School of Public Health
Permanent URI for this communityhttp://hdl.handle.net/1903/1633
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 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 DISPARITIES IN ADOLESCENT MENTAL HEALTH SERVICES UTILIZATION AND HELP-SEEKING(2024) Truong, Michelle L; Sehgal, Neil J; Boudreaux, Michel; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Inequities in access to and utilization of mental and behavioral health care for adolescents have persisted for numerous decades. Adolescents from racial and ethnic minority backgrounds, as well as those in underserved geographic regions, are disproportionately impacted. As the youth mental health crisis escalates, it is critical to study the mechanisms driving these disparities to inform effective and targeted interventions and policies. Divided into three studies, this dissertation explored the influence of individual, cultural, and contextual factors on adolescent help-seeking behaviors using data from the 2009 and 2011 to 2019 California Health Interview Survey (CHIS).The first study employed mediation analyses to assess the extent to which having a subjective or perceived need for mental health care, conditional on objective need, contributes to racial and ethnic disparities in mental health services utilization. I found significant racial and ethnic differences in subjective needs for mental health services and that these differences partially explain the racial and ethnic disparities in service utilization. The second study explored differences in mental health service utilization among subgroups of non-Hispanic (NH) Asian and Latino/Hispanic adolescents compared to NH white adolescents. I found that Vietnamese and Mexican adolescents were significantly less likely to utilize mental health services relative to their NH white counterparts. The third study merged the adolescent data with provider data from the National Plan and Provider Enumeration System (NPPES), facility data from the National Substance Use and Mental Health Services Survey (N-SUMHSS), and population data from the US Decennial Census Redistricting Data Summary Files to assess the moderating effects of distance to the nearest pediatric mental health facility and provider-to-population densities on the relationship between subjective mental health care needs and service utilization. I discovered that provider density and subjective needs interact, resulting in a diminished effect of subjective needs on service utilization among adolescents residing in areas with lower primary care provider density. I did not find that distance to the nearest pediatric mental health facility had a significant impact on service utilization. This dissertation examined racial, ethnic, and geographic mental health care disparities among a diverse adolescent population in California. Findings from this work contribute to the understanding of adolescent help-seeking behaviors and provide insights for targeted interventions and policies to advance mental health care equity.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 Distress and Deaths of Despair in the U.S. Healthcare Delivery System: Understanding Patterns in Healthcare among Distressed Americans(2024) Spencer, Merianne Rose Tiglao; Chen, Jie; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)The United States has experienced rising mortality rates for the past several decades. Drug poisonings have increased nearly five-fold, suicide rates by nearly 40%, and by nearly 30% percent for alcohol-induced deaths between 1999 and 2021. This collection of drug-, alcohol- and suicide deaths are oftentimes referred to as “deaths of despair”, first coined by economists Anne Case and Angus Deaton who cited health and socioeconomic disparities driving Americans into mental distress, depression, and anxiety. The impact on the mental health of Americans was further exacerbated by the COVID-19 pandemic; this exposed vulnerabilities in the mental healthcare system as well as the various stressors that negatively impacted individuals across the globe. Using nationally representative data, this dissertation delves into the deaths of despair phenomenon using a multidisciplinary health services research lens. Access, utilization, and risk from deaths of despair are examined by using psychological distress (which is treated as a proxy for despair in the first two aims). Using the Kessler-6 scale, a well-accepted and clinically valid tool for non-specific mental distress, this dissertation explores patterns of healthcare spending among those with varying severity levels of psychological distress over a two-decade period; delves into patterns of healthcare utilization among young adults aged 18-30 (a population disproportionately impacted by stressors during the COVID-19 pandemic) by psychological distress; and quantifies the risk of death among those with varying severity levels of psychological distress.Item ALLOSTATIC LOAD INFLUENCES VASCULAR FUNCTION AND SYMPATHOLYSIS IN YOUNG BLACK ADULTS(2024) Eagan, Lauren Elizabeth; Ranadive, Sushant M; Kinesiology; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)In the U.S., Black individuals tend to face a disproportionately higher risk for hypertension. This is largely attributed to chronic sympathetic activation induced by heightened exposure to psychosocial stressors. Allostatic load (AL), an index of cumulative physiological dysfunction from chronic stress, is associated with hypertensive risk and is also heightened in Black adults compared to those of other racial groups. Indeed, increased sympathetic activity is a hallmark characteristic of both hypertension and AL. The inability to blunt sympathetic-induced vasoconstriction during exercise (impaired functional sympatholysis) is also associated with hypertension. This dissertation aimed to investigate whether AL was associated with measures of vascular health in young Black adults, both at rest and during a sympathetic stressor. In our first study, we examined associations between AL and indices of vascular function and structure among young Black adults at rest, finding that higher AL was associated with greater macrovascular dysfunction and amplified wave-reflections. Additionally, we identified significant correlations among greater self-perceived stress with smaller brachial artery diameters and greater wave-reflections. The second aim of this dissertation focused on the associations between AL and the magnitude of functional sympatholysis among this population. Results indicated a positive association between AL and functional sympatholysis, with amplified sympatholytic responses among young Black females, as compared to their male counterparts, when forearm volume was controlled for. Overall, our findings suggest that elevated AL might predict macrovascular dysfunction at rest, with larger arterial diameters potentially compensating for chronic stress. These adaptive mechanisms, commonly observed in aging and diseased states, may also explain the positive correlations between AL and the functional sympatholytic response in young Black adults. Our consistent observations of the redundant vascular mechanisms among young Black adults allowing for adaptation to chronic stress strengthen our findings and further highlight the complex interplay between stress and cardiovascular health in Black adults.Item CHARACTERISTICS AND HEALTH INSURANCE COVERAGE AMONG ADOPTED CHILDREN IN THE UNITED STATES(2024) Fleishman, Jamie Lin; Yue, Dahai; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)The practice of adopting a child is a common occurrence within the United States. Research on adoption, birth parents, and adoptive parents has traditionally focused on psychology and social work outcomes. This master’s thesis shifts the focus of adoption outcomes to a public health perspective, examining the demographics, socioeconomic conditions, and health insurance rates of domestic and international adoptees. To help determine the rates of any health insurance, public health insurance, and private health insurance, this thesis examined American Community Survey 2022 5-year data, a nationally representative study of adoptees and their counterparts—non-adoptees who are biologically related to their parents or head of household. It was determined that domestic adoptees and non-adoptees had similar demographic and socioeconomic statuses whereas international adoptees were predominantly non-Hispanic Asians, females, and have wealthier and White heads of households. After controlling for demographic and socioeconomic variables, it was discovered that international adoptees have higher uninsured rates compared to non-adoptees and domestic adoptees, which could be attributed to geographic differences in health insurance coverage. Further research is needed to examine health insurance coverage rates in the United States for adoptees.Item THE POLICY IMPACT OF STATE REINSURANCE PROGRAMS UNDER THE ACA 1332 WAIVER(2024) Wang, Ren Hao; Yue, Dahai; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Ten years after the implementation of the ACA, US families have been experiencing a continuing increase in the average premium for health insurance coverage. Although the case differs for the low-income population, providing affordable health insurance remains a significant policy issue. Section 1332 waiver of the ACA allows states to develop innovative strategies to provide affordable health insurance upholding the required high-quality care and basic protections. Seventeen states took the market-oriented approach of state reinsurance programs to stabilize the health insurance market and restrain premium increases. Using RWJF HIX data as well as public and restricted MEPS data, this dissertation investigated the policy impact of state reinsurance programs over premium reduction in the health exchange market, unintended consequence of crowding out Employer-Sponsored Insurance, as well as changes in out-of-pocket premium and insurance coverage on the consumer perspective.Item THE EFFECTS OF MEDICAID COVERAGE FOR ABORTION(2024) Kim, Taehyun; Boudreaux, Michel; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)In this dissertation, I examine the causal impact of Medicaid abortion coverage on abortion utilization, births, economic, and maternal health outcomes. I do so by leveraging benefit changes in Illinois, Maine, and West Virginia. Major findings suggest Medicaid abortion coverage increases the abortion rate and decreases birth rates, although the effects differ by state. I also found that Medicaid abortion coverage increases individual wage income and decreases the poverty rate among females of reproductive age. I did not find evidence that introducing Medicaid abortion coverage increased educational attainment or decreased maternal morbidity. The findings have important policy implications for the wellbeing of people capable of pregnancy.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 COVID-19 Vaccine Hesitancy and Uptake in the United States Considered Through the Lens of Health Behavior Theory(2024) Kauffman, Lauren Emily; Nguyen, Quynh; Epidemiology and Biostatistics; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Given the low COVID-19 vaccine uptake rates in many areas of the United States despite their demonstrated safety and effectiveness, COVID-19 vaccine hesitancy and vaccination barriers continue to be critical areas of research in epidemiology and behavioral health science. This series of studies focuses on COVID-19 vaccine hesitancy and vaccination barriers, as they relate to vaccination intention and vaccine uptake, considered in the context of established health behavior theories. The first study is a systematic review of existing research on COVID-19 vaccine hesitancy using one or more health behavior theories as key components of the design or analysis. This study examined the types of theories that are most often used, how they are used, and where research gaps exist. The remaining two studies use data from the U.S. COVID-19 Trends and Impact Survey, a national cross-sectional survey. The second study investigates the association between recent feelings of anxiety or depression and vaccination intention, as well as between these feelings and identifying with specific vaccine hesitancy reasons. The third study examines vaccine hesitancy and barriers among those with chronic illness or disease, a particularly vulnerable population. Factor analysis was conducted using constructs from the Theory of Planned Behavior as a framework, and the results were used in a regression model to investigate the association between these underlying factors and vaccination intention. This research demonstrated the usefulness of the Theory of Planned Behavior, the Health Belief Model, and the 3 Cs Model in existing and future COVID-19 vaccine hesitancy research, as well as identified Protection Motivation Theory as a promising area for future research. Additionally, psychological states were demonstrated to be significantly associated with vaccine hesitancy, adjusting for demographic, socioeconomic, and time factors. Lastly, the Theory of Planned Behavior was found to be applicable to those unvaccinated and with chronic illness, as the construct factor scores developed were significantly associated with vaccine hesitancy (adjusting for the presence of specific chronic conditions and demographic, socioeconomic, and time factors). These associations were also consistently demonstrated in subgroup analyses of participants with specific chronic conditions.