Behavioral & Community Health Theses and Dissertations

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ASSESSING HEALTH CARE USE, COSTS, AND QUALITY FOR CENTERS OF EXCELLENCE FOR PEDIATRIC CONGENITAL HEART DISEASE CARE FOR THE MILITARY BENEFICIARY POPULATION
(2022) El-Amin, Amber Jovan; Franzini, Luisa; Public and Community Health; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
Background: For the military beneficiary population with cardiac or congenital anomalies, the Fiscal Year 2019 health care costs were $83 million, including $55 million for newborns who were less than one year of age and $28 million for youth ages 1 to 17 (Kennell and Associates Inc., 2020). The 2019 Military Health System (MHS) costs were approximately $50 billion (Mendez, 2019) and are expected to increase significantly through 2028 (Congressional Budget Office, 2014). In an attempt to close the gap between cost and benefit for its 9.6 million beneficiaries, the MHS has considered targeted inclusion of Centers of Excellence (CoE) for purchased care within TRICARE insurance coverage and MHS policies. In general, a CoE produces consistent outstanding measurable outcomes for a specific medical condition. A Congenital Heart Defect (CHD) is the presence of abnormalities in the heart structure that develop in the uterus during pregnancy. CHDs are the most common types of birth defects and the principal cause of illness and death for birth defect conditions. CHDs are associated with comorbidities and repeat surgical interventions resulting in significant use of health care services during infancy, childhood, and adulthood, making CHDs a great candidate for CoE use.Objective: To compare health care use, costs, and quality of care for pediatric CHD care at CoEs and non-CoEs for the military beneficiary population. Data Sources: Retrospective claims data from the MHS Data Repository for MHS beneficiaries aged 0 to 17 years who received CHD care from 2016 to 2020. Study Design: Using an instrumental variable approach to estimate the impact of CoE use on clinical outcomes (annual admissions, annual emergency room use, and mortality) and health care costs (total costs and hospitalization costs) for pediatric CHD care within the military beneficiary population. Results: A total of 10,865 patients were included, of which 82.9% used a CoE at some point for CHD care. Results suggested that racial disparities in CoE use were not significant for CHD care for the military beneficiary population. There were disparities noted in CoE use by military rank, suggesting that Senior Enlisted and Other ranks were associated with lower odds of CoE use than Junior Enlisted ranks. Results of the IV approach proved that the causal effect of CoE use was a lower probability (-14.1) of emergency room use post one-year CHD diagnosis for the military beneficiary population (p<0.01). The causal effect of CoE use on annual admissions and mortality was insignificant at the .05 significance level but proved that CoE use did not increase annual admissions nor jeopardize patients’ survival post one-year CHD diagnosis for the military beneficiary population. The causal effect of CoE use on CHD related annual costs was a $40,898 decrease in annual costs (p=.059). Although the relationship was not significant at the .05 level, the magnitude of the reduction was approximately 53% of the mean annual cost. When stratified by complexity of CHD diagnosis, the causal effect of CoE use on CHD related annual costs was a statistically significant reduction of $84,852 in annual costs post one-year CHD diagnosis for patients diagnosed with a moderate-complex or single ventricle CHD diagnosis, equating to an approximate 76% reduction in mean annual costs. The causal effect of CoE use on CHD related hospitalization costs was a $33,170 decrease in hospitalization costs (p=.087). Although the relationship was not significant at the .05 level, the magnitude of the reduction was approximately 47% of the mean hospitalization costs. When stratified by CHD diagnosis complexity, the causal effect of CoE use on CHD related hospitalization costs was a statistically significant reduction of $73,084 in hospitalization costs post one-year CHD diagnosis for patients diagnosed with a moderate-complex or single ventricle CHD, equating to an approximate 76% reduction in the mean admission costs. Conclusions: Patients with more severe CHD diagnoses were more likely to use CoEs. After adjusting for selection bias due to disease severity, CoE use improved clinical outcomes, reduced health care resource utilization, and reduced costs for CHD care for the military beneficiary population.
DEVELOPMENT OF A CORE OUTCOME SET FOR STUDIES INVESTIGATING SAFETY, EFFICACY, AND IMPLEMENTATION OF COVID-19 VACCINES: A COLLABORATION WITH AFRICAN AMERICAN/BLACK COMMUNITIES IN BALTIMORE CITY, MARYLAND
(2022) Datar, Reva; Howard, Donna; Public and Community Health; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
Background: Since it was declared a global pandemic in March 2020, Coronavirus Disease 2019 (COVID-19) has claimed over one million lives in the United States. Since COVID-19 vaccine rollout efforts began in Baltimore City, Maryland in December 2020, approximately 63.4% of all residents have been fully vaccinated (i.e., received their first and second doses in a two-dose series or received a single-dose vaccine). Despite efforts to implement equitable vaccine distribution in Baltimore City, prominent disparities in COVID-19 vaccine uptake persist, with poorer, predominantly Black neighborhoods frequently reporting lower levels of vaccine uptake than affluent, predominantly White neighborhoods. Guided by key principles of community-based participatory research, this dissertation explores community experiences with COVID-19 vaccines and develops a core outcome set (COS), inclusive of community-important outcomes, for use in studies evaluating the safety, efficacy, and implementation of COVID-19 vaccines. Methods: In March 2022, semi-structured interviews were held with vaccinated and unvaccinated Black residents of a community in Baltimore City reporting 40% vaccination uptake. Data were analyzed using inductive thematic analysis with subsequent subgroup analyses and thematic network analyses. To assess the extent to which outcomes measured in COVID-19 vaccine studies published between December 2019 and March 2022 aligned with factors of vaccine hesitancy, a systematic literature review (SLR) was conducted. Results from the qualitative analyses and the SLR informed the development of a candidate list of outcomes used in the first round of a Delphi study held in June 2020. After two rounds of Delphi survey distribution, a face-to-face consensus meeting was held with community members and community health workers to prioritize outcomes of interest to all relevant stakeholders and finalize the COS.Results: Thematic analysis yielded four emergent themes relating to COVID-19 vaccine uptake decision making: (I) Safety and efficacy of vaccines, (II) Perceived importance of COVID-19 vaccines in relation to pre-existing community needs, divided into two subthemes, a) Environmental injustice and (b) Personal health concerns, (III) Access to trustworthy, understandable information, and (IV) Physical access to vaccines. Participants acknowledged that physical access to COVID-19 vaccines was not a major barrier to uptake, however finding trustworthy and understandable information about the safety and efficacy of the vaccines were common areas of concern. Of all primary outcomes (N=20) identified in the 56 articles included in the SLR, 85% (n=17) corresponded with factors of vaccine hesitancy. The final COS included 19 outcomes across four “domains:” “Is the vaccine safe?”; “Does the vaccine work in my body?”; “Does the vaccine work in the community?”; and “Outcomes identified during consensus meeting.” Conclusion: The findings from this dissertation suggest that although community-important outcomes related to safety and efficacy of vaccines are often addressed in clinical studies, outcomes measuring institutional trust, economic and health impacts, community acceptance of the vaccines, and trustworthiness of vaccine information are underutilized in studies of vaccine implementation. As these social factors function as barriers to vaccine uptake, particularly among underserved communities, they should be regarded as indicators of equitable access to COVID-19 vaccines. The findings from this dissertation provide a framework with which public health researchers can begin to rethink measures of equity in vaccine rollout efforts.
A NATIONAL SURVEY EVALUATING FACTORS INFLUENCING AMERICANS’ WILLINGNESS TO USE AND UPTAKE OF EMERGENCY CONTRACEPTIVE PILLS
(2022) Jasczynski, Michelle Laurin; Aparicio, Elizabeth M; Public and Community Health; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
In the United States, a paradox exists around the issue of contraception; there are more highly effective contraceptive methods available than ever before, including emergency contraception, yet unintended pregnancies have increased in the last 2 decades. Currently, 1 in 2 pregnancies in the United States are unplanned. These disparities are not equitably distributed among women of reproductive age and people who can become pregnant; the burden disproportionately falls upon those with limited access to healthcare, people of color, gender and sexual minorities, those with lower socioeconomic status, and people living in the South. Recognizing the multiple factors driving decisions made about contraception, evaluation of the underutilization and other potential barriers to emergency contraceptive pills (ECP) can be in part addressed by the completion of a national survey. Most of the existing survey data for the United States provide insight into the perceptions of pharmacists, health care providers in emergency rooms, and college-aged women. A survey capturing the needs and experiences of a wider range of Americans has not yet been developed—most notably the need for a survey that is inclusive of an expansive understanding of gender identity and sexual orientation to evaluate what, if any, differences exist in how members of these groups view and choose to use ECPs.A web survey was completed in March 2022. Two groups of participants were recruited simultaneously: a group of cisgender, heterosexual women (n = 351), and a group of cisgender sexual minority women and gender minorities assigned female at birth (n = 408), for a total of 759 participants. Comparisons between cisgender heterosexual participants and cisgender sexual minority participants were completed using chi-squared tests and t tests to determine if there were differences in willingness to use and uptake of ECPs by sexual orientation. Latent class analysis (LCA) was completed to identify subgroups among the respondents. The latent class model was then used to determine if membership in the three latent classes predicted willingness to use ECPs and the number of times ECPs were used. Differences between classes on these two outcomes of interest were compared using chi-squared tests. Among each group, approximately 1 in 3 respondents had used ECPs at least once. Cisgender sexual minority participants had a higher willingness to use ECPs when compared to cisgender heterosexual participants (F[2, 708] = 16.33, p < .001). Cisgender sexual minority participants who used ECPs previously also were found to be less willing to reuse ECPs again when compared to their cisgender, heterosexual counterparts (χ2 [2] = 5.14, p = .023), with the most common reason of not wanting to use ECPs again due to participants indicating they would desire to be pregnant. The LCA final model had three classes: high reproductive coercion/low stigma (Class 1), low reproductive coercion/low stigma (Class 2), and low reproductive coercion/high stigma (Class 3). When regressed on the number of times ECPs were used, the three-class model was found to be statistically significant for the overall model (χ2 = 28.95, p < .001). Class 3 (low reproductive coercion, high stigma) was significantly different from Class 1 and Class 2 when comparing the mean number of times ECPs had been used, with members of Class 3 averaging using ECPs 1.56 times versus Class 1 and Class 2 both averaging .56 times use (p < .001). The high levels in which sexual minority women were willing to use ECPs but were less likely to reuse them again should be explored more in depth to understand underlying factors in decision making around contraceptive uptake and pregnancy intentions. The desire to become pregnant is the most common reason given for why sexual minority women would not use ECPs, highlighting the need for healthcare providers to have regular conversations with their patients about sexual behavior, contraceptive use, and pregnancy intentions. Individuals experiencing higher levels of stigma toward their use of ECPs have a higher prevalence of use. Although the direction of this association is yet to be determined, further investigation of this phenomenon can inform practice and policy to understand the impact of stigma and promote reproductive justice.
Meditation, Flow, and Heavy Social Alcohol Use among College Students
(1992) Francis, Timothy Lewis; Iso-Ahola, Seppo; Recreation; Digital Repository at the University of Maryland; University of Maryland (College Park, Md)
The basis for this study was an experiment designed to explore the effectiveness of various meditation practices and choice and combination of such, regardless of focus, in achieving more drug-free flow experiences, longer periods of meditation adherence, and decreases in heavy social alcohol use among college students. The study also examined the hypothesis that higher frequencies of reported flow in meditation were associated with lower levels of reported alcohol use and higher frequencies of post-training meditation practice, regardless of meditation focus. The interaction of several critical intervening variables not comprehensively addressed in previous studies on meditation and substance abuse, including experimental expectancy and demand, previous alcohol use, hypnotic susceptibility, and personality was checked and controlled for in this experiment. After receiving basic meditation training, 53 subjects with drinking rates typical of heavy social alcohol users were randomly assigned to one of four meditation groups or to a control group. Three groups practiced only one of three foci--object focused, visualization, or mindfulness. The fourth group chose their meditation foci each day from any of the above three types. The fifth (control) group practiced an attention Placebo activity. Four weeks of daily diaries following meditation were used to determine the level of the dependent variables--frequency of flow and amount of alcohol use. Subjects then reported post-required meditation frequency and alcohol use through four weekly phone interviews. MANOVA, ANOVA, and zero-order correlations were employed to analyze the relationships between the variables. No one specific meditation focus nor having choice and combination of foci, was indicated to result in significantly more flow, less alcohol use, or longer mediation adherence. There was a slight indication that higher frequencies of flow were related to higher frequencies of meditation practice, but no indication that more flow was related to less alcohol use. These results should be interpreted with caution for several reasons, including the short meditation training and practice period, low reliability and validity of subject reports, and problems associated with large variations in drinking rates. Future research on these issues should refine training and testing methods so that better treatment methods can be found.
AN INTERSECTIONALITY, MINORITY STRESS, AND LIFE-COURSE THEORY INFORMED LATENT PROFILE ANALYSIS OF STRESS(OR) AND PSYCHOSOCIAL BUFFERING FACTORS AMONG FIRST-GENERATION LATINX IMMIGRANT YOUTH FROM THE NORTHERN TRIANGLE: EFFECTS ON MENTAL HEALTH AND SUICIDALITY
(2022) Salerno, John P.; Boekeloo, Bradley O; Public and Community Health; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
In alignment with the intersectionality theoretical framework, first-generation Latinx immigrant youth from the Northern Triangle (i.e., El Salvador, Guatemala, and Honduras) may suffer from complex forms of vulnerability as a result of their multiple marginalized social identities and statuses. Indeed, consistent with the life-course perspective, immigrant youth from the Northern Triangle face unique risks for experiencing cumulative external stressors across the life-course in the context of the phases of migration, including pre- to post-migration victimization, and immigration-related family separation (e.g., forced family separation). The minority stress theory adds the potential for experiencing immigrant minority identity/status-related stress, such as discrimination or negative feelings attributed to being an immigrant, specifically during the post-migration context in the U.S., which could exacerbate mental health by adding to cumulative stress. Yet, the post-migration time period may be an important turning point for Latinx immigrant youth from the Northern Triangle, during which psychosocial buffering resources, like school, peer, and family support, and ethnic identity importance may have a strong and distinct impact that could significantly mitigate the cumulative mental health effects of life-course and minority stress(ors). Considering the increasing surge of immigrant youth from the Northern Triangle, which account for the majority of youth being apprehended at the U.S.-Mexico border, as well as grave concerns about their experiences of vulnerability and mental health, it is of utmost importance to utilize intersectionality, minority stress, and life-course theories to identify and understand the psychosocial risk and protective factors that can mitigate or exacerbate their mental health during post-migration in the U.S. To this end, in collaboration with a community-partner and a high school in Hyattsville, Maryland, primary surveys assessing external life-course stressors across the phases of migration (i.e., pre- to post-migration victimization, and family separation), post-migration immigrant-related minority stress (i.e., immigrant-related discrimination and negative immigrant stress-related feelings), and post-migration psychosocial buffering factors (i.e., family, peer, and school support, and ethnic identity importance) among first-generation Latinx immigrant youth from the Northern Triangle were administered (N = 172). In Paper 1, the aim was to identify potential intersections of minority stress (post-migration immigrant minority stress) and psychosocial buffering resources (family, peer, and school support, and ethnic identity importance), and their associations with external stressors (pre- to post-migration victimization and immigration-related family separation). Latent profile analysis was conducted to identify and describe latent profiles that varied at the intersections of post-migration immigrant minority stress and psychosocial buffering factors, and their associations with pre- to post- migration victimization, and family separation stressors. In Paper 2, the aim was to understand whether latent profiles characterized by the intersections of immigrant minority stress and psychosocial buffering factors, and external stressors (pre- to post-migration victimization and immigration-related family separation) jointly predicted mental health outcomes. ANOVA models were conducted to examine the associations of latent profile membership, pre- to post-migration victimization, and family separation with mental health outcomes (i.e., PTSD, depression, anxiety, and emotional problem symptoms) when all were included in the model as independent predictors. In Paper 3, the aim was to understand whether latent profile membership and external stressors jointly predicted suicidality. Logistic regression models were conducted to examine the associations of latent profile membership, pre- to post-migration victimization, and family separation with suicidality (i.e., suicidal ideation) when all were included in the model as independent predictors. Paper 1 findings revealed a three latent-profile model characterized by post-migration 1) moderate immigrant minority stress and low psychosocial buffering factors (moderate stress/low buffer), 2) moderate immigrant minority stress and moderate psychosocial buffering factors (moderate stress/moderate buffer), and 3) low immigrant minority stress and high psychosocial buffering factors (low stress/high buffer). Post-migration victimization was significantly associated with latent profile membership, such that those in the low stress/high buffer profile group (11%) were least likely to experience post-migration victimization compared to the moderate stress/moderate buffer (most likely; 49%) and moderate stress/low buffer (33%) profile groups (p < .001). Overall prevalence of in-transit victimization (7.70%) was too low for valid statistical assessment. Pre-migration victimization and family separation were not significantly associated with latent profile membership. Paper 2 factorial ANOVA analyses demonstrated that latent profile membership post-migration victimization, and family separation were statistically significant predictors of mental health outcomes (PTSD, depression, anxiety, and emotional problem symptoms) when all were included in the models. Bonferroni-corrected factorial ANOVA test findings revealed that youth in the low stress/high buffer profile group were significantly less likely to experience PTSD (p < .001, p = .003), depression (p < .001, p < .001), anxiety (p < .001, p < .001), and emotional problem symptoms (p = .002, p = .041) compared to youth in both the moderate stress/moderate buffer and moderate stress/low buffer profile groups (respectively). The moderate stress/low buffer profile group did not differ significantly from the moderate stress/moderate buffer profile group in-terms of any mental health outcome. Post-migration victimization was independently and positively associated with PTSD (p = .010), anxiety (p < .001), and emotional problem (p = .042) symptoms (but not depression symptoms), and forced family separation was independently and positively associated with PTSD (p = .026), anxiety (p = .017), and depression symptoms (p = .009; but not emotional problem symptoms) in factorial ANOVA. Pre-migration victimization was not a significant predictor of any mental health outcomes, and in-transit victimization prevalence was too low for valid statistical assessment of its association with mental health outcomes. Paper 3 multivariable logistic regression analyses demonstrated that latent profile membership was the only statistically significant predictor of suicidality. The low stress/high buffer profile group was significantly less likely to experience suicidality compared to both the moderate stress/moderate buffer (87.8% decrease in the odds; OR = 0.122; p < .001) and moderate stress/low buffer (95.6% decrease in the odds; OR = 0.044; p < .001) profile groups in multivariable logistic regression. The moderate stress/low buffer profile group did not differ significantly from the moderate stress/moderate buffer profile group in-terms of suicidality. Post-migration victimization was no longer a statistically significant predictor of suicidality in the multivariable logistic regression model. Pre-migration victimization and family separation were not significant predictors of suicidality, and in-transit victimization prevalence was too low for valid statistical assessment of its association with suicidality. Considering the results of all three studies in Papers 1-3, latent profiles, characterized by the intersections of immigrant minority stress and psychosocial buffering resources, were a significant independent predictor of all mental health outcomes and suicidality. Yet, external stressors, particularly post-migration victimization (PTSD, anxiety, and emotional problem symptoms) and immigration-related family separation (PTSD, anxiety, and depression symptoms) were also significant independent predictors of mental health outcomes, suggesting that these factors also explain post-migration mental health outcomes to some degree above and beyond latent profile membership. In totality, findings strongly suggest that further exploration of post-migration immigrant minority stress and psychosocial buffering resources is urgently warranted to identify ways of overcoming the effects of externalized immigrant-related stressors and reducing mental health burden among first-generation Latinx immigrant youth from the Northern Triangle, a highly vulnerable population. Consistent with minority stress and intersectionality theories, protective associations with mental health were present when post-migration immigrant minority stress was low and psychosocial buffering was high, but these protective associations were lost when immigrant minority stress increased to moderate level and when psychosocial buffering decreased to moderate or low level. From another viewpoint, there were risk associations with mental health when post-migration immigrant minority stress was moderate and psychosocial buffering was low or moderate, but these risk associations were reversed toward being protective when immigrant minority stress lowered to low level and when psychosocial buffering increased to high level. That post-migration victimization and forced family separation remained positive predictors of mental health outcomes in multivariable analyses highlights that these external life-course stressors exacerbated mental health above and beyond the associations of post-migration immigrant minority stress and psychosocial buffering latent profile membership alone. Findings provide valuable information for policy and intervention development and reform in the U.S. that focuses on factors that can be intervened on during the post-migration phase in the U.S. (as opposed to less intervenable factors that occurred during pre and in-transit migration) to positively impact mental health and wellbeing among first-generation Latinx immigrant youth from the Northern Triangle. When immigrant youth experience low immigrant minority stress, strong peer and family support networks, as well as supportive schools and feeling that their foreign, cultural, and ethnic identities are celebrated and welcomed, this could have a significant protective effect toward their mental health and suicidality. However, if youth are facing low levels of these psychosocial buffering experiences and moderate (or potentially high) levels of immigrant minority stress, they may experience negative effects that hinder their mental health and suicidality. Additionally, post-migration victimization and forced family separation are particularly impactful predictors of mental health above and beyond the effects of latent profile group membership alone, which indicate the urgent need for mental health services and support resources that address these stressful and traumatic life-course experiences among first-generation Latinx immigrant youth from the Northern Triangle. Findings elucidate post-migration immigrant minority stress and psychosocial buffering pathways for future development and evaluation to improve Northern Triangle immigrant youths’ mental health and suicidality.

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