Behavioral & Community Health Theses and Dissertations
Permanent URI for this collectionhttp://hdl.handle.net/1903/2802
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Item Diabetes and Periodontal Disease Bi-Directional Relationship: An Examination of Diabetics' Knowledge, Understanding, Social Determinants and Self-Efficacy Impact on Dental Hygiene Practices(2019) Oguntimein, Oluwamurewa Ayodeji; Butler, James; Horowitz, Alice M; Public and Community Health; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Thirty million Americans are living with diabetes; making it the seventh leading cause of death, with 1.3 million Americans dying every year. As such, the total treatment costs of diabetes rose from $245 billion in 2012 to $327 billion in 2017. One factor driving these high costs is diabetes’ comorbidity with other chronic diseases and associated complications – e.g., hypertension, , heart disease, stroke, amputation and blindness. Little attention has focused on periodontal disease- the sixth complication of diabetes awareness, education, and intervention. This research adds to the literature via two studies that assessed diabetics’ knowledge and understanding of the bi-directional relationship between diabetes and periodontal disease. The first study examined gender and self-efficacy differences in knowledge and understanding of the bi-directional relationship between diabetes and periodontal disease among 927 diabetics. Findings suggest diabetics are unaware of their increased risk of periodontal disease based on the low mean 5.79±2.366 scores on the knowledge and understanding scale. After controlling for diabetes duration, smoking status, and other covariates, males had less knowledge and understanding of the bi-directional relationship (p<.0001). Self-efficacy was not significantly associated with participants’ knowledge and understanding of the bi-directional relationship (p= 0.543). The second study assessed health literacy differences in diabetics’ knowledge and understanding of the bidirectional relationship between diabetes and periodontal disease. Education, employment and income were tested as moderators between knowledge and understanding of the bidirectional relationship and dental hygiene practices. After controlling for diabetes duration, dental insurance status, and other covariates, participants with marginal or inadequate health literacy had less knowledge and understanding of the bi-directional relationship compared to participants with adequate health literacy (p<.0001). Education, employment, and income were not moderators. The findings support the need for targeted periodontal disease risk and dental hygiene practice education. These studies are presumably the first to assess diabetics’ knowledge and understanding of the bi-directional relationship between diabetes and periodontal disease. These studies are significant contributions to the limited amount of research and illuminate the need to educate diabetics regarding their increased risk of periodontal disease and the importance of practicing dental hygiene behaviors to prevent diabetes complications.Item Addressing Unsubmitted Sexual Assault Kits and Reforming Processes Going Forward: Burnout and Vicarious Trauma Among Staff Working the Cases(2019) Meadows, Kristi; Curbow, Barbara; Public and Community Health; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Burnout and vicarious trauma continue to be high priority topics in healthcare and law enforcement research, but there is a sizeable deficit within the literature among professions working directly with sexual assault cases. Generally, burnout and vicarious trauma among specific professions within the justice system including attorneys, victim advocates, and sexual assault nurse examiners (SANE) have been significantly understudied. Additionally, reforms are currently underway to address the problem of unsubmitted sexual assault kits stored in warehouses across the United States. However, implications for the employees have not been studied by researchers to understand potential consequences in working with these cases nor the added stress of reforms. Secondary qualitative analysis was conducted using data from a sample of interviews with key informants (n=135) who are victim-facing and involved in processes to address both unsubmitted sexual assault kits and current cases of sexual assault. Informants were more likely to focus on facilitators and challenges in their daily work than to discuss the outcomes of burnout and vicarious trauma. Insufficient access to resources and increased workloads were the most significant challenges discussed among key informants, although, emotional labor and other difficult aspects of the job were also a common theme throughout this population. Social support including support across agencies, as well as supervisory support, were the most discussed potential protective factors of burnout. This study contributes information regarding key challenges faced by individuals working on sexual assault cases and has direct implications for employees in the field as well as those undergoing reform on sexual assault kit processing. These findings should be used to understand potential contributors to burnout and vicarious trauma in order to better mitigate negative outcomes associated with this work.Item THE IMPACT OF DISEASE SEVERITY AND PHENOTYPE ON SMOKING AMONG ADULTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE(2019) Tilert, Timothy; Wang, Min Q; Public and Community Health; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Chronic Obstructive Pulmonary Disease (COPD) is estimated to be the third leading cause of death in the US. The most significant risk factor for COPD is long-term cigarette smoking. In spite of the myriad benefits of cessation, the proportion of adults with COPD who currently smoke is still nearly 50%. Little is known, however, about the characteristics of, and subsequent differences between, smokers with COPD, particularly at differing lung obstruction severity levels. The goals of this dissertation were to examine and compare the characteristics of smokers with diagnosed COPD as well as to explore the impact of disease severity and disease phenotype on smoking status among persons with COPD. This research utilized secondary data on 10,219 examined adults, aged 40-79 years, from the 2007-2012 National Health and Nutrition Examination Survey. In Study 1, adjusted logistic regression analyses revealed multiple factors that were associated with self-reported COPD diagnosis with those reporting three or more respiratory symptoms having the strongest association (AOR=22.1, 95% CI=12.0-40.5). In Study 2, it was shown that smoking status proportions did not differ by lung obstruction severity among those reporting a COPD diagnosis. In adjusted logistic regression analyses, multiple factors were associated with current smoking status among those with self-reported COPD with the presence of other smokers in the household having the strongest association with being a current smoker (AOR=19.5, 95% CI=10.2-37.5). In Study 3, three distinct phenotypes were found among the COPD population analyzed. In adjusted logistic regression analyses, COPD phenotype was differentially associated with continued smoking, above and beyond other predictors, with the older, heavy-smoking males with emphysema phenotype showing a significant positive association with continued smoking (AOR=3.7, 95% CI=1.3-10.9). Understanding how differences in disease severity and disease phenotypes impact smoking status among persons with diagnosed COPD could help inform more targeted, and effective, interventions to reduce smoking rates in this high-risk population. These findings potentially provide guidance for current smoking cessation interventions aimed at smokers with COPD as well as provide the foundation for further exploration of the association between COPD phenotype and continued smoking.Item INVESTIGATING CARDIOVASCULAR RISK AT THE INTERSECTION OF RACE, GENDER, AND EDUCATION(2019) Taiwo, Omolola Tanya; Boekeloo, Bradley O; Public and Community Health; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)As a risk factor of cardiovascular disease (CVD), systemic inflammation is differentially distributed by race, with black populations disproportionately impacted. Additionally, inflammation, as measured by the inflammatory marker C-reactive protein (CRP), is documented to be higher among women when compared to men and varies by educational level. Despite evidence suggesting that various chronic stress domains may contribute to the relationship between race and inflammation, there is limited data exploring the possible mediating role of chronic stress. Furthermore, to date, no study has examined if the potential indirect effect of race on CRP through chronic stress domains are moderated by gender and education. This secondary data analysis stems from the Midlife Development in the United States (MIDUS II) study, and the sample consisted of 193 black and 582 white adults. Study 1: Examined the association between CRP and seven racial/gender/education subgroups. With educated white men as the reference group, findings revealed that educated black and white women had the highest significant risk for elevated CRP. Study 2: Assessed the psychometric properties of a Chronic Stress Scale (CSS) comprised of nine chronic stress subscales. Analyses revealed CSS to be a three-dimensional scale with questionable validity and reliability. Study 3: First, tested for significant correlations between nine chronic stress domains, race, and CRP. Everyday discrimination and financial strain were found to be the only two domains significantly correlated to race and CRP. Second, two mediation analyses assessed the mediating effect of financial strain and discrimination, finding that they both respectively mediated the relationship between race and CRP. Third, two moderated mediation analyses examined if the indirect effect of financial strain and discrimination were moderated by gender and education. Results indicated that the indirect effect of race on CRP through discrimination was significant only among educated black men. Additionally, findings revealed that the indirect effect of race on CRP through financial strain was significant among black men and women regardless of educational attainment. Combined, these studies characterized the social patterning of CRP, illustrated validity and reliability concerns when developing a multidimensional chronic stress scale, and revealed that discrimination and financial strain did have mediating roles and these mediators were moderated by gender and education.Item The Health Literacy Process Older Adult Long-Term Smokers Use to Make an Informed Decision about Lung Cancer Screening: A Grounded Theory Study(2019) Platter, Heather N; Feldman, Robert; Public and Community Health; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Lung cancer is the leading cause of cancer-related death in the United States with 160,000 annual deaths. Recent advances in screening technologies have proven effective in reducing mortality and increasing early stage detection of lung cancer, yet only 3.9% of the 6.8 million eligible Americans were screened in 2015. Potential barriers to lung cancer screening have been examined; however, there is limited research available on the impact of health literacy and the process of informed decision-making about lung cancer screening. To fill this gap, this study explored how health literacy relates to intentions and behaviors to screening for lung cancer among long-term smokers between 55 to 80 years old who have a 30-pack year smoking history, health insurance, and a provider seen in the past two years. The study was guided by the following research question: “How does health literacy relate to intentions and behaviors to screen for lung cancer?” Twelve participants (N=12) were enrolled in the study. Participants were 58.3% female, 83.3% black, 83.3% had screened for any cancer besides lung cancer, and 75% were current smokers with a 41.8 mean pack-year history. The majority of the sample (91.7%) had adequate health literacy based on the Short Test of Functional Health Literacy in Adults. Data were transcribed verbatim and analyzed using constructivist grounded theory methods, proceeding through four stages of coding (open, focused, axial, and theoretical). Analysis produced a Health Literacy Theoretical Model of Informed Decision-Making about Lung Cancer Screening. The theoretical model is underpinned by a core category: Making an Informed Decision about Lung Cancer Screening. This core category is supported by eight categories characterizing how health literacy relates to lung cancer screening among older adult long-term smokers, including Health Information Seeking Behaviors, Trusted Sources, Knowledge, Trusted Provider, Advocacy, Perceived Risk, Patient-Provider Communication, and Shared Decision-Making. This is one of the only known studies that describes the health literacy process of informed decision-making about lung cancer screening. The results of this grounded theory study have several implications for public health practice, research, and policy and have the ability to increase lung cancer early detection and survival.Item Decisional Needs of African American Smokers for Lung Cancer Screening(2019) Williams, Randi Marie; Knott, PhD, Cheryl L.; Public and Community Health; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)The burden of lung cancer is significant for African Americans, especially African American men, who have the highest lung cancer death rates compared to all racial and ethnic groups. In 2013, the United States Preventive Services Task Force (USPSTF) provided a recommendation for annual screening using low-dose computed tomography (LDCT) due to the disease-specific mortality benefit. Given the test’s limitations (e.g., false positives, radiation exposure) the USPSTF and other medical organizations endorse informed decision-making, a process by which individuals weigh the benefits and harms of the test and make a decision about usage. The recent release of the screening guidelines and promotion of informed decision-making provides a timely opportunity to examine patients’ decision-making processes around lung cancer screening. The purpose of this study was to describe aspects of decision-making for lung cancer screening including knowledge and awareness about LDCT, values related to screening, uncertainty about the test, and decision-making preferences among African American adult smokers. Additionally, this study examined the extent to which decision-making components are associated with screening intentions. The Ottawa Decision Support Framework provided the conceptual framework for this study, positing that patients’ decisional needs (e.g., knowledge, personal values) impact decisional quality (e.g., being informed, low regret) which ultimately influences behavior (e.g., use of health services). First, patient and provider key informant interviews (N=9) were conducted to inform the development of a decisional values measure. Next, a survey was administered to African American (N=119) long-term smokers. Among the study sample, lung cancer screening awareness and knowledge were limited (Mean=7.1 out of 15). Individuals were experiencing uncertainty about the screening decision, but lower decisional conflict was associated with greater likelihood of talking with friends about LDCT as well as screening intention (p’s<.05). This is one of the first studies to describe the decisional needs of an entirely African American sample of smokers for lung cancer screening using LDCT and to examine the associations between these components of decision-making and screening intentions. Findings have implications for addressing the decisional needs of African American smokers to promote informed decision-making for LDCT and to thwart further cancer inequities.Item PRESENCE AND PREDICTORS OF HEALTH PROGRAMMING IN A SAMPLE OF AFRICAN AMERICAN CHURCHES(2019) Woodard, Nathaniel; Fryer, Craig S; Public and Community Health; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Churches have played a central role in African American communities for decades. In addition to religious services, African American churches have increasingly offered a variety of health programs. However, there is a dearth of empirical literature on church-initiated health programming. This study examines quantity and variety of health programs and areas addressed by a convenience sample of African American churches (N = 119), as well as church characteristics that predict these health initiatives. Churches offered a mean of 6.08 (SD = 2.15) health programs targeting 4.66 (SD = 3.63) different health topics within the previous 12 months. Various church characteristics indicating greater availability of programming resources were positively associated with the quantity and variety of health initiatives. It is recommended that practitioners partner with under-resourced churches to support their existing health activities and address gaps in health programming. Future research should seek to evaluate the effectiveness of church-initiated health programs.Item Examining the Food-Insecurity Obesity Paradox among Latino Immigrants(2019) Amador, Maria Aileen; Garza, Mary A; King-Marshall, Evelyn C; Public and Community Health; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Obesity is linked to chronic illnesses such as type 2 diabetes, cardiovascular disease, and some cancers (breast, kidney, and liver). Food insecurity refers to lack of access to nutritious and safe food. Latinos are a rapidly growing population in the US with higher levels of food insecurity than the national average, and higher obesity rates than non-Latino white adults. The “food insecurity-obesity” is a paradoxical relationship seen in rising obesity and correspondingly high food insecurity rates. We examined demographic factors, acculturation, stress, dietary habits, and food access among Latina immigrants to understand this paradox. This sub-analysis (n=128) found that education level (p=0.03) and marital status (p=0.08) were significantly and marginally significantly associated with food security level. Additionally, this analysis helped to better describe a population that lacks research. A better understanding of the “food insecurity-obesity” paradox and related factors will inform future culturally-tailored interventions to address obesity among Latina immigrants.Item THE PREVALENCE OF MATERNAL SMOKING INTENSITY STATUS IN EARLY AND LATE PREGNANCY AND ITS ASSOCIATION WITH EARLY MORBIDITY IN SINGLETON TERM BIRTHS IN THE UNITED STATES, 2016(2019) Kondracki, Anthony; Moser Jones, Marian; Thoma, Marie; Public and Community Health; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Relatively little is known about how maternal cigarette smoking influences the health of infants delivered at term. This study was based on the 2016 United States Natality File of live births (N= 3,956,112). The first aim was to examine the prevalence and patterns of smoking in the three months before and during pregnancy and the distribution of smoking intensity in early (1st and 2nd trimester) and late (3rd trimester) pregnancy across race/ethnicity, age, and educational attainment of mothers with all births and with singleton term births (37-41 completed weeks gestation) in the United States in 2016. The second aim was to compare the odds of low birthweight (LBW), low 5-minute Apgar score, and neonatal intensive care unit (NICU) transfer/admission in term singletons with changing maternal smoking status in early and late pregnancy indicating a potential prenatal exposure effect. The third aim was to test and identify the role of low birthweight, as a potential mediator, in the association with maternal smoking status and NICU transfer/admission of a newborn delivered at term. The prevalence of smoking in the three months before pregnancy was 9.42% among all mothers and 9.20% among mothers of term singletons, and high intensity smoking was the highest in the first trimester among non-Hispanic White women, 20-24 years of age, and less educated women for all births and for singleton term births. High intensity smoking in early and late pregnancy was associated with a greater risk of LBW (aOR 3.33; 95% CI: 3.23, 3.44), low 5-min Apgar score (aOR 1.46; 95% CI: 0.88, 2.44), and NICU transfer/admission (aOR 1.62; 95% CI: 1.58, 1.67) in term neonates. The odds ratios of the natural direct and natural indirect effects of NICU transfer/admission were aOR 1.52 (95% CI: 1.47, 1.57) vs. aOR 1.07 (95% CI: 1.07, 1.09) and the proportion mediated through LBW (18.3%) indicated partial mediation. This study has important implications for clinical practice, public health policy and research, and it is particularly timely because of an information gap on the health of infants delivered at term with LBW to mothers who continue smoking at high intensity during pregnancy.Item “NOTHING TO BE WORRIED ABOUT YET”: PERCEPTIONS OF COLORECTAL CANCER AMONG INDIVIDUALS BELOW THE AGE OF 50.(2019) Mueller, Nora M.; Curbow, Barbara A; Public and Community Health; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)National guidelines recommend regular screening for colorectal cancer (CRC) begin at age 50. Recent research however showed rates rising among adults below the age of 50 despite declining overall rates of CRC. Screening guidelines have not been updated to reflect new findings. Younger individuals may not be aware of their CRC risk and providers may be unaware of the need to screen younger patients. An online survey of individuals between the ages of 24 and 45 was conducted in April and May of 2018 using Amazon© Mechanical Turk. Measures collected included perceived CRC risk and susceptibility, screening knowledge, and understanding of screening results. Analysis I examined these variables by generational cohort. Analysis II randomized participants to receive one of two fictional colonoscopy result reports, the first being the standard of care report provided by a medical center in Maryland and the second a modified report containing a “gist” synthesis of findings. Mixed methods examined participants’ interpretations of these reports. Analysis III randomized participants to receive one of two statements describing trends in the rates of colon cancer to examine participants’ ability to discern false and true information. Analysis I found Gen-Xers more likely to report higher perceived risk (general cancer and CRC) and severity (general cancer) and be aware of current CRC screening guidelines. Both groups displayed a lack of awareness of CRC screening methods. Analysis II showed that individuals who received the gist report correctly rated the report as more serious and the importance of follow-up higher than those who received the standard medical report. Analysis III revealed a lack of knowledge among participants to differentiate between correct and incorrect statements regarding colon cancer trends, with participants defaulting to accepting the validity of the statement. Findings revealed gaps in knowledge of recommended screening activity and available screening methods. Providers should be prepared to discuss available screening options and accurate risk information; in addition, providers should discuss with patients which medical information they read online and remind individuals to take a more critical stance. CRC screening reports that contain a synthesis of findings may help patients plan next steps accordingly.