Public Health Commons^™

Improving Access To Mainehealth Care At Home, Amanda Kunkel, Mhcah Intake Department, Mhcah Scheduling Department, Mhcah Clinical Leadership Team

Operations Transformation

It is known that there are capacity limitations at MaineHealth Care at Home caused by a decrease in staffing. This leads to limited availability of home health services to patients in the community and can also contribute to increased length of stay for patients in acute care hospitals. MaineHealth Care at Home needs a way to measure current capacity to accept referrals and improved systems for communicating with referral sources.

Gut Microbiota, Blood Metabolites, And Left Ventricular Diastolic Dysfunction In Us Hispanics/Latinos, Kai Luo, Alkis Taryn, Eun-Hye Moon, Brandilyn A Peters, Scott D Solomon, Martha L Daviglus, Mayank M Kansal, Bharat Thyagarajan, Marc D Gellman, Jianwen Cai, Robert D Burk, Rob Knight, Robert C Kaplan, Susan Cheng, Carlos J Rodriguez, Qibin Qi, Bing Yu

Faculty, Staff and Student Publications

BACKGROUND: Left ventricular diastolic dysfunction (LVDD) is an important precursor of heart failure (HF), but little is known about its relationship with gut dysbiosis and microbial-related metabolites. By leveraging the multi-omics data from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL), a study with population at high burden of LVDD, we aimed to characterize gut microbiota associated with LVDD and identify metabolite signatures of gut dysbiosis and incident LVDD.

RESULTS: We included up to 1996 Hispanic/Latino adults (mean age: 59.4 years; 67.1% female) with comprehensive echocardiography assessments, gut microbiome, and blood metabolome data. LVDD was defined through a composite criterion …

Extension-Clinical Approach To Covid-19 Testing And Vaccination, Camden Bryan, Rhonda Matthews, Kapri Kreps, David Thornal, Danielle Mcfall, David Sudduth, Michelle Parisi

Journal of Extension

Vaccination rates against COVID-19 are lower in rural areas across the country, including SC. This paper highlights the work conducted by Clemson Cooperative Extension Service in SC to increase rural access to COVID-19 testing and vaccine services. Extension Agents engaged in clinical and community partnerships to coordinate COVID-19 vaccine and testing clinics in rural and underserved communities. Agents established 204 test clinics and 220 vaccination clinics. The total number of people tested and vaccinated was 9,331 and 2,037, respectively. The success of this project shows Extension agents can be instrumental in bridging the gap between clinical resources and rural communities.

Pregnancy-Related Maternal Deaths In The State Of Georgia According To Timing And Causes Of Death, Anthony Kondracki, Wei Li, Mitch Mokhtari, Bhuvaneshwari Muchandi, John A. Ashby, Jennifer L. Barkin

Georgia Public Health Association Annual Meeting & Conference

BACKGROUND: This study examines pregnancy-related maternal deaths in the State of Georgia according to timing and causes of death in association with maternal sociodemographic characteristics. METHODS: Maternal mortality data from 2016 to 2019 were obtained from the Georgia Department of Public Health and the study sample was restricted to pregnancy-related deaths. Descriptive analyses compared timing and six leading underlying causes of maternal death in association with basic sociodemographic characteristics. A distribution of the leading underlying causes of death was conducted among the four time-points, i.e., during pregnancy, 0 to 60 days, 61 to 180 days, and 181 to 365 days …

Trends In Substance Use And Mental Health Among Adolescents In Georgia, 2002-2022, Saumya S. Palipudi, Bangaru Talli Palipudi, Murty Komanduri

Georgia Public Health Association Annual Meeting & Conference

Background: While substance use and absence of mental health disorders among youth in the United States (US) have declined over the past two decades, post COVID-19 pandemic, these conditions have increased significantly with notable disparities, and witnessed a crisis in public health. In 2022, 24.7% or 6.1 million adolescents aged 12 to 17 in the US had either Major Depressive Episodes (MDE) or Substance Use Disorder (SUD) and 3.7 percent had both in the prior year². Increased stress, lack of peer connections, parental abuse, and poor mental health conditions were attributed to this increase in substance use^{3-7 …}

Forgotten Clientele: A Systematic Review Of Patient-Centered Pathology Reports, Eric Steimetz, Elmira Mostafidi, Carolina Castagna, Raavi Gupta, Rosemary Frasso

College of Population Health Faculty Papers

CONTEXT: Patient portals, designed to give ready access to medical records, have led to important improvements in patient care. However, there is a downside: much of the information available on portals is not designed for lay people. Pathology reports are no exception. Access to complex reports often leaves patients confused, concerned and stressed. We conducted a systematic review to explore recommendations and guidelines designed to promote a patient centered approach to pathology reporting.

DESIGN: In consultation with a research librarian, a search strategy was developed to identify literature regarding patient-centered pathology reports (PCPR). Terms such as "pathology reports," "patient-centered," and …

The Relationship Between Social Risk Factors And Pre-Term Births In Hawai’I, Rina Therese Ramos Amposta

Walden Dissertations and Doctoral Studies

Premature birth remains the leading cause of neonatal death and is associated with birth defects and long-term health morbidities. Hawai’i, with dominant Pacific Islander, Asian, and White populations, ranks 18th amongst the states with the highest rate of preterm birth. Guided by the social ecological model, the purpose of this quantitative, cross-sectional research study was to determine the extent of the association of social risk factors and preterm birth in the state of Hawai’i for the years 2012-2015 using the Hawai’i Pregnancy Risk Assessment and Monitoring Systems (PRAMS). Preterm birth in Hawai’i from 2012- 2015 was found to be 17% …

How Financial Beliefs And Behaviors Influence The Financial Health Of Individuals Struggling With Opioid Use Disorder, James R Langabeer, Francine R Vega, Marylou Cardenas-Turanzas, A Sarah Cohen, Karima Lalani, Tiffany Champagne-Langabeer

Faculty, Staff and Student Publications

The surge in opioid use disorder (OUD) over the past decade escalated opioid overdoses to a leading cause of death in the United States. With adverse effects on cognition, risk-taking, and decision-making, OUD may negatively influence financial well-being. This study examined the financial health of individuals diagnosed with OUD by reviewing financial beliefs and financial behaviors. We evaluated quality of life, perceptions of financial condition during active use and recovery, and total debt. We distributed a 20-item survey to 150 individuals in an outpatient treatment program for OUD in a large metropolitan area, yielding a 56% response rate. The results …

Physical Activity In Underserved Preadolescents: Characterization Of Accumulation And Patterns, Alma I. Behar, Matthew T. Mahar, Gregory Norman, John P. Elder, Michael Pratt, Patricia Dionicio, Noe C. Crespo

International Journal of Physical Activity and Health

Objectives: The increasing rates of physical inactivity and sedentary behaviors among youth are a significant public health concern. The greatest disparities in physical activity (PA) are experienced by underserved (racial/ethnic minority, low-income) youth. This study aimed to characterize accelerometer-measured PA behaviors in a sample of low-income, predominantly Latino, preadolescents. Methods: Participants wore wrist worn GENEActiv accelerometers for 7 days. PA levels were classified as sedentary (< 50 mg), light (50-150 mg), moderate (> 150-500 mg), vigorous (> 500 mg), and MVPA (≥ 150 mg). Time spent in PA levels and sedentary time (ST), prevalence of meeting MVPA guidelines, and PA volume were estimated from accelerometer data. Three-way …

A Bioinformatic Analysis Of T-Cell Epitope Diversity In Sars-Cov-2 Variants: Association With Covid-19 Clinical Severity In The United States Population, Grace J. Kim, Jacob H. Elnaggar, Mallory Varnado, Amy K. Feehan, Darlene Tauzier, Rebecca Rose, Susanna L. Lamers, Maya Sevalia, Najah Nicholas, Elizabeth Gravois, Daniel Fort, Judy S. Crabtree, Lucio Miele

School of Graduate Studies Faculty Publications

Long-term immunity against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) requires the identification of T-cell epitopes affecting host immunogenicity. In this computational study, we explored the CD8+ epitope diversity estimated in 27 of the most common HLA-A and HLA-B alleles, representing most of the United States population. Analysis of 16 SARS-CoV-2 variants [B.1, Alpha (B.1.1.7), five Delta (AY.100, AY.25, AY.3, AY.3.1, AY.44), and nine Omicron (BA.1, BA.1.1, BA.2, BA.4, BA.5, BQ.1, BQ.1.1, XBB.1, XBB.1.5)] in analyzed MHC class I alleles revealed that SARS-CoV-2 CD8+ epitope conservation was estimated at 87.6%–96.5% in spike (S), 92.5%–99.6% in membrane (M), and 94.6%–99% in …

Perception Of African Immigrants Living In The United States Towards Latent Tuberculosis Infection Treatment Hesitancy, Akinwale O. Obatayo

Walden Dissertations and Doctoral Studies

About 80% of active tuberculosis (TB) cases are caused by untreated latent tuberculosis infection (LTBI), with most being foreign-born United States residents. Despite the availability of preventive therapies, African immigrants living in the United States are hesitant to accept LTBI treatment. Although researchers have explored LTBI treatment hesitancy among foreign-born United States citizens, no study has explored the perspectives of African immigrants living in the United States. This generic qualitative study explored the perception of African immigrants living in the United States on LTBI treatment hesitancy. Participants’ inclusion criteria include those 18 years and older with a positive TB test, …

Type 2 Diabetes As A Risk Factor For The Development Of Cognitive Dysfunction In U.S. Adults, Bobbi Johnson

Walden Dissertations and Doctoral Studies

There is no consensus as to whether having type 2 diabetes increases an individual’s risk for developing cognitive dysfunction. Though cognitive dysfunction is considered a risk factor for type 2 diabetes, it is also classified as a newly formed diabetes-related complication. The purpose of the study was to evaluate if self-reported healthcare – diagnosed diabetes has any association in the risk of the development of cognitive dysfunction in individuals living with type 2 diabetes. Self-determination theory served as the theoretical framework. The research questions concerned whether (a) an association exists between diabetes and cognitive dysfunction, (b) ethnicity plays a vital …

A Case Study On The Effects Of Pregnancy On Expiratory Flow Limitation (Efl) And Operating Lung Volumes During Exercise, Hannah Young

Masters Theses, 2020-current

The purpose of this study was to examine the effects of pregnancy on expiratory flow limitation (EFL) and operating lung volumes (end expiratory lung volume and end inspiratory lung volume; EELV and EILV) during exercise, with an exploratory aim to assess differences in the above measures between exercise modalities. EFL has been shown to occur in several other subgroups but has never been studied in pregnant individuals. We followed one 35-year-old pregnant subject throughout her pregnancy, completing exercise and pulmonary testing every other week from 8 weeks gestation to 38 weeks gestation, and once again ~8 weeks postpartum. Testing was …

Assessing The Effectiveness Of Treatment Programs Among Veterans With Opioid Use Disorder In New York State, Olatoye Oluwaseyi Itaniyi

Walden Dissertations and Doctoral Studies

New York State (NYS) is home to millions of veterans and has the fifth-largest veteran population in the country. Veterans represent a vulnerable population and are at higher risk for mental and physical health struggles. The focus of this quantitative study was to assess if there is any significant difference between pre- and post-OUD 24-hour detoxification treatment services, residential/rehabilitation treatment services, ambulatory outpatient treatment services, frequency of opioid use at discharge, and mental disorder among veterans with opioid use disorder in NYS when controlling for age, gender, race, and marital status. The study utilized the harm reduction framework and the …

Construction And Mutagenesis Of Ssv1 Mutants In Extreme Viruses, Lou Ann F. O'Connor, Jono Abshier, Kenneth M. Stedman

Student Research Symposium

Archaeal viruses with unique structures such as spindle-shaped virions are found abundantly in extreme environments like geothermal hot springs around the world. Among all spindle-shaped viruses, the model Sulfolobus Spindle-shaped Virus 1 (SSV1) is best studied. Creating the lemon-shaped or spindle-shaped virion structure are two proteins, VP1 as the major capsid protein, and VP3 as the minor capsid protein. The primary structure of VP1 consists of a proteolytic cleavage site at position 66 that is believed to be necessary for virus evolution. Recent studies showed that genetic mutation of the amino acid, glutamate (E) at position 66 in VP1 which …

Considering The Historical And Systemic Context, To What Extent Are Cuban Women’S Healthcare And Reproductive Rights Affected By The Privacy And Social Influence Of Cuba Today?, Autumn Cowell

Student Research Symposium

This paper will examine how historical and systemic values continue to frame social influences thus impacting Cuban women’s healthcare and reproductive rights. If the impact of history and systems still affects social influences then Women’s Healthcare and Reproductive Rights may be compromised. This investigation will highlight the potential benefits and risks of historical and systemic values that have affected challenges or changes within Cuban culture. And how these social influences are found within the areas of prevention, intervention, and treatment. This paper hopes to outline how the Cuban government and society are sustaining the protection of Cuban women’s access to …

Improving Quality Of Life In Menopausal Women Through A Best Practice Protocol: The Use Of Hormone Therapy, Mindfulness-Based Module And Exercise, Claire Czerwonka

Evidence-Based Practice Project Reports

Menopause is a normal process of aging, but many of the symptoms negatively impact women’s day-to-day quality of life (QOL), as well as activities of daily living, physical and mental health (ACOG, 2014). Generally, systemic estrogen hormone therapy is indicated for menopause-related vasomotor symptoms, but there is no research further addressing QOL issues or lifestyle management in addition to hormone therapy. The purpose of this evidence-base practice (EBP) project was to implement a menopause protocol to address QOL issues in menopausal women with the use of hormone replacement therapy, education through an online mindfulness module, and the use of exercise. …

Humanizing Affordable Housing: A Public Health Centered Approach To Affordable Housing, Eiman Mohamed

Graduate School of Architecture & Urban Design Theses & Dissertations

This thesis focuses on exploring housing as a determinant of health; thus, the aim is to investigate the historical and current influence of housing design and city planning on occupant health and population health in metropolitan cities. The thesis will primarily examine how housing affects the health of low-income individuals. Historically and presently, this demographic has been disproportionately affected by health issues stemming from overcrowding, substandard housing design, declining neighborhood conditions, and environmental inequities. The goal is to discern the dimensions and standards for healthy housing against which designers and planners can define health outcomes. By acknowledging the factors that …

Health Care Utilization And Behavior Changes After Workplace Genetic Testing At A Large Us Health Care System, Elizabeth Charnysh, Subhamoy Pal, Jonathan Reader, Wendy R. Uhlmann, Sarah Mccain, Kunal Sanghavi, Drew Blasco, Rachael Brandt, William Gregory Feero, Rebecca Ferber, Veda N. Giri, Katherine Hendy, Anya E. R. Prince, Charles Lee, J. Scott Roberts

College of Life Sciences Faculty Papers

PURPOSE: This study explored employee health behavior changes and health care utilization after workplace genetic testing (wGT). Wellness-program-associated wGT seeks to improve employee health, but the related health implications are unknown.

METHODS: Employees of a large US health care system offering wGT (cancer, heart disease, and pharmacogenomics [PGx]) were sent electronic surveys. Self-reported data from those who received test results were analyzed. Descriptive statistics characterized responses, whereas logistic regression analyses explored correlates of responses to wGT.

RESULTS: 53.9% (n = 418/776) of respondents (88.3% female, mean age = 44 years) reported receiving wGT results. 12.0% (n = 48/399) received results …

Emotion Regulation Strategies And Perceived Emotional Intelligence: The Effect Of Age., Iwanna Sepiadou

Adultspan Journal

The aim of this study was to investigate the relationship between perceived emotional intelligence and the reported use of cognitive reappraisal and expressive suppression. We also investigated the possible effects of age on the aforementioned variables. The total sample consisted of 379 people (158 men, 220 women, 1 unreported). Across participants, 273 were young (20-39 years old) and 106 were middle-aged (40-65 years old). We found statistically significant positive correlations between the dimensions of perceived emotional intelligence and the reported use of cognitive reappraisal and negative primarily correlations between the dimensions of perceived emotional intelligence and the reported use of …

Impact Of Covid-19 On Opioid Misuse, Mental Health, And Substance Abuse Treatment Of Adults, David Stephen Reed

Walden Dissertations and Doctoral Studies

The purpose of this quantitative cross-year comparison of two cross-sectional studies was to examine whether there is an impact of the COVID-19 pandemic on opioid misusers seeking mental health and substance abuse treatment, taking into consideration the social, ecological, and economic factors of age, gender, poverty status, and county of residence metropolitan status. The theoretical foundations of this study are the social-ecological framework in terms of the geographic and economic impacts, and the structural and social determinants of health framework to examine the influences of economic and community on individual behaviors, to answer the research questions while controlling for the …

Effect Of An Hpv Vaccination Multi-Level, Multi-Component Program On Hpv Vaccination Initiation And Completion In A Pediatric Clinic Network, Lara S Savas, Ross Shegog, Erica L Frost, C Mary Healy, Dale S Mantey, Sharon P Coan, L Aubree Shay, Travis A Teague, Juan J Ferreris, Sharice M Preston, Sally W Vernon

Faculty, Staff and Student Publications

Despite clear evidence of the public health benefits of the human papillomavirus (HPV) vaccine in preventing HPV-related cancers and genital warts, underutilization of HPV vaccination in the United States persists. Interventions targeting multi-level determinants of vaccination behavior are crucial for improving HPV vaccination rates. The study's purpose was to implement and evaluate the adapted Adolescent Vaccination Program (AVP), a clinic-based, multi-level, multi-component intervention aimed at increasing HPV vaccine initiation and completion rates in a five-clinic pediatric network in Bexar County, Texas. The adaptation process was guided by established frameworks and involved formative work with clinic stakeholders. The study utilized a …

Risks Of Depression, Anxiety, And Suicide In Partners Of Men With Prostate Cancer: A National Cohort Study, Casey Crump, Pär Stattin, James D Brooks, Jan Sundquist, Alexis C Edwards, Kristina Sundquist, Weiva Sieh

Faculty, Staff and Student Publications

BACKGROUND: A diagnosis of prostate cancer (PC) may cause psychosocial distress not only in a man but also in his intimate partner. However, long-term risks of depression, anxiety, or suicide in partners of men with PC are largely unknown.

METHODS: A national cohort study was conducted of 121 530 partners of men diagnosed with PC during 1998-2017 and 1 093 304 population-based controls in Sweden. Major depression, anxiety disorder, and suicide death were ascertained through 2018. Cox regression was used to compute hazard ratios (HRs) while adjusting for sociodemographic factors.

RESULTS: Partners of men with high-risk PC had increased risks …

The State Of Mental Health In The Mountain West, 2023, Ayda Atici, Freddy Nie, Jesse M. Fager-Larsen, Caitlin J. Saladino, William E. Brown Jr.

Health

This fact sheet examines the state of mental health for both youth and adults and availability of mental health care in the Mountain West states of Arizona, Colorado, Nevada, New Mexico, and Utah. The data are retrieved from Mental Health America’s (MHA) 2023 report, The State of Mental Health in America.

A Study On The 2016 And 2022 Ms And Oh Populations: How Obesity Is Related To The Co-Mingling Of Median Household Income, Limited Access To Healthy Foods And Limited Access To Exercise Opportunities, Ben Schlessel, Justice Williams

Scholarship in Medicine - All Papers

Background: Obesity has plagued the United States for decades, and while the implications of obesity have drastically changed over time (from a sign of wealth to a possible implication of mal/low nutrition), its impacts on the country’s population are abrasive and costly. Objective: The aim is to address and investigate how factors such as Median Household Income (MHI), Limited Access to Healthy Food and Limited Access to Exercise interplay with and correlate to obesity. Methods: Data acquired from the County Health Rankings was analyzed using several analysis strategies (paired and unpaired T-tests, and regression plots, etc.). Only Mississippi and Ohio …

Researching Covid To Enhance Recovery (Recover) Pediatric Study Protocol: Rationale, Objectives And Design, Rachel S. Gross, Tanayott Thaweethai, Erika B. Rosenzweig, James Chan, Lori B. Chibnik, Mine S. Cicek, Amy J. Elliott, Valerie J. Flaherman, Andrea S. Foulkes, Margot Gage Witvliet, Richard Gallagher, Maria Laura Gennaro, Terry L. Jernigan, Elizabeth W. Karlson, Stuart D. Katz, Patricia A. Kinser, Lawrence C. Kleinman, Michelle F. Lamendola-Essel, Joshua D. Milner, Sindhu Mohandas, Praveen C. Mudumbi, Jane W. Newburger, Kyung E. Rhee, Amy L. Salisbury, Jessica N. Snowden, Cheryl R. Stein, Melissa S. Stockwell, Kelan G. Tantisira, Tamara Bradford, Et Al

School of Medicine Faculty Publications

Importance The prevalence, pathophysiology, and long-term outcomes of COVID-19 (post-acute sequelae of SARS-CoV-2 [PASC] or “Long COVID”) in children and young adults remain unknown. Studies must address the urgent need to define PASC, its mechanisms, and potential treatment targets in children and young adults. Observations We describe the protocol for the Pediatric Observational Cohort Study of the NIH’s REsearching COVID to Enhance Recovery (RECOVER) Initiative. RECOVER-Pediatrics is an observational meta-cohort study of caregiver-child pairs (birth through 17 years) and young adults (18 through 25 years), recruited from more than 100 sites across the US. This report focuses on two of …

Improving Early Identification And Management Of Depression Symptomology Through Implementation Of Universal Depression Screening In A University Student Health Center, Jessica M. Monjaras

Evidence-Based Practice Project Reports

Depression is the leading cause of disability in the United States for individuals aged 15 to 44 (Anxiety and Depression Association of America, 2023). The purpose of this evidence-based practice (EBP) project was to increase early identification of depression through implementation of universal depression screening, and to implement management strategies to decrease symptoms of depression. A two-tiered approach to universal depression screening was utilized through use of the PHQ-2 and PHQ-9 screening tools. Ten young adult patients, between the ages of 18 to 25, from a university student health center clinic in Northwest Indiana participated in this project. Participants underwent …

Identification Of Potent Pan-Ephrin Receptor Kinase Inhibitors Using Dna-Encoded Chemistry Technology, Chandrashekhar Madasu, Zian Liao, Sydney E Parks, Kiran L Sharma, Kurt M Bohren, Qiuji Ye, Feng Li, Murugesan Palaniappan, Zhi Tan, Fei Yuan, Chad J Creighton, Suni Tang, Ramya P Masand, Xiaoming Guan, Damian W Young, Diana Monsivais, Martin M Matzuk

Faculty, Staff and Students Publications

EPH receptors (EPHs) are highly sought-after drug targets owing to their essential roles in maintaining appropriate cellular functions in both physiological and disease conditions. However, limited potency and specificity pose significant obstacles to the development of small-molecule inhibitors for EPHs. Here, using high-throughput DNA-encoded chemical library screenings, we developed potent and selective inhibitors of the EPH receptor kinase family. Our results also emphasize the therapeutic potential of our EPH inhibitors in cancer and endometriosis, a global health concern that causes chronic pain and often leads to infertility in women. This study showcases the robust pipeline of using DNA-encoded chemistry technology …

Progress Toward A Vaccine For Extraintestinal Pathogenic Coli (Expec) Ii: Efficacy Of A Toxin-Autotransporter Dual Antigen Approach, Yikun Xing, Justin R Clark, James D Chang, Jacob J Zulk, Dylan M Chirman, Felipe-Andres Piedra, Ellen E Vaughan, Haroldo J Hernandez Santos, Kathryn A Patras, Anthony W Maresso

Faculty, Staff and Students Publications

Extraintestinal pathogenic Escherichia coli (ExPEC) is a leading cause of worldwide morbidity and mortality, the top cause of antimicrobial-resistant (AMR) infections, and the most frequent cause of life-threatening sepsis and urinary tract infections (UTI) in adults. The development of an effective and universal vaccine is complicated by this pathogen’s pan-genome, its ability to mix and match virulence factors and AMR genes via horizontal gene transfer, an inability to decipher commensal from pathogens, and its intimate association and co-evolution with mammals. Using a pan virulome analysis of >20,000 sequenced E. coli strains, we identified the secreted cytolysin α-hemolysin (HlyA) as a …

The Relationship Between Ultrarunning Status, Subjective Well-Being, And Life Satisfaction, Raquel Ramirez Hernandez

Walden Dissertations and Doctoral Studies

The COVID-19 pandemic resulted in a rise in mental health challenges across the United States. Consequently, two important well-being measures for Healthy People 2030—subjective well-being and life satisfaction—were negatively impacted. A plethora of evidence exists about the benefits of running for physical and mental health. Yet, there is no available evidence that shows the benefits of ultrarunning, subjective well-being, and life satisfaction. This quantitative cross-sectional study examined the relationship between ultrarunning status, subjective well-being, and life satisfaction among adult runners in the United States. The advanced triangle of epidemiology served as the conceptual framework. A convenience sample included 369 adult …