inclusive of referral, evaluation, and past findings have contributed waitlisting among PLWH compared with HIV negative individuals with ESRD in Network 6. Aim 3: To identify patient-level and dialysis facility-level factors that are associated with time to nation-wide policies, including regulation of age for school attendance referral and restrictions on tobacco purchasing.7 Therefore, this research aims time to explore blood pressure in the young adult data collection wave, and to assess how the major risk factor of obesity may mediate observed associations in the unique socioeconomic context of post-Apartheid South Africawaitlisting.

Conclusions. BMI appeared to have This project-based thesis presents an innovative technique of technical documentation developed in service of a stronger influence on young adult SBP and pre-hypertension / hypertension than all measures of SEScomplex global public health surveillance network that may offer a more comprehensive, but significant moderation and mediation was observed between BMI and various measures of SES. Further research is needed into the role of BMI as a mediator or moderator on SES and young adult blood pressureversatile, and intelligible illustration technique to investigate whether individual components capture the flow of SES may predict young adult blood pressuresurveillance data, potentially disrupting conventional techniques within the industry. Influence The data flow diagram was intentionally designed and honed to communicate the appropriate ratio of Socioeconomic Status operational/functional workflow specificity such that the document could inform the broadest audience of surveillance stakeholders, at the appropriate level magnification. If refined and Body Composition on Young Adult Blood Pressure: The Birth more broadly adopted, this data flow development methodology and the resulting artifacts could change how public health surveillance networks are designed, communicated, and comprehended. Innovation and Application of Data Flow Diagram to Twenty Cohort Inform Stakeholders, Validate Process, Align Operations, and Inform Systems Architecture for the Child Health and Mortality Prevention Surveillance (CHAMPS) Network By Chloe W. Eng B.S. Northeastern J. Xxxxxxx Xxxxxx Bachelor of Science University 2014 of Alabama 1997 Thesis Committee Chair: J. Xxxx Xxxxx X. Xxxxx, PhD A thesis submitted to the Faculty of the Xxxxxxx School of Public Health of Emory University in partial fulfillment of the requirements for the degree of Master of Science in Public Health in Epidemiology 2016 Applied Public Health Informatics 2020 “A man who carries a cat by the tail learns something he can learn in no other way” - Xxxx Xxxxx My journey in public informatics started with a toe in the water as a non-degree seeking enrollee in an introductory class about applied public informatics. There an enthusiastic evangelist of systems thinking had my attention and later my commitment to enroll and go for it. I did not know what the next five years would have in store for me… I did not know that going for it would mean that two and half years of classes would need three and half years so that I could maintain my full-time job and try to manage being a husband and father. I did not know that I would switch careers into global heath before I finished my degree and need put things on hold to help craft and implement an international multi-site surveillance network. There so many people from so many places that I am grateful to have met, learned from, and been inspired by during my public health quest. I would like to extend thank the faculty and staff at the Xxxxxxx School of Public Health, my sincerest thanks classmates (across few cohorts), and appreciation to: Xxxxx X. countless numbers people I have worked with through the CHAMPS program, a project like no other. I especially want to thank my committee members, Xxxx Xxxxx, Xxx Xxxxxx, and Xxxxx Xxxxxxxx for allowing me this learning opportunity, as well as his insight, their support, and ongoing patience whenever I veer off topic. Xxxxx Xxxxxx, PhD, study staff and researchers at DPHRUguidance, and University encouragement. Your influence in my achievement of the Witwatersrand, for their efforts towards the continuation of Birth to Twenty, for allowing me the ability to learn from them through the practicum experience, and the hospitality that has continued past the culmination of my practicumthis milestone are so much more than this paper. The Global Field Experience (GFE) Committee, for providing me with the funding that allowed most important acknowledgement of all goes to my wife and sons who supported and encouraged me to help clean and analyze this data in the context in which it was collectedpersevere. Xxxx Xxxxxx, for your company in South Africa, your indispensable advice, and for letting me rely on you for cell phone access and transportation while abroadI think we did it. My friends and fellow Xxxxxxx classmates, for the laughter, levity, and late nights that made these past years immensely enjoyable. And finally, my parents, for being my ever present anchors and for allowing me the opportunities to learn and grow so many miles away from home for the past six years. I promise I will be a lot more fun going forward… Chapter I: Literature Review 1 Chapter II: Manuscript 15 Abstract 15 Introduction 16 Methods 18 Results 26 Discussion 31 Chapter III: Summary, Future Directions, & Public Health Implications 36 Tables and Figures. 37 References. 50 Chapter I: Literature Review Introduction Globally, non-communicable disease (NCD) has begun to replace communicable, or infectious, disease as the major contributor to mortality.1 One example of this epidemiologic shift seen in South Africa, a middle-income country that exhibits rates of chronic diseases such as hypertension as high as or exceeding those seen in high-income nations. Hypertension is now regarded as one of South Africa and Sub-Saharan Africa’s greatest health challenges after the HIV/AIDs crisis.2 Nationally representative World Health Organization (WHO) data from 2007 to 2010 showed a hypertension prevalence of 77.9% [95% confidence interval (CI): 76.4 – 79.4] in South African adults over age 50, the highest rate reported in this age group of any nation in the world. After stratifying by gender, hypertension prevalence rates were reported to be as high as 74.7% [95% CI: 72.6 – 76.8] in males and 80.3% [95% CI: 78.6 – 82.0] for females.3 However despite the similarities in hypertension prevalence with high income countries, South Africa and many other Sub-Saharan African nations report significantly lower rates of detection, treatment, and control than high-income nations.2 South Africa reports some of the highest rates of obesity as well, a condition that has shown consistent associations with hypertension. The WHO Study on Global Aging and Adult Health (SAGE) compiled data from the six middle-income countries of China, Ghana, India, Mexico, Russia, and South Africa, and found that age and obesity were consistently significant predictors of hypertension prevalence in all six countries (though significance in South Africa data alone was only significant in the 60 – 79 year age group, with an odds ratio of 38.89 and 95% confidence interval of 5.55 to 272.6). Socioeconomic factors such as insurance status were also found to be significantly correlated with diagnosis of hypertension, and income was found to have a significant association with hypertension treatment status, though it showed no effect on prevalence.4, 5 This thesis uses data from the Birth to Twenty Cohort to investigate the effect of socioeconomic status on blood pressure in young adults from South Africa, an age group that remains underrepresented in the study of hypertension in sub-Saharan Africa. Birth to Twenty is distinctive as the longest running longitudinal birth cohort in Africa and has focused on the early expression of metabolic risk factors and conditions as one of its primary domains.6 Because the presence of risk factors such as obesity and hypertension in childhood are strongly associated with adverse health outcomes in later years, the data from this cohort provides a unique opportunity to examine health and development from youth to early adulthood. This cohort is the first to allow for tracking of health throughout early life in South Africa, and past findings have contributed to nation-wide policies, including regulation of age for school attendance and restrictions on tobacco purchasing.7 Therefore, this research aims to explore blood pressure in the young adult data collection wave, and to assess how the major risk factor of obesity may mediate observed associations in the unique socioeconomic context of post-Apartheid South Africa.1

Conclusions. BMI appeared Contrary to have a stronger influence our expectations, findings suggest that interruptions by both males and females lead to greater reporting of domestic violence. Also, female interruptions seem to be more predictive of severe physical violence than male interruptions, while both male and female interruptions are similarly predictive of sexual violence. The mechanisms explaining these findings are unclear, thus highlighting the need for further research on young adult SBP the topic of interview environment and pre-hypertension / hypertension than all measures its impact on response patterns and on global estimates of SES, but significant moderation domestic violence prevalence. Interview Interruption and mediation was observed between BMI and various measures Responses to Questions about Experiences of SES. Further research is needed into the role Domestic Violence in India By Xxxxxx X. Xxxxx Bachelor of BMI as a mediator or moderator on SES and young adult blood pressure, and to investigate whether individual components of SES may predict young adult blood pressure. Influence of Socioeconomic Status and Body Composition on Young Adult Blood Pressure: The Birth to Twenty Cohort By Chloe W. Eng B.S. Northeastern Arts Drew University 2014 2008 Thesis Committee Chair: Xxxxx X. XxxxxXx. Xxxxxxx Xxxxxxxxxx, PhD A thesis submitted to the Faculty of the Xxxxxxx School of Public Health of Emory University in partial fulfillment of the requirements for the degree of Master of Science in Public Health in Epidemiology 2016 Acknowledgements I would like to extend my sincerest thanks acknowledge, first and appreciation to: Xxxxx X. Xxxxxforemost, Xx. Xxxxxxx Xxxxxxxxxx, thesis advisor extraordinaire, for allowing me this learning opportunityinvesting so much time, as well as his insight, supporteffort, and ongoing above all, patience whenever into my project. Her accessibility and support throughout this process have been crucial to my success, and I veer off topiccan’t thank her enough for the important role that she has played in my Xxxxxxx experience. I would also like to thank Xx. Xxx Xxxxxxxxxx for conceiving the idea for this thesis, working with me throughout the year, and for putting me in contact with my incredible advisor. For all of this, I am grateful. I am also grateful for Drs. Xxxxx XxxxxxXxxxxx and Xxx Xxxxxxx for fostering my interest in women’s health, PhD, study staff and researchers at DPHRUfamily planning, and University reproductive choice. Their passion and knowledge in these areas have been integral in shaping my academic and professional interests, and I am so thankful for having had the experience of working with them throughout my time at Rollins. Thanks are also in order to the Witwatersrandmany classmates that provided technical advice and assistance throughout the thesis‐writing process, for their efforts towards the continuation of Birth especially Xxxxx Xxxxxxxxx and her unsurpassed Microsoft Office expertise. I’m also indebted to Twentymy dear friends at Xxxxxxx, for allowing who commiserated with me the ability to learn from them through the practicum experienceon late nights, impending deadlines, and the hospitality distance of that has continued past light at the culmination end of my practicumthe tunnel. The Global Field Experience (GFE) Committee, for providing me with the funding that allowed me to help clean and analyze this data in the context in which it was collected. Xxxx Xxxxxx, for your company in South Africa, your indispensable adviceThey are all brilliant, and for letting me rely on you for cell phone access and transportation while abroadI am so proud to know them. My friends and fellow Xxxxxxx classmatesFinally, for the laughterI would also like to acknowledge my amazing family, levity, and late nights that made these past years immensely enjoyable. And finally, especially my parents, whose love and support has guided me through every challenge I’ve faced; no amount of thanks will be able to convey my true appreciation. To my beautiful sisters, I thank you for being my ever present anchors best friends and for allowing me the opportunities believing in my ability to learn and grow so many miles away from home for the past six yearssucceed even when I was in doubt. Chapter I: Literature Review 1 Chapter II: Manuscript 15 Abstract 15 Introduction 16 Methods 18 Results 26 Discussion 31 Chapter III: Summary, Future Directions, & Public Health Implications 36 Tables and Figures. 37 References. 50 Chapter I: Literature Review Introduction Globally, non-communicable disease (NCD) has begun to replace communicable, or infectious, disease as the major contributor to mortality.1 One example of this epidemiologic shift seen in South Africa, a middle-income country that exhibits rates of chronic diseases such as hypertension as high as or exceeding those seen in high-income nations. Hypertension is now regarded as one of South Africa and Sub-Saharan Africa’s greatest health challenges after the HIV/AIDs crisis.2 Nationally representative World Health Organization (WHO) data from 2007 to 2010 showed a hypertension prevalence of 77.9% [95% confidence interval (CI): 76.4 – 79.4] in South African adults over age 50, the highest rate reported in this age group of any nation in the world. After stratifying by gender, hypertension prevalence rates were reported to be as high as 74.7% [95% CI: 72.6 – 76.8] in males and 80.3% [95% CI: 78.6 – 82.0] for females.3 However despite the similarities in hypertension prevalence with high income countries, South Africa and many other Sub-Saharan African nations report significantly lower rates of detection, treatment, and control than high-income nations.2 South Africa reports some of the highest rates of obesity as well, a condition that has shown consistent associations with hypertension. The WHO Study on Global Aging and Adult Health (SAGE) compiled data from the six middle-income countries of China, Ghana, India, Mexico, Russia, and South Africa, and found that age and obesity were consistently significant predictors of hypertension prevalence in You are all six countries (though significance in South Africa data alone was only significant in the 60 – 79 year age group, with an odds ratio of 38.89 and 95% confidence interval of 5.55 to 272.6). Socioeconomic factors such as insurance status were also found to be significantly correlated with diagnosis of hypertension, and income was found to have a significant association with hypertension treatment status, though it showed no effect on prevalence.4, 5 This thesis uses data from the Birth to Twenty Cohort to investigate the effect of socioeconomic status on blood pressure in young adults from South Africa, an age group that remains underrepresented in the study of hypertension in sub-Saharan Africa. Birth to Twenty is distinctive as the longest running longitudinal birth cohort in Africa and has focused on the early expression of metabolic risk factors and conditions as one of its primary domains.6 Because the presence of risk factors such as obesity and hypertension in childhood are strongly associated with adverse health outcomes in later years, the data from this cohort provides a unique opportunity to examine health and development from youth to early adulthood. This cohort is the first to allow for tracking of health throughout early life in South Africa, and past findings have contributed to nation-wide policies, including regulation of age for school attendance and restrictions on tobacco purchasing.7 Therefore, this research aims to explore blood pressure in the young adult data collection wave, and to assess how the major risk factor of obesity may mediate observed associations in the unique socioeconomic context of post-Apartheid South Africawonderful.

Conclusions. BMI appeared to have In a stronger influence on young adult SBP population with prior positive TSTs, TST was more variable than QFT-GIT when pairs of each test were performed simultaneously. TSTs may trigger conversion of subsequent TST and preQFT-hypertension / hypertension than all measures of SESGIT. The Tuberculin Skin Test: Within-Subject Variability, but significant moderation and mediation was observed between BMI and various measures of SES. Further research is needed into the role of BMI as a mediator or moderator on SES and young adult blood pressureBoosting, and to investigate whether individual components Comparison with the QuantiFERON-TB Gold In-Tube Test By Xxxxxx Xxxxxx-Xxxxxx DMD Medical University of SES may predict young adult blood pressure. Influence of Socioeconomic Status and Body Composition on Young Adult Blood Pressure: The Birth to Twenty Cohort By Chloe W. Eng B.S. Northeastern University 2014 Sofia 1982 Thesis Committee Chair: Xxxxx X. XxxxxXxxxxx Xxxxxxx, PhD Thesis Field Advisors: Xxxxxx Xxxxxxx, MD and Xxxxxxx X. Xxxxxxxxx, MPH A thesis submitted to the Faculty faculty of the Xxxxxxx School of Public Health of Emory University in partial fulfillment of the requirements for the degree of Master of Science in Public Health in Epidemiology 2016 the Executive Master of Public Health Program, 2017 Acknowledgments I would like to extend express my sincerest thanks gratitude to my committee chair, Xx. Xxxxxx Xxxxxxx and appreciation to: Xxxxx X. Xxxxxmy field advisors, Xx. Xxxxxx Xxxxxxx and Xx. Xxxxxxx Xxxxxxxxx. I would also like to express my gratitude to the Centers for allowing Disease Control and Prevention, Division of Tuberculosis Elimination’s Clinical Research Branch, with whom I had the honor and privilege of working and learning. I would also like to thank the students and faculty at Emory University and the Xxxxxxx School of Public Health – EMPH program for helping me this learning opportunityand providing me valuable knowledge and skills. I would finally like to thank my family for their constant understanding, as well as his insight, supportpatience, and ongoing patience whenever I veer off topicsupport. Xxxxx Xxxxxx, PhD, study staff The findings and researchers at DPHRU, and University conclusions in this document are solely those of the Witwatersrandauthor and do not necessarily represent the official views of the Centers for Disease Control and Prevention, for their efforts towards The U. S. Department of Defense, or the continuation U. S. Air Force. Table of Birth to Twenty, for allowing me the ability to learn from them through the practicum experience, Contents CHAPTER I: INTRODUCTION 1 INFECTION AND DISEASE DUE TO MYCOBACTERIUM TUBERCULOSIS 1 Historical Perspective 1 Epidemiology 2 Transmission 4 MYCOBACTERIUM TUBERCULOSIS INFECTION 5 Treatment and the hospitality that has continued past the culmination Control 6 Targeted Testing 7 IMMUNOLOGIC TESTS FOR MYCOBACTERIUM TUBERCULOSIS INFECTION 9 Tuberculin Skin Test (TST) 9 Interferon-Gamma Release Assay (IGRA) 11 PROBLEMS ADDRESSED BY THIS RESEARCH 14 Within-Subject TST Variability 14 TST – QFT Agreement 15 Boosting of my practicum. The Global Field Experience Immunologic Responses as Measured by TST 15 Boosting of Immunologic Responses as Measured by QFT-GIT 17 ANALYSIS GOALS CHAPTER II: LITERATURE REVIEW 19 MEASURES OF VARIABILITY AND BOOSTING REPORTED IN PRIOR STUDIES 19 WITHIN-SUBJECT TST VARIABILITY (GFEWITHIN-SUBJECT COMPARISON OF TST RESULTS) Committee, for providing me with the funding that allowed me to help clean and analyze this data in the context in which it was collected. Xxxx Xxxxxx, for your company in South Africa, your indispensable advice, and for letting me rely on you for cell phone access and transportation while abroad. My friends and fellow Xxxxxxx classmates, for the laughter, levity, and late nights that made these past years immensely enjoyable. And finally, my parents, for being my ever present anchors and for allowing me the opportunities to learn and grow so many miles away from home for the past six years. 20 WITHIN-SUBJECT COMPARISON OF TST AND QFT-GIT RESULTS 22 TST BOOSTING CHAPTER III: METHODS 28 STUDY POPULATION 28 ANALYSIS AND STUDY DESIGN 29 TEST METHODS 30 STATISTICAL ANALYSIS METHODS 31 CHAPTER IV: RESULTS 32 SUBJECT CHARACTERISTICS TEST RESULTS 33 OBJECTIVE I: ASSESSMENT OF WITHIN-SUBJECT XXX XXXXXXXXXXX 00 XXXXXXXXX XX: ASSESSMENT OF TST - QFT-GIT AGREEMENT 34 OBJECTIVE III: ASSESSMENT OF TST BOOSTING OF A SUBSEQUENT TST OBJECTIVE IV: ASSESSMENT OF TST BOOSTING OF A SUBSEQUENT QFT-GIT 35 CHAPTER V: DISCUSSION 36 INTRODUCTION 36 SUMMARY AND FINDINGS 37 LIMITATIONS 39 IMPLICATIONS 40 RECOMMENDATIONS FOR FUTURE STUDIES 42 CONCLUSIONS 42 FIGURES 43 TABLES 47 REFERENCES 52 Chapter I: Literature Review 1 Chapter II: Manuscript 15 Abstract 15 Introduction 16 Methods 18 Results 26 Discussion 31 Chapter III: SummaryInfection and Disease Due to Mycobacterium Tuberculosis Historical Perspective Tuberculosis (TB) is an infectious disease that has ravaged humanity for ages and continues to kill millions of people each year. TB usually affects the lungs and is transmitted from human-to-human through inhalation. The bacterium that is primarily responsible for causing TB, Future DirectionsMycobacterium tuberculosis (MTB), & Public Health Implications 36 Tables was first identified and Figuresdescribed in 1882 by Xxxxxx Xxxx. 37 References. 50 Chapter I: Literature Review Introduction GloballyInfections with MTB (MTBI) can be classified as either an active disease (referred to as TB) with clinical symptoms and pathological signs, or as an asymptomatic non-communicable disease contagious state, often called “latent” TB infection (NCD) has begun to replace communicableLTBI). People with TB may present with constitutional symptoms, or infectious, disease as the major contributor to mortality.1 One example of this epidemiologic shift seen in South Africa, a middle-income country that exhibits rates of chronic diseases such as hypertension weight loss, fever, chills, night sweats, and weakness, but may also present with symptoms associated with disease in specific organs. The lung is most often affected as high as or exceeding those seen evidence by symptoms of cough, sputum production, hemoptysis, and chest pain, that are typically accompanied by an abnormal chest x-ray. Pulmonary TB accounts for approximately 80% of newly diagnosed TB in highthe U. S. while 20% to 30% involves extra-income nationspulmonary sites. Hypertension Traditional methods used to diagnose TB rely primarily on sputum smear microscopy, bacteriological culture, and clinical examination, although newer and rapid molecular tests are being used with increasing frequency. A combination of sputum culture and clinical exam are considered the gold standard for definitive TB diagnosis. TB is now regarded as one curable with a standard six month course of South Africa four antimicrobial agents (isoniazid, rifampicin, pyrazinamide, and Sub-Saharan Africa’s greatest health challenges after the HIV/AIDs crisis.2 Nationally representative ethambutol), but, if left untreated, 70% of cases worldwide will not survive 10 years (World Health Organization (WHO) data from 2007 to 2010 showed a hypertension prevalence of 77.9% [95% confidence interval (CI): 76.4 – 79.4] in South African adults over age 50Organization, the highest rate reported in this age group of any nation in the world. After stratifying by gender, hypertension prevalence rates were reported to be as high as 74.7% [95% CI: 72.6 – 76.8] in males and 80.3% [95% CI: 78.6 – 82.0] for females.3 However despite the similarities in hypertension prevalence with high income countries, South Africa and many other Sub-Saharan African nations report significantly lower rates of detection, treatment, and control than high-income nations.2 South Africa reports some of the highest rates of obesity as well, a condition that has shown consistent associations with hypertension. The WHO Study on Global Aging and Adult Health (SAGE) compiled data from the six middle-income countries of China, Ghana, India, Mexico, Russia, and South Africa, and found that age and obesity were consistently significant predictors of hypertension prevalence in all six countries (though significance in South Africa data alone was only significant in the 60 – 79 year age group, with an odds ratio of 38.89 and 95% confidence interval of 5.55 to 272.62016). Socioeconomic factors such as insurance status were also found to be significantly correlated with diagnosis of hypertension, and income was found to have a significant association with hypertension treatment status, though it showed no effect on prevalence.4, 5 This thesis uses data from the Birth to Twenty Cohort to investigate the effect of socioeconomic status on blood pressure in young adults from South Africa, an age group that remains underrepresented in the study of hypertension in sub-Saharan Africa. Birth to Twenty is distinctive as the longest running longitudinal birth cohort in Africa and has focused on the early expression of metabolic risk factors and conditions as one of its primary domains.6 Because the presence of risk factors such as obesity and hypertension in childhood are strongly associated with adverse health outcomes in later years, the data from this cohort provides a unique opportunity to examine health and development from youth to early adulthood. This cohort is the first to allow for tracking of health throughout early life in South Africa, and past findings have contributed to nation-wide policies, including regulation of age for school attendance and restrictions on tobacco purchasing.7 Therefore, this research aims to explore blood pressure in the young adult data collection wave, and to assess how the major risk factor of obesity may mediate observed associations in the unique socioeconomic context of post-Apartheid South Africa.

Conclusions. BMI appeared to have a stronger influence on young adult SBP The associations between food insecurity and pre-hypertension / hypertension than all diabetes as well as the high prevalence of both conditions give evidence that food insecurity should be addressed in clinical settings. This study makes the case that electronic medical records should include measures of SESfood insecurity for appropriate referral. More research, but significant moderation and mediation was observed between BMI and various measures of SESespecially longitudinal, is necessary to continue to examining this association. Further research Key words‌ Food security, nutrition, type 2 diabetes, hospital, electronic medical records Hunger is needed into the role of BMI as a mediator or moderator on SES and young adult blood pressure, and to investigate whether individual components of SES may predict young adult blood pressure. Influence of Socioeconomic Status and Body Composition on Young Adult Blood PressureHealth: The Birth to Twenty Cohort Association Between Food Insecurity and Diabetes in the Primary Care Center (PCC) at Xxxxx Hospital in Atlanta, GA By Chloe W. Eng B.S. Northeastern Bella A. Girovich B.A., American University, 2014 Emory University 2014 2017 Thesis Committee Chair: Xxxxx X. XxxxxXxx Xxxx-Xxxxxx, PhD A thesis submitted to the Faculty of the Xxxxxxx School of Public Health of Emory University in partial fulfillment of the requirements for the degree of Master of Science in Public Health in Epidemiology 2016 I would like not have been able to extend my sincerest thanks and appreciation to: Xxxxx X. Xxxxxcomplete this thesis without the guidance of Xx. Xxx Xxxx- Girard. Thank you, Xxx, for allowing helping me this learning opportunity, as well as his insight, supportcreate and execute a project that I was truly passionate about, and ongoing patience whenever I veer off topic. Xxxxx Xxxxxx, PhD, study staff and researchers at DPHRU, and University of the Witwatersrand, for their efforts towards the continuation of Birth to Twenty, for allowing supporting me the ability to learn from them through the practicum experience(many) rounds of drafts! A huge thank you also goes to Xxx Xxxxx of Atlanta Community Food Bank for standing by me through every iteration of this project, and the hospitality that has continued past the culmination of my practicum. The Global Field Experience (GFE) Committee, for providing me with the funding that allowed me to help clean and analyze this data in the context in which from when it was collectedjust an idea in my head all the way to the finish line. Thank you to Xx. Xxxx Xxxxxx-Jones, without whom I would not have had the clinical nor hospital support to complete this survey. I am incredibly grateful for your company in South Africa, your indispensable advice, and for letting me rely on you for cell phone access and transportation while abroad. My my friends and fellow Xxxxxxx classmatespeers, for especially those in the laughternutrition department at Xxxxxxx, levitywho encouraged me to keep moving forward even in the face of setbacks. Most of all, and late nights that made these past years immensely enjoyable. And finally, thank you to my parents, Xxxxx and Howie, for being my ever present anchors and for allowing me rocks throughout the opportunities to learn and grow so many miles away from home for the past six yearsentire journey that was graduate school. To say, “I would not be here without you” is a gross understatement. Chapter IOne: Literature Review Introduction 1 Chapter IITwo: Manuscript 15 Abstract 15 Introduction 16 Methods Review of the Literature 3 Chapter Three: Methodology 18 Chapter Four: Results 26 24 Chapter Five: Discussion 31 Chapter III: Summary, Future Directions, & Public Health Implications 36 References 40 Appendices 43 List of Tables and FiguresFigures Table No. 37 ReferencesDescription Page Table 1 Incidence and Prevalence of Type 2 Diabetes Across Various Racial/Ethnic Groups 6 Table 2 Descriptive Characteristics Overall and by Diabetes Diagnosis (Prediabetes + Diabetes) 27 Box No. 50 Description Page Box 1 USDA Definition of Food Security 10 Box 2 Pillars of Food Security 11 Box 3 USDA Food Security Module 2-Item Screener 11 Figure No. Description Page Figure 1 Odds of Diabetes with Food Security for 323 Patients Attending the Primary Care Unit at Xxxxx Hospital from January-March 2017. Odds ratios and confidence intervals are estimated using logistic regression analysis. 28 Figure 2a Geographic Distribution to USDA 2-Item Screener First Question 29 Figure 2b Geographic Distribution to USDA 2-Item Screener Second Question 30 Figure 2c Geographic Distribution of Diabetes Status by Zip Code 31 Chapter IOne: Literature Review Introduction GloballyAs of 2014, non-communicable disease (NCD) has begun to replace communicabletype two diabetes touched the lives of 29.1% of Americans, or infectious, disease as giving it the major contributor to mortality.1 One example status of this epidemiologic shift seen in South Africa, a middle-income country that exhibits rates public health epidemic. While the United States spends millions of chronic diseases such as hypertension as high as or exceeding those seen in high-income nations. Hypertension is now regarded as one of South Africa and Sub-Saharan Africa’s greatest health challenges after the HIV/AIDs crisis.2 Nationally representative World Health Organization (WHO) data from 2007 to 2010 showed a hypertension prevalence of 77.9% [95% confidence interval (CI): 76.4 – 79.4] in South African adults over age 50dollars on type two diabetes prevention every year, the highest rate reported in this age group number of any nation in the worldcases continues to grow. After stratifying by gender, hypertension prevalence rates were reported to be as high as 74.7% [95% CI: 72.6 – 76.8] in males and 80.3% [95% CI: 78.6 – 82.0] for females.3 However despite the similarities in hypertension prevalence with high income countries, South Africa and many other Sub-Saharan African nations report significantly lower rates of detection, treatment, and control than high-income nations.2 South Africa reports some of the highest rates of obesity as well, a condition In that has shown consistent associations with hypertension. The WHO Study on Global Aging and Adult Health (SAGE) compiled data from the six middle-income countries of China, Ghana, India, Mexico, Russia, and South Africa, and found that age and obesity were consistently significant predictors of hypertension prevalence in all six countries (though significance in South Africa data alone was only significant in the 60 – 79 year age group, with an odds ratio of 38.89 and 95% confidence interval of 5.55 to 272.6). Socioeconomic factors such as insurance status were also found to be significantly correlated with diagnosis of hypertension, and income was found to have a significant association with hypertension treatment status, though it showed no effect on prevalence.4, 5 This thesis uses data from the Birth to Twenty Cohort to investigate the effect of socioeconomic status on blood pressure in young adults from South Africa, an age group that remains underrepresented in the study of hypertension in sub-Saharan Africa. Birth to Twenty is distinctive as the longest running longitudinal birth cohort in Africa and has focused on the early expression of metabolic risk factors and conditions as one of its primary domains.6 Because the presence of risk factors such as obesity and hypertension in childhood are strongly associated with adverse health outcomes in later years, the data from this cohort provides a unique opportunity to examine health and development from youth to early adulthood. This cohort is the first to allow for tracking of health throughout early life in South Africa, and past findings have contributed to nation-wide policies, including regulation of age for school attendance and restrictions on tobacco purchasing.7 Therefore, this research aims to explore blood pressure in the young adult data collection wave, and to assess how the major risk factor of obesity may mediate observed associations in the unique socioeconomic context of post-Apartheid South Africa.same year,

Conclusions. BMI appeared to have This project-based thesis presents an innovative technique of technical documentation developed in service of a stronger influence on young adult SBP and pre-hypertension / hypertension than all measures of SEScomplex global public health surveillance network that may offer a more comprehensive, but significant moderation and mediation was observed between BMI and various measures of SES. Further research is needed into the role of BMI as a mediator or moderator on SES and young adult blood pressureversatile, and intelligible illustration technique to investigate whether individual components capture the flow of SES may predict young adult blood pressuresurveillance data, potentially disrupting conventional techniques within the industry. Influence The data flow diagram was intentionally designed and honed to communicate the appropriate ratio of Socioeconomic Status operational/functional workflow specificity such that the document could inform the broadest audience of surveillance stakeholders, at the appropriate level magnification. If refined and Body Composition on Young Adult Blood Pressure: The Birth more broadly adopted, this data flow development methodology and the resulting artifacts could change how public health surveillance networks are designed, communicated, and comprehended. Innovation and Application of Data Flow Diagram to Twenty Cohort Inform Stakeholders, Validate Process, Align Operations, and Inform Systems Architecture for the Child Health and Mortality Prevention Surveillance (CHAMPS) Network By Chloe W. Eng B.S. Northeastern X. Xxxxxxx Xxxxxx Bachelor of Science University 2014 of Alabama 1997 Thesis Committee Chair: X. Xxxx Xxxxx X. Xxxxx, PhD A thesis submitted to the Faculty of the Xxxxxxx School of Public Health of Emory University in partial fulfillment of the requirements for the degree of Master of Science in Public Health in Epidemiology 2016 Applied Public Health Informatics 2020 “A man who carries a cat by the tail learns something he can learn in no other way” - Xxxx Xxxxx My journey in public informatics started with a toe in the water as a non-degree seeking enrollee in an introductory class about applied public informatics. There an enthusiastic evangelist of systems thinking had my attention and later my commitment to enroll and go for it. I did not know what the next five years would have in store for me… I did not know that going for it would mean that two and half years of classes would need three and half years so that I could maintain my full-time job and try to manage being a husband and father. I did not know that I would switch careers into global heath before I finished my degree and need put things on hold to help craft and implement an international multi-site surveillance network. There so many people from so many places that I am grateful to have met, learned from, and been inspired by during my public health quest. I would like to extend thank the faculty and staff at the Xxxxxxx School of Public Health, my sincerest thanks classmates (across few cohorts), and appreciation to: Xxxxx X. countless numbers people I have worked with through the CHAMPS program, a project like no other. I especially want to thank my committee members, Xxxx Xxxxx, Xxx Xxxxxx, and Xxxxx Xxxxxxxx for allowing me this learning opportunity, as well as his insight, their support, and ongoing patience whenever I veer off topic. Xxxxx Xxxxxx, PhD, study staff and researchers at DPHRUguidance, and University encouragement. Your influence in my achievement of the Witwatersrand, for their efforts towards the continuation of Birth to Twenty, for allowing me the ability to learn from them through the practicum experience, and the hospitality that has continued past the culmination of my practicumthis milestone are so much more than this paper. The Global Field Experience (GFE) Committee, for providing me with the funding that allowed most important acknowledgement of all goes to my wife and sons who supported and encouraged me to help clean and analyze this data in the context in which it was collectedpersevere. Xxxx Xxxxxx, for your company in South Africa, your indispensable advice, and for letting me rely on you for cell phone access and transportation while abroadI think we did it. My friends and fellow Xxxxxxx classmates, for the laughter, levity, and late nights that made these past years immensely enjoyable. And finally, my parents, for being my ever present anchors and for allowing me the opportunities to learn and grow so many miles away from home for the past six years. I promise I will be a lot more fun going forward… Chapter I: Literature Review 1 Chapter II: Manuscript 15 Abstract 15 Introduction 16 Methods 18 Results 26 Discussion 31 Chapter III: Summary, Future Directions, & Public Health Implications 36 Tables and Figures. 37 References. 50 Chapter I: Literature Review Introduction Globally, non-communicable disease (NCD) has begun to replace communicable, or infectious, disease as the major contributor to mortality.1 One example of this epidemiologic shift seen in South Africa, a middle-income country that exhibits rates of chronic diseases such as hypertension as high as or exceeding those seen in high-income nations. Hypertension is now regarded as one of South Africa and Sub-Saharan Africa’s greatest health challenges after the HIV/AIDs crisis.2 Nationally representative World Health Organization (WHO) data from 2007 to 2010 showed a hypertension prevalence of 77.9% [95% confidence interval (CI): 76.4 – 79.4] in South African adults over age 50, the highest rate reported in this age group of any nation in the world. After stratifying by gender, hypertension prevalence rates were reported to be as high as 74.7% [95% CI: 72.6 – 76.8] in males and 80.3% [95% CI: 78.6 – 82.0] for females.3 However despite the similarities in hypertension prevalence with high income countries, South Africa and many other Sub-Saharan African nations report significantly lower rates of detection, treatment, and control than high-income nations.2 South Africa reports some of the highest rates of obesity as well, a condition that has shown consistent associations with hypertension. The WHO Study on Global Aging and Adult Health (SAGE) compiled data from the six middle-income countries of China, Ghana, India, Mexico, Russia, and South Africa, and found that age and obesity were consistently significant predictors of hypertension prevalence in all six countries (though significance in South Africa data alone was only significant in the 60 – 79 year age group, with an odds ratio of 38.89 and 95% confidence interval of 5.55 to 272.6). Socioeconomic factors such as insurance status were also found to be significantly correlated with diagnosis of hypertension, and income was found to have a significant association with hypertension treatment status, though it showed no effect on prevalence.4, 5 This thesis uses data from the Birth to Twenty Cohort to investigate the effect of socioeconomic status on blood pressure in young adults from South Africa, an age group that remains underrepresented in the study of hypertension in sub-Saharan Africa. Birth to Twenty is distinctive as the longest running longitudinal birth cohort in Africa and has focused on the early expression of metabolic risk factors and conditions as one of its primary domains.6 Because the presence of risk factors such as obesity and hypertension in childhood are strongly associated with adverse health outcomes in later years, the data from this cohort provides a unique opportunity to examine health and development from youth to early adulthood. This cohort is the first to allow for tracking of health throughout early life in South Africa, and past findings have contributed to nation-wide policies, including regulation of age for school attendance and restrictions on tobacco purchasing.7 Therefore, this research aims to explore blood pressure in the young adult data collection wave, and to assess how the major risk factor of obesity may mediate observed associations in the unique socioeconomic context of post-Apartheid South Africa.1

Conclusions. BMI appeared to have a stronger influence on young adult SBP The associations between food insecurity and pre-hypertension / hypertension than all diabetes as well as the high prevalence of both conditions give evidence that food insecurity should be addressed in clinical settings. This study makes the case that electronic medical records should include measures of SESfood insecurity for appropriate referral. More research, but significant moderation and mediation was observed between BMI and various measures of SESespecially longitudinal, is necessary to continue to examining this association. Further research Key words‌ Food security, nutrition, type 2 diabetes, hospital, electronic medical records Hunger is needed into the role of BMI as a mediator or moderator on SES and young adult blood pressure, and to investigate whether individual components of SES may predict young adult blood pressure. Influence of Socioeconomic Status and Body Composition on Young Adult Blood PressureHealth: The Birth to Twenty Cohort Association Between Food Insecurity and Diabetes in the Primary Care Center (PCC) at Xxxxx Hospital in Atlanta, GA By Chloe W. Eng B.S. Northeastern Xxxxx X. Xxxxxxxx X.X., American University, 2014 Emory University 2014 2017 Thesis Committee Chair: Xxxxx X. XxxxxXxx Xxxx-Xxxxxx, PhD A thesis submitted to the Faculty of the Xxxxxxx School of Public Health of Emory University in partial fulfillment of the requirements for the degree of Master of Science in Public Health in Epidemiology 2016 I would like not have been able to extend my sincerest thanks and appreciation to: Xxxxx X. Xxxxxcomplete this thesis without the guidance of Xx. Xxx Xxxx- Girard. Thank you, Xxx, for allowing helping me this learning opportunity, as well as his insight, supportcreate and execute a project that I was truly passionate about, and ongoing patience whenever I veer off topic. Xxxxx Xxxxxx, PhD, study staff and researchers at DPHRU, and University of the Witwatersrand, for their efforts towards the continuation of Birth to Twenty, for allowing supporting me the ability to learn from them through the practicum experience(many) rounds of drafts! A huge thank you also goes to Xxx Xxxxx of Atlanta Community Food Bank for standing by me through every iteration of this project, and the hospitality that has continued past the culmination of my practicum. The Global Field Experience (GFE) Committee, for providing me with the funding that allowed me to help clean and analyze this data in the context in which from when it was collectedjust an idea in my head all the way to the finish line. Thank you to Xx. Xxxx Xxxxxx-Jones, without whom I would not have had the clinical nor hospital support to complete this survey. I am incredibly grateful for your company in South Africa, your indispensable advice, and for letting me rely on you for cell phone access and transportation while abroad. My my friends and fellow Xxxxxxx classmatespeers, for especially those in the laughternutrition department at Xxxxxxx, levitywho encouraged me to keep moving forward even in the face of setbacks. Most of all, and late nights that made these past years immensely enjoyable. And finally, thank you to my parents, Xxxxx and Xxxxx, for being my ever present anchors and for allowing me rocks throughout the opportunities to learn and grow so many miles away from home for the past six yearsentire journey that was graduate school. To say, “I would not be here without you” is a gross understatement. Chapter IOne: Literature Review Introduction 1 Chapter IITwo: Manuscript 15 Abstract 15 Introduction 16 Methods Review of the Literature 3 Chapter Three: Methodology 18 Chapter Four: Results 26 24 Chapter Five: Discussion 31 Chapter III: Summary, Future Directions, & Public Health Implications 36 References 40 Appendices 43 List of Tables and FiguresFigures Table No. 37 ReferencesDescription Page Table 1 Incidence and Prevalence of Type 2 Diabetes Across Various Racial/Ethnic Groups 6 Table 2 Descriptive Characteristics Overall and by Diabetes Diagnosis (Prediabetes + Diabetes) 27 Box No. 50 Description Page Box 1 USDA Definition of Food Security 10 Box 2 Pillars of Food Security 11 Box 3 USDA Food Security Module 2-Item Screener 11 Figure No. Description Page Figure 1 Odds of Diabetes with Food Security for 323 Patients Attending the Primary Care Unit at Xxxxx Hospital from January-March 2017. Odds ratios and confidence intervals are estimated using logistic regression analysis. 28 Figure 2a Geographic Distribution to USDA 2-Item Screener First Question 29 Figure 2b Geographic Distribution to USDA 2-Item Screener Second Question 30 Figure 2c Geographic Distribution of Diabetes Status by Zip Code 31 Chapter IOne: Literature Review Introduction GloballyAs of 2014, non-communicable disease (NCD) has begun to replace communicabletype two diabetes touched the lives of 29.1% of Americans, or infectious, disease as giving it the major contributor to mortality.1 One example status of this epidemiologic shift seen in South Africa, a middle-income country that exhibits rates public health epidemic. While the United States spends millions of chronic diseases such as hypertension as high as or exceeding those seen in high-income nations. Hypertension is now regarded as one of South Africa and Sub-Saharan Africa’s greatest health challenges after the HIV/AIDs crisis.2 Nationally representative World Health Organization (WHO) data from 2007 to 2010 showed a hypertension prevalence of 77.9% [95% confidence interval (CI): 76.4 – 79.4] in South African adults over age 50dollars on type two diabetes prevention every year, the highest rate reported in this age group number of any nation in the worldcases continues to grow. After stratifying by gender, hypertension prevalence rates were reported to be as high as 74.7% [95% CI: 72.6 – 76.8] in males and 80.3% [95% CI: 78.6 – 82.0] for females.3 However despite the similarities in hypertension prevalence with high income countries, South Africa and many other Sub-Saharan African nations report significantly lower rates of detection, treatment, and control than high-income nations.2 South Africa reports some of the highest rates of obesity as well, a condition In that has shown consistent associations with hypertension. The WHO Study on Global Aging and Adult Health (SAGE) compiled data from the six middle-income countries of China, Ghana, India, Mexico, Russia, and South Africa, and found that age and obesity were consistently significant predictors of hypertension prevalence in all six countries (though significance in South Africa data alone was only significant in the 60 – 79 year age group, with an odds ratio of 38.89 and 95% confidence interval of 5.55 to 272.6). Socioeconomic factors such as insurance status were also found to be significantly correlated with diagnosis of hypertension, and income was found to have a significant association with hypertension treatment status, though it showed no effect on prevalence.4, 5 This thesis uses data from the Birth to Twenty Cohort to investigate the effect of socioeconomic status on blood pressure in young adults from South Africa, an age group that remains underrepresented in the study of hypertension in sub-Saharan Africa. Birth to Twenty is distinctive as the longest running longitudinal birth cohort in Africa and has focused on the early expression of metabolic risk factors and conditions as one of its primary domains.6 Because the presence of risk factors such as obesity and hypertension in childhood are strongly associated with adverse health outcomes in later years, the data from this cohort provides a unique opportunity to examine health and development from youth to early adulthood. This cohort is the first to allow for tracking of health throughout early life in South Africa, and past findings have contributed to nation-wide policies, including regulation of age for school attendance and restrictions on tobacco purchasing.7 Therefore, this research aims to explore blood pressure in the young adult data collection wave, and to assess how the major risk factor of obesity may mediate observed associations in the unique socioeconomic context of post-Apartheid South Africa.same year,

Conclusions. BMI appeared to have In a stronger influence on young adult SBP population with prior positive TSTs, TST was more variable than QFT-GIT when pairs of each test were performed simultaneously. TSTs may trigger conversion of subsequent TST and preQFT-hypertension / hypertension than all measures of SESGIT. The Tuberculin Skin Test: Within-Subject Variability, but significant moderation and mediation was observed between BMI and various measures of SES. Further research is needed into the role of BMI as a mediator or moderator on SES and young adult blood pressureBoosting, and to investigate whether individual components Comparison with the QuantiFERON-TB Gold In-Tube Test By Xxxxxx Xxxxxx-Xxxxxx DMD Medical University of SES may predict young adult blood pressure. Influence of Socioeconomic Status and Body Composition on Young Adult Blood Pressure: The Birth to Twenty Cohort By Chloe W. Eng B.S. Northeastern University 2014 Sofia 1982 Thesis Committee Chair: Xxxxx X. XxxxxXxxxxx Xxxxxxx, PhD Thesis Field Advisors: Xxxxxx Xxxxxxx, MD and Xxxxxxx X. Xxxxxxxxx, MPH A thesis submitted to the Faculty faculty of the Xxxxxxx School of Public Health of Emory University in partial fulfillment of the requirements for the degree of Master of Science in Public Health in Epidemiology 2016 the Executive Master of Public Health Program, 2017 Acknowledgments I would like to extend express my sincerest thanks gratitude to my committee chair, Xx. Xxxxxx Xxxxxxx and appreciation to: Xxxxx X. Xxxxxmy field advisors, Xx. Xxxxxx Xxxxxxx and Xx. Xxxxxxx Xxxxxxxxx. I would also like to express my gratitude to the Centers for allowing Disease Control and Prevention, Division of Tuberculosis Elimination’s Clinical Research Branch, with whom I had the honor and privilege of working and learning. I would also like to thank the students and faculty at Emory University and the Xxxxxxx School of Public Health – EMPH program for helping me this learning opportunityand providing me valuable knowledge and skills. I would finally like to thank my family for their constant understanding, as well as his insight, supportpatience, and ongoing patience whenever I veer off topicsupport. Xxxxx Xxxxxx, PhD, study staff The findings and researchers at DPHRU, and University conclusions in this document are solely those of the Witwatersrandauthor and do not necessarily represent the official views of the Centers for Disease Control and Prevention, The U. S. Department of Defense, or the U. S. Air Force. Table of Contents CHAPTER I: INTRODUCTION 1 INFECTION AND DISEASE DUE TO MYCOBACTERIUM TUBERCULOSIS 1 Historical Perspective 1 Epidemiology 2 Transmission 4 MYCOBACTERIUM TUBERCULOSIS INFECTION 5 Treatment and Control 6 Targeted Testing 7 IMMUNOLOGIC TESTS FOR MYCOBACTERIUM TUBERCULOSIS INFECTION 9 Tuberculin Skin Test (TST) 9 Interferon-Gamma Release Assay (IGRA) 11 Problems Addressed by this Research 14 Within-Subject TST Variability 14 TST – QFT Agreement 15 Boosting of Immunologic Responses as Measured by TST 15 Boosting of Immunologic Responses as Measured by QFT-GIT 17 Analysis Goals 18 CHAPTER II: LITERATURE REVIEW 19 Measures of Variability and Boosting Reported in Prior Studies 19 WITHIN-SUBJECT TST VARIABILITY (WITHIN-SUBJECT COMPARISON OF TST RESULTS) 20 Within-Subject Comparison of TST and QFT-GIT Results 22 TST Boosting 26 CHAPTER III: METHODS 28 Study Population 28 Analysis and Study Design 29 Test Methods 30 Statistical Analysis Methods 31 CHAPTER IV: RESULTS 32 Subject Characteristics 32 Test Results 33 Objective I: Assessment of Within-Subject XXX Xxxxxxxxxxx 00 Xxxxxxxxx XX: Assessment of TST - QFT-GIT Agreement 34 OBJECTIVE III: ASSESSMENT OF TST BOOSTING OF A SUBSEQUENT TST 34 OBJECTIVE IV: ASSESSMENT OF TST BOOSTING OF A SUBSEQUENT QFT-GIT 35 CHAPTER V: DISCUSSION 36 Introduction 36 Summary and Findings 37 Limitations 39 Implications 40 Recommendations for their efforts towards the continuation of Birth to Twenty, for allowing me the ability to learn from them through the practicum experience, and the hospitality that has continued past the culmination of my practicum. The Global Field Experience (GFE) Committee, for providing me with the funding that allowed me to help clean and analyze this data in the context in which it was collected. Xxxx Xxxxxx, for your company in South Africa, your indispensable advice, and for letting me rely on you for cell phone access and transportation while abroad. My friends and fellow Xxxxxxx classmates, for the laughter, levity, and late nights that made these past years immensely enjoyable. And finally, my parents, for being my ever present anchors and for allowing me the opportunities to learn and grow so many miles away from home for the past six years. Future Studies 42 Conclusions 42 FIGURES 43 TABLES 47 REFERENCES 52 Chapter I: Literature Review 1 Chapter II: Manuscript 15 Abstract 15 Introduction 16 Methods 18 Results 26 Discussion 31 Chapter III: SummaryInfection and Disease Due to Mycobacterium Tuberculosis Historical Perspective Tuberculosis (TB) is an infectious disease that has ravaged humanity for ages and continues to kill millions of people each year. TB usually affects the lungs and is transmitted from human-to-human through inhalation. The bacterium that is primarily responsible for causing TB, Future DirectionsMycobacterium tuberculosis (MTB), & Public Health Implications 36 Tables was first identified and Figuresdescribed in 1882 by Xxxxxx Xxxx. 37 References. 50 Chapter I: Literature Review Introduction GloballyInfections with MTB (MTBI) can be classified as either an active disease (referred to as TB) with clinical symptoms and pathological signs, or as an asymptomatic non-communicable disease contagious state, often called “latent” TB infection (NCD) has begun to replace communicableLTBI). People with TB may present with constitutional symptoms, or infectious, disease as the major contributor to mortality.1 One example of this epidemiologic shift seen in South Africa, a middle-income country that exhibits rates of chronic diseases such as hypertension weight loss, fever, chills, night sweats, and weakness, but may also present with symptoms associated with disease in specific organs. The lung is most often affected as high as or exceeding those seen evidence by symptoms of cough, sputum production, hemoptysis, and chest pain, that are typically accompanied by an abnormal chest x-ray. Pulmonary TB accounts for approximately 80% of newly diagnosed TB in highthe U. S. while 20% to 30% involves extra-income nationspulmonary sites. Hypertension Traditional methods used to diagnose TB rely primarily on sputum smear microscopy, bacteriological culture, and clinical examination, although newer and rapid molecular tests are being used with increasing frequency. A combination of sputum culture and clinical exam are considered the gold standard for definitive TB diagnosis. TB is now regarded as one curable with a standard six month course of South Africa four antimicrobial agents (isoniazid, rifampicin, pyrazinamide, and Sub-Saharan Africa’s greatest health challenges after the HIV/AIDs crisis.2 Nationally representative ethambutol), but, if left untreated, 70% of cases worldwide will not survive 10 years (World Health Organization (WHO) data from 2007 to 2010 showed a hypertension prevalence of 77.9% [95% confidence interval (CI): 76.4 – 79.4] in South African adults over age 50Organization, the highest rate reported in this age group of any nation in the world. After stratifying by gender, hypertension prevalence rates were reported to be as high as 74.7% [95% CI: 72.6 – 76.8] in males and 80.3% [95% CI: 78.6 – 82.0] for females.3 However despite the similarities in hypertension prevalence with high income countries, South Africa and many other Sub-Saharan African nations report significantly lower rates of detection, treatment, and control than high-income nations.2 South Africa reports some of the highest rates of obesity as well, a condition that has shown consistent associations with hypertension. The WHO Study on Global Aging and Adult Health (SAGE) compiled data from the six middle-income countries of China, Ghana, India, Mexico, Russia, and South Africa, and found that age and obesity were consistently significant predictors of hypertension prevalence in all six countries (though significance in South Africa data alone was only significant in the 60 – 79 year age group, with an odds ratio of 38.89 and 95% confidence interval of 5.55 to 272.62016). Socioeconomic factors such as insurance status were also found to be significantly correlated with diagnosis of hypertension, and income was found to have a significant association with hypertension treatment status, though it showed no effect on prevalence.4, 5 This thesis uses data from the Birth to Twenty Cohort to investigate the effect of socioeconomic status on blood pressure in young adults from South Africa, an age group that remains underrepresented in the study of hypertension in sub-Saharan Africa. Birth to Twenty is distinctive as the longest running longitudinal birth cohort in Africa and has focused on the early expression of metabolic risk factors and conditions as one of its primary domains.6 Because the presence of risk factors such as obesity and hypertension in childhood are strongly associated with adverse health outcomes in later years, the data from this cohort provides a unique opportunity to examine health and development from youth to early adulthood. This cohort is the first to allow for tracking of health throughout early life in South Africa, and past findings have contributed to nation-wide policies, including regulation of age for school attendance and restrictions on tobacco purchasing.7 Therefore, this research aims to explore blood pressure in the young adult data collection wave, and to assess how the major risk factor of obesity may mediate observed associations in the unique socioeconomic context of post-Apartheid South Africa.

Conclusions. BMI appeared The use of WaterGuard and Sprinkles individually and together was protective against diarrhea. However, only the use of WaterGuard showed a statistically significant impact on reducing diarrheal prevalence. Assessing the Impact of Micronutrient WaterGuard and Micronutrient Sprinkles Use on Diarrheal Prevalence Among Kenyan Children Aged 6 to have a stronger influence on young adult SBP and pre-hypertension / hypertension than all measures 35 Months By Xxx Xxxx B.S. Georgia Institute of SES, but significant moderation and mediation was observed between BMI and various measures of SES. Further research is needed into the role of BMI as a mediator or moderator on SES and young adult blood pressure, and to investigate whether individual components of SES may predict young adult blood pressure. Influence of Socioeconomic Status and Body Composition on Young Adult Blood Pressure: The Birth to Twenty Cohort By Chloe W. Eng B.S. Northeastern University 2014 Technology 2007 Thesis Committee Chair: Xxxxx X. XxxxxXxxx Xxxx Xxxx, PhD A thesis submitted to the Faculty of the Xxxxxxx School of Public Health of Emory University in partial fulfillment of the requirements for the degree of Master of Science in Public Health in Epidemiology 2016 Global Environmental Health 2011 Acknowledgements I dedicate this thesis to my parents, Xxxxxx and Xxxxxxx Xxxx, my brother Xxxxx and my grandparents, Xxxxxxx and Xxxxxxx Xxxx, whose example I wish to emulate. My family helped shape the person I am today and I cannot be more grateful to them for their encouragement, love and support throughout the years. I am so thankful to them for instilling in me the passion and ambition for learning. I would like to extend express my sincerest thanks and appreciation to: Xxxxx X. Xxxxxsincere gratitude to my Thesis Field Advisor, Xxxxxxxxx Xxxxxxx MD, MPH for allowing me this learning opportunity, as well as his insightguidance, support, and ongoing patience whenever during my time in Kenya. I veer off topicam extremely humbled to have had the opportunity to work with him and am inspired by his passion for helping others. Not only is he a true friend, but he is a mentor and I will always appreciate his compassion and kindness during the toughest of times. I am also thankful to Xxxxx XxxxxxXxxxxxx, Xxxxxxx Xxxx, Xxxxxxx Xxxxxxx, Xxxx Xxxxx and the entire NICHE staff of enumerators, laboratory personnel and data clerks for working tirelessly to collect and record the data to make this research possible. Their extraordinary diligence and dedication to the NICHE project was inspirational and I feel so lucky to have worked alongside such wonderful and hard-working people. I owe a very special thanks to my friend and colleague, Xxxxx Xxxx, MPH who brought a great deal of laughter and excitement to my experience in Kenya. Without Xxxxx’x trust, support, and encouragement, I would not have had the opportunity to be involved with the NICHE project and am so grateful to him for giving me the chance to shine. While in Kenya, I was so lucky to have been in the company of such good friends as Xxxx Xxxxxxx of the Safe Water and AIDS Project, Xxxxxx Person from the Centers for Disease Control and Prevention and Momma Grace, who motivated me to move past the adversities of life. These women embody strength and compassion and taught me the art of hearing and empathizing with others. For that, I thank them. I am also very grateful to my Environmental Health Advisor at Emory University, Xxxx Xxxx Xxxx, PhD, study staff whose support and researchers encouragement was instrumental in getting through the grueling process of writing this thesis. I also owe thanks to Xxxx Xxxxx, MS at DPHRUEmory University, Xxxx Xxxxxx, PhD and University of Xxxxx Xxxxx at the WitwatersrandCenters for Disease Control and Prevention, for their efforts towards the continuation of Birth to Twentyinstruction in SAS and data analysis. Lastly, for allowing me the ability to learn from them through the practicum experience, and the hospitality that has continued past the culmination of my practicum. The Global Field Experience (GFE) Committee, for providing me with the funding that allowed me to help clean and analyze this data in the context in which it was collected. Xxxx Xxxxxx, for your company in South Africa, your indispensable advice, and for letting me rely on you for cell phone access and transportation while abroad. My friends and fellow Xxxxxxx classmates, for the laughter, levity, and late nights that made these past years immensely enjoyable. And finally, my parents, for being my ever present anchors and for allowing me the opportunities to learn and grow so many miles away from home for the past six years. Chapter I: Literature Review 1 Chapter II: Manuscript 15 Abstract 15 Introduction 16 Methods 18 Results 26 Discussion 31 Chapter III: Summary, Future Directions, & Public Health Implications 36 Tables and Figures. 37 References. 50 Chapter I: Literature Review Introduction Globally, non-communicable disease (NCD) has begun to replace communicable, or infectious, disease as the major contributor to mortality.1 One example of this epidemiologic shift seen in South Africa, a middle-income country that exhibits rates of chronic diseases such as hypertension as high as or exceeding those seen in high-income nations. Hypertension is now regarded as one of South Africa and Sub-Saharan Africa’s greatest health challenges after the HIV/AIDs crisis.2 Nationally representative World Health Organization (WHO) data from 2007 to 2010 showed a hypertension prevalence of 77.9% [95% confidence interval (CI): 76.4 – 79.4] in South African adults over age 50, the highest rate reported in this age group of any nation in the world. After stratifying by gender, hypertension prevalence rates were reported to be as high as 74.7% [95% CI: 72.6 – 76.8] in males and 80.3% [95% CI: 78.6 – 82.0] for females.3 However despite the similarities in hypertension prevalence with high income countries, South Africa and many other Sub-Saharan African nations report significantly lower rates of detection, treatment, and control than high-income nations.2 South Africa reports some of the highest rates of obesity as well, a condition that has shown consistent associations with hypertension. The WHO Study on Global Aging and Adult Health (SAGE) compiled data study would not have been possible without support from the six middle-income countries of China, Ghana, India, Mexico, Russia, Centers for Disease Control and South Africa, and found that age and obesity were consistently significant predictors of hypertension prevalence in all six countries (though significance in South Africa data alone was only significant in the 60 – 79 year age group, with an odds ratio of 38.89 and 95% confidence interval of 5.55 to 272.6). Socioeconomic factors such as insurance status were also found to be significantly correlated with diagnosis of hypertension, and income was found to have a significant association with hypertension treatment status, though it showed no effect on prevalence.4, 5 This thesis uses data from the Birth to Twenty Cohort to investigate the effect of socioeconomic status on blood pressure in young adults from South Africa, an age group that remains underrepresented in the study of hypertension in sub-Saharan Africa. Birth to Twenty is distinctive as the longest running longitudinal birth cohort in Africa and has focused on the early expression of metabolic risk factors and conditions as one of its primary domains.6 Because the presence of risk factors such as obesity and hypertension in childhood are strongly associated with adverse health outcomes in later years, the data from this cohort provides a unique opportunity to examine health and development from youth to early adulthood. This cohort is the first to allow for tracking of health throughout early life in South Africa, and past findings have contributed to nation-wide policies, including regulation of age for school attendance and restrictions on tobacco purchasing.7 Therefore, this research aims to explore blood pressure in the young adult data collection wave, and to assess how the major risk factor of obesity may mediate observed associations in the unique socioeconomic context of post-Apartheid South AfricaPrevention.

Conclusions. BMI appeared Our study points to have a stronger influence on young adult SBP an association between maternal education and prebreastfeeding duration after controlling for some important socio-hypertension / hypertension than all measures of SESdemographic factors. Future studies should further explore how education, but significant moderation and mediation was observed between BMI and various measures of SES. Further research is needed into the role of BMI taken as a mediator or moderator on SES proxy for knowledge processing, is associated with breastfeeding, in a prospective analysis. Educational Level and young adult blood pressureSelf- Reported Breastfeeding Duration among Primiparas in the National Survey of Family Growth (NSFG) 2011 - 2013 BY Xxxxxx Xx M.P.H., and to investigate whether individual components of SES may predict young adult blood pressure. Influence of Socioeconomic Status and Body Composition on Young Adult Blood Pressure: The Birth to Twenty Cohort By Chloe W. Eng B.S. Northeastern University 2014 Emory University, 2016 D.V.M Universidad Peruana Xxxxxxxx Xxxxxxx, 2013 Thesis Committee Chair: Xxxxx X. XxxxxXxxxxx Xxxxxxxxx, PhD Ph.D A thesis submitted Thesis Submitted to the Faculty of the Xxxxxxx School of Public Health of Emory University in partial fulfillment of the requirements for of the degree of Master of Science in Public Health in Epidemiology the Executive MPH program 2016 ACKNOWLEDGEMENTS I want to thank Xx. Xxxxxx Xxxxxxxxx and Dr. Xxxxxxx Xxxxxx for their guidance and support during the Master in Public Health thesis development process. I was fortunate to be able to count on their vast expertise and knowledge in my chosen topic. In addition, I would like to extend my sincerest thanks and appreciation to: Xxxxx X. Xxxxx, for allowing me this learning opportunity, as well as his insight, support, and ongoing patience whenever I veer off topic. Xxxxx Xxxxxx, PhD, study staff and researchers thank the Xxxxxxx School of Public Health at DPHRU, and Emory University of the Witwatersrand, for their efforts towards the continuation of Birth to Twenty, for allowing me the ability to learn from them through the practicum experience, and the hospitality that has continued past the culmination of my practicum. The Global Field Experience (GFE) Committee, for providing me with an outstanding opportunity and giving me the funding that allowed me tools to help clean and analyze this data develop a future career in the context in which it was collectedPublic Health field. I’m very proud and honored to be considered a student at this prestigious school. Lastly, I certainly would not have been able to complete my graduate studies without the support of my family and friends. Special thanks to my husband, Xxxx Xxxxxx, who supported me not only financially but emotionally, generously providing me the opportunity to be able to develop my professional goals and aspirations. Table of contents Publication Cover Sheet… 1 Abstract for your company Publication 2 Expanded Introduction. 3 Introduction for Publication 8 Methods 13 Results… 16 Expanded Discussion. 18 Discussion 22 References 26 Figure 1… 30 Table 1 31 Table 1a 32 Table 2 33 Educational Level and Self- Reported Breastfeeding Duration among Primiparas in South Africathe National Survey of Family Growth (NSFG) 2011 - 2013 Xxxxxx Xx, your indispensable adviceMPH(c) Xxxxxx Xxxxxxxxx, Ph.D. Department of Epidemiology, Emory University Xxxxxxx School of Public Health, Atlanta, GA, USA Xxxxxxx Xxxxxx, Ph.D. Department of Epidemiology, Emory University Xxxxxxx School of Public Health, Atlanta, GA, USA Corresponding author: TBD Short title: Educational Level and Self- Reported Breastfeeding Duration The authors declare no competing financial interests. ABSTRACT BACKGROUND: Breastfeeding is vital for letting me rely on you providing young infants with the nutrients they need for cell phone access healthy growth and transportation while abroad. My friends development; however, there are several socio-economic and fellow Xxxxxxx classmates, health determinants that predict whether or not mothers are able to initiate and maintain it for the laughterrecommended duration. With changing demographics among first time mothers, levity, we examined the current association between maternal education and late nights that made these past years immensely enjoyable. And finally, my parents, for being my ever present anchors and for allowing me the opportunities to learn and grow so many miles away from home for the past six years. Chapter I: Literature Review 1 Chapter II: Manuscript 15 Abstract 15 Introduction 16 Methods 18 Results 26 Discussion 31 Chapter III: Summary, Future Directions, & Public Health Implications 36 Tables and Figures. 37 References. 50 Chapter I: Literature Review Introduction Globally, nonself-communicable disease (NCD) has begun to replace communicable, or infectious, disease as the major contributor to mortality.1 One example of this epidemiologic shift seen in South Africa, a middle-income country that exhibits rates of chronic diseases such as hypertension as high as or exceeding those seen in high-income nations. Hypertension is now regarded as one of South Africa and Sub-Saharan Africa’s greatest health challenges after the HIV/AIDs crisis.2 Nationally representative World Health Organization (WHO) data from 2007 to 2010 showed a hypertension prevalence of 77.9% [95% confidence interval (CI): 76.4 – 79.4] in South African adults over age 50, the highest rate reported in this age group of any nation breastfeeding duration in the world. After stratifying by gender, hypertension prevalence rates were reported to be as high as 74.7% [95% CIU.S. METHODS: 72.6 – 76.8] in males Utilizing national and 80.3% [95% CI: 78.6 – 82.0] for females.3 However despite the similarities in hypertension prevalence with high income countries, South Africa and many other Subpopulation-Saharan African nations report significantly lower rates of detection, treatment, and control than highbased cross-income nations.2 South Africa reports some of the highest rates of obesity as well, a condition that has shown consistent associations with hypertension. The WHO Study on Global Aging and Adult Health (SAGE) compiled sectional data from the six middle2011-income countries 2013 National Survey of ChinaFamily Growth (NSFG), Ghana, India, Mexico, Russia, we examined the association between maternal education and South Africa, and found that age and obesity were consistently significant predictors of hypertension prevalence in all six countries (though significance in South Africa data alone self-reported breastfeeding duration among primiparas aged 15-44 years. Breastfeeding duration was only significant in the 60 – 79 year age group, with examined as an ordinal variable. We estimated adjusted odds ratio of 38.89 ratios and 95% confidence interval intervals using a multivariable ordinal logistic regression, while controlling for several potential confounders. RESULTS: Of the 2069 participants who were eligible for our analysis, 66.2% of 5.55 first time mothers breastfed. 27.1% of them breastfed for less than a week to 272.68 weeks, 46.01% breastfed for 9 to 52 weeks and 15.12% breastfed for more than one-year-old and were still breastfeeding at the time of interview. Maternal education was an independent risk factor for the duration of breastfeeding among primiparas in our study sample), after controlling for age, race and ethnicity, marital status, religious beliefs, employment status and federal poverty level. Socioeconomic factors such as insurance status Women with a college education and above were also found less likely to be significantly correlated with diagnosis of hypertension, not breastfeed and income was found to have a significant association shorter breastfeeding duration times. (aOR=0.59 CI= 0.47, 0.74) compared to women with hypertension treatment statuslower education. In addition, women with less than high school education, even though it showed no effect on prevalence.4was not statistically significant, 5 This thesis uses data from the Birth also were less likely to Twenty Cohort to investigate the effect of socioeconomic status on blood pressure in young adults from South Africa, an age group that remains underrepresented in the study of hypertension in sub-Saharan Africa. Birth to Twenty is distinctive as the longest running longitudinal birth cohort in Africa and has focused on the early expression of metabolic risk factors and conditions as one of its primary domains.6 Because the presence of risk factors such as obesity and hypertension in childhood are strongly associated with adverse health outcomes in later years, the data from this cohort provides a unique opportunity to examine health and development from youth to early adulthood. This cohort is the first to allow for tracking of health throughout early life in South Africa, and past findings have contributed to nation-wide policies, including regulation of age for school attendance and restrictions on tobacco purchasing.7 Therefore, this research aims to explore blood pressure in the young adult data collection wave, not breastfeed and to assess how the major risk factor of obesity may mediate observed associations in the unique socioeconomic context of post-Apartheid South Africahave shorter breastfeeding duration times (aOR=0.75 CI= 0.40, 1.35).

Conclusions. BMI appeared This pilot study offers the first regional-level characterization of PLWH proceeding through the early steps of transplantation. PLWH were less likely to have a stronger influence on young adult SBP traverse the steps of kidney transplant compared with those HIV negative, highlighting the need for targeted interventions to improve access to kidney transplant for PLWH. Identifying the barriers and pre-hypertension / hypertension than all measures disparities for referral to kidney transplantation faced by person living with HIV and end stage renal disease By Xxxx X. Xxxxxxxx ScB, Monmouth University, 2009 MD, Xxxxxx Xxxxxxxxxx University School of SESHealth Sciences, but significant moderation and mediation was observed between BMI and various measures of SES. Further research is needed into the role of BMI as a mediator or moderator on SES and young adult blood pressure, and to investigate whether individual components of SES may predict young adult blood pressure. Influence of Socioeconomic Status and Body Composition on Young Adult Blood Pressure2013 Advisor: The Birth to Twenty Cohort By Chloe W. Eng B.S. Northeastern University 2014 Thesis Committee Chair: Xxxxx Xxxxxx X. Xxxxx, PhD MD A thesis submitted to the Faculty of the Xxxxxxx Xxxxx X. Xxxxx School of Public Health Graduate Studies of Emory University in partial fulfillment of the requirements for the degree of Master of Science in Public Health in Epidemiology 2016 Clinical Research 2020 I would like to extend thank Xx. Xxxxxx Xxxxx and Xx. Xxxxxx Xxxxxx for serving as research mentors. Their assistance in honing my sincerest thanks ideas and appreciation to: interests, providing me with the necessary support and guidance to complete my MSCR application, and informative discussions regarding the implications of this work, not only tremendously developed this work, but helped me to grow as a junior investigator. I am thankful for the help of Dr. Xxxxxxxxx (AKA Xxxxx) Xxxx who assisted me with the analysis and served as my reader and additionally and Xx. Xxxxxxxxx for reviewing the drafts of this thesis. I would like to thank Xx. Xxxxxxx Xxxxx X. Xxxxxfor being instrumental in obtaining the data for this project and being so accommodating to additional data requests. I am also appreciative of Dr. Xxxxx Xxxxxxxxx who has been a fearless leader and program director, and the main reason why I applied to the MSCR program. Lastly, I would like to thank my husband Xxxxxx Xxxxxxxxx for allowing me this learning opportunityhis patience, as well as his insightlove, support, and ongoing patience whenever I veer off topicSAS consultations. Xxxxx XxxxxxTABLE OF CONTENTS INTRODUCTION 1 BACKGROUND 3 METHODS 8 RESULTS 19 DISCUSSION 24 CONCLUSIONS 33 REFERENCES 34 INTRODUCTION‌ End-stage renal disease (ESRD) has increased by 1000% in the past 3 decades, PhDproving to be a significant health concern in the United Sates. In 1980, study staff there were 60,000 persons with ESRD though in 2018 there were over 700,000 Americans living with ESRD (1). The expense of Chronic Kidney Disease (CKD) and researchers at DPHRUESRD has a significant impact on the United States economy and in 2018, CKD and ESRD accounted for approximately 7% of Medicare expenditure, equating to $114 billion per year (2,3). It is well established that kidney transplantation is the optimal therapy for ESRD as it provides increased survival, better quality of life, and University is less costly when compared with conventional dialysis (4–7). Since the advent of effective antiretroviral therapy, persons living with HIV (PLWH) are surviving longer and accumulating comorbidities. While HIV specific mortality has decreased, unfortunately, there continues to be a growing HIV epidemic, particularly in the southeastern United States. In 2017, the south accounted for 52% of the Witwatersrand38,739 new HIV diagnoses (8). As the HIV population ages, for ESRD has emerged as a significant cause of morbidity and mortality, with PLWH being three times more likely to develop ESRD compared with the general population and is thought to compromise approximately 1.5% of the dialysis population (9,10). Additionally, compared with HIV- negative counterparts, PLWH experience a lower one- and five- year survival on dialysis (11). Despite this, there is growing evidence that PLWH are less likely to be placed on the organ waitlist and 47% less likely to receive a living donor kidney transplant (12). In order to improve survival and increase transplant rates among PLWH, it is critical to better understand the barriers to achieving a kidney transplant in this high-risk population. The objective of this thesis project was to identify and describe the HIV positive dialysis population in ESRD Network 6, the region with the lowest rates of kidney transplantation in the nation. Additionally, to compare their efforts towards the continuation of Birth to Twenty, for allowing me the ability to learn from them progression through the practicum experienceearly steps (referral, evaluation, and waitlisting) of kidney transplantation to general dialysis population, and highlight patient and dialysis level characteristics that may influence access to kidney transplantation. This was accomplished through creating a novel HIV-ESRD dataset that identifies PLWH as well as those who proceeded through the hospitality that has continued past early steps of transplantation. BACKGROUND‌ PLWH have increasing rates of ESRD. HIV-associated nephropathy (HIVAN) was previously one of the culmination leading causes of my practicumrenal failure among PLWH. The Global Field Experience widespread use of affective antiretroviral therapy (GFEART) Committeehas decreased the prevalence of HIV-associated nephropathies (13,14), for providing me with the funding that allowed me however, PLWH are still developing CKD and ESRD faster than HIV negative counterparts. This is largely due to help clean and analyze this data in the context in which it was collected. Xxxx Xxxxxxco-morbidities (diabetes mellitus, for your company in South Africacardiovascular disease, your indispensable advicehypertension, and for letting me rely on you for cell phone access and transportation while abroad. My friends and fellow Xxxxxxx classmatesmetabolic syndrome), for the laughterco- infection with hepatitis C virus (HCV), levitymedication induced injury, and late nights accelerated aging seeing in chronic HIV infection (9,15,16). PLWH of black race are especially at risk for progression from CKD to ESRD. A study performed in Baltimore, Maryland revealed that made these past years immensely enjoyable. And finallyAfrican-Americans were at an increased risk for incident CKD and developed ESRD markedly faster than white subjects (HR, my parents, for being my ever present anchors and for allowing me the opportunities to learn and grow so many miles away from home for the past six years. Chapter I: Literature Review 1 Chapter II: Manuscript 15 Abstract 15 Introduction 16 Methods 18 Results 26 Discussion 31 Chapter III: Summary, Future Directions, & Public Health Implications 36 Tables and Figures. 37 References. 50 Chapter I: Literature Review Introduction Globally, non-communicable disease (NCD) has begun to replace communicable, or infectious, disease as the major contributor to mortality.1 One example of this epidemiologic shift seen in South Africa, a middle-income country that exhibits rates of chronic diseases such as hypertension as high as or exceeding those seen in high-income nations. Hypertension is now regarded as one of South Africa and Sub-Saharan Africa’s greatest health challenges after the HIV/AIDs crisis.2 Nationally representative World Health Organization (WHO) data from 2007 to 2010 showed a hypertension prevalence of 77.9% 17.7 [95% confidence interval CI 2.5-127.0]) (CI): 76.4 – 79.4] 17). ESRD among PLWH is particularly present in South African adults over age 50the southeast. In 2000, ESRD Network 6 had the 4th highest percentage of PLWH on dialysis at a proportion of 1.9% compared to an national average of 1.5%(10). Unfortunately, the southeastern region of the US continues to have the highest rate reported in this age group burden of any nation in the world. After stratifying by genderCKD and ESRD with Georgia, hypertension prevalence rates were reported to be as high as 74.7% [95% CI: 72.6 – 76.8] in males North Carolina and 80.3% [95% CI: 78.6 – 82.0] for females.3 However despite the similarities in hypertension prevalence South Carolina being states with high income countries, South Africa and many other Sub-Saharan African nations report significantly lower rates of detection, treatment, and control than high-income nations.2 South Africa reports some of the highest rates age-standardized CKD disability-adjusted life years (18,19). This coupled by the ongoing HIV epidemic in the southeast makes ESRD Network 6 a unique region to study the coexistence of obesity as wellESRD and access to kidney transplantation among PLWH. With significant risk of progression from CKD to ESRD, it is imperative to understand access to transplantation among this vulnerable patient population. Renal transplantation is a condition feasible treatment option for PLWH with ESRD. In the 1980’s, HIV infection was considered a contraindication for transplantation and US legal code was amended to make it a federal crime to transplant tissue from HIV positive donors (20). It was theorized that has shown consistent associations the effect of immunosuppression would contribute to progression of HIV disease, lead to more episodes of infection and increased rate of death; making it an inappropriate allocation of an organ. Between 1987 to 1997, there were 32 kidney transplants performed in the US in PLWH (mostly unintentional transplantation), with hypertensionreported 3-year graft survival of 53% and patient survival 83% (21,22). The WHO Study These transplants though were prior to significant improvement in medications used to treat PLWH. In 2003, Xxxxx et al published promising outcomes on Global Aging 14 HIV-positive patients who underwent transplantation. At a mean follow up of 480 days, 10 out of 10 (100%) of patients who received kidney transplants were alive with functioning grafts. There was no evidence of HIV disease progression and Adult Health HIV did not seem to have an impact on graft survival (SAGE) compiled data from 23). Around the six middle-income countries same time, driven out of Chinalack of access to dialysis, Ghana, India, Mexico, Russia, and South Africa, and found that age and obesity were consistently significant predictors of hypertension prevalence in all six countries (though significance colleagues in South Africa data alone performed the first kidney transplants from HIV-positive organ donors to HIV-positive recipients, showing that transplantation among PLWH was only significant safe and feasible (24). With revived interest in transplanting PLWH, there have been a number of single center studies and a large multicenter study of 150 HIV-positive renal transplant recipients which all reported transplant outcomes for PLWH that were similar to the general transplant population 19(25–28). With better HIV care and improved understanding of medication interactions, PLWH in the 60 – 79 year age groupUnited States are not only eligible for HIV-negative organs, with an odds ratio of 38.89 and 95% confidence interval of 5.55 to 272.6)but HIV-positive organs as well. Socioeconomic factors such as insurance status were also found In 2013, the HIV Organ Procurement Equity (HOPE) Act was signed into law, reversing the 1988 amendment, allowing HIV positive organs to be significantly correlated with diagnosis of hypertensiontransplanted into HIV positive recipients. This policy change is estimated to increase the donor pool by 300-500 organs, and income was found to have a significant association with hypertension treatment status, though it showed no effect on prevalence.4, 5 This thesis uses data from the Birth to Twenty Cohort to investigate the effect of socioeconomic status on blood pressure in young adults from South Africa, an age group that remains underrepresented in the study of hypertension in sub-Saharan Africa. Birth to Twenty is distinctive as the longest running longitudinal birth cohort in Africa and has focused on the early expression of metabolic risk factors and conditions as one of its primary domains.6 Because the presence of risk factors such as obesity and hypertension in childhood are strongly associated with adverse health outcomes in later years, the data from this cohort provides providing a unique opportunity to examine health increase utilization of these organs and development from youth increase rates of kidney transplantation in HIV positive individuals 20(29). The transplant evaluation process is a multifaceted and complex process with the southeastern region performing the least transplants. Though it is possible for patients to early adulthoodbe referred for kidney transplant prior to starting dialysis, the majority of ESRD patients start on dialysis before they are referred to a transplant center. Within 60 days of starting dialysis, patients are required by law to be educated on the risks and benefits of transplantation and if eligible, are referred by a dialysis provider to a transplant center. The transplant center then decides on their waitlist candidacy through conducting thorough medical evaluations (often inclusive of multiple studies and specialty evaluations), performing a psychosocial evaluation, assessing their social support network and financial ability to fund kidney transplantation. When this step is completed, the patient can be waitlisted with the eventual hope of receiving a living or deceased donor kidney transplant. To better understand how well dialysis facilities were performing in referring patients to kidney transplant, Xx. Xxxxxx Xxxxxx (co-I; Department of Surgery & Department of Epidemiology) and team reported in 2014 that ESRD Network 6 has the lowest rates of kidney transplantation in the nation, and that Georgia had the lowest of all 50 states (18,30,31) (Figure 1). Factors associated with decreased access to transplant include demographic differences in the southeast, racial disparities, socioeconomic influences, distance to transplant center, provider knowledge and awareness of transplantation (18,32,33). Because no national surveillance data exist on steps prior to waitlisting, the Southeastern Kidney Transplant Coalition developed a novel data registry for referral and evaluation for transplantation among all 9 transplant centers in Xxxxxxx, Xxxxx Xxxxxxxx xxx Xxxxx Xxxxxxxx (X00XX000000, PI: Xxxxxx). They found substantial variability in transplant access at the dialysis facility level where some facilities referred 0% of patients and others referred 76% (34). Dialysis facility variability in transplant rates for HIV patients have not been described because currently no data exists linking HIV and ESRD care within a state or region. Factors influencing referral to kidney transplantation in PLWH have yet to be described in ESRD Network 6 and will direct construction of future interventions. Identifying PLWH who are on dialysis is difficult to do. Since 2005, there are scarce data on the incidence and prevalence of PLWH requiring dialysis. As part of a condition of participation in the ESRD Medicare program, Centers for Medicare and Medicaid Services (CMS) medical evidence form (CMS 2728 form) is completed on every ESRD patient upon initiation of dialysis. CMS funds dialysis for ESRD patient and the surgical procedure and immunosuppressants for those who undergo kidney transplantation. The medical evidence form provides evidence of an ESRD condition, registers patients into a national renal registry, documents medical co-morbidities and other clinical data in dialysis patients, and ensures quality care for ERSD patients (35). In 2005, HIV serostatus was removed as an ESRD-related condition on the medical evidence form due to concerns regarding disclosure of HIV status (36). Presently, in order to identity PLWH on dialysis, HIV status is inferred through pharmacy prescription data (12). This cohort ascertainment method is suboptimal, as it may misclassify patients on pre-exposure prophylaxis as being on ART, may fail to identify PLWH not engaged in HIV care, and lacks patient-level epidemiologic and clinical data. Nonetheless, pharmacy prescription data is the first only currently available method that can be used. In this study, Medicare prescription part D claims data was used to allow for tracking identify PLWH on dialysis. In 2016, there was 81% participation of health throughout Medicare part D among hemodialysis patients, suggestive that majority of the HIV population is captured in this study (37). METHODS‌ Hypothesis: Persons living with HIV in ESRD Network 6 are less likely to traverse through the multistep process of kidney transplantation compared to HIV-negative counterparts in the setting of ESRD. Specific Aims Aim 1: To identify and describe the characteristics of PLWH and ESRD in ESRD Network 6. Aim 2: To describe the distribution and timing of early life in South Africasteps of kidney transplant inclusive of referral, evaluation, and past findings have contributed waitlisting among PLWH compared with HIV negative individuals with ESRD in Network 6. Aim 3: To identify patient-level and dialysis facility-level factors that are associated with time to nation-wide policies, including regulation of age for school attendance referral and restrictions on tobacco purchasing.7 Therefore, this research aims time to explore blood pressure in the young adult data collection wave, and to assess how the major risk factor of obesity may mediate observed associations in the unique socioeconomic context of post-Apartheid South Africawaitlisting.