Behavioral & Community Health Theses and Dissertations

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A NATIONAL SURVEY EVALUATING FACTORS INFLUENCING AMERICANS’ WILLINGNESS TO USE AND UPTAKE OF EMERGENCY CONTRACEPTIVE PILLS
(2022) Jasczynski, Michelle; 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, healthcare 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.
STATE-LEVEL STRUCTURAL RACISM AND ALCOHOL AND TOBACCO USE BEHAVIORS IN A NATIONAL PROBABILITY SAMPLE OF AFRICAN AMERICANS
(2023) Woodard, Nathaniel; Knott, Cheryl L; Public and Community Health; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
Structural racism is how society maintains and promotes racial discrimination through established and interconnected systems. Structural racism is a historical driver of health disparities, including those in the area of cancer. One pathway posited for this effect is through the promotion of maladaptive coping behaviors, such as alcohol and tobacco use. This dissertation empirically assessed the association between state-level structural racism and alcohol and tobacco use behaviors among African Americans, including within various subgroups of African Americans based on age, gender, and household income. This project analyzed secondary self-report data collected from a national probability sample of 1,946 African Americans in the Religion and Health in African Americans (RHIAA) Study. Existing measures of state level structural racism were merged into the RHIAA dataset including a composite index of structural racism assessed using five dimensions (i.e., residential segregation, and economic, employment, education, and incarceration disparities). Analyses were performed in SPSS Version 28 using hierarchical linear and logistic regression models. In the first study, two models (Model A and Model B) were constructed for each of four outcomes, frequency of alcohol consumption (measured in days per month), frequency of binge drinking (measured in the number of occurrences per month), smoking status (current smoker or not a current smoker), and smoking frequency (never smoked, former smoker, currently smoke on some days, and currently smoke every day). Model A used the composite structural racism index measure to model the four alcohol and tobacco use measures and Model B analyzed the disaggregated dimensions of structural racism rather than the composite measure. All hierarchical analyses controlled for confounding variables (i.e., participant gender, age, education, income, and employment status). In the second study, analyses using the dimension-level approach in Model B from study one were repeated in subgroups stratified by participant age, gender, and income for the frequency of binge drinking and smoking status behaviors. Statistical comparisons of the slope estimates between corresponding subgroups (e.g., younger and older age) were used to test the moderation effects of age, gender, and income on the association between structural racism and alcohol and tobacco use behaviors. Results from these studies generally indicated a positive association between state level structural racism, especially in the incarceration dimension, and binge drinking and tobacco use behaviors. Stratified analyses generally did not support age, gender, or income as moderating variables of the association between structural racism and binge drinking and tobacco use behaviors. Current findings demonstrate a need for further research on structural racism and health and progress in structural racism measurement, including further emphasis of dimension-level measurement and analysis. Findings from the current dissertation highlight the importance of addressing structural racism, especially in incarceration, to reduce alcohol and tobacco use behaviors among African Americans and help address existing health disparities.
EXAMINING THE IMPACT OF PRECONCEPTION AND EARLY PREGNANCY SERUM LEVELS OF MATERNAL VITAMIN D ON CLINICAL MARKERS OF IMPLANTATION AND PREECLAMPSIA
(2023) Alkhalaf, Zeina; Thoma, Marie; Public and Community Health; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
Vitamin D is a hormone rather than a vitamin, that is essential for overall health and wellbeing, including but not limited to the reproductive system. Although vitamin D is available through several sources, such as natural ultraviolet sunlight, food, and supplements, low circulating 25-hydroxyvitamin D (25(OH)D) levels of <30 ng/mL are common among pregnant women, with up to 69% of the US population suffering from the condition. Epidemiologic studies have suggested that low maternal serum 25(OH)D levels may be associated with adverse pregnancy outcomes, such as early pregnancy loss and preeclampsia, which may be initiated early in the pregnancy process during implantation and placentation. From a life course perspective, the periconception and early pregnancy period marks a critical time for establishing a healthy pregnancy. Implantation and placentation occur early in pregnancy and involve a complex process that relies on optimal endometrial receptivity and a host of hormonal and immunologic signaling events. Disruptions to this process may be indicated by early clinical markers of pregnancy complications (e.g., vaginal bleeding or subchorionic hemorrhage) and associated with later adverse outcomes (e.g., preeclampsia). In contrast, higher Human Chorionic Gonadotropin (hCG) levels, which have been linked to nausea and vomiting, may be markers of robust implantation and placentation. Therefore, I sought to investigate the preconception and early gestation maternal serum 25(OH)D levels on: (i) vaginal bleeding and subchorionic hemorrhage; (ii) nausea and vomiting; (iii) preeclampsia. In Aim 1, an analysis of medical record documentation of vaginal bleeding and subchorionic hemorrhage found that women who were persistently deficient/insufficient in maternal serum 25(OH)D at both preconception and 8-week gestation had 2.18 times higher (95% CI: 1.13, 4.20) odds of having subchorionic hemorrhage compared to women who remained sufficient across both time periods, even after adjustment for potential confounders. Additionally, an analysis of daily diaries showed women with deficient 25(OH)D levels had a higher odds (OR: 3.02, 95% CI: 1.13, 8.13) of moderate/heavy bleeding versus none compared to women with sufficient 25(OH)D levels based on self-reported daily diaries on vaginal bleeding at the start of pregnancy. In Aim 2, women with persistently deficient 25(OH)D levels at both preconception and early gestation had lower odds (OR: 0.34, 95% CI: 0.20, 0.60) of experiencing nausea and vomiting based on medical records. In comparison, women who increased their 25(OH)D levels early in pregnancy (i.e., were deficient/insufficient at preconception then became sufficient at 8-week gestation) had 1.71 (95% CI: 1.12, 2.61) times higher odds of nausea and vomiting compared to those who were persistently sufficient across both time periods. Based on self-reported nausea and vomiting symptoms from daily diaries, deficient 25(O)D was associated with lower odds (OR 0.65; 95% CI 0.40, 1.06) of both nausea and vomiting when comparing to sufficient 25(OH)D levels. In Aim 3, women who had deficient 25(OH)D at preconception had an increased risk (RR: 1.45, 95% CI: 0.64, 3.29) of preeclampsia (as identified from medical records), although results were insignificant. Linear spline models demonstrated that the risk of preeclampsia declined with each 1 ng/mL increase of 25(OH)D levels up to 40-45 ng/mL (RR: 0.97, 95% CI: (0.93, 1.00), but that levels beyond this threshold show an increase in the risk of preeclampsia for each 1 ng/mL increase in 25(OH)D (RR: 1.03; 95% CI: 1.00, 1.06). This research highlights the importance of exploring the maternal serum levels of 25(OH)D at both preconception and early gestation and how it may affect adverse pregnancy outcomes, such as vaginal bleeding, subchorionic hemorrhage, preeclampsia, and pregnancy outcomes that signify a robust implantation response, such as nausea and or vomiting. It further underscores the importance of assessing maternal serum 25(OH)D levels prior to critical time of implantation and placentation and potential biologic mechanisms that may lead to adverse pregnancy outcomes. Supporting healthy implantation and placentation is of utmost importance as this may guide the remainder of the health of the pregnancy, and any disruption to this process may increase the mother and infant’s risk of maternal morbidity and mortality (e.g., preeclampsia, vaginal bleeding, subchorionic hemorrhage). Future studies are needed with more diverse, larger sample sizes, and both paternal and maternal nutrition to further assess preconception nutritional risk factors on adverse and robust pregnancy outcomes. Accordingly, this research is vital as it may aid in identifying early factors that may reduce adverse maternal and infant health outcomes.
ADAPTING A BREAST CANCER CONTROL INTERVENTION FOR AFRICAN AMERICAN WOMEN BELOW SCREENING AGE: A CO-DESIGN APPROACH
(2023) Huq, Maisha R; Knott, Cheryl L; Public and Community Health; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
Background: Despite African American women below screening age facing greater mortality from early onset breast cancer relative to similar aged peers of other races/ethnicities and African American women of screening age, little attention is given to this group of younger women. Evidence-based breast cancer educational interventions do not exist for this group of younger women. The purpose of the current work was to address the gap of evidence-based breast cancer educational interventions for African American women below screening age. Aims: The current study had two aims. Aim 1 was to adapt an evidence-based breast cancer educational intervention for African American women of screening age, to be targeted to younger African American women (i.e. those below screening age) using a systematic process guided by the seven-step adaptation framework by Card and colleagues, documented using an established implementation science model, the Framework for Reporting Adaptations and Modifications Enhanced Model (FRAME), and using a virtual co-design approach. Aim 2 was to assess the appropriateness of the adapted intervention for African American women below screening age through online surveys administered at the conclusion of Community Chat sessions. Methods: The adaptation process was guided by Card and colleagues’ seven-step framework. Five virtual co-design sessions with n=15 potential users and key stakeholders were conducted in step 7. Observational notes and FRAME Form data were collected from the co-design sessions and analyzed using five-step thematic and descriptive statistics analyses, respectively. Appropriateness data was collected through an online survey; quantitative data were analyzed using descriptive statistics and open-text survey responses were analyzed using five-step thematic analysis. Results: Application of Card and colleagues’ seven step framework was described. Six themes emerged from observing virtual co-design sessions: technological tools can encourage equal participation; personal relationships and stories enhance design; participants introduced content to promote equity; context of original intervention critical to adapt; challenges to virtual designing; and need for facilitator during co-design. Documentation of the adaptation process guided by FRAME found 14 adaptations led to “Black and Breasted (B&B)”, an Instagram and beauty brand partnership-based breast health education tool prototype. Motivations for adaptations were to promote fit (100%), reach (71%), and equity (29%). Adaptations were content (63%) and context-related (37%). All participants rated B&B as highly appropriate—selecting an average of 4.5 (SD=1.4) and 1.2 (SD=.75) reasons, respectively, B&B would and would not be a good fit. Thematic analysis of open-text responses on how to further enhance B&B identified four themes: increase strategies to improve health equity, use multiple social media, consider non-beauty brands, revise visuals/messages. Conclusions & Implications: While usage of the implementation science models led to a highly appropriate adapted intervention, initial testing identified the need for further strategies to improve equity of health outcomes through the intervention. Findings indicate implementation science frameworks may benefit from centering equity more. Co-design may also be an apt approach to promote health equity in public health interventions.
Exploring the Politics and Radical Health Activism Strategies of Black-Led Grassroots Organizations in Washington, D.C.
(2023) Fox, Imani; Simon-Rusinowitz, Lori; White, Kellee; Public and Community Health; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
Black communities in Washington, DC have long experienced health inequities due to a history of inequitable social policies and inadequate access to health-related resources (Jackson, 2017). Critical, academic scholars and social justice activists implicate the political economy and racial oppression as a root cause of health inequities in the country. Black grassroots organizations demonstrate a history of political and social resistance to oppressive health and social systems, defending their right to health and autonomy, known as radical health activism (Nelson, 2011). Despite rich accounts of Black-led health interventions, their contributions to public health practice and frameworks have not been widely reviewed in public health discourse. Using informant interviews and descriptive study analysis, the health politics and subsequent health intervention strategies of Black grassroots organizations in Washington, D.C were examined. The 3 core themes that emerged from this study were health politics, radical health intervention strategies, and successes and challenges.

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