Richard M. Fairbanks School of Public Health Theses and Dissertations

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A Bridge to Dying Well: Understanding the Role of End-of-Life Doulas in Vermont with Implications for Policy Changes
(2024-12) Mize, Lucy Shackleford; Archer, Sarah E.; Walter McCabe, Heather; Mallon, Annetta
End-of-Life Doulas (EOLD) are an emerging profession attending to dying clients and their families. There are currently no national regulations, standards, or training mandates for EOLDs or policy solutions. Vermont has good EOLD training programs, a history of policy discussion on dying and an EOLD community organizing throughout the state, making it an excellent study site. There is a strong reluctance within the Vermont EOLD community to allow regulations for fear of creating barriers to entry to practice. EOLDs wish to contribute to any legislative processes impacting their work. Vermont EOLDs are implementing new models that rely on collective services to optimize care, provide an adequate income stream and respond to socio-geographic factors. Collectives allow for a community of practice to flourish, where EOLDs with experience can collaborate. Because current training models do not emphasize practical learning or address grief and loss in the community, collaboration is essential. Foundational training should be standardized so Vermont EOLDs have common skills and knowledge, while still bringing their unique backgrounds and talents to each client. There is little consensus on the need for regulation, and whether payment validates their skills or negates the sacred nature of their work. EOLD’s roles are much larger than the literature would suggest, with significant effort being devoted to death literacy as well as promoting agency in the dying. This research illustrates that these providers are making a significant contribution to the well- being of Vermonters and proposes nine policy recommendations to public health leaders and legislators. EOLDs need very little regulation to continue delivering essential services amidst a state-wide health care system that is seriously strained by its aging population and poverty, and they need a living wage. Or as one Vermont EOLD said “we look at this rich end of lifetime as a time of coming to terms, of healing places that still need to heal, of celebrating and affirming and rejoicing and validating the things that were rich and precious. And mourning the things that will be lost, and feeling all of the depths of that, just the whole package. It’s an amazing opportunity.”
A Qualitative Study to Improve Performance of Medi-Cal's Grievance & Appeals System Through a New Conceptual Framework
(2025-01) Banks, La Rae Robin; Archer, Sarah E.; Coburn, Kenneth D.; Moore, Robert
In 2022, Medicaid expenses represented 18% of national health care spending costs totaling $805.7 billion, while health inequities cost approximately $146.8 billion. The Centers for Medicare & Medicaid Services (CMS) requires all Managed Care Organizations (MCOs) to administer a Grievance & Appeal (G&A) system if they provide medical coverage to any of the 88 million Medicaid beneficiaries living in the United States, giving Medicaid beneficiaries the legal right to report any problem using their Medicaid plan to their MCO who has a responsibility to investigate. This includes health inequities and disparities such as wrongfully denied hospitalizations, botched surgeries, discriminatory treatment, doctor refusing to treat Medi-Cal patients, and/or complaints against the MCO itself. Formally called Medi-Cal, California administers the largest state Medicaid program in the nation. In 2022, it incurred $109 billion in health care costs for its 15 million Medi-Cal enrollees, yet 70% of all MCOs were operating non-compliant with Federal and/or State G&A regulations according to evidence-based research. Member-reported problems go unsolved due to multiple deficiencies resulting untimely, ineffective, and incorrect investigations, if conducted at all. The number of G&A cases have increased by an astounding 480% since California enforced CMS’ Final Rule on July 1, 2017. This study explores the new Medi-Cal G&A Best Practice (M-GABp) Framework, a systems-thinking approach to improve the performance of Medi-Cal’s G&A system to foster a more equitable and accountable healthcare system. It establishes guiding principles for conducting high-quality investigations and resolving systemic issues equitably, while offering transparency to community stakeholders regarding G&A performance metrics and equitable solutions to inequitable problems. Drawing insights from 21 G&A Experts - including directors, physicians, investigators - who participated in three focus groups from 10 local MCOs, this deductive qualitative study examines their professional insights about the utility of the M-GABp Framework. Research findings showed G&A Experts agreed with M-GABp’s best practices and 85% agreed with transparency via MCPs’ website. It also revealed deficiencies responsible for today’s poor G&A performance. This paper provides a roadmap for implementation, leveraging Kotter’s 8-Step change management system to guide MCOs in adopting this transformative framework with continuous improvement post-implementation.
Enabling Policy to Advance Black Maternal Health Equity Through the Use of Doulas in Indiana
(2024-08) Brown, Jenell Nicole; Archer, Sarah E.; Jackson, Emily; Walter-McCabe, Heather
Disproportionately high maternal mortality rates (MMR) among Black women continue to be a significant public health equity concern in the United States, particularly in the state of Indiana, where Black women experienced the highest MMR at 156.3 deaths per 100,000 live births in 2021. In comparison, White women experienced 90.7 deaths per 100,000 live births in the same year (Indiana Department of Health, 2024). Equity recognizes that high-risk populations have different needs and disadvantages and aims to address disparities by providing targeted opportunities, resources, and support to account for these differences. Health equity is achieved when everyone can attain their full potential for health and well-being (World Health Organization, n.d.). Equality refers to equal access for everyone, which in turn perpetuates inequities. While not the sole solution to Indiana’s Black maternal health equity crisis, Doulas are an evidence-based solution to reducing racial disparities in maternal health outcomes. Building on the current body of literature, this dissertation explores how Indiana can enable policy to expand access to Doula care and integrate Doula services into maternal healthcare systems. Through the employment of qualitative, semi-structured interviews with Doulas and other key stakeholders, findings identified that current barriers in Indiana include a lack of a supportive environment to legitimize the profession, lack of Medicaid reimbursement and inadequate private insurance coverage, processes that “medicalize” Doula care, and the need for collaborative efforts with Doulas when crafting Doula-related policies. By leveraging a policy and stakeholder analysis, an implementation plan was developed to provide recommendations on how Indiana policy can advance Black maternal health equity through the use of Doulas. This research's importance lies in its potential to inform policy and practice in Indiana and provide foundational information for other states that have yet to begin incorporating Doula care into policy to advance maternal health equity.
Examining Policy Solutions to Address Barriers Impeding the Adoption of Universal Adverse Childhood Experiences (ACE) Screening in Pediatric Primary Care Settings
(2024-05) Ball, Tristyn Denyse; Archer, Sarah E.; Coburn, Kenneth; Jones-Kelley, Helen
Over 93% of adults in Western Ohio have experienced at least one adverse childhood experience (ACE). This figure is significantly higher than the national average of 61% of adults who have experienced at least one ACE. Exposure to adversity in childhood increases levels of toxic stress, impacts brain development, and creates a predisposition for a variety of psychological and physiological ailments known as ACEassociated health conditions. While many pediatric healthcare professionals understand the implications associated with ACE exposure, the integration of ACE screening in pediatric healthcare facilities in the region is limited. The study aimed to determine the barriers to implementing ACE screening in pediatric primary care settings in Western Ohio and identify policy levers to increase the integration of ACE screening and care among pediatric healthcare professionals. The study used thematic analysis to identify themes in the results, as there is limited existing research in this area. Key informant interviews were conducted with local pediatric healthcare professionals to determine their views regarding the potential barriers and facilitators associated with implementing universal ACE screening in their organizations. The results concluded that barriers around workforce shortages, perceived diminished patient relationships, time, ethics, reimbursement, and overall discomfort lead to low screening integration in local pediatric healthcare organizations. Ohio’s current pediatric healthcare infrastructure can be leveraged to ease the implementation of the statewide initiative. ACE screening can be integrated into Ohio’s Early and Periodic Screening, Diagnosis, and Treatment program, which provides guidelines for developmental screening. Further, advocacy for the integration of ACE screening in the American Academy of Pediatrics Bright Future Guidelines will increase the utilization of the tool. The current state General Assembly has introduced legislation focusing on ACEs, and with new streams of state tax revenue, the policy window to advance this initiative is open.
Expanding Access to Novel Antibacterial Therapeutics in Low- and Middle-Income Countries: Leveraging Donor-Funded Pooled Procurement
(2024-07) Swenson, Jessica Emily; Archer, Sarah E.; Coburn, Kenneth; Houchens, Christopher
Antibiotics are one of the most significant advances of modern medicine, however, bacteria continue to evolve faster than new antibacterials are being developed. In 2019, 1.27 million deaths were directly attributable to bacterial antimicrobial resistance (AMR) globally—more than either HIV or malaria that year—with the highest death rates occurring in low- and middle-income countries (LMICs) (Murray et al., 2022). Because of limited returns on investment, multinational pharmaceutical companies have largely abandoned antibacterial development. This void has been filled by smaller product developers vastly located in the United States and Europe who have limited resources and experience in seeking licensure and commercialization in LMICs, where the need is greatest (WHO, 2021). When these smaller developers only seek regulatory approval in the high-income countries where they are located, they often cannot sell enough of their product to avoid bankruptcy because of the low volume of patients with susceptible infections there (Alm & Gallant, 2020). Building on the current body of literature, this study assessed the factors necessary to leverage an existing donor-funded pooled procurement strategy to expand its scope to include novel antibacterial therapeutics, with the goal of expanding access to these products in LMICs. Market access expansion would bring new products to patients where they are needed most while also ensuring financial viability for developers of novel antibacterials who struggle to retain financial solvency. A qualitative case study gathering expertise from individuals familiar with current procurement practices for novel antibacterials and donor-funded global procurement strategies for other infectious disease therapeutics elucidated that the Global Drug Facility (GDF) is the entity best positioned to expand scope to include novel antibacterials for AMR. An eight-stage action plan was developed to provide recommended actions, resource needs, measures of success, and an anticipated timeline over the next decade for GDF and a consortium of technical partners to implement the scope expansion. By pairing a market-driven access expansion initiative with a pragmatic approach to support financial sustainability of product developers, these critical medicines can be available for patients globally, and the AMR pipeline can support the demand for new antibacterials for decades to come.

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Browsing Richard M. Fairbanks School of Public Health Theses and Dissertations by Author "Archer, Sarah E."

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