Behavioral & Community Health Theses and Dissertations

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    Exploring the Politics and Radical Health Activism Strategies of Black-Led Grassroots Organizations in Washington, D.C.
    (2023) Fox, Imani; Simon-Rusinowitz, Lori; White, Kellee; Public and Community Health; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
    Black communities in Washington, DC have long experienced health inequities due to a history of inequitable social policies and inadequate access to health-related resources (Jackson, 2017). Critical, academic scholars and social justice activists implicate the political economy and racial oppression as a root cause of health inequities in the country. Black grassroots organizations demonstrate a history of political and social resistance to oppressive health and social systems, defending their right to health and autonomy, known as radical health activism (Nelson, 2011). Despite rich accounts of Black-led health interventions, their contributions to public health practice and frameworks have not been widely reviewed in public health discourse. Using informant interviews and descriptive study analysis, the health politics and subsequent health intervention strategies of Black grassroots organizations in Washington, D.C were examined. The 3 core themes that emerged from this study were health politics, radical health intervention strategies, and successes and challenges.
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    "Alexa, do I have an STD?": An Exploration of Young Adult Information Seeking Behaviors When Engaging With Home Assistant Devices About Sexually Transmitted Infections
    (2023) Siddiqui, Junaed Ahmad; Baur, Cynthia; Public and Community Health; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
    BACKGROUND: Sexually transmitted diseases and infections continue to disproportionately affect young adults in the United States, with half of all new STIs annually occurring in young adults between the ages of 15 and 24. Advances in digital technologies have allowed for the facilitation of fast and discreet information about sexual health but remains understudied in the context of newer technologies. There is limited research on the effectiveness of Home Assistant Devices as channels to facilitate the information seeking process in young adults. To address this gap, this study explored whether Home Assistant Devices can facilitate the sexual health information seeking process in young adults between the ages of 18 and 26 who already use the internet to search for health information. The purpose of this dissertation was to explore the perspectives of young adults to understand the depth of their sexual health information needs and whether a user-centric designed HAD can be a suitable alternative for fulfilling those information needs. METHODS: Informed by the Theory of Motivated Information Management and Technology Acceptance Model, this qualitative study used the Design Thinking framework to understand young adults’ information needs and created a prototype voice skill to address that need. In-depth interviews were conducted virtually on Google Meet or Zoom and were recorded. This qualitative study occurred in three phases: in the first phase, 10 young adults were interviewed about their information seeking needs, current gaps, and how they thought Home Assistant Devices could fill that need. Insights from those interviews were then analyzed and used to create a prototype that would address sexual health information needs. The prototype was then tested with a new group of ten young adults, and their reactions to the prototype was recorded via interviews. In the third phase, the prototype was refined based on feedback from the previous group, and then re-tested with a new group of 10 young adults. In total, in depth interviews were conducted virtually with 30 young adults to understand information needs and create a prototype voice skill that could serve to facilitate the transfer of sexual health information in a convenient and relevant manner. Inductive thematic analysis was conducted to identify emergent themes. RESULTS: Overall, the sample (n=30) was 63% female, 43% White, with 53% having completed a bachelor’s degree, and 47% having owned a Home Assistant Device for over 12 months. The average age of the sample was 24 years old. After analyzing interviews through inductive thematic analysis in NVivo, four themes that were noted in the first phase as it related to Home Assistant Devices and information needs: the use of HADs as a means of convenience, preferring to use screen-based devices for research, tradeoffs between privacy and functionality, and the ability to emergency triage users for medical attention based on symptoms. Three main themes emerged in the second phase after reacting to the first version of the prototype, including anxiety and frustration when experiencing the unknown, pre-existing positive perceptions of Home Assistant Devices, and negative perceptions of Home Assistant Devices. In the third phase, two main themes emerged: a desire to share visuals to build comfort and bridge the information gap, and an ambivalence towards privacy. DISCUSSION: Privacy concerns remain prominent with Home Assistant Devices when engaging with them for information seeking purposes. These concerns are sometimes met with ambivalence by young adults, who were willing to trade some of their privacy for added features or functionality that could improve their user experience. Furthermore, challenges remain with voice search and screen-based devices are perceived to be easier to use. Lastly, the sexual health information seeking process is sensitive, and many young adults in this sample expressed wanting to have a more personalized experience that acknowledged their specific situations. To the author’s knowledge, this is the first study that explored the factors contributing to the sexual health information seeking process using Home Assistant Devices among young adults between the ages of 18 and 26. The results of this study have several implications for public health practice and research, especially as it relates to the Design Thinking approach for public health voice skill development, as well as addressing a new approach to providing sexual health information to young adults that may be more discreet and relevant to them. The findings from this study contribute to the emerging literature base on the use of Home Assistant Devices to address sensitive health information seeking behaviors.
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    Maternal and Neonatal Health Intervention Coverage and Measurement in Urban Kenya
    (2023) St-Onge Ahmad, Sacha Marie; Howard, Donna E; Stoebenau, Kirsten M; Public and Community Health; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
    High coverage of recommended maternal and neonatal health (MNH) interventions can reduce neonatal mortality in low- and middle-income countries. In Kenya, however, despite overall gains in MNH intervention coverage and neonatal survival, progress in urban areas has slowed. The neonatal mortality rate in Nairobi is 24% higher than rural areas, reversing a longstanding urban advantage in MNH. This multiple method dissertation draws on both quantitative and qualitative data to examine the role of five MNH interventions in explaining this urban disadvantage—health facility delivery (HFD), skilled birth attendance (SBA), early postnatal care (ePNC), skilled postnatal care (sPNC), and early breastfeeding initiation (eBFI). First, using data on mother-child pairs from the Kenya Demographic and Health Survey (KDHS) (n=1,058) this dissertation examines intra-urban variation in coverage, as high urban mortality rates may be explained by differences in coverage in rapidly expanding and impoverished urban informal settlements (IS) as compared to formal settlements (FS). Urban places of residence were operationalized using household- and neighborhood-level characteristics to differentiate informal settlements from formal ones. IS were defined as KDHS clusters where >50% of households lacked >=2 of 4 planned community features (access to improved water and sanitation, durable housing materials, and sufficient living area). Urban categories included: IS in cities, IS in towns, and FS in cities and towns. No differences were observed between settlement type and coverage of any intervention except ePNC. Neonates in IS in towns were less likely to receive ePNC compared to those in FS, suggesting that quality-adjusted measures of intervention coverage might offer evidence of intra-urban variation. Second, using semi-structured qualitative interviews with mothers (n=20) and providers (n=12) in two IS, this dissertation addresses concerns with the measurement of these five interventions within household-based surveys. Specifically, it explores the potential influence of social desirability bias and comprehension of questions and key terms on the validity of mothers’ responses to survey questions that capture coverage. Data were analyzed using template and thematic analysis. Most mothers (1) associate payment with private facilities, (2) generalize the term “hospital” to other facility types, (3) generalize the terms “doctor” and “nurse” to other facility-based employees, (4) determine provider cadre based on role, uniform color, and gender, (5) understand the meaning of ‘assisting with delivery’ and ‘postnatal care check’ as intended, (6) report the timing of a range of postnatal checks, and (7) did not provide concrete descriptions of how they identify time to initiation of breastfeeding or first postnatal check. Women in these communities might: (1) indicate they delivered at a private facility to appear to be wealthier than their peers, (2) indicate they had a SBA if their true attendant was a TBA, and (3) over-report breastfeeding. Findings from this dissertation suggest that the urban disadvantage in neonatal mortality may not be explained by differences in intervention coverage within growing IS communities and may be more complex. Poor quality of facility-based care and low validity of data measuring intervention coverage in household surveys may partly explain these findings. Linking household surveys with facility-based data, using quality-adjusted measures to examine intra-urban variation in coverage, and further exploring of the role of desirability bias and comprehension in survey data across diverse settings is recommended moving forward.
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    (2023) Channell Doig, Amara J; Aparicio, Elizabeth M; Public and Community Health; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
    Nutrition during the first 1000 days of life is critical for lifelong physical and mental health. Infant milk choices, introduction of complementary foods, and responsive feeding methods can contribute to risk for infection, chronic disease, mental health, and later nutrition and dietary practices. Current feeding interventions are likely to focus on the mother’s decision-making and frequently neglect to explore the impact of the people around her. Little is known about how social networks can influence feeding decisions and how this may impact the acceptance of recommendations from health professionals or intervention content. This dissertation used a convergent mixed methods approach to explore how social networks influence infant feeding decisions and practices for Latinx women in the U.S. In the quantitative portion, 30 participants completed egocentric network mapping to explore network structure and tie strength. In the qualitative portion, 15 of the participants completed in-depth interviews to allow for a better understanding of the influence that network members have, as well as mothers’ decision-making processes. The quantitative and qualitative strands were integrated to allow for a deeper understanding of the social context in which feeding decisions are made. Three manuscripts are presented in the dissertation. The first explores infant feeding support networks and other social influences, including culture and maternal intuition. The participants tended to have small networks and different levels of cultural influence depending on immigration status. The second manuscript examined the influence of information about infant feeding from personal communication compared to online channels. Participants valued the information from medical providers or their support networks and although many used the internet, they had concerns about the information found there. The third manuscript looked at the experiences of the participants who were formula-feeding during the 2022 formula shortage. Although the participants fought to breastfeed their children, they needed to switch to formula to protect their physical and mental health and be there for them. The formula shortage added stress and took an emotional toll on the participants. The dissertation results confirm the importance of social networks as sources of information and support for Latinx mothers with infants during the first year of life. Overall, there was a need for additional support during this time and additional barriers to infant feeding for immigrant mothers. Direct practice implications include how interventions can be developed to provide support. Policy implications include the need to improve structural support for infant feeding, including access to lactation care and food. Future research should continue to assess network support and could look at sociodemographic differences.
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    (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.