Traffic crashes are a major cause of preventable deaths and pose significant social and economic burdens. Substantial reductions in alcohol-related fatal traffic crashes were observed in the U.S. during the 1980s and 1990s (Voas & Fell, 2011). However, progress on reducing alcohol-related traffic deaths has slowed in recent years and remains a substantial problem (Bergen, Shults, Beck, & Qayad, 2012; Fell & Voas, 2013; Williams, 2006). Further reductions in alcohol-related traffic fatalities may require a better understanding of how people make decisions about travel choice in this context and how these decisions are shaped. Among drinking and driving efforts, there has been little focus on understanding travel choice and the attitudes towards those travel alternatives. Further, lower risk perceptions of being caught and/or being in a crash have been associated with a greater risk for various measures of drinking and driving (Bertelli & Richardson, 2008; Dionne, Fluet, & Desjardins, 2007; Guppy, 1993; McCarthy, Lynch, & Pederson, 2007; Turrisi & Jaccard, 1992; Voas, Holder, & Gruenewald, 1997). Some have suggested that enforcement works indirectly through risk perceptions (Bertelli & Richardson, 2008). It has also been suggested that the effects of checkpoint enforcement of these policies are temporary (Turrisi & Jaccard, 1992) and that traffic injuries may be more salient than enforcement for modifying risk perceptions (Beck, Yan, Wang, Kerns, & Burch, 2009). However, little is known about how perceived crash risk and objective crash risk are correlated. Further, understanding the behavioral impact of laws requires testing enforcement and perceptions (Bertelli & Richardson, 2008).

This study utilized data from a roadside survey that took place on weekend nights June-August 2012 in 9 jurisdictions throughout California. This study reports on 2 analysis cohorts in an effort to understand the perceptions of risk, drinking and driving, and transportation mode choice and how these are shaped by the environment. The first cohort consists of 689 respondents who reported drinking alcohol in the past year and who completed a mode choice survey for a recent drinking occasion outside the home ("choice" cohort). The second consists of 1,147 respondents who reported perceptions of risk for drinking and driving and resided in California ("risk" cohort). This study reports on a particularly relevant segment of the population for this issue, weekend nighttime drivers.

While drinking and driving may be viewed as a failure to act in one's best interest, it is acknowledged that a variety of risks and benefits, in addition to biases and emotions, are associated with decisions. Using a revealed preference approach to reduce cognitive incongruence, a survey was administered to identify travel choice home for a recent drinking occasion. To better understand the impact of residential accessibility (i.e. access to amenities and destinations) and perceptions of risk on travel preferences and choices, hybrid choice modeling was conducted. Choice models are flexible and allow decision makers to weight aspects of choice differently, assuming utility maximization. Hybrid choice modeling incorporates psychological factors with discrete choice modeling to better represent the choice process (Ben-Akiva et al., 1999; Ben-Akiva et al., 2002). In the first cohort, nearly a third reported being a drinking-driver for a recent drinking occasion.

In an effort to better understand how risk perceptions are shaped, the relationship of environmental cues and risk perceptions for drinking and driving were evaluated and how these, in turn, impact drinking and driving behavior were explored using population average models. In the second cohort of abstainers and drinkers, 4% reported driving at least once in the past year when they had had too much to drink. In addition, 19% were somewhat accepting of drinking and driving and 66% perceived high arrest likelihood for drinking and driving.

The role of driving is deeply embedded in our society. Reducing reliance on personal driving has numerous health implications, including, traffic safety. However, the results of this research suggest that some forms of the built environment may encourage driving. The results also suggest that the environment may influence drinking and driving through different mechanisms and that different perceptions of risk influence pathways to drinking and driving. Local deterrence efforts may reduce drinking and driving among those most likely to be concerned about enforcement. In addition, the local environment may provide cues for risk perceptions or indicate populations where the norms are less permissive of drinking and driving. Perceived level of service (i.e. travel time and travel cost) and convenience and safety attitudes towards travel alternatives impacted mode choice in this study. Among the sample who drink alcohol, perceived high arrest likelihood impacted attitudes towards travel alternatives. Among a subset of drivers most likely to drink outside the home, acceptance of drinking and driving was associated with drinking and driving while perceptions of arrest were not.

To this author's knowledge, this is one of the few, if only, studies to evaluate both the environmental and perceived risk impact on travel choice and transportation attitudes in the context of drinking alcohol outside one's home. There are nuances to how people make decisions. The results of the present study add to the previous research by examining attitudes towards other travel alternatives as part of the behavioral process. Understanding human behavior is crucial for developing effective community, public health, and transportation planning. This research has implications for city and transportation planning, risk communication, and enforcement. Transportation planning could improve level of service for leisure, evening trips and increase the cost of parking to discourage car use in accessible areas. However, with the potential for greater alcohol consumption, the displacement of alcohol problems in communities should be considered. Enforcement and sobriety checkpoints require substantial resources. Traffic crashes may be a salient cue to impact risk perceptions and supplement efforts. Social media could be leveraged for both risk communication and for facilitating ride sharing. Regularly assessing risk perceptions can assist in benchmarking traffic safety efforts and in understanding how drivers, including new cohorts, respond to these efforts.

Abstract

The Examination of Time Orientation of Smokers

in a Smoking Cessation Interventation

By

Preety Kalra

Doctor of Philosophy in Epidemiology

University of California, Berkeley

Professor William Satariano, Chair

Time perspective may be an important predictor of success in smoking cessation programs. Thus, it is important to better understand the role of time perspective for smoking cessation. More specifically, there needs to a greater understanding of the role that time perspective plays in initiating a quit attempt and in the success of that quit attempt. We hope the information generated from this study will allow us to better understand the role of time perspective and behavior change and to make recommendations for improving smoking cessation treatment programs. Such a project would be valuable because it would allow for identification of specific attributes of the individuals who are more likely to succeed in a smoking cessation intervention and for tailoring of referrals to different forms of smoking cessation treatment to make them better matched to individual recipients. This individualized approach would conserve resources by allocating patients more appropriately to treatment. Gaining a clearer perspective on the relationship between time orientation and smoking cessation outcome will help us understand if treatment programs are appropriately designed for those who enter such programs.

Although there is some information relating time perspective to substance use there is only limited information on the role of time perspective in individuals' making a smoking cessation attempt and whether it fluctuates for those trying to quit. Time perspective may be an important predictor of treatment response in smoking cessation programs. More specifically, there needs to a greater understanding of the role that time perspective plays in initiating a quit attempt and in the success of that quit attempt. Gaining a clearer perspective on the relationship between time orientation and smoking cessation outcome will allow us to guide patients with different time perspectives to appropriate smoking cessation treatment programs.

The proposed study investigated time orientation as a predictor of individuals' successfully completing a smoking cessation treatment program. The aims of this study are to identify the time orientation of patients at entry into a smoking cessation program and to explore the relationship of time orientation to other potential predictors of smoking cessation.

We will assess the validity of the Zimbardo Time Perspective Inventory in an on-going intervention trial. We will obtain psychometric data on the Zimbardo Time Perspective Inventory in an adult population at the initiation of an intervention. We will use exploratory factor analysis to determine the most appropriate number of dimensions.

Then we will identify the time orientation of patients at entry into a smoking cessation program and to explore the relationship of time orientation to other potential predictors of smoking cessation. We will conduct a cross-sectional analysis and then examine how time orientation varies across socioeconomic factors of the population. We will also examine whether a single item of the Zimbardo Time Perspective Inventory proves to be more predictive than a domain of the scale. Having a single item that could be used to screen participants in health care settings would alleviate the time necessary to classify an individual by time orientation and allow for tailoring of health interventions to match individual to treatment.

Lastly, we will examine the change for each individual item of the Zimbardo Time Perspective Inventory and the number of cigarettes smoked from baseline to six months post-intervention. We will also assess change for each of the five domains, present fatalistic, present hedonistic, future, past negative and past positive and number of cigarettes smoked from baseline to follow-up.

Characterizing the time orientation of smokers and its relation with smoking cessation is the first step toward designing future tailored smoking cessation interventions that would better meet the cessation needs of smokers. Because of the substantial health, quality of life and economic benefits of smoking cessation, even later in life, determining if time perspective is a predictor of success could have a potentially large impact on public health. Such a study would be valuable because it would allow for identification of specific attributes of the individuals who are more likely to succeed in a smoking cessation intervention and would allow for tailoring of referrals and for appropriate modification of smoking cessation programs to make them better matched to individual recipients.

The most pressing health problems of the 21st century - such as obesity, diabetes, osteoporosis, cancer, depression, and cardiovascular disease - cannot be addressed using traditional public health interventions. Population growth and climate warming are global challenges that threaten not just the health but perhaps the very survival of human beings. These, too, require innovative, "outside-the-box" solutions. At the root of these problems, and their solutions, lies the intimate relationship between where we live (our built environment) and how we live (our behavior). The separation of the disciplines has also been blamed, at least in part, for the failure to recognize the links between the built environment and the health disparities found among communities of color and of low socio-economic status. Correctly designed communities can improve their residents' health by encouraging physical activity, providing access to healthy food, and strengthening social networks and capital, while also decreasing waste and pollution, shortening commute times and the resulting stress, and addressing issues of social inequity.

A century ago, the relationships and dependencies between land use planning and public health were well understood - then, through the 20th century, the two disciplines evolved independently, and each lost its appreciation for the value of collaboration with the other. Before we can bring together the concerns of the built environment and public health, we must first reconnect the disciplines of land use planning and public health and reestablish the mutually beneficial relationship they once enjoyed.

This study explores the current state of collaboration between public health and land use planning agencies in California, in order to identify contextual factors that can act as either incentives or barriers for collaboration. The study consists of 18 in-depth, semi-structured interviews with land use planners and public health professionals that explored the relationship between the disciplines. By using Grounded Theory Methods and Social Exchange Theory, a Five Stage Model for Collaboration has been elaborated and the central theoretical construct of Cost-Benefit Analysis has been identified. A Cost-Benefit Audit tool (the Collaboration Manual for Public Health and Planning) based on the study results has been developed; a social ecologic model approach was used, and it suggests ways to improve and promote collaboration between public health and land use planning. The study proposes that a transdisciplinary approach to collaboration may be the most appropriate means to address the complex health problems that result from, and can be influenced by, the interaction of the built environment and the individual.

Background

Mobility, "the ability to move oneself [e.g., by walking, by using assistive devices, or by using transportation) within community environments that expand from one's home, to the neighborhood, and to regions beyond" (Webber, Porter et al. 2010) ], is important to healthy aging. Walking, both for recreation and for transportation, has been suggested to be a particularly accessible, affordable, and safe way to be physically active. It is important to understand the barriers to and supports for walking in one's neighborhood for older adults. Neighborhood socioeconomic status and other neighborhood characteristics, such as perceived safety from crime, are associated with walking and physical activity. Health symptoms may also be important determinants of walking and physical activity for older adults.

Objectives

1. Determine to what extent objective and perceived neighborhood characteristics of older adults vary by the socioeconomic status of the neighborhood. Determine what objective neighborhood and personal characteristics are associated with perceived neighborhood safety in older adults.

2. Determine the leading health symptoms reported by older people as causing difficulty when walking outdoors.

3. Determine the different physical activities engaged in by older men and women. Determine the association between both neighborhood socioeconomic status and perceived safety from crime and physical activity.

Methods

The study titled "Environmental Correlates of Physical Activity among Older Adults: A Healthy Aging Research Network (HAN) Collaboration" (referred to in this dissertation as the "HAN Walking Study") was designed to examine how the neighborhood environment may influence physical activity and walking behavior in older adults, and how this relationship may be modified by the functional capacity of older adults. Data were collected from 884 older adults at four sites across the country, from a diversity of physical environments. Data collection included in person interviews, lower-body functional capacity testing, accelerometers, walking diaries, and secondary GIS data.

Results

1. Participants living in neighborhoods of low socioeconomic status (low SES) have objectively shorter block lengths, higher housing density, and more businesses. Participants living in low SES neighborhoods perceive that they are less safe from crime and traffic. They also perceive that their neighborhood is more densely populated with greater percentages of apartments and condominiums. Perceived crime safety is associated with both neighborhood characteristics as well as the characteristics of the people who live there.

2. Most participants report multiple barriers to walking outside. Overall, 95.5% report at least one health symptom or other barrier to walking, with a range of 0-37 and a mean of 7.9 barriers.

3. The most frequent types of activity reported by both women and men are light housework (93.0%) and shopping or running errands (93.0%), followed by walking at a normal or leisurely pace (77.7%). In a combined model, crime safety, but not neighborhood poverty or primary type of neighborhood housing, is associated with physical activity.

Conclusions

Walking is engaged in by the majority of both older men and women in this study. However, they perceive multiple barriers to walking. Neighborhood determinants of walking may be one pathway through which neighborhood socioeconomic status influences health outcomes. Perceived safety from crime is possibly an important neighborhood determinant of walking and physical activity. Further research is needed to determine how changes in neighborhoods as well as other interventions may reduce barriers and lead to increased walking behavior in older adults.

Objective: To assess in women whether exercise affects the estimated age-related increase in adiposity, and contrariwise, whether age affects the estimated exercise-related decrease in adiposity.Subjects and Design: Cross-sectional analyses of 64,911 female runners who provided data on their body mass index (97.6 percent), waist (91.1 percent), and chest circumferences (77.9 percent).Results: Age affected the relationships between vigorous exercise and adiposity. The decline in BMI per km/wk run was linear in 18-25 year olds (-0.023+-0.002 kg/m2 per km run) and became increasingly nonlinear (convex or upwardly concave) with age. The waist, hip and chest circumferences declined significantly with running distance across all age groups, but the declines were 52-58 percent greater in older than younger women (P<10-5). The relationships between body circumferences and running distance became increasingly convexity (upward concavity) in older women. Conversely, vigorous exercise diminished the apparent increase in adiposity with age. The rise in average BMI with age was greatest in women who ran less than 8 km/week (0.065+-0.005 kg/m2 per y), intermediate of women who ran 8-16 km/wk (0.025+-0.004kg/m2 per y) or 16-32 km/wk (0.022+-0.003 kg/m2 per y), and least in those who averaged over 32 km/wk (0.017+-0.001 kg/m2 per y). Before age 45, waist circumference rose 0.055+-0.026 cm in for those who ran 0-8 km/wk, showed no significant change for those who ran 8-40 km./wk, and declined -0.057+-0.012 and -0.069+-0.014 cm per year in those who ran 40 -56 and over 56 km/wk. The rise in hip and chest circumferences with age were significantly greater in women who ran under eight km/wk than longer distance runners for hip (0.231+-0.018 vs 0.136+-0.004 cm/year) and chest circumferences (0.137+-0.013 vs 0.053+-0.003 cm/year).Conclusions: These cross-sectional associations suggest that in women, age and vigorous exercise interact with each other in affecting adiposity. The extent that these cross-sectional associations are causally related to vigorous exercise or are the consequence of self-selection remains to be determined.

In an era of growing interest in transdisciplinary collaboration, evidence-based decision-making, open government, and social impact strategies responding to political and economic challenges, Health Impact Assessment (HIA) is increasingly relevant. HIA sits at the juncture of a number of paradigms for democratic processes for dealing with uncertainty and adding value in decision-making. It draws from a rich history of impact assessment that has accounted for multiple bottom lines. While HIA has gained attention as a specific tool, it is also recognized as part of a suite of more ecological and equitable approaches to health. HIA developers are asking both how to make it work better, so that ultimately government will work better.

This research examines the state of HIA in the United States. It examines the earliest efforts to train a variety practitioners across the country, acknowledging multiple opportunities for capacity-building and many influences on effective HIA practice. More importantly, it identifies a broad definition of effectiveness. Research on HIA practice builds on this, finding that practice is not fully aligned with standards but not necessarily deficient. While objectives should guide HIA processes, the research on training and practice highlights resources as a key driver. The third component of this research considers the resource constraints of public health in general and the opportunities to leverage outside resources using the paradigm of HIA.

In moving the field forward, frameworks for community-based prevention and transdisciplinary education can inform HIA capacity-building. Evaluation of both processes and outcomes will be useful. While methodological challenges remain, the institutionalization of partnerships, processes, and indicators will support public health goals. The definition and standardization of HIA practice must be balanced with efforts to expand its utility in new areas such as community development. In such cases the HIA process and paradigm can leverage investments by estimating returns in health and social denominations. HIA also helps solve the "wrong pocket" problem by accounting for outcomes across sectors and institutions. If used wisely, HIA will be a critical component of health in all policy, sustainability agendas, and social impact strategies.

The last 40 years have seen a large influx of Vietnamese immigrants to the United States (U.S.) as a result of the Vietnam War. The Vietnamese now constitute one of the fastest growing Asian and Pacific Islander populations in the U.S. Breast cancer is the most commonly diagnosed cancer in Vietnamese American women, with incidence rates steadily increasing in this immigrant population. Early detection of breast cancer through mammography screening and clinical breast examination is critical for reducing breast cancer morbidity and mortality. However, Vietnamese American women are less likely to be screened than non-Hispanic white women. This dissertation investigates social network characteristics and their relationship to breast cancer screening behavior in Vietnamese American women aged 40 and older within a community-based breast cancer screening intervention study based in Santa Clara County, California. Because this intervention study was embedded in the framework of interpersonal relationships, it presents an ideal opportunity and optimal approach to exploring how social networks influence breast screening behavior in an underserved population.

A positive association between social network integration and breast cancer screening was found for recent receipt of a clinical breast examination (CBE) but not for mammography. Women in the highest tertile of social network integration were more likely to receive a CBE than women in the lowest tertile (OR = 1.20, 95% CI: 1.07-1.33). This dissertation also examined perceived availability of different types of social support (emotional, instrumental, informational, affectionate, and positive social interaction) and the relative contributions of each type of support to recent use of mammography and CBE. Findings indicate that Vietnamese American women generally perceived moderate to high levels of available social support across all types. Instrumental support was the single most important social support predictor for recent use of mammography (OR = 1.05, 95% CI: 1.02-1.08). Because breast cancer screening is only optimally effective for early detection if women adhere to annual screening guidelines, this dissertation also examined breast cancer screening norms as one type of social network influence on intention to receive screening in the future. Results showed no associations between social influence and intention to receive a mammogram or CBE within the next 12 months. Findings from this analysis suggest challenges in measuring both social influence and screening intention constructs in Vietnamese American women and warrant further methodological investigation in developing more culturally appropriate, accurate, and comprehensive measures.

Overall, findings from this dissertation have laid the necessary groundwork for identifying new opportunities for future research on social networks and health. Such research will enable us to gain a better understanding of ways in which social networks can inform more effective interventions and programs to close the gap in breast cancer health disparities.

Planning research has shown correlations between urban sprawl and obesity. Additional work has correlated higher walkability with increased walking behavior and improved population health independent of race, education, income, or lifestyle preferences. Presumably, people with access to a walkable neighborhood might improve their total well-being; however, housing research suggests that walkability is not equitably allocated and that price, sorting, discrimination and individual preferences may pose barriers to walkable neighborhoods as a health resource.

As such, this work evaluates the inclusiveness of walkable neighborhoods in the San Francisco Bay Area, with the primary question of whether or not those with lower income can afford to live in walkable neighborhoods. Based on exploratory analysis and mapping, while the study finds no evidence of a positive association between income and walkable neighborhoods, the analysis does suggest a negative correlation between race and walkability for the most concentrated populations. Specifically, neighborhoods that are more Black, in locations with a higher share of the total regional population, appear correlated with less walkability.

This pattern leads to the hypotheses that affordability and socio-cultural factors may be contributing to Black clustering in less walkable neighborhoods - that there may be barriers for these individuals to live in the most walkable areas and that many of these individuals may be either, 1) moving to less walkable suburban areas, or 2) left in less-walkable urban pockets. Interviews inform these hypotheses, suggesting that walkability may not factor in to housing decisions and that more research is needed to analyze whether or not income is a barrier to accessing a walkable neighborhood.

Given the possibility that barriers exist, policies are suggested to improve streets, increase affordability, influence behavior, and to change the type of housing and financial tools available - with the goal of encouraging inclusiveness, and better ensuring that more individuals have access to walkable neighborhoods and the health benefits associated with walking.

Many health problems, especially those associated with older age, can have an impact on an individual’s mobility. This paper addresses how specific functional limitations and medical conditions may be associated with driving status, while controlling for age and gender. This paper uses baseline data (N=2025) from a longitudinal survey of adults, ages 55 and older, the Study of Physical Performance and Age-Related Changes in Sonomans (SPPARCS). For the 35 selected medical conditions and functional limitations, this report presents the prevalence, the relative “risk” ratio (i.e., the risk that an individual with that condition no longer drives), and the attributable risk (i.e., the percent of ex-drivers with each condition). Compared to current drivers, ex-drivers had higher rates of physical limitations (ability to ascend one flight of stairs or walk three blocks), cognitive impairment, vision problems and stroke. The conditions with the highest relative risk included personal mobility limitations (such as the ability to transfer onto or from bed and the ability to use the lavatory) and decreased peripheral vision. The relative risks of medical conditions’ effects on driving status offer a perspective on individuals’ mobility choices, and the attributable risks offer a perspective on the most important causes of driving cessation in the elderly population.