Theses and Dissertations from UMD
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Item The Critical Race Framework Study: Standardizing Critical Evaluation for Research Studies That Use Racial Taxonomy(2024) Williams, Christopher M.; Fryer, Craig S.; Public and Community Health; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Introduction: Race is one of the most common variables in public health surveillance and research. Yet, studies involving racial measures show poor conceptual clarity and inconsistent operational definitions. There does not exist a bias tool in the public health literature for structured qualitative evaluation in critical areas of critical appraisal – reliability, validity, internal validity, and external validity – for studies that use racial taxonomy. This study developed the Critical Race (CR) Framework to address a major gap in the literature. Methods: The study involved three iterative phases to answer five research questions (RQs). Phase I was a pilot study of the CR Framework among public health faculty and doctoral students to assess measures of fit (RQ1) and to identify areas of improvement in training, instrumentation, and study design (RQ2). Study participants received training and performed a single article evaluation. Phase II was a national cross-sectional study of public health experts to assess perceptions of the revised training and tool to assess measures of fit (RQ1), to determine the influence of demographic and research factors on perceptions (RQ3), and to gather validity evidence on constructs (RQ4). In Phase III, three raters performed article evaluations to support reliability evidence (RQ4) and to determine the quality of health disparities and behavioral health research studies against the CR Framework (RQ5). Analysis: We assessed the reliability of study results and the CR Framework using non-differentiation analysis, thematic analysis, missingness analysis, user data, measures of internal consistency for adopted instruments, interrater agreement, and interrater reliability. Validity was assessed using content validity (CVI and k*), construct validity, and exploratory factor analyses (EFA). Results: The study recruited 30 highly skilled public health experts across its three phases as part of the final analytic sample. Phase I had poor reliability in which the results could not be confidently interpreted (RQ1) and indicated needed improvement in study design, training, and instrumentation (RQ2). Based on Phase II results, we met or exceeded acceptable thresholds for measures of fit – acceptability, appropriateness, feasibility, and satisfaction (RQ1). Demographic or research factors were not associated with responses (RQ3). Interrater agreement was moderate to high among rater pairs (RQ4). Due to lack of confidence in significance testing, interrater reliability results were inconclusive. Overall data results showed excellent content validity. Based on EFA results, construct validity for reliability and validity items was poor to fair (RQ4). Data results were inconclusive on internal validity and external validity. The twenty studies used in critical appraisal showed low quality or no discussion when the Critical Race Framework was used (RQ5). Discussion: The CR Framework study developed a tool and training with quality evidence for implementation effectiveness, content validity, and interrater reliability to fill a major gap in the public health literature. It contributed an innovative theory-based tool and training to the literature. Future research should seek to study individual perceptions and practices that influence outcomes of CR Framework application and to reduce barriers to ensure that minimum sample sizes can be met for additional testing.Item Assessing Changes in Access to Health care and Utilization of Preventive Services among Immigrants of African Descent Before and After Implementation of the Affordable Care Act(2020) Williams-Parry, Kester F; Chen, Jie; Thomas, Stephen B.; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)In the U.S., African Americans experience a disproportionate burden of health disparities. The African American population includes 4.3 million people who are foreign-born. Yet, a paucity of empirical data exists on the health of immigrants of African descent. The lack of data disaggregation by subpopulations of African Americans, disregards the unique characterization of the African American diaspora and the influence of different cultural, linguistic, political, social, economic, environmental, and historical experience on the overall health of the population. Access to health care including lack of health insurance coverage has been a longstanding contributor to poor health outcomes among African Americans. The passage of the Affordable Care Act aimed to improve access to care including health insurance coverage and utilization of preventive services with no cost-sharing. Studies have shown significant reductions in the uninsured rate among African Americans and uptake in some preventive services, but the impact of the ACA on immigrants of African descent is not well understood. This dissertation research examined changes in access to health care, and utilization of preventive screenings for cancer, high blood pressure, diabetes, and high cholesterol among immigrants of African descent and U.S.-born African Americans before and after implementation of the ACA. This research integrated three studies to understand changes in access and utilization of health care using t-test for descriptive analyses and multivariable logistic regressions to assess any differences post-ACA. Results showed lower odds of being uninsured (OR=0.52, p=0.000), delaying care (OR=0.72, p=0.000), and forgoing care (OR=0.71, p=0.000) post-ACA, for all groups. There were higher odds of having cholesterol (OR=1.33, p=0.000) and hypertension screenings (OR=1.32, p=0.000) after the ACA. Cancer screening results found slightly higher odds of obtaining a mammogram (OR=1.07, p=0.069) after the ACA, but lower odds of having a pap smear (OR=0.89, p=0.002) or colorectal cancer (OR=0.91, p=0.021) screening. Citizenship was a significant factor that influenced screening rates with non-citizen immigrants having the lowest screenings for all groups.Item Health Policy, Care Coordination, and Racial and Ethnic Disparities Among US Adults Aged 18-64 with Serious Psychological Distress(2019) Novak, Priscilla; Chen, Jie; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)About one in five Americans have a mental health condition, and in any given year, 3-5% of the population experiences serious psychological distress (SPD). The goal of this dissertation is to examine the impact of health policy on racial and ethnic disparities among people experiencing SPD. The literature review in my dissertation details evidence on systemic racial and ethnic differences in access, quality, and care coordination. I develop a causal theory examining the reasons why the problem of SPD and racial and ethnic health disparities exist and specific evidence that illuminates how the problems come into existence. Using National Health Interview Survey data from 2011-2016, access to care among Non-Hispanic (NH) Whites, NH Blacks and Hispanics with SPD is examined. Findings suggest that in comparison to NH Whites, NH Blacks and Hispanics experienced greater gains in health care access following the Affordable Care Act (ACA). Next, using data from the 2015 and 2016 Medical Expenditure Panel Survey, differences in racial and ethnic minorities being served by usual sources of care with care coordination services is examined. Findings suggest that in comparison with NH Whites with SPD, Hispanics with SPD had lower odds of being seen at a Patient Centered Medical Home (OR 0.55, (p <0.05)). Hispanics had higher odds (1.29 (p <0.03)) of being seen at a practice that used case managers; and Non-Hispanic Blacks with SPD had higher odds (3.25 (p< 0.001)) of being seen at a practice that used care managers. Given that people with diabetes experiences mental health conditions occur at about twice the rate of the general population, this dissertation examined the quality of care provided to people with doctor-diagnosed diabetes and SPD using data from the Medical Expenditure Panel Survey. Findings suggest that between 2012 and 2016, racial and ethnic disparities in the receipt of glycated hemoglobin (HbA1c) testing improved but were not eliminated. Results suggest that increased health insurance coverage alone does not eliminate health disparities, and work remains to be done to ensure that all Americans benefit from high-quality, evidence-based care.Item PREVENTIVE CARE UTILIZATION AND ITS IMPACT ON POTENTIALLY PREVENTABLE HOSPITALIZATIONS: IMPLICATIONS OF MEDICAID COST-SHARING, MEDICAID EXPANSION, AND THE AFFORDABLE CARE ACT FOR VULNERABLE POPULATIONS(2017) Bloodworth, Robin; Chen, Jie; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)About half of Americans have at least one chronic disease, and chronic diseases account for nearly 90% of healthcare expenditures in the US. Primary care can reduce potentially preventable hospitalizations and overall costs of chronic diseases. However, only about 3% of US healthcare spending is on prevention. Racial/ethnic disparities and income disparities have been well documented in the use of primary care. The ACA expanded insurance coverage for millions of Americans and included a mandate that all insurance plans must cover recommended preventive services at no cost to the patient. Literature shows the ACA resulted in an increase in access to care, but results on utilization rates of primary care post-ACA are mixed. Using nationally representative data sets from 2009-2015, I examined the utilization rates of preventive services among vulnerable populations after the full implementation of the ACA, and how Medicaid state policy and expansion under the ACA affected the utilization of preventive services among vulnerable populations. Next, using the Maryland Medical Care Database from 2012-2014, I examined how continuity of primary care affects the odds of having any hospitalization as well as potentially preventable hospitalizations. I found that the ACA was associated with an increase in preventive services recommended yearly, and the ACA was not associated with disparities in preventive service utilization among vulnerable populations. Additionally, I found that state Medicaid policies on preventive services were associated with increased utilization of flu shot, but Medicaid expansion was not associated with increased utilization of preventive services or many changes in disparities in preventive service utilization among vulnerable populations. Finally, I found that primary care, especially ongoing primary care, was strongly associated with a decrease in the odds of having any hospitalization and potentially preventable hospitalizations. Results suggest that increased access alone will not increase utilization rates and reduce health disparities, but rather, a focus on education of what coverage options are available through the ACA, the importance of ongoing primary care, and how to navigate the healthcare system once insured could increase utilization of preventive care, especially in vulnerable populations.Item FACTORS ASSOCIATED WITH COMPLETION OF THE HUMAN PAPILLOMAVIRUS VACCINE SERIES AMONG HISPANIC AND NON-HISPANIC WHITE ADOLESCENT GIRLS IN THE UNITED STATES(2011) Demarco, Maria Teresa; Carter-Pokras, Olivia; Epidemiology and Biostatistics; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Despite recommendations of three Human Papillomavirus (HPV) vaccine shots for all adolescent girls, only 29.1% of non-Hispanic Whites and 23.4% of Hispanics achieve completion. This study describes factors associated with completion of the HPV vaccine series among Hispanic and non-Hispanic White 13-17 year old girls who initiated the series. A secondary data analysis was performed of the cross-sectional 2009 National Immunization Survey-Teen survey. Despite similar initiation rates (one in five), Hispanic girls who had initiated the series (59.9%) were less likely to complete the series than non-Hispanic Whites (76.4%). After accounting for poverty status and home ownership, Hispanics were less likely to complete the HPV vaccine series. Factors associated with HPV vaccine series initiation were age at interview and age at HPV vaccine series initiation for Hispanics; and continuous health insurance since age of 11, mother's marital status, and number of children in the household for non-Hispanic Whites.Item Neighborhood Level Disadvantage, Race/Ethnicity and Infant Mortality in Washington DC(2010) Amutah, Ndidi N.; Anderson, Elaine A; Hofferth, Sandra L; Family Studies; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)This study examines the effects of neighborhood level disadvantage and individual level characteristics such as race/ethnicity on infant mortality. Social determinants of health theory and ecological theory were used to construct a neighborhood advantage index for Washington DC. Secondary analyses were conducted using linked birth/death certificate and census data from the DC State Center for Health Statistics. Live births (55,938) and infant deaths (607) occurring in Washington DC from 2001-2007 were examined. Multilevel modeling techniques were utilized to determine the relationship between individual and neighborhood level factors on infant mortality. The research questions were: (a) Do women who are comparable on factors such as maternal education and marital status experience different rates of infant mortality by race? (b) Do women living in areas of high disadvantage experience higher rates of infant mortality than women living in areas of low disadvantage? (c) Does the effect of race/ethnicity on infant mortality change if the mother lives in a place of high disadvantage versus low disadvantage? (d) Does having an infant born preterm or low birth weight increase the risk of infant mortality? Whites have the lowest rates of infant mortality (2.8/1000), followed by Hispanics (7.4/1000), with Blacks having the highest rates (15.2/1000) after adjusting for age, education, and marital status. These findings are consistent with previous research affirming a relationship between race/ethnicity and infant mortality. Infants born in disadvantaged neighborhoods are 1.63 times more likely to die before their first birthday than those born in advantaged neighborhoods. The odds for infant mortality compared to Whites decreases especially for Blacks (5.39 to 3.10; 42% change), living in disadvantaged communities even when race/ethnicity was interacted with the neighborhood disadvantage index. This suggests that disadvantage has different consequences for different race/ethnicity populations living in those neighborhoods. The importance of place (disadvantaged or advantaged neighborhood) in relation to infant mortality at the neighborhood level in addition to improving individual level factors is discussed for program development and policymakers. Implications for health disparities, maternal and child health, social support and future public health research are presented.Item Residential Segregation: Hurting or Helping U.S. Hispanic Health?(2009) Nelson, Kyle Anne; Iceland, John; Sociology; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)U.S. Hispanics experience health disparities that are in part socially determined. My dissertation explores the connections between health and residential segregation for Hispanics and key Hispanic subgroups in metropolitan America. I conduct a multivariate analysis combining individual-level health survey data on Hispanics from the 1997-2002 Urban Institute National Survey of America's Families with metropolitan area-level residential segregation scores from Census 2000. My primary research question is: What is the role of residential segregation in shaping the health disparities of U.S. Hispanics? I compare the link between segregation and health for U.S. Hispanics with African Americans, and evaluate differences among Hispanics by nativity and country of origin. My outcome measures are self-rated health, insurance status, and having a usual source of health care. I find a significant negative effect on health status of residential segregation from whites for U.S. Hispanics even after accounting for compositional factors such as poverty status and education. Consistent with spatial assimilation theory, however, much of the observed negative effects of segregation on health are overshadowed by individual-level socioeconomic characteristics. In support of place stratification theory which emphasizes the relative disadvantage of African Americans as racial minorities in the U.S., I find that African Americans experience modestly greater health disparities associated with segregation than Hispanics. Despite my prediction that health outcomes for foreign-born Hispanics may actually improve with higher segregation, nativity does not significantly alter the link between health and segregation among U.S. Hispanics. I do find a significant interaction between nativity and segregation for Mexicans in the prediction of being uninsured and for Cubans in the prediction of self-rated health. For foreign-born Mexicans, segregation is more of a disadvantage in the prediction of being uninsured. The only evidence I find of any positive or protective link between segregation and health is for Cuban-origin Hispanics whose odds of reporting good self-rated health increase with higher levels of segregation. While segregation has a positive association with health status for both U.S.-born and foreign-born Cubans, the effect is substantially stronger for the foreign born. This research highlights the importance of examining residential segregation as a social determinant of health, and reveals important nuances in the link between health and segregation for nativity and country-of-origin subgroups of U.S. Hispanics.Item The Impact of Formal Social Support on Outpatient Care Among a Sample of Adults Living with HIV/AIDS in the United States(2007-11-19) Matoff-Stepp, Sabrina A; Boekeloo, Ph.D., Bradley O.; Public and Community Health; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Background The HIV Cost and Services Utilization Study and HIV Research Network (HIVRN) clinical studies showed disparities among HIV-positive men and women in outpatient care use in the U.S. Formal social support provided by case managers may help patients access outpatient care. The primary purpose of this study was to determine if having case managers is associated with levels of outpatient care visits among 797 individuals living with HIV/AIDS, and whether this association varies by patient sex. Other aims were to determine if the number of in-person case management visits and the type of formal social support are associated with these same outcomes. Outpatient visit levels were defined as 2-5 (average) or 6+ (high). Based on Andersen's (1995) Behavioral Model of Health Services Use, a conceptual model was developed as a framework for examining the study's hypothesized relationships. Methods The HIVRN is a convenience sample of 17 U.S. clinical sites serving more than 15,000 people living with HIV/AIDS. In 2003, interviews were conducted with a stratified sample of 951 clients at 14 HIVRN sites. The current study sample consisted of 797 adult respondents (543 males and 254 females). Logistic regression was used to identify significant predictors of outpatient care visit levels. Results Patients who had one or two case managers versus no case managers were significantly more likely to have 6+ outpatient visits, while patients who were employed and had higher self-reported perceptions of their health were significantly less likely to have 6+ outpatient visits. These relationships did not vary by patient sex. Level of outpatient visits also did not vary by patient sex. No significant associations were found between the number of in-person case management visits or the type of formal social support and level of outpatient visits. In sub-analyses that separated patients with one case manager from those with two case managers, no new predictors emerged. Conclusion Case management was associated with higher levels of outpatient visits for both male and female patients in this study. This finding suggests that utilization of HIV-related outpatient care may be increased among both men and women with case management.Item Factors related to counseling Asian patients by primary care physicians on cancer prevention and screening recommendations(2007-04-26) Kwon, Harry; Gold, Robert S.; Public and Community Health; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Primary care physicians are a critical source for communicating important cancer screening recommendations and play a significant role in increasing the cancer screening behavior of their patients. Asians, one of the fastest growing minority groups in the United States, experience disproportionate incidence and mortality rates of certain cancers, as compared to those of other racial/ethnic groups. Further, cancer deaths among Asians have increased at a rate faster than that of any other racial/ethnic group, and since 1980, cancer has been the leading cause of death among Asian women. This exploratory study assessed and evaluated the issues and barriers related to appropriate and effective screening recommendations for the early detection of cancer for Asians in the U.S. It also sought to identify the factors associated with the likelihood of physicians making appropriate and persuasive cancer screening recommendations and to assess primary care physicians' perceptions of cancer risk in Asians. In addition, this exploratory study examined whether the Elaboration Likelihood Model (ELM) could be applied in a nontraditional manner to examine ELM components in relation to the occurrence of cancer screening recommendations. Primary care physicians practicing in New Jersey and New York City were mailed a 30-question (91-item) survey on medical practice characteristics, Asian patient communication, cancer screening guidelines, Asian cancer risk, and demographics. In total, 100 surveys were returned. Results showed that liver cancer and stomach cancer were perceived as higher cancer risks among Asians, as compared to those of the general population, and breast and prostate cancer were perceived as lower cancer risks. Significant relationships (p < .05) were found between the individual and aggregate components of the theoretical components and the occurrence of prevention screening recommendations made by physicians to their Asian patients. Physicians are integral public health liaisons who can be both influential and resourceful toward educating Asians about specific cancer awareness and screening information. The findings from this study provide pertinent information toward the development of interventions for physicians to recommend cancer screening in a way that maximizes the likelihood that Asian patients will follow up and be screened.