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 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 ASSESSING HEALTH CARE USE, COSTS, AND QUALITY FOR CENTERS OF EXCELLENCE FOR PEDIATRIC CONGENITAL HEART DISEASE CARE FOR THE MILITARY BENEFICIARY POPULATION(2022) El-Amin, Amber Jovan; Franzini, Luisa; Public and Community Health; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Background: For the military beneficiary population with cardiac or congenital anomalies, the Fiscal Year 2019 health care costs were $83 million, including $55 million for newborns who were less than one year of age and $28 million for youth ages 1 to 17 (Kennell and Associates Inc., 2020). The 2019 Military Health System (MHS) costs were approximately $50 billion (Mendez, 2019) and are expected to increase significantly through 2028 (Congressional Budget Office, 2014). In an attempt to close the gap between cost and benefit for its 9.6 million beneficiaries, the MHS has considered targeted inclusion of Centers of Excellence (CoE) for purchased care within TRICARE insurance coverage and MHS policies. In general, a CoE produces consistent outstanding measurable outcomes for a specific medical condition. A Congenital Heart Defect (CHD) is the presence of abnormalities in the heart structure that develop in the uterus during pregnancy. CHDs are the most common types of birth defects and the principal cause of illness and death for birth defect conditions. CHDs are associated with comorbidities and repeat surgical interventions resulting in significant use of health care services during infancy, childhood, and adulthood, making CHDs a great candidate for CoE use.Objective: To compare health care use, costs, and quality of care for pediatric CHD care at CoEs and non-CoEs for the military beneficiary population. Data Sources: Retrospective claims data from the MHS Data Repository for MHS beneficiaries aged 0 to 17 years who received CHD care from 2016 to 2020. Study Design: Using an instrumental variable approach to estimate the impact of CoE use on clinical outcomes (annual admissions, annual emergency room use, and mortality) and health care costs (total costs and hospitalization costs) for pediatric CHD care within the military beneficiary population. Results: A total of 10,865 patients were included, of which 82.9% used a CoE at some point for CHD care. Results suggested that racial disparities in CoE use were not significant for CHD care for the military beneficiary population. There were disparities noted in CoE use by military rank, suggesting that Senior Enlisted and Other ranks were associated with lower odds of CoE use than Junior Enlisted ranks. Results of the IV approach proved that the causal effect of CoE use was a lower probability (-14.1) of emergency room use post one-year CHD diagnosis for the military beneficiary population (p<0.01). The causal effect of CoE use on annual admissions and mortality was insignificant at the .05 significance level but proved that CoE use did not increase annual admissions nor jeopardize patients’ survival post one-year CHD diagnosis for the military beneficiary population. The causal effect of CoE use on CHD related annual costs was a $40,898 decrease in annual costs (p=.059). Although the relationship was not significant at the .05 level, the magnitude of the reduction was approximately 53% of the mean annual cost. When stratified by complexity of CHD diagnosis, the causal effect of CoE use on CHD related annual costs was a statistically significant reduction of $84,852 in annual costs post one-year CHD diagnosis for patients diagnosed with a moderate-complex or single ventricle CHD diagnosis, equating to an approximate 76% reduction in mean annual costs. The causal effect of CoE use on CHD related hospitalization costs was a $33,170 decrease in hospitalization costs (p=.087). Although the relationship was not significant at the .05 level, the magnitude of the reduction was approximately 47% of the mean hospitalization costs. When stratified by CHD diagnosis complexity, the causal effect of CoE use on CHD related hospitalization costs was a statistically significant reduction of $73,084 in hospitalization costs post one-year CHD diagnosis for patients diagnosed with a moderate-complex or single ventricle CHD, equating to an approximate 76% reduction in the mean admission costs. Conclusions: Patients with more severe CHD diagnoses were more likely to use CoEs. After adjusting for selection bias due to disease severity, CoE use improved clinical outcomes, reduced health care resource utilization, and reduced costs for CHD care for the military beneficiary population.Item APPLICATION OF A CULTURALLY RELEVANT HEALTH BELIEF MODEL TO BLACK AND AFRICAN AMERICAN YOUNG ADULTS WITH SICKLE CELL DISEASE DURING TRANSITION TO ADULT HEALTHCARE SERVICES(2022) Pantaleao, Ashley; Fish, Jessica; Anderson, Elaine A.; Public and Community Health; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Sickle cell disease (SCD) is a hereditary chronic illness hallmarked by pain and functional disability that impacts psychosocial well-being. Within the United States, SCD largely affects Black and African American populations, and general health disparities present in these populations may be further magnified by SCD. Due to the complexity of symptom management, consistent healthcare adherence is imperative and is often scaffolded by family caregivers prior to transition. The transition from the pediatric to adult healthcare facility is a life stage public health concern for young adults with SCD, as it is a time characterized by high mortality and morbidity. Navigating new medical systems and working with new providers are factors contributing to delays in treatment-seeking behavior. Unexplored factors that may impact illness course and outcomes include health-related stigma, racial discrimination, and preparation for bias. This research assessed whether the perceived barriers (e.g., racial discrimination, externalized stigma, and internalized stigma) are linked to SCD-specific self-efficacy and transitioning to the adult healthcare setting, utilizing an adapted Health Belief Model. It additionally explored whether a culturally relevant factor, preparation for bias, contributes to transition readiness. Questionnaires were administered to young adults with SCD who were preparing for transition or actively transitioning to an adult healthcare facility. This work was a first step at exploring the relationships between these variables utilizing a culturally relevant Health Belief Model. Strong positive significant correlations among perceived barrier variables were noted as well as a positive significant correlation between SCD-specific self-efficacy and transition readiness. Results from multivariate models suggest that externalized stigma was significantly positively related to SCD-specific self-efficacy. Counter to expectations, no significant predictors of transition readiness were identified. Additionally, results did not support preparation for bias moderating the relationships between racial discrimination or externalized stigma with SCD-specific self-efficacy or transition readiness. These findings may highlight that our study was underpowered to detect large effects, or that there are additional complex relationships that need to be further explored. A short-term goal of this study was to highlight the value of identifying youth with low self-efficacy or preparation for bias in order to guide educational resources and interventions to increase self-efficacy and readiness to transition for this underserved illness group.Item Predictors of Patient Activation Among Underserved Patients in a Nurse-managed Health Center: A Pilot Study(2016) Antol, Susan Marie; Boekeloo, Bradley O.; Public and Community Health; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)The concept of patient activation has gained traction as the term referring to patients who understand their role in the care process and have “the knowledge, skills and confidence” necessary to manage their illness over time (Hibbard & Mahoney, 2010). Improving health outcomes for vulnerable and underserved populations who bear a disproportionate burden of health disparities presents unique challenges for nurse practitioners who provide primary care in nurse-managed health centers. Evidence that activation improves patient self-management is prompting the search for theory-based self-management support interventions to activate patients for self-management, improve health outcomes, and sustain long-term gains. Yet, no previous studies investigated the relationship between Self-determination Theory (SDT; Deci & Ryan, 2000) and activation. The major purpose of this study, guided by the Triple Aim (Berwick, Nolan, & Whittington, 2008) and nested in the Chronic Care Model (Wagner et al., 2001), was to examine the degree to which two constructs– Autonomy Support and Autonomous Motivation– independently predicted Patient Activation, controlling for covariates. For this study, 130 nurse-managed health center patients completed an on-line 38-item survey onsite. The two independent measures were the 6-item Modified Health Care Climate Questionnaire (mHCCQ; Williams, McGregor, King, Nelson, & Glasgow, 2005; Cronbach’s alpha =0.89) and the 8-item adapted Treatment Self-Regulation Questionnaire (TSRQ; Williams, Freedman, & Deci, 1998; Cronbach’s alpha = 0.80). The Patient Activation Measure (PAM-13; Hibbard, Mahoney, Stock, & Tusler, 2005; Cronbach’s alpha = 0.89) was the dependent measure. Autonomy Support was the only significant predictor, explaining 19.1% of the variance in patient activation. Five of six autonomy support survey items regressed on activation were significant, illustrating autonomy supportive communication styles contributing to activation. These results suggest theory-based patient, provider, and system level interventions to enhance self-management in primary care and educational and professional development curricula. Future investigations should examine additional sources of autonomy support and different measurements of autonomous motivation to improve the predictive power of the model. Longitudinal analyses should be conducted to further understand the relationship between autonomy support and autonomous motivation with patient activation, based on the premise that patient activation will sustain behavior change.