Behavioral & Community Health
Permanent URI for this communityhttp://hdl.handle.net/1903/2271
Prior to January 24, 2011, this unit was named the Department of Public & Community Health.
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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 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 Prevention is a Privilege: Black Drug-free Community Leaders Implementing Drug-free Community Coalitions in Black Communities(Journal of Ethnicity in Substance Abuse, 2024-02-15) Quinton, Sylvia L.; Burgon E; Hicks Harper, P. Thandi; Parker, Rosalind M.; Cunningham, Suzanne Randolph; Boekeloo, Bradley O.Community-based interventions for youth substance use prevention require high levels of capacity to organize and coordinate community resources to support youth development and create opportunities to prevent youth substance use. This project aimed to better understand what Black prevention practitioners perceive as the requirements for a successful drug-free community coalition. Black prevention practitioners, who were engaged in drug-free community funded coalitions had discussions about coalitions as a strategy for youth substance use prevention in Black communities. These facilitated discussions resulted in consensus over a set of nine core principles regarding successful youth substance use prevention coalition building in these communities.Item Measuring Union Formalization for a New Generation of Family Demography: A Case Study from Urban Kenya(Wiley, 2024-01-08) Stoebenau, Kirsten; Madhavan, Sangeetha; Kim, Seungwan; Wainaina, CarolDespite repeated calls for improved measures of marriage as a process in sub-Saharan Africa, large-scale surveys continue to rely on static marital status. As a result, there is an incomplete understanding of the effects of marriage on outcomes of interest. We use qualitative and survey data from a longitudinal study of 1,203 young mothers residing in informal settlements of Nairobi, Kenya, to (1) describe the development of an innovative measure of union formalization (UF) defined as the steps through which a union attains social legitimacy; (2) compare UF with a conventional current marital status measure; (3) examine the distribution of UF steps across union history; and (4) examine the sequence and timing of pregnancy and childbearing within the UF process. We find UF steps indicative of both increasing individualization of marriage and the ongoing importance of kin involvement hold meaning. We demonstrate extensive heterogeneity in the sequence and extent of UF steps completed and interrogate the classification of premarital childbearing using sequence analysis. We argue that measuring UF is feasible and necessary for the next generation of family demography in Africa; UF measures facilitate understanding the linkages among family dynamics, health, and social stratification within the context of ongoing socioeconomic change.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 LGBTQ+ cultural-competence training effectiveness: Mental health organization and therapist survey outcome results from a pilot randomized controlled trial(Wiley, 2023-08-25) Boekeloo, Bradley; Fish, Jessica; Turpin, Rodman; Aparicio, Elizabeth M.; Shin, Richard; Vigorito, Michael A.; Lare, Sean M.; McGraw, James S.; King-Marshall, EvelynLesbian, gay, bisexual, transgender, queer/questioning and other sexual and gender diverse (LGBTQ+) persons frequently lack access to mental health service organizations (MHOs) and therapists who are competent with LGBTQ+ clients. Existing continuing education programmes to better equip therapists to work with LGBTQ+ clients are often not widely accessible or skills focused, evaluated for effectiveness and inclusive of MHO administrators who can address the organizational climate needed for therapist effectiveness. A virtual, face-to-face, multi-level (administrators and therapists) and multi-strategy (technical assistance, workshop and clinical consultations) LGBTQ+ cultural competence training—the Sexual and Gender Diversity Learning Community (SGDLC)—was tested in a pilot randomized controlled trial. Ten organizations were randomly assigned to the intervention (SGDLC plus free online videos) or control (free online videos only) group. Pretest/posttest Organization LGBTQ+ Climate Surveys (n = 10 MHOs) and pretest/posttest Therapist LGBTQ+ Competence Self-Assessments (n = 48 therapists) were administered. Results showed that at pretest, average ratings across organization LGBTQ+ climate survey items were low; twice as many items improved on average in the intervention (10/18 items) than control (5/18 items) group organizations. At pretest, therapist average scores (range 0–1) were highest for knowledge (0.88), followed by affirmative attitudes (0.81), practice self-efficacy (0.81), affirmative practices (0.75) and commitment to continued learning (0.69). Pretest/posttest change scores were higher for the intervention relative to the control group regarding therapist self-reported affirmative attitudes (cumulative ordinal ratio [OR] = 3.29; 95% confidence interval [CI] = 1.73, 6.26), practice self-efficacy (OR = 5.28, 95% CI = 2.00, 13.93) and affirmative practices (OR = 3.12, 95% CI = 1.18, 8.25). Average therapist and administrator satisfaction scores were high for the SGDLC. These findings suggest the SGDLC training can affect organizational- and therapist-level changes that may benefit LGBTQ+ clients.Item Exploring Young Bi+ Women's Intersecting Mental Health and Sexual and Reproductive Health Experiences in Context: A Multi-Analytic Method Qualitative Study(2023) Robinson, Jennifer Lynn; Aparicio, Elizabeth M; Butler, James; Public and Community Health; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Young bi+ women report worse mental health and sexual and reproductive health (SRH) outcomes compared to gay, lesbian, and straight young adults. They experience intersecting threats to their health and well-being due to their sexuality, gender, and stage of development. There is a lack of research on bi+ women’s unique mental health and SRH experiences, and often bi+ women are overlooked due to bi-erasure and biphobia. Regressive policies related to LGBTQ+ and women’s rights, including increased restrictions to reproductive healthcare after the Dobbs v. Jackson Women’s Health Organization decision overturning abortion protections, further threaten bisexual women’s health. This dissertation used a multi-analytic method qualitative approach to explore the intersecting mental health and SRH experiences of young bisexual women in the current socio-political context. Semi-structured in-depth interviews were conducted over Zoom with 16 young bi+ women from across the U.S. A narrative inquiry approach was used to explore young bi+ women’s mental health experiences and coping strategies. In addition, thematic analysis was used to investigate how young bi+ women describe their mental health as intersecting with their SRH in the current socio-political context. The study yielded rich and nuanced information about challenges these young bi+ women experienced throughout their lives that affected their mental health and SRH. Experiencing trauma had far-reaching negative effects on their mental health. Participants discussed the challenges of forming their identity within the social context, particularly as bi+ women in a society that often invalidates bisexual identities and subjugates women. They also discussed the joys along with difficulties of navigating young adulthood. They further described coping with challenges in a variety of adaptive (e.g., therapy, exercise) and maladaptive (e.g., substance use, self-injury) ways. They discussed relying on social support such as partners, friends, family, therapists, and teachers. Participants desired more support with sexuality-related issues, particularly in early adolescence. These bi+ women described their mental health and SRH as intertwined and discussed how bodily autonomy and agency were essential to their well-being. The socio-political context, including social norms, rhetoric, and federal- and state-level policies, influenced participants’ well-being. The current study shows that young bi+ women face unique threats to their mental health and SRH. Practice implications include improving access to affordable and LGBTQ+-affirming healthcare and developing interventions attuned to the needs of young bi+ women. Policies are needed that uphold the choice and agency of young women in their reproductive health decision-making. Future research should continue to explore the needs and experiences of young bi+ women concerning their mental health and SRH including demographic differences along with potential mechanisms resulting in poorer health.Item “People Will Continue to Suffer If the Virus Is Around”: A Qualitative Analysis of Sub-Saharan African Children’s Experiences during the COVID-19 Pandemic(MDPI, 2021-05-25) Kallander, Samantha Watters; Gordon, Rebecca; Borzekowski, Dina L.G.Children are particularly impressionable and at risk during a global public health crisis, making it important to examine their unique perspectives. To hear and understand sub-Saharan African children’s experiences with the COVID-19 pandemic, we conducted an exploratory qualitative analysis based on interviews with 51 children, ages 9 to 13, from Nigeria, Tanzania, and Sierra Leone. Applying the organization of Bronfenbrenner’s ecological systems theory, we reveal how COVID-19 affected children’s daily lives and domestic challenges, schooling and neighborhood issues, media use (and its relationship to knowledge and fear of the disease), perceptions of the country and government response, and thoughts of religion and hope. Children’s responses differed greatly, but patterns emerged across sex, age, household size, religion, and country. This study offers guidance and recommendations for meeting the needs of children, especially in times of crisis.Item A NATIONAL SURVEY EVALUATING FACTORS INFLUENCING AMERICANS’ WILLINGNESS TO USE AND UPTAKE OF EMERGENCY CONTRACEPTIVE PILLS(2022) Jasczynski, Michelle; Aparicio, Elizabeth M; Public and Community Health; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)In the United States, a paradox exists around the issue of contraception; there are more highly effective contraceptive methods available than ever before, including emergency contraception, yet unintended pregnancies have increased in the last 2 decades. Currently, 1 in 2 pregnancies in the United States are unplanned. These disparities are not equitably distributed among women of reproductive age and people who can become pregnant; the burden disproportionately falls upon those with limited access to healthcare, people of color, gender and sexual minorities, those with lower socioeconomic status, and people living in the South. Recognizing the multiple factors driving decisions made about contraception, evaluation of the underutilization and other potential barriers to emergency contraceptive pills (ECP) can be in part addressed by the completion of a national survey. Most of the existing survey data for the United States provide insight into the perceptions of pharmacists, healthcare providers in emergency rooms, and college-aged women. A survey capturing the needs and experiences of a wider range of Americans has not yet been developed—most notably the need for a survey that is inclusive of an expansive understanding of gender identity and sexual orientation to evaluate what, if any, differences exist in how members of these groups view and choose to use ECPs. A web survey was completed in March 2022. Two groups of participants were recruited simultaneously: a group of cisgender, heterosexual women (n = 351), and a group of cisgender sexual minority women and gender minorities assigned female at birth (n = 408), for a total of 759 participants. Comparisons between cisgender heterosexual participants and cisgender sexual minority participants were completed using chi-squared tests and t tests to determine if there were differences in willingness to use and uptake of ECPs by sexual orientation. Latent class analysis (LCA) was completed to identify subgroups among the respondents. The latent class model was then used to determine if membership in the three latent classes predicted willingness to use ECPs and the number of times ECPs were used. Differences between classes on these two outcomes of interest were compared using chi-squared tests. Among each group, approximately 1 in 3 respondents had used ECPs at least once. Cisgender sexual minority participants had a higher willingness to use ECPs when compared to cisgender heterosexual participants (F[2, 708] = 16.33, p < .001). Cisgender sexual minority participants who used ECPs previously also were found to be less willing to reuse ECPs again when compared to their cisgender, heterosexual counterparts (χ2 [2] = 5.14, p = .023), with the most common reason of not wanting to use ECPs again due to participants indicating they would desire to be pregnant. The LCA final model had three classes: high reproductive coercion/low stigma (Class 1), low reproductive coercion/low stigma (Class 2), and low reproductive coercion/high stigma (Class 3). When regressed on the number of times ECPs were used, the three-class model was found to be statistically significant for the overall model (χ2 = 28.95, p < .001). Class 3 (low reproductive coercion, high stigma) was significantly different from Class 1 and Class 2 when comparing the mean number of times ECPs had been used, with members of Class 3 averaging using ECPs 1.56 times versus Class 1 and Class 2 both averaging .56 times use (p < .001). The high levels in which sexual minority women were willing to use ECPs but were less likely to reuse them again should be explored more in depth to understand underlying factors in decision making around contraceptive uptake and pregnancy intentions. The desire to become pregnant is the most common reason given for why sexual minority women would not use ECPs, highlighting the need for healthcare providers to have regular conversations with their patients about sexual behavior, contraceptive use, and pregnancy intentions. Individuals experiencing higher levels of stigma toward their use of ECPs have a higher prevalence of use. Although the direction of this association is yet to be determined, further investigation of this phenomenon can inform practice and policy to understand the impact of stigma and promote reproductive justice.Item STATE-LEVEL STRUCTURAL RACISM AND ALCOHOL AND TOBACCO USE BEHAVIORS IN A NATIONAL PROBABILITY SAMPLE OF AFRICAN AMERICANS(2023) Woodard, Nathaniel; Knott, Cheryl L; Public and Community Health; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Structural racism is how society maintains and promotes racial discrimination through established and interconnected systems. Structural racism is a historical driver of health disparities, including those in the area of cancer. One pathway posited for this effect is through the promotion of maladaptive coping behaviors, such as alcohol and tobacco use. This dissertation empirically assessed the association between state-level structural racism and alcohol and tobacco use behaviors among African Americans, including within various subgroups of African Americans based on age, gender, and household income. This project analyzed secondary self-report data collected from a national probability sample of 1,946 African Americans in the Religion and Health in African Americans (RHIAA) Study. Existing measures of state level structural racism were merged into the RHIAA dataset including a composite index of structural racism assessed using five dimensions (i.e., residential segregation, and economic, employment, education, and incarceration disparities). Analyses were performed in SPSS Version 28 using hierarchical linear and logistic regression models. In the first study, two models (Model A and Model B) were constructed for each of four outcomes, frequency of alcohol consumption (measured in days per month), frequency of binge drinking (measured in the number of occurrences per month), smoking status (current smoker or not a current smoker), and smoking frequency (never smoked, former smoker, currently smoke on some days, and currently smoke every day). Model A used the composite structural racism index measure to model the four alcohol and tobacco use measures and Model B analyzed the disaggregated dimensions of structural racism rather than the composite measure. All hierarchical analyses controlled for confounding variables (i.e., participant gender, age, education, income, and employment status). In the second study, analyses using the dimension-level approach in Model B from study one were repeated in subgroups stratified by participant age, gender, and income for the frequency of binge drinking and smoking status behaviors. Statistical comparisons of the slope estimates between corresponding subgroups (e.g., younger and older age) were used to test the moderation effects of age, gender, and income on the association between structural racism and alcohol and tobacco use behaviors. Results from these studies generally indicated a positive association between state level structural racism, especially in the incarceration dimension, and binge drinking and tobacco use behaviors. Stratified analyses generally did not support age, gender, or income as moderating variables of the association between structural racism and binge drinking and tobacco use behaviors. Current findings demonstrate a need for further research on structural racism and health and progress in structural racism measurement, including further emphasis of dimension-level measurement and analysis. Findings from the current dissertation highlight the importance of addressing structural racism, especially in incarceration, to reduce alcohol and tobacco use behaviors among African Americans and help address existing health disparities.