Theses and Dissertations from UMD
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New submissions to the thesis/dissertation collections are added automatically as they are received from the Graduate School. Currently, the Graduate School deposits all theses and dissertations from a given semester after the official graduation date. This means that there may be up to a 4 month delay in the appearance of a give thesis/dissertation in DRUM
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Item Novel Immunotherapy Agents in Oncology: Generalizability of Trial Results and Drivers of Clinical Utilization(2021) Mishkin, Grace; Franzini, Luisa; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Cancer is the second most common cause of death in the United States after heart disease. Novel immunotherapy agents such as nivolumab and pembrolizumab have become an essential, albeit extremely expensive, component of oncology care since their first approvals in melanoma in 2014 and lung cancer in 2015. However, little is known about differences between immunotherapy clinical trial participants and the real-world patient population, or about the drivers of provider utilization of these agents. The first objective of this dissertation used the SEER-Medicare linked database with claims data from 2014-2016 to conduct two aims analyzing potential disparities between Medicare beneficiaries on active treatment for melanoma and lung cancer and Medicare clinical trial participants. Aim one compared the characteristics of Medicare patients on active cancer treatment to Medicare patients on active cancer treatment clinical trials. Aim two compared Medicare patients receiving the novel immunotherapy agents nivolumab or pembrolizumab to Medicare patients participating in trials of these two immunotherapy agents. Because of the demographic differences in the melanoma and lung cancer patient populations, these aims were analyzed separately in melanoma and lung cancer. As hypothesized, patients in clinical trials were significantly younger and had fewer comorbid conditions than patients undergoing active cancer treatment not in clinical trials. Underrepresentation of non-White and female patients in clinical trials was hypothesized, but these results were less consistent. The second objective used Medicare Open Payments data from 2016 and Medicare provider utilization data from 2017 to analyze 1) if industry payments promoting nivolumab or pembrolizumab were positively associated with whether a provider was a high utilizer of the agent, and 2) among these high utilizers, if industry payments were positively associated with greater utilization amounts. The hypothesized results, that industry payments were associated with greater likelihood of high utilization and more utilization among high utilizers, were seen in some of the analyses but not consistently throughout the study. Through unique analyses of recent datasets, this dissertation advances our understanding of potential disparities in clinical trial representativeness and the generally positive relationship between promotional payments and provider utilization of immunotherapy agents in the Medicare cancer patient population.Item DISPARITIES IN PRE-EXPOSURE PROPHYLAXIS AWARENESS AMONG WOMEN: A SYSTEMATIC REVIEW OF THE LITERATURE AND LATENT CLASS ANALYSIS OF SYNDEMIC RISK FACTORS(2020) Stubbs, Leandra Nicole; Curbow, Barbara; Public and Community Health; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)While rates of HIV infection have declined among women in recent years, women still account for 19% of all new infections each year in the United States (US). Sociodemographic disparities remain with much of the burden falling on Black adult women aged 25-44. Ongoing transmission of HIV in this population has mostly resulted from heterosexual contact and prior studies have identified interpersonal and sociocultural factors that impede a woman’s choice to engage in safe sex and prevent HIV acquisition. With the debut of pre-exposure prophylaxis (PrEP), an FDA-approved once-daily pill to prevent HIV transmission, researchers believed that this user-controlled method would be an innovative method in reducing HIV in this subpopulation. However, since its release in 2012, there has been insufficient knowledge of PrEP among women in the U.S, resulting in slow and disproportionate uptake of PrEP in this population. While we know the clinical efficacy of PrEP, more understanding of the behavioral, social, and structural factors that impede PrEP awareness among women is important in the dissemination of PrEP-related information and subsequent use.In this dissertation, I took an exploratory approach to: a) identify awareness, knowledge, barriers and facilitators of PrEP use among US-based women through a systematic review; b) identify factors associated with PrEP awareness among female participants in the 2018 Community Health Survey; and c) explore how the presence of multiple deleterious factors can create distinct subgroups of women and further exacerbate disparities in PrEP awareness. In Paper 1, the systematic review of PrEP knowledge among Black/African American women identified 12 articles with findings disaggregated by both race and gender. Primary findings included gaps in PrEP knowledge; acceptability and willingness to use once informed of PrEP; perceived disadvantages as a result of exclusion in clinical trials and early dissemination; and social, structural, and institutional barriers to engagement in the PrEP care continuum. Papers 2 and 3 leveraged data from the 2018 Community Health Survey, a cross-sectional telephone survey of randomly selected adults aged 18 and older from all five boroughs of New York City. In Paper 2, 36% of a female subsample (N=2,295) were aware of PrEP at time of survey. As a result of multinomial linear regression, nine variables were significantly associated with PrEP awareness: nativity, education level, recent HIV test, number of sex partners, IPV, age, race/ethnicity, general health, and prior incarceration. In Paper 3, latent class analysis was used to identify distinct classes of women with varied responses to behavioral and structural variables. The adjusted item-response probabilities resulted in three distinct profiles of women: high resource and low risk group (39%), low resource and moderate risk group (33%), and moderate resource and high-risk group (28%). Key differences between groups include PrEP awareness, perceived health, count of sexual partners, and neighborhood poverty level. These findings have key implications for the way in which PrEP is marketed to women. Future studies should consider the importance of intersectionality and the social and structural context through which women engage with HIV prevention materials and promotional campaigns.Item Racial/Ethnic Disparities in Amputation and Revascularization: The Roles of Socioexonomic Reighborhood Stress and Allostatic Load(2020) Hughes, Kakra; Sehgal, Neil J; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Blacks are several times more likely to undergo a leg amputation as compared to Whites. This is because while peripheral artery disease (PAD), the most common cause of amputation, is more likely to be treated by revascularization (restoration of blood flow) in Whites, PAD is more likely to be treated by amputation in Blacks. Whereas an ongoing debate argues as to whether this disparity is primarily a sociologic versus a biologic phenomenon, I proposed that there are socioeconomic neighborhood stressors that create more severe PAD and renders individuals less likely to undergo successful revascularization and more likely to undergo amputation. Three specific aims are addressed in this dissertation resulting in three manuscripts. In Study 1, utilizing the Nationwide Inpatient Sample Database (NIS) in a retrospective study design, I determined that among patients admitted to the hospital for severe PAD, low socioeconomic status (SES) correlates positively with the likelihood of amputation, but paradoxically correlates negatively with the severity of PAD. In Study 2, I used the National Health and Nutrition Examination Survey, in a cross-sectional study design, to evaluate if there was a relationship between PAD severity, as determined by the ankle-brachial index (ABI) and the level of allostatic load. I did not identify an association. In Study 3, I employed the Nationwide Readmission Databases to show that low SES positively correlates with readmission for amputation following surgical revascularization. Findings from these three papers indicate that there is a positive correlation between low SES and the likelihood of amputation both upon initial admission as well as during subsequent follow up after surgical revascularization. I was unable to establish a clear relationship between PAD severity and allostatic load. The paradoxical finding that low SES individuals present with less severe manifestation of PAD signifies that there are yet-to-be-established factors involved in this complex disparity. This dissertation underscores the dominant role of social determinants of health and submits that in order to adequately address this amputation-revascularization disparity and avoid unnecessary amputations, major investments need to be made not only in healthcare, but also in America’s social infrastructure.Item SOCIAL AND ENVIRONMENTAL BARRIERS TO HEALTHCARE ACCESS AND UTILIZATION FOR LESBIAN, GAY, AND BISEXUAL PEOPLE IN CALIFORNIA.(2020) Akre, Ellesse-Roselee; Roby, Dylan H; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Sexual minorities, lesbian, gay and bisexual people, are exposed to chronic stigmatization and heteronormativity in their daily lives and when they access health care. There are no genetic differences between sexual minorities and their heterosexual counterparts; the literature demonstrates that chronic stress related to being a minority, experiences associated with accessing care in a system that assumes one is heterosexual, exposure to negative attitudes from others, and internalized negative attitudes regarding one’s sexuality impact health outcomes and healthcare access and utilization. While there are known barriers to healthcare access the literature does not examine how multiple social identities influence healthcare access in sexual minorities. Intersectionality posits that the interconnected nature of social identities creates an overlapping and interdependent system of disadvantage. This study had three aims: 1) To examine differences in healthcare access at the intersections of urbanicity, race/ethnicity, and sexual identity; 2) examine differences in healthcare access at the intersections of sexual identity, gender, and income; and 3) determine whether non-identifying sexual minorities have disparate access to healthcare compared to identifying sexual minorities. Using 2014-2017 California Health Interview Survey data combined with the supplemental sexual orientation special use research file, I examined the relationship between healthcare access and utilization outcomes and the intersections between sexual identity, urbanicity, gender, income, and sexual identity disclosures. Using known evidence of barriers to healthcare access as dependent variables I used predictive modeling to estimate odds ratios of experiencing barriers to healthcare access using adjusted logistic regressions. The results of my dissertation produced evidence that for sexual minorities in California, sexual identity is associated with varying levels of healthcare access when examined within the context of other social identities. That is, there are differences in access and utilization amongst sexual minorities based on income and gender, and within subgroups of sexual minorities, especially in female and bisexual subgroups. Urban and rural environment did not determine healthcare access in sexual minorities and there was not enough data to confidently estimate differences in access between urban and rural sexual minorities of color. Study findings demonstrate that the female gender has more disadvantages to healthcare access that advantages regardless of income and sexual identity. They also demonstrated that income does not fully mitigate access barriers in sexual minority women. Lastly, findings from the study demonstrate that the non-identifying sexual minority identity is associated with less access to healthcare, specifically in men. Findings from this dissertation contributes to the knowledge of how disparities in healthcare access and utilization continue to persist in the sexual minority population despite increased access to healthcare coverage. This dissertation suggests that other factors uniquely related to being female and bisexual are salient for accessing healthcare for sexual minorities. It is essential that researchers, policy makers, and healthcare providers and staff provide more data on sexual minorities, create curated policy to support the most vulnerable sexual minorities, and engage in culturally sensitive training to eliminate barriers to healthcare access for sexual minorities to eliminate healthcare access disparities.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 DEVELOPMENT OF A COMMUNITY INFORMED CUMULATIVE STRESSORS AND RESILIENCY INDEX (CSRI) TO EXAMINE ENVIRONMENTAL HEALTH DISPARITIES AND DISEASE RISK IN SOUTH CAROLINA(2017) Naney, Kristen Burwell; Wilson, Sacoby M; Maryland Institute for Applied Environmental Health; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Communities with environmental justice (EJ) issues usually have disparities in exposure to chemical and non-chemical stressors and health status compared to other communities without underlying EJ issues. Improving cumulative risk assessment (CRA) screening tools and models can provide the necessary information needed to reduce health disparities and create more resilient communities. To address these gaps in EJ science, this dissertation has three specific aims: 1) Identify perceptions of environmental and resilience factors that may influence health among African-Americans in North Charleston, South Carolina (SC) (Study 1), 2) Develop a Cumulative Stressors and Resiliency Index (CSRI) used to rank risk in SC (Study 2), and 3) Examine associations between CSRI scores and risk of asthma hospitalizations/emergency department (ED) visits in SC (Study 3). Community stakeholders (N=18) participated in key-informant interviews and completed a 26-item paper survey in study one. Interviews were transcribed and coded, while mode, frequencies, and percentages were calculated for each indicator based on its ability to influence health. Statistical tests performed in study two included a Principal Component Analysis (PCA), one-way analysis of variance (ANOVA), and linear regression performed in SAS Enterprise Guide 7.1. Choropleth maps were also developed in ArcMap 10.5. We concluded by calculating descriptive statistics by Environmental Affairs (EA) region, Spearman’s rank-order correlation, one-way ANOVA, and negative binomial regression analyses in study three. Many of the indicators (61%) were rated as extremely high priority items and included environmental hazards, sociodemographic attributes, and factors that may influence resiliency. CSRI scores ranged from 7.4 – 64.0 with a mean score of 29.1. Statistically significant differences in CSRI scores were evident by EA region (p <0.0001) and a one-unit increase in the percentage of non-white populations per census tract projected to increase CSRI scores by roughly 6.1%. The CSRI was not able to predict risk of asthma hospitalizations/ED visits as hypothesized. Overall, we demonstrated that identifying and addressing chemical and non-chemical stressors and resiliency gaps in areas impacted by environmental injustice may lead to overall improvements in community resilience. We anticipate this work will be used as a blueprint to build more resilient and equitable communities in SC.Item H1N1 Risk and Vulnerability: Applying Intersectionality in a Pandemic Context(2016) Jamison, Amelia Montgomery; Slopen, Natalie B; Epidemiology and Biostatistics; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)During influenza pandemics, existing health disparities are exacerbated, increasing vulnerability to disease among minority populations. This research utilized national survey data collected during 2009-10 H1N1 Influenza pandemic to examine the relationship between vulnerability and perceived H1N1 risk in a sample (N=1,479) of non-Hispanic White, non-Hispanic Black, and Hispanic adults and the prospective association of vulnerability and perceived H1N1 risk on vaccine uptake seven months later (N=913). Bivariate analysis and linear regression modeling were used to detect patterns in perceived H1N1 risk. Logistic regression modeling was used to test independent variables on vaccine uptake. Hispanics and non-Hispanic Blacks had higher vulnerability compared to non-Hispanic Whites. Race/ethnicity and vulnerability were significant independent predictors for perceived H1N1 risk. We observed a positive, graded relationship between odds of vaccination and perceived H1N1 risk.Item An Intersectional Gaze at Latinidad, Nation, Gender and Self-Perceived Health Status(2008-04-25) Logie, Laura Ann; Zambrana, Ruth E; Women's Studies; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)This study's main objective is to examine selected health care factors that are associated with self-perceived health status. Five research questions guided this study: Are there differences by gender on health access, English language proficiency, literacy levels, health behaviors, perceived discrimination and depression? Are there differences in reported number of chronic conditions, sources of health information and complementary/alternative medicine (CAM) used by gender? What factors are most likely to predict self-perceived health status by gender? What complementary and alternative medicines are Central and South Americans most likely to use by gender? And what sociodemographic factors distinguish Central and South Americans from other Latinos subgroups? The study used a cross-sectional design. Data was collected using a survey instrument that obtained sociodemographic information, and measured literacy, health behaviors, perceived discrimination and self-reported presence of chronic conditions, sources of health information and use of CAM. Multi-methods were used to analyze data: descriptive, univariate and bivariate analytic techniques; content analyses and regrouping of responses into thematic categories; and comparative analyses of socio-demographic and access indicators of study sample to national data. The major findings of this study are that few gender differences were found on the major study variables. However, women are less likely to drink alcohol and smoke but have higher rates of depression. Reported number of chronic conditions, sources of health information, and complementary/alternative medicine showed no difference by gender. The strongest predictor of self-perceived health status was higher education level. Sociodemographic factors that distinguish Central and South Americans from Latinos subgroups include: the study sample has significantly less income than the national sample although similar education levels; self-perceived health status of fair/poor is higher among study sample than other Latino subgroups with Central and South American women respondents having higher rates than male respondents. This study contributes to knowledge in the field of Women's Studies and Latino Studies by expanding the lens of the study of women's health by theorizing the importance of the intersection of race/ethnicity and class as experienced by Latinas.