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 Preventing Drowsy Driving in Young Adults Through Messaging Strategies that Influence Perceptions of Control and Risk(2024) Lee, Clark Johnson; Butler III, James; Beck, Kenneth H; Public and Community Health; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Drowsy driving is a serious health and safety problem in the United States: thousands of car crashes on U.S. roadways each year are attributed to this risky driving behavior. Although young drivers under the age of 26 years are especially at risk for being involved in drowsy driving car crashes, few anti-drowsy driving interventions targeting such drivers have been developed. Furthermore, most existing educational materials and interventions against drowsy driving have focused primarily on providing factual information about the dangers of drowsy driving and countermeasures against these dangers rather than on influencing beliefs and motivations underlying drowsy driving behavior, which may explain their apparent ineffectiveness at preventing drowsy driving behavior and resultant car crashes. Recent research indicates that messages targeting perceptions of control may be effective intervention strategies against drowsy driving behavior for young adult drivers by influencing their drowsy driving-related perceptions of risk, intentions, and willingness. This dissertation continues this line of research by pursuing two lines of inquiry. In Study #1, the efficacy of anti-drowsy driving messaging strategies designed to influence perceptions of control and risk related to drowsy driving behavior in reducing drowsy driving intentions, willingness, and behavior in a sample of young adult U.S. drivers between 18 and 25 years of age was evaluated through a randomized controlled trial. Study #1 sought to test the following hypotheses: Hypothesis 1: Participants exposed to interventional messaging strategies primarily aimed at lowering perceptions of control or heightening perceptions of risk related to drowsy driving report significantly less perceived control, greater perceived risk, less intentions, less willingness, and less behavior related to drowsy driving at 30-day post-intervention follow-up compared to participants exposed to messaging strategies providing only factual information about the dangers of drowsy driving; and Hypothesis 2: Participants exposed to interventional messaging strategies aimed at both lowering perceptions of control and heightening perceptions of risk related to drowsy driving report significantly less perceived control, greater perceived risk, less intentions, less willingness, and less behavior related to drowsy driving at 30-day post-intervention follow-up compared to participants exposed to messaging strategies providing only factual information about the dangers of drowsy driving, messaging strategies primarily aimed at lowering perceptions of control related to drowsy driving, or messaging strategies primarily aimed at heightening perceptions of risk related to drowsy driving. In Study #2, the relationships between perceived behavioral control, risk perception, intentions, willingness, and drowsy driving behavior in a sample of young adult U.S. drivers between 18 and 25 years of age were examined. Study #2 sought to test the following hypotheses: Hypothesis 3: The impact of interventional messaging strategies targeting drowsy driving perception of control on drowsy driving intentions, willingness, and behavior is mediated by drowsy driving risk perception such that messages lowering drowsy driving perceptions of control also heighten drowsy driving risk perception, which in turn decreases drowsy driving intentions, willingness, and behavior; Hypothesis 4: Interventional messaging strategies targeting drowsy driving-related perceptions of control or risk have a greater impact on drowsy driving willingness than on drowsy driving intentions; and Hypothesis 5: Drowsy driving willingness is a stronger predictor of drowsy driving behavior than is drowsy driving intentions. Study #1 provided supporting evidence of short-term cognitive effects but not short-term behavioral effects after exposure to messaging interventions designed to influence perceptions of control and risk related to drowsy driving behavior. Perceptions of risk were especially influenced by the messaging strategies examined, including those that provided only factual, knowledge-based information about drowsy driving. Study #2 provided supporting evidence that perceived behavioral control influenced drowsy driving intentions and drowsy driving willingness indirectly through perceptions of risk. Furthermore, willingness to drive drowsy was a stronger predictor of actual drowsy driving behavior than intentions to drive drowsy. The findings from these two studies should inform future research aimed at developing more effective messaging strategies against drowsy driving behavior in young adults.Item DISPARITIES IN ADOLESCENT MENTAL HEALTH SERVICES UTILIZATION AND HELP-SEEKING(2024) Truong, Michelle L; Sehgal, Neil J; Boudreaux, Michel; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Inequities in access to and utilization of mental and behavioral health care for adolescents have persisted for numerous decades. Adolescents from racial and ethnic minority backgrounds, as well as those in underserved geographic regions, are disproportionately impacted. As the youth mental health crisis escalates, it is critical to study the mechanisms driving these disparities to inform effective and targeted interventions and policies. Divided into three studies, this dissertation explored the influence of individual, cultural, and contextual factors on adolescent help-seeking behaviors using data from the 2009 and 2011 to 2019 California Health Interview Survey (CHIS).The first study employed mediation analyses to assess the extent to which having a subjective or perceived need for mental health care, conditional on objective need, contributes to racial and ethnic disparities in mental health services utilization. I found significant racial and ethnic differences in subjective needs for mental health services and that these differences partially explain the racial and ethnic disparities in service utilization. The second study explored differences in mental health service utilization among subgroups of non-Hispanic (NH) Asian and Latino/Hispanic adolescents compared to NH white adolescents. I found that Vietnamese and Mexican adolescents were significantly less likely to utilize mental health services relative to their NH white counterparts. The third study merged the adolescent data with provider data from the National Plan and Provider Enumeration System (NPPES), facility data from the National Substance Use and Mental Health Services Survey (N-SUMHSS), and population data from the US Decennial Census Redistricting Data Summary Files to assess the moderating effects of distance to the nearest pediatric mental health facility and provider-to-population densities on the relationship between subjective mental health care needs and service utilization. I discovered that provider density and subjective needs interact, resulting in a diminished effect of subjective needs on service utilization among adolescents residing in areas with lower primary care provider density. I did not find that distance to the nearest pediatric mental health facility had a significant impact on service utilization. This dissertation examined racial, ethnic, and geographic mental health care disparities among a diverse adolescent population in California. Findings from this work contribute to the understanding of adolescent help-seeking behaviors and provide insights for targeted interventions and policies to advance mental health care equity.Item Values in American Hearing Healthcare(2024) Menon, Katherine Noel; Hoover, Eric C; Hearing and Speech Sciences; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)The long-term objective of this research is to create a more inclusive, patient-centered hearing healthcare system that aligns with all stakeholders’ diverse values and needs. This dissertation explores the values shaping hearing healthcare through three complementary studies. Chapter 2 analyzes the introduction of over-the-counter (OTC) hearing aids, revealing a values shift from traditional audiology’s focus on accuracy, safety, and subjective benefit to prioritizing access and affordability. Implementing an OTC service delivery model for hearing healthcare promoted values different from those of traditional audiology. Still, the creation of OTC offers affordances that enable us to create more patient-centered hearing healthcare systems to reflect stakeholders’ values. Chapter 3 validates a comprehensive list of values in audiology through a national survey of audiologists, confirming alignment with best-practice guidelines. Previous work developed a codebook of values based on textual documents representing best practices in traditional audiology, and it was essential to validate these findings by directly engaging with audiologists. Chapter 4 develops a codebook based on the values of individuals with hearing difficulties, categorizing their concerns into Material, Social, and Healthcare domains. Results from this study highlight the importance of considering the values of individuals with hearing loss, which encompasses not only the use of hearing aids and affordable hearing healthcare but also concerns regarding the effectiveness, usefulness, and social implications of hearing aids. Together, these studies underscore the balance between efforts to improve accessibility and the need to maintain patient-centered outcomes, suggesting that future research should focus on understanding how values intersect with the daily lives and decision-making processes of all people with difficulty hearing.Item Examining pre-training interpersonal skills as a predictor of post-training competence in mental health care among lay health workers in South Africa(2023) Rose, Alexandra Leah; Magidson, Jessica F.; Psychology; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)A worldwide shortage of mental health specialists contributes to a substantial global mental health treatment gap. Despite evidence that lay health workers (LHWs), or health workers with little formal training, can effectively deliver mental health care, LHWs vary widely in their abilities to competently deliver mental health care, which undermines the quality of care and patient safety. Prior research from both high-income and low- and middle-income countries suggests this variability may be predicted by LHW interpersonal skills, yet this relationship is little explored to date. The first aim of the current study, which uses an exploratory sequential mixed methods design, was to explore qualitative perspectives through semi-structured individual interviews (n=20, researchers, policymakers, NGO staff, LHWs) in Cape Town, South Africa on interpersonal skills relevant to delivery of mental health interventions by LHWs. The second aim was to quantitatively examine the preliminary effectiveness of pre-training interpersonal skills in predicting post-training competence following a mental health training among LHWs in Cape Town (n=26). Using a standardized LHW assessment measure adapted to the setting, two raters rated ten-minute standardized role plays conducted before and after the training for pre-training interpersonal skills and post-training competence. Qualitative findings highlight the perceived importance of and challenges with assessing interpersonal skills among LHWs being trained in psychological intervention. Quantitative analyses did not identify any interpersonal skills as significant predictors of post-training competence. However, interpersonal skills improved during the training itself, specifically verbal communication, suggesting the potential promise of further research in this area. Recruitment of larger samples with more variable training outcomes would be important in future studies examining predictors of LHW competence. Further research may ultimately help identify areas of intervention to support more LHWs in attaining competence and can help play an important role in increasing access to psychological services globally.Item COLLABORATIVE CO-DESIGN OF PORTABLE WORK BENEFITS POLICY MODEL AND NON-POLICY PROTOTYPE BASED ON DIRECT CARE WORKERS' NEEDS, ATTITUDES, AND BELIEFS(2024) Kuo, Charlene C.; Aparicio, Elizabeth M.; Public and Community Health; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Direct care workers (DCWs) assist people with disabilities and frail elders with activities of daily living, thereby preventing institutionalization, hospitalization, and other costly medical services. From 2016 to 2060, the number of adults aged 65 and over is expected to increase from 49.2 million to 94.7 million. The number of adults 18 to 64 will remain the same, leading to a shortage of family caregivers. A shortage of family caregivers will require a robust direct care workforce. The direct care workforce is expected to grow by 1.3 million from 2019 to 2029 but this growth will not keep pace with the projected demand. The turnover rate among DCWs is high due to poor work conditions and inadequate compensation. Exploring ways to improve DCW working conditions and compensation is critical to prevent further shortages. DCWs' health is put at risk due to the nature of the work, low wages, and lack of worker protections and traditional work benefits. DCWs are vulnerable to injury, abuse, infectious diseases, and other poor health outcomes due to the previously listed disadvantages (Campbell, 2019c; Hughes, 2020; Jaffe, 2017; M. M. Quinn et al., 2016). DCWs in the United States are predominantly women, members of racial and ethnic minority groups, and one in four workers are immigrants.Work benefits improve health outcomes and protect clients of DCWs from healthcare-associated infections by allowing DCWs to take paid sick leave when ill. Portable benefits are benefits employees can take from job to job, prorated so that multiple employers can contribute, and accessible to all workers. Portable benefits are not widely available. I held 1)individual in-depth interviews and focus groups to explore the needs, attitudes, and beliefs of DCWs regarding work benefits, 2) two co-design sessions and a member checking session with DCWs to develop and refine policy recommendations for Maryland DCWs' portable work benefits, and 3) a co-design session and member checking sessions to develop usability recommendations for websites delivering portable benefits to DCWs. This study provides findings about direct care workers' experiences with inadequate or nonexistent work benefits, their recommendations for policy to support benefits that meet their needs and preferences, and their usability recommendations for portable benefits websites. This study provides information on how to design work benefits for DCWs that protect them, protect those around them, and improve work conditions in hopes of improving work conditions and compensation.Item Distress and Deaths of Despair in the U.S. Healthcare Delivery System: Understanding Patterns in Healthcare among Distressed Americans(2024) Spencer, Merianne Rose Tiglao; Chen, Jie; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)The United States has experienced rising mortality rates for the past several decades. Drug poisonings have increased nearly five-fold, suicide rates by nearly 40%, and by nearly 30% percent for alcohol-induced deaths between 1999 and 2021. This collection of drug-, alcohol- and suicide deaths are oftentimes referred to as “deaths of despair”, first coined by economists Anne Case and Angus Deaton who cited health and socioeconomic disparities driving Americans into mental distress, depression, and anxiety. The impact on the mental health of Americans was further exacerbated by the COVID-19 pandemic; this exposed vulnerabilities in the mental healthcare system as well as the various stressors that negatively impacted individuals across the globe. Using nationally representative data, this dissertation delves into the deaths of despair phenomenon using a multidisciplinary health services research lens. Access, utilization, and risk from deaths of despair are examined by using psychological distress (which is treated as a proxy for despair in the first two aims). Using the Kessler-6 scale, a well-accepted and clinically valid tool for non-specific mental distress, this dissertation explores patterns of healthcare spending among those with varying severity levels of psychological distress over a two-decade period; delves into patterns of healthcare utilization among young adults aged 18-30 (a population disproportionately impacted by stressors during the COVID-19 pandemic) by psychological distress; and quantifies the risk of death among those with varying severity levels of psychological distress.Item ALLOSTATIC LOAD INFLUENCES VASCULAR FUNCTION AND SYMPATHOLYSIS IN YOUNG BLACK ADULTS(2024) Eagan, Lauren Elizabeth; Ranadive, Sushant M; Kinesiology; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)In the U.S., Black individuals tend to face a disproportionately higher risk for hypertension. This is largely attributed to chronic sympathetic activation induced by heightened exposure to psychosocial stressors. Allostatic load (AL), an index of cumulative physiological dysfunction from chronic stress, is associated with hypertensive risk and is also heightened in Black adults compared to those of other racial groups. Indeed, increased sympathetic activity is a hallmark characteristic of both hypertension and AL. The inability to blunt sympathetic-induced vasoconstriction during exercise (impaired functional sympatholysis) is also associated with hypertension. This dissertation aimed to investigate whether AL was associated with measures of vascular health in young Black adults, both at rest and during a sympathetic stressor. In our first study, we examined associations between AL and indices of vascular function and structure among young Black adults at rest, finding that higher AL was associated with greater macrovascular dysfunction and amplified wave-reflections. Additionally, we identified significant correlations among greater self-perceived stress with smaller brachial artery diameters and greater wave-reflections. The second aim of this dissertation focused on the associations between AL and the magnitude of functional sympatholysis among this population. Results indicated a positive association between AL and functional sympatholysis, with amplified sympatholytic responses among young Black females, as compared to their male counterparts, when forearm volume was controlled for. Overall, our findings suggest that elevated AL might predict macrovascular dysfunction at rest, with larger arterial diameters potentially compensating for chronic stress. These adaptive mechanisms, commonly observed in aging and diseased states, may also explain the positive correlations between AL and the functional sympatholytic response in young Black adults. Our consistent observations of the redundant vascular mechanisms among young Black adults allowing for adaptation to chronic stress strengthen our findings and further highlight the complex interplay between stress and cardiovascular health in Black adults.Item CHARACTERISTICS AND HEALTH INSURANCE COVERAGE AMONG ADOPTED CHILDREN IN THE UNITED STATES(2024) Fleishman, Jamie Lin; Yue, Dahai; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)The practice of adopting a child is a common occurrence within the United States. Research on adoption, birth parents, and adoptive parents has traditionally focused on psychology and social work outcomes. This master’s thesis shifts the focus of adoption outcomes to a public health perspective, examining the demographics, socioeconomic conditions, and health insurance rates of domestic and international adoptees. To help determine the rates of any health insurance, public health insurance, and private health insurance, this thesis examined American Community Survey 2022 5-year data, a nationally representative study of adoptees and their counterparts—non-adoptees who are biologically related to their parents or head of household. It was determined that domestic adoptees and non-adoptees had similar demographic and socioeconomic statuses whereas international adoptees were predominantly non-Hispanic Asians, females, and have wealthier and White heads of households. After controlling for demographic and socioeconomic variables, it was discovered that international adoptees have higher uninsured rates compared to non-adoptees and domestic adoptees, which could be attributed to geographic differences in health insurance coverage. Further research is needed to examine health insurance coverage rates in the United States for adoptees.Item Second Wave Mechanics(2024) Fabbri, Anthony; Herrmann, Jeffrey W; Mechanical Engineering; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)The COVID-19 pandemic experienced very well-documented "waves" of the virus's progression, which can be analyzed to predict future wave behavior. This thesis describes a data analysis algorithm for analyzing pandemic behavior and other, similar problems. This involves splitting the linear and sinusoidal elements of a pandemic in order to predict the behavior of future "waves" of infection from previous "waves" of infection, creating a very long-term prediction of a pandemic. Common wave shape patterns can also be identified, to predict the pattern of mutations that have recently occurred, but have not become popularly known as yet, to predict the remaining future outcome of the wave. By only considering the patterns in the data that could possibly have acted in tandem to generate the observed results, many false patterns can be eliminated, and, therefore, hidden variables can be estimated to a very high degree of probability. Similar mathematical relationships can reveal hidden variables in other underlying differential equations.Item THE POLICY IMPACT OF STATE REINSURANCE PROGRAMS UNDER THE ACA 1332 WAIVER(2024) Wang, Ren Hao; Yue, Dahai; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Ten years after the implementation of the ACA, US families have been experiencing a continuing increase in the average premium for health insurance coverage. Although the case differs for the low-income population, providing affordable health insurance remains a significant policy issue. Section 1332 waiver of the ACA allows states to develop innovative strategies to provide affordable health insurance upholding the required high-quality care and basic protections. Seventeen states took the market-oriented approach of state reinsurance programs to stabilize the health insurance market and restrain premium increases. Using RWJF HIX data as well as public and restricted MEPS data, this dissertation investigated the policy impact of state reinsurance programs over premium reduction in the health exchange market, unintended consequence of crowding out Employer-Sponsored Insurance, as well as changes in out-of-pocket premium and insurance coverage on the consumer perspective.