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 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.Item EXAMINING THE IMPACT OF PRECONCEPTION AND EARLY PREGNANCY SERUM LEVELS OF MATERNAL VITAMIN D ON CLINICAL MARKERS OF IMPLANTATION AND PREECLAMPSIA(2023) Alkhalaf, Zeina; Thoma, Marie; Public and Community Health; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Vitamin D is a hormone rather than a vitamin, that is essential for overall health and wellbeing, including but not limited to the reproductive system. Although vitamin D is available through several sources, such as natural ultraviolet sunlight, food, and supplements, low circulating 25-hydroxyvitamin D (25(OH)D) levels of <30 ng/mL are common among pregnant women, with up to 69% of the US population suffering from the condition. Epidemiologic studies have suggested that low maternal serum 25(OH)D levels may be associated with adverse pregnancy outcomes, such as early pregnancy loss and preeclampsia, which may be initiated early in the pregnancy process during implantation and placentation. From a life course perspective, the periconception and early pregnancy period marks a critical time for establishing a healthy pregnancy. Implantation and placentation occur early in pregnancy and involve a complex process that relies on optimal endometrial receptivity and a host of hormonal and immunologic signaling events. Disruptions to this process may be indicated by early clinical markers of pregnancy complications (e.g., vaginal bleeding or subchorionic hemorrhage) and associated with later adverse outcomes (e.g., preeclampsia). In contrast, higher Human Chorionic Gonadotropin (hCG) levels, which have been linked to nausea and vomiting, may be markers of robust implantation and placentation. Therefore, I sought to investigate the preconception and early gestation maternal serum 25(OH)D levels on: (i) vaginal bleeding and subchorionic hemorrhage; (ii) nausea and vomiting; (iii) preeclampsia. In Aim 1, an analysis of medical record documentation of vaginal bleeding and subchorionic hemorrhage found that women who were persistently deficient/insufficient in maternal serum 25(OH)D at both preconception and 8-week gestation had 2.18 times higher (95% CI: 1.13, 4.20) odds of having subchorionic hemorrhage compared to women who remained sufficient across both time periods, even after adjustment for potential confounders. Additionally, an analysis of daily diaries showed women with deficient 25(OH)D levels had a higher odds (OR: 3.02, 95% CI: 1.13, 8.13) of moderate/heavy bleeding versus none compared to women with sufficient 25(OH)D levels based on self-reported daily diaries on vaginal bleeding at the start of pregnancy. In Aim 2, women with persistently deficient 25(OH)D levels at both preconception and early gestation had lower odds (OR: 0.34, 95% CI: 0.20, 0.60) of experiencing nausea and vomiting based on medical records. In comparison, women who increased their 25(OH)D levels early in pregnancy (i.e., were deficient/insufficient at preconception then became sufficient at 8-week gestation) had 1.71 (95% CI: 1.12, 2.61) times higher odds of nausea and vomiting compared to those who were persistently sufficient across both time periods. Based on self-reported nausea and vomiting symptoms from daily diaries, deficient 25(O)D was associated with lower odds (OR 0.65; 95% CI 0.40, 1.06) of both nausea and vomiting when comparing to sufficient 25(OH)D levels. In Aim 3, women who had deficient 25(OH)D at preconception had an increased risk (RR: 1.45, 95% CI: 0.64, 3.29) of preeclampsia (as identified from medical records), although results were insignificant. Linear spline models demonstrated that the risk of preeclampsia declined with each 1 ng/mL increase of 25(OH)D levels up to 40-45 ng/mL (RR: 0.97, 95% CI: (0.93, 1.00), but that levels beyond this threshold show an increase in the risk of preeclampsia for each 1 ng/mL increase in 25(OH)D (RR: 1.03; 95% CI: 1.00, 1.06). This research highlights the importance of exploring the maternal serum levels of 25(OH)D at both preconception and early gestation and how it may affect adverse pregnancy outcomes, such as vaginal bleeding, subchorionic hemorrhage, preeclampsia, and pregnancy outcomes that signify a robust implantation response, such as nausea and or vomiting. It further underscores the importance of assessing maternal serum 25(OH)D levels prior to critical time of implantation and placentation and potential biologic mechanisms that may lead to adverse pregnancy outcomes. Supporting healthy implantation and placentation is of utmost importance as this may guide the remainder of the health of the pregnancy, and any disruption to this process may increase the mother and infant’s risk of maternal morbidity and mortality (e.g., preeclampsia, vaginal bleeding, subchorionic hemorrhage). Future studies are needed with more diverse, larger sample sizes, and both paternal and maternal nutrition to further assess preconception nutritional risk factors on adverse and robust pregnancy outcomes. Accordingly, this research is vital as it may aid in identifying early factors that may reduce adverse maternal and infant health outcomes.Item ADAPTING A BREAST CANCER CONTROL INTERVENTION FOR AFRICAN AMERICAN WOMEN BELOW SCREENING AGE: A CO-DESIGN APPROACH(2023) Huq, Maisha R; Knott, Cheryl L; Public and Community Health; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Background: Despite African American women below screening age facing greater mortality from early onset breast cancer relative to similar aged peers of other races/ethnicities and African American women of screening age, little attention is given to this group of younger women. Evidence-based breast cancer educational interventions do not exist for this group of younger women. The purpose of the current work was to address the gap of evidence-based breast cancer educational interventions for African American women below screening age. Aims: The current study had two aims. Aim 1 was to adapt an evidence-based breast cancer educational intervention for African American women of screening age, to be targeted to younger African American women (i.e. those below screening age) using a systematic process guided by the seven-step adaptation framework by Card and colleagues, documented using an established implementation science model, the Framework for Reporting Adaptations and Modifications Enhanced Model (FRAME), and using a virtual co-design approach. Aim 2 was to assess the appropriateness of the adapted intervention for African American women below screening age through online surveys administered at the conclusion of Community Chat sessions. Methods: The adaptation process was guided by Card and colleagues’ seven-step framework. Five virtual co-design sessions with n=15 potential users and key stakeholders were conducted in step 7. Observational notes and FRAME Form data were collected from the co-design sessions and analyzed using five-step thematic and descriptive statistics analyses, respectively. Appropriateness data was collected through an online survey; quantitative data were analyzed using descriptive statistics and open-text survey responses were analyzed using five-step thematic analysis. Results: Application of Card and colleagues’ seven step framework was described. Six themes emerged from observing virtual co-design sessions: technological tools can encourage equal participation; personal relationships and stories enhance design; participants introduced content to promote equity; context of original intervention critical to adapt; challenges to virtual designing; and need for facilitator during co-design. Documentation of the adaptation process guided by FRAME found 14 adaptations led to “Black and Breasted (B&B)”, an Instagram and beauty brand partnership-based breast health education tool prototype. Motivations for adaptations were to promote fit (100%), reach (71%), and equity (29%). Adaptations were content (63%) and context-related (37%). All participants rated B&B as highly appropriate—selecting an average of 4.5 (SD=1.4) and 1.2 (SD=.75) reasons, respectively, B&B would and would not be a good fit. Thematic analysis of open-text responses on how to further enhance B&B identified four themes: increase strategies to improve health equity, use multiple social media, consider non-beauty brands, revise visuals/messages. Conclusions & Implications: While usage of the implementation science models led to a highly appropriate adapted intervention, initial testing identified the need for further strategies to improve equity of health outcomes through the intervention. Findings indicate implementation science frameworks may benefit from centering equity more. Co-design may also be an apt approach to promote health equity in public health interventions.Item Experiences of child welfare social workers in addressing substance use among maltreated young mothers to prevent child maltreatment(Wiley, 2023-02-24) Doig, Amara Channell; Jasczynski, Michelle; Phillips, Danielle R.; Robinson, Jennifer L.; Aden, Faduma; Huq, Maisha; Lee, Kaitlyn; Jones, Gary; Bernardi, Chloe; Aparicio, Elizabeth M.Substance use during the perinatal period and while parenting can pose a significant risk to children's safety and well-being. Mothers who have experienced child maltreatment are more likely to use substances than mothers without a history of maltreatment. This study explores how child welfare social workers experience supporting young, maltreated mothers struggling with substance use to prevent the intergenerational transmission of child maltreatment. Semi-structured in-depth interviews were conducted with four social workers working with young mothers with a history of maltreatment and substance use. Interpretative Phenomenological Analysis revealed two themes: (1) grappling with system challenges and (2) supporting strategies for disrupting intergenerational transmission of child maltreatment. The results highlight the need for systemic changes around support for social workers who work with young mothers who use substances and have a history of maltreatment, and substance use treatment and mental health programs themselves. Mothers need access to prenatal programs that are trauma-informed, non-judgemental and that support participants' basic needs and parenting skills.Item Familial sources of encouragement and breast-feeding practices among women participating in the US Special Supplemental Nutrition Programme for Women, Infants and Children(Cambridge University Press, 2023-04-05) Channell Doig, Amara; Aparicio, Elizabeth M; Gallo, SinaObjective: To explore how sources of familial encouragement are associated with breast-feeding initiation and duration among a national sample participating in the US Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Design: This study uses the 2013–2015 WIC Infant and Toddler Feeding Practices Study 2 (WIC ITFPS-2) data. Breast-feeding initiation was measured at the first month, while duration was derived from a composite of the first 13 months. The analysis used logistic and linear regression to explore the association between encouragement sources and breast-feeding outcomes. Setting: A nationally representative sample of WIC participants in the USA. Participants: WIC participants who completed the 13-month interview of the WIC ITFPS-2 (n 2807). Results: Encouragement was significantly associated with both initiation and duration. Each source of encouragement was associated with a 3·2 (95 % CI 2·8, 3·8) increase in odds of initiating breast-feeding in the unadjusted model and 3·0 (95 % CI 2·5, 3·6) increased odds, controlling for age, education, nativity, poverty status, race and ethnicity (<0·0001). When predicting log duration, each percent increase in source of encouragement was associated with an increasing duration on average by 0·003 d (95 % CI 0·2, 0·3, <0·0001). When controls were added, it was associated with an increase of an average of 0·002 d (95 % CI 0·2, 0·3) per percent increase in encouragement source (<0·0001). Conclusions: Women who receive encouragement appear to be more likely to breastfeed. Additional work is needed to explore sources of encouragement and how to include them in intervention work.Item Impact of early, weekly drinking on latent classes of alcohol involvement progression and recovery: Evidence from the NESARC Waves 1 and 2.(Elsevier, 2022-01-26) Green, Kerry M.; Reboussin, Beth A.; Storr, Carla L.; Mojtabai, Ramin; Susukida, Ryoko; Young, Andrea S.; Cullen, Bernadette A.; Luken, Amanda; Amin-Esmaeili, MasoumehIntroduction: Early drinkers have been found to have higher risk of developing alcohol use disorder; however, the association of early drinking with progression to problematic alcohol involvement that does not meet disorder criteria (i.e., subclinical problems) or to severe stages of alcohol involvement, sex-specific associations, and relationship of early drinking with alcohol recovery have rarely been investigated. Methods: Using data from Waves 1 and 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), we applied latent transition analyses to investigate the impact of weekly drinking before age 18 on alcohol progression and recovery operationalized as three classes of alcohol involvement using abuse and dependence indicators. We analyzed data separately for male (n = 12,276) and female (n = 14,750) drinkers and applied propensity score methods to address confounding. Results: We observed significant associations between early, weekly drinking and alcohol involvement class membership at Wave 1 for both males and females. For males, early, weekly drinking was also associated with greater odds of transitioning from moderate to severe alcohol problems (aOR = 3.19, 95% CI = 1.72, 5.35). For females, early, weekly drinking predicted the transition from no to severe problems (aOR = 2.98, 95% CI = 1.11–8.00). Contrary to our hypothesis, early, weekly drinking was associated with greater likelihood of transition from severe to no problems for males (aOR = 3.23, 95% CI = 1.26, 8.26). Discussion: Frequent, early drinking seems to be an important indicator of drinking progression with differential associations by sex. This information is useful to identify those at greater risk of progressing to severe drinking problems to intervene appropriately.