School of Public Health
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The collections in this community comprise faculty research works, as well as graduate theses and dissertations.
Note: Prior to July 1, 2007, the School of Public Health was named the College of Health & Human Performance.
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Item Addressing refugee health through evidence-based policies: A case study(Elsevier, 2018-06) Thiel de Bocanegra, Heike; Carter-Pokras, Olivia; Ingleby, J. David; Pottie, Kevin; Tchangalova, Nedelina; Allen, Sophia I.; Smith-Gagen, Julie; Hidalgo, BerthaThe cumulative total of persons forced to leave their country for fear of persecution or organized violence reached an unprecedented 24.5 million by the end of 2015. Providing equitable access to appropriate health services for these highly diverse newcomers poses challenges for receiving countries. In this case study, we illustrate the importance of translating epidemiology into policy to address the health needs of refugees by highlighting examples of what works as well as identifying important policy-relevant gaps in knowledge. First, we formed an international working group of epidemiologists and health services researchers to identify available literature on the intersection of epidemiology, policy, and refugee health. Second, we created a synopsis of findings to inform a recommendation for integration of policy and epidemiology to support refugee health in the United States and other high-income receiving countries. Third, we identified eight key areas to guide the involvement of epidemiologists in addressing refugee health concerns. The complexity and uniqueness of refugee health issues, and the need to develop sustainable management information systems, require epidemiologists to expand their repertoire of skills to identify health patterns among arriving refugees, monitor access to appropriately designed health services, address inequities, and communicate with policy makers and multidisciplinary teams.Item Self-reported discrimination among Asian Americans: An examination of its measurement and relationship with health-related quality of life(2019) Jung, Mary; Lee, Sunmin; Epidemiology and Biostatistics; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Labeled as a “model minority,” Asian Americans have often been excluded from the dialogue on discrimination. Previous studies frequently used discrimination measures that were initially developed for African Americans and lack items related to language and nativity. Although discrimination adversely affects mental and physical health, its relationship to health-related quality of life (HRQOL) has been understudied in this population. This dissertation evaluated self-reported discrimination among Asian Americans by examining its measurement and relationship with HRQOL. Manuscript 1 assessed the psychometric properties of everyday (ERDS) and major racial discrimination scales (MRDS) that were developed for Asian Americans. In a sample of 569 Asian American immigrant adults, reliability was excellent for ERDS but moderate for MRDS (Cronbach’s α=0.94 and 0.60). The latter is likely low given that MRDS is an inventory of events. For construct validity, weak positive linear correlations with perceived stress and depressive symptoms were observed (r=0.22 and 0.28 for ERDS and r=0.11 and 0.14 for MRDS; p<0.001). Factor analysis confirmed the unidimensionality of both measures. Manuscript 2 cross-sectionally examined the association between the racial discrimination measures from Manuscript 1 and HRQOL among 524 foreign-born Asian American adults. Multivariable logistic regression and negative binomial regression were performed to examine self-rated health (poor vs. good) and days of poor physical health, mental health, and activity limitation. ERDS (IRR range: 1.04-1.08) and MRDS scores (IRR range: 1.19-1.61) were significantly and positively associated with worse HRQOL for all measures, except for self-rated health. Manuscript 3 examined discrimination trajectories and assessed their relationship with self-rated health in a longitudinal, multi-ethnic sample of 2,004 middle-aged women in the Study of Women’s Health Across the Nation (SWAN). Group-based trajectory analysis identified three distinct discrimination groups. The “high and decreasing” but not “moderate and decreasing” group was significantly associated with poor self-rated health compared to the “low and decreasing” group (OR=1.61; 95% CI: 1.12-2.31). This dissertation provides insight into discrimination measures and their relationships with HRQOL among Asian Americans. Proper measurement and health impact assessment of discrimination in this population can contribute to better monitoring and provide improved accountability and support for interventions and public policies.Item DOES PATIENT-CENTERED COMMUNICATION AND TRUST IN PHYSICIAN INFORMATION VARY BY CANCER SURVIVORSHIP STATUS? AN ANALYSIS OF THE HEALTH INFORMATION NATIONAL TRENDS SURVEY (HINTS) 2017(2019) Al-Nassir, Marwa Fawzi; Dallal, Cher M; Epidemiology and Biostatistics; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Trust is the foundation of the patient-physician relationship. Patients’ trust in a physician has been associated with patient satisfaction, adherence to treatment, continuity of care, and improved health outcomes. Trust in a physician is especially important for health-vulnerable populations, such as cancer survivors, as they tend to endure complex emotional needs related to re-acclimating to the new normal post cancer diagnosis. The patient-physician relationship also relies heavily on effective patient-centered communication (PCC), however, associations between PCC and trust in physician information overall and by cancer survivorship status is not well understood. Using nationally representative data (N = 2604) ascertained from Cycle 1 of the fifth iteration of the 2017 Health Information National Trends Survey (HINTS), a cross-sectional analysis was conducted to examine PCC in relation to trust in physician information. PCC was assessed on a 4-point Likert scale using responses from seven sub-questions that address the main functions of PCC: 1) fostering healing relationships, 2) exchanging clinical information, 3) responding to emotional needs, 4) managing uncertainty, 5) facilitating shared decision-making, and 6) enabling patient self-management. Trust in physician information was analyzed dichotomously (high versus low) based on responses from a single item question. PCC was analyzed as individual components (optimal versus sub-optimal) and as an overall score. Confounders included age, sex, race/ethnicity, education, and household annual income. Odds ratios (OR) and 95% confidence intervals (CI) for the relationship between PCC and trust in physician information were estimated using multivariable logistic regression. Analyses of cancer survivorship status (cancer survivor versus never had cancer) as an effect modifier of the relationship between PCC and trust in physician information was also conducted using an interaction term. Results from the weighted multivariable models revealed that for every one-unit increase in the overall PCC score (range 1 to 100), the odds of having high trust in physician information increased by 4% (adj OR = 1.04, 95% CI = 1.03–1.05). The odds of reporting high level of trust in physician information were significantly associated with each individual component of PCC when comparing those who felt their communication component was optimal versus sub-optimal (PCC components: exchanging clinical information (adj OR = 2.57, 95% CI = 1.82–3.62), responding to emotional needs (adj OR = 2.34, 95% CI = 1.65–3.30), facilitating in shared decision-making (adj OR = 2.35, 95% CI = 1.70–3.26), enabling patient self-management (adj OR = 2.88, 95% CI = 2.11–3.92), managing uncertainty (adj OR = 2.45, 95% CI = 1.74–3.44), fostering healing relationships (adj OR = 2.79, 95% CI = 2.18–3.57), and spending enough time with you (adj OR = 2.09, 95% CI = 1.49–2.93)). When examining relationships by cancer survivorship status, estimates among cancer survivors were of greater magnitude compared to persons who reported never having cancer, however, no significant interactions were observed in the weighted multivariable models (all p-interaction>0.05). These findings provide insight on how optimal experiences of PCC influence trust in physician information and can help inform the development of PCC strategies to ultimately improve health outcomes and reduce consequences related to poor patient-physician trust overall and among cancer survivors.Item TOOTH RESORPTION AND RISK FOR ANESTHETIC COMPLICATION DURING ANESTHETIZED DENTAL PROCEDURES IN DOMESTIC FELINES(2019) Jenkins, Emily J; Slopen, Natalie B; Epidemiology and Biostatistics; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Tooth resorption (TR) in felines may present an increased risk for complications during dental procedures, and it is currently unknown whether oral examination is a valid diagnostic method for type 1 TR. Using existing data from 1,530 felines from a large veterinary hospital in Washington, D.C., I examined the association between type 1 TR and complication under anesthesia during a dental procedure, and the validity of oral examination as a diagnostic tool. Controlling for breed, weight, age, sex, hematocrit, total protein, technician, veterinarian, and presence of oral and systemic disease, type 1 TR was associated with a complication under anesthesia during a dental procedure (p<0.0001). Sensitivity (93.1%) and specificity (97.6%) support the reliability of oral examination for diagnosing type 1 TR. Veterinarians can proactively anticipate lower blood pressures when anesthetizing felines with type 1 TR. There are similarities between TR in humans and felines, and further research is needed on the pathophysiology and health implications of TR in both species.Item Using the Index of Concentration at the Extremes to Examine the Impact of Air Pollution Exposure on Infant Mortality in the United States(2019) Ammons, Samantha; Nguyen, Quynh; Epidemiology and Biostatistics; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Background: The concentration of privilege in a geographic area can determine how vital resources are distributed among certain groups in that area, thus influencing a community’s health. High air pollutant exposure is often concentrated in deprived neighborhoods with lack of vital resources. Objective: Determine whether states with a high concentration of air pollution exposure have higher infant mortality rates (IMR) than states with lower concentrations of air pollution exposure. Methods: The Index of Concentration of the Extreme was utilized to measure the concentration of air pollution exposure for each state. Incidence Rate Ratios and 95% Confidence Intervals for state infant mortality rate were computed using Poisson regression in Statistical Analysis Software. Results: States with high concentrations of air pollution exposure had 19% lower IMR than states with low air pollution exposure (95%CI:0.70 – 0.94). Conclusions: These findings can enable researchers to conduct census-tract research on adverse health outcomes and societal distributions.Item THE PREVALENCE OF MATERNAL SMOKING INTENSITY STATUS IN EARLY AND LATE PREGNANCY AND ITS ASSOCIATION WITH EARLY MORBIDITY IN SINGLETON TERM BIRTHS IN THE UNITED STATES, 2016(2019) Kondracki, Anthony; Moser Jones, Marian; Thoma, Marie; Public and Community Health; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Relatively little is known about how maternal cigarette smoking influences the health of infants delivered at term. This study was based on the 2016 United States Natality File of live births (N= 3,956,112). The first aim was to examine the prevalence and patterns of smoking in the three months before and during pregnancy and the distribution of smoking intensity in early (1st and 2nd trimester) and late (3rd trimester) pregnancy across race/ethnicity, age, and educational attainment of mothers with all births and with singleton term births (37-41 completed weeks gestation) in the United States in 2016. The second aim was to compare the odds of low birthweight (LBW), low 5-minute Apgar score, and neonatal intensive care unit (NICU) transfer/admission in term singletons with changing maternal smoking status in early and late pregnancy indicating a potential prenatal exposure effect. The third aim was to test and identify the role of low birthweight, as a potential mediator, in the association with maternal smoking status and NICU transfer/admission of a newborn delivered at term. The prevalence of smoking in the three months before pregnancy was 9.42% among all mothers and 9.20% among mothers of term singletons, and high intensity smoking was the highest in the first trimester among non-Hispanic White women, 20-24 years of age, and less educated women for all births and for singleton term births. High intensity smoking in early and late pregnancy was associated with a greater risk of LBW (aOR 3.33; 95% CI: 3.23, 3.44), low 5-min Apgar score (aOR 1.46; 95% CI: 0.88, 2.44), and NICU transfer/admission (aOR 1.62; 95% CI: 1.58, 1.67) in term neonates. The odds ratios of the natural direct and natural indirect effects of NICU transfer/admission were aOR 1.52 (95% CI: 1.47, 1.57) vs. aOR 1.07 (95% CI: 1.07, 1.09) and the proportion mediated through LBW (18.3%) indicated partial mediation. This study has important implications for clinical practice, public health policy and research, and it is particularly timely because of an information gap on the health of infants delivered at term with LBW to mothers who continue smoking at high intensity during pregnancy.Item Relationships of social and physical environmental factors with cardiometabolic outcomes(2019) Huang, Dina; Puett, Robin; Nguyen, Quynh C; Epidemiology and Biostatistics; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)The social and physical environmental factors impact health in general and have been linked with increased risks of cardiometabolic outcomes including obesity, diabetes, hypertension and cardiometabolic biomarkers. The dissertation added to important knowledge on this topic in two ways: 1) by leveraging innovative Twitter-derived characteristics to study the potential influence of social environment on cardiometabolic outcomes, 2) investigating the effects of air pollution exposures on cardiometabolic outcomes in youth living with type I diabetes. The first study investigated the associations between Twitter-derived area-level predictors (happiness, diet, physical activity) with cardiometabolic outcomes (obesity, diabetes, hypertension) using a nationally representative sample from National Health and Nutrition Examination Survey (NHANES). People living in neighborhoods with higher happiness, healthier diet and more physical activity had lower prevalence of obesity and hypertension but not diabetes. Twitter-derived social neighborhood characteristics can be used to identify communities with higher risk of cardiometabolic outcomes. We obtained data from SEARCH for Diabetes in Youth (SEARCH) study for the second and the third study. The second study examined the associations between chronic exposure to air pollution and glucose hemostasis (HbA1c) in youth living with type I diabetes. Particulate matter with aerodynamic diameter <2.5 (PM2.5), proximity to heavily trafficked roads and annual average daily traffic count were associated with higher HbA1c in study site South Carolina, Colorado and Washington, but not in study site Ohio and California. Differences in particulate matter compositions may explain the inconsistent results. The third study assessed the effect of acute exposure to air pollution on subclinical CVD markers including pulse wave velocity (PWV), augmentation index (AIx) and brachial distensibility (BrachD) using a repeated measures design. Reduction in PM2.5 on the day prior to assessment was associated with lower AIx, but not associated with either PWV or BrachD. In summary, exposure to air pollution may be associated with cardiometabolic outcomes and reducing air pollution may have implications in early prevention of cardiovascular complications for youth living with type I diabetes. Overall, reducing social stressors and reducing hazardous physical environmental factors may decrease the risk of cardiometabolic outcomes, providing possible directions for CVD prevention for public health practitioners.Item Exposure to Ambient Air Pollution and Correlates of Cardiovascular Disease among Youth with Type 1 Diabetes(2019) Montresor-Lopez, Jessica Anne; Puett, Robin C; Maryland Institute for Applied Environmental Health; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Air pollution from traffic-related sources is associated with cardiovascular disease (CVD), potentially through changes in systemic inflammatory responses, vascular function and oxidative stress leading to atherosclerosis, thrombosis or endothelial dysfunction. Individuals with type 1 diabetes (T1D) have a greater risk of CVD-related morbidity and mortality than the general population, and they may be more susceptible to the effects of air pollution on CVD. Although these increased risks begin during childhood, very few studies have assessed the impact of air pollution on children and youth with T1D. This dissertation directly addresses gaps in the epidemiologic evidence by: 1) evaluating the relationship of short-term exposures to traffic-related air pollutants with pulse wave velocity (PWV), a measure of arterial stiffness, 2) assessing the effects of changes in air pollution exposures on changes in inflammatory biomarkers, including C-reactive protein, fibrinogen and interleukin-6 (IL-6), and 3) examining the relationship of long-term exposures to traffic-related air pollution with allostatic load (AL), a measure of cumulative biological risk, among a cohort of youth with T1D. Data were obtained from the SEARCH for Diabetes in Youth (SEARCH) study. SEARCH was initiated in 2000 and includes a diverse population of US youth diagnosed with diabetes prior to age 20 years. Anthropometric and laboratory measures were taken at SEARCH study visits, and standardized questionnaires were used to collect information on important covariates. Air pollution exposures were estimated using spatio-temporal models and assigned to residential addresses for each participant. In the first study, we identified a significant association between increased exposure to PM2.5 on the day of the examination with higher PWV using generalized linear models adjusted for lifestyle and demographic characteristics. In the second analysis, we found consistent positive effects of increases in PM2.5 over the week prior to the examination with IL-6 using longitudinal mixed models. In the third study, no significant associations were observed for monthly and annual PM2.5 exposures or proximity to major roadways with AL in fully adjusted linear mixed models. However, effects differed by race/ethnicity and gender. Overall, this research indicates that youth with T1D may be at higher risk for air pollution-related cardiovascular impacts.Item TRACKING ACUTE RESPIRATORY INFEECTIONS IN A COLLEGE RESIDENT COMMUNITY(2018) Adenaiye, Oluwasanmi; Milton, Donald K; Public and Community Health; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Influenza and other acute respiratory infections (ARIs) contribute significantly to human morbidity and mortality globally. Animal experiments and human challenge studies have not provided an adequate explanation about the relative importance of social, behavioral and physical environment in the transmission of ARIs and are limited due to uncertainty about the generalizability of their findings to a natural infection. Also, household transmission studies seldom characterize all potential transmission covariates e.g. environmental conditions, leaving a gap in the knowledge of transmission mechanisms. Here, we describe the design and preliminary results of an extensive college dormitory ARI transmission study that has the potential to characterize several important ARI transmission covariates; we critically appraise the design and show how the findings from such design can be applied to answer most of the vital questions that exist about the transmission of ARIs.Item NEW METHODOLOGY TO IDENTIFY POTENTIAL ENVIRONMENTAL TRIGGERS FOR ANCA-ASSOCIATED VASCULITIDES(2018) Beins, Kaley Elizabeth; Milton, Donald K.; Maryland Institute for Applied Environmental Health; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)A series of rare autoimmune disorders that affect the blood vessels, vasculitis is chronic and potentially deadly. Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) comprise three diagnostic forms of this autoimmune disorder: granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (EGPA or Churg-Strauss syndrome). The limited resources available to vasculitis researchers have been mostly targeted toward treatment and relapse prediction with a small amount of research examining genetic and environmental etiologic factors. Therefore, additional research is needed to understand the role of gene-environment interactions in AAV etiology. This thesis reviews the current body of AAV literature with a focus on candidate genes, occupational and environmental exposures, and the hygiene hypothesis. It also designs an original survey and study methodology to further investigate these etiologic factors. A better understanding of AAV etiology will lead to prevention and improved treatment of these costly diseases.