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.
Advancing the Implementation of CLAS Standards to Support Health of South Asian Americans
(2023) Barnabas, Beatrice Benjamin; Stone, Cynthia; Nicholas, Celeste; Reed, Steven
Asian Americans are the fastest-growing racial and ethnic group in the United States, projected to reach nearly 34 million by 2050. A subset of Asian Americans, South Asians, face tremendous cultural, socioeconomic, linguistic, and structural obstacles to achieving good health. In 2018, the Office of Minority Health established the National Culturally and Linguistically Appropriate Services Standards (CLAS) framework for improving healthcare quality and advancing health equity for increasingly diverse communities, including South Asians. The purpose of this qualitative study is to understand how providers in California, a state with a large South Asian population, are implementing the CLAS Standard. California is one of ten states that enacted legislation requiring mandatory cultural competency training in accordance with the CLAS standards. Semi-structured interviewers were conducted with a range of providers (n=12) in California to identify facilitators and barriers to successful implementation and inform strategies to advance the CLAS standard to support the health of South Asians. Responses were categorized within the three elements of Solberg’s (2007) framework for quality improvement: Compliance and Enforcement of the CLAS Standard (priority), Cultural Competence Training and Adherence to the CLAS Standard (change process capability); and Support for the Health of South Asian Americans (care process content). Within each element, responses were identified as facilitators or barriers, including examples from multiple participants. Findings show that while there is enforcement of cultural competency training in the workplace, lack of clear understanding and/or delineation between CLAS and other training promoting health equity is evident amongst providers. Further, providers value supporting South Asian Americans by advocating for proper inclusion and health data that is representative and disaggregated for this population. A plan for change to advance the implementation of the CLAS Standard is presented guided by Kotter’s Change Management Model.
Aligning Priorities Between Community Need for Lung Cancer Screening Programs and Hospital Effectiveness - A Policy Analysis
(2025-05) Tackett, Scott Michael; Marstein, Egil; Babich, Suzanne; Culbertson, Richard
Objective: Investigate structural factors impacting the prioritization and funding of public health preventive lung cancer screening programs in U.S. hospitals. Additionally, provide change leadership recommendations on policies to improve the implementation of evidence-based practices. Data sources and study setting: Data was gathered through a systematic literature review and primary qualitative research from health system or hospital organizational leadership across the U.S. Study design: The research employed a descriptive, non-experimental, convergent mixed-methods approach. Quantitative and qualitative data were collected and analyzed independently, then combined to obtain detailed insights from various perspectives across a diverse system for a situational analysis. Data Collection and Methods: A systematic literature review, combined with semi-structured interviews with Chief Medical Officers, Chief Financial Officers, and lung cancer program executives, was conducted across U.S. hospitals and health systems. Purposive sampling included thirteen dyad executive pairs and two executives from integrated delivery network lung cancer programs, representing various regions with a 'representative voice' of 6% of U.S. hospitals. Principal findings: The data synthesis identified 18 factors affecting lung cancer screening programs, categorized into five themes: differing missions, governance models, misaligned economics, competing goals, and broad agreements. These themes illustrate national discussions influencing the implementation of these types of preventive public health programs in hospitals and integrated delivery network organizations. Discussion: Despite efforts to implement evidence-based practices, outcomes and annual adherence rates remain low, showing room for improvement. This study is the first to provide empirical evidence that system-level factors in healthcare governance, processes, economics, and strategic decisions significantly influence the prioritization and investment in lung cancer screening programs and initiatives to implement an evidence-based practice. Summary & Conclusions: CMS should implement policies linking quality measurement with economic incentives in lung cancer care. These policies aim to prioritize investments supporting implementation practices. Their adoption requires political and agency leadership and represents a significant shift in approach. Aligning with these types of motivating economic incentive policies could impact the entire U.S. healthcare system.
An Exploratory Pilot Study of the Experience of Vicarious Trauma and Burnout in the Workforce of Indiana Health Centers
(2023-07) Harris, Lori Gail; Stone, Cynthia; Maxey, Hannah; Day, Christopher
Study Question: Does the unique population and experiences (such as adverse social determinants of health and trauma) of the patients served contribute to the burnout of the workforce in Indiana health centers? Methods: A quantitative exploratory study conducted via a survey sent to 241 participants of an Indiana Department of Health quality collaborative cohort. The questionnaire used the Copenhagen Burnout Inventory (CBI) with questions (similar to) 5 &6 from the Secondary Traumatic Stress Scale (STSS). Two open ended questions were also included to gather potential interventions to reduce burnout. Results: Survey was available March to April 2023 with IRB approval 18567. A total of 146 surveys were completed (60.6%). Respondents represented a geographically diverse cross section of health center types and locations in Indiana. Many types of exhaustion were experienced, including: emotional exhaustion being reported by 59% of the respondents, and work-related emotional effect by 68% of the sample. Work related burnout was present in 64.7% of respondents. Collecting information from the patient’s about lack of housing, lack of adequate income, food insecurity, and other SDOH factors exposed 42.7% of respondents to patient trauma experiences. Participants reported worksite resources that could decrease stress such as more paid time off, team building activities during work time, and more time to document care activities. Plan for Change: The Kotter Change model was applied. Some actions would include forming a collaborative with Indiana State Department of Health, Indiana Primary Care Association, and others to implement the reported worksite changes that would benefit health center staff and decrease burnout. A co-production of healthcare model is suggested to provide insight from both health center workers and administration to create collaborative solutions in an attempt to reduce burnout with the long-term goal of reducing turnover. Any successful solutions to be shared with state and national health center leaders and a proposal for a scale up of the study project to gain new or additional potential solutions. Conclusion: Emotional and physical exhaustion in the health center workforce is evident with study results. Collecting and addressing social determinants of health factors (like food and housing insecurity and others) is an important part of caring for vulnerable patient populations. Exposure to patient trauma may be a partial contributor to the levels of burnout experienced for providers, and additional studies would be useful to determine the degree of influence or other contributing demographics (like age, gender, etc.) However, the gathering of SDOH is critical to understand patient trauma to assist staff in improving their quality of life. Additional support for the providers and support staff can decrease the impact of their exposure to vicarious trauma.
Association Between Built Environment or Health Behavior and Good Health Status Using ACSM American Fitness Index® Data Between 2018 and 2022
(2023-12) Seo, Bojung; Han, Jiali; Nan, Hongmei; Monahan, Patrick O.; Duszynski, Thomas J.
The US cities still have room for improvement in residents’ health and there are significant differences in general health measures between the cities. High quality environment assets and personal healthier behaviors of residents were known as factors related to better health. Because both sufficient sleep and higher level of personal physical activity are well-known indicators to attain optimal health of individuals, city-level measures of resident health behaviors, such as sleep quantity, and environmental assets that support physical activity may jointly improve residents’ general health. Further, sufficient sleep may mediate the effect of activity-related environmental factors on general health. However, evidence regarding such associations at the city level is lacking. The American College of Sports Medicine (ACSM) American Fitness Index® (AFI) data currently provide both environment assets and health indicators for the 100 largest US cities. The aim of this research was to test the following three hypotheses using the 2018 to 2022 AFI data. First, the association between environment indicators of cities and good health status of residents was examined. Second, the association between personal health behaviors of residents and good health status was also examined. Lastly, the moderating or mediating effect of sleep on the association between significant environmental factors and good health status was examined. This study discovered that activity-related environment factors, such as availability of parks within a 10-minute walk, Walk Score®, Bike Score®, and adoption of Complete Streets policy, were significantly associated with the self-reported general health status of residents. This study also demonstrated all measured healthy behaviors including meeting physical activity guidelines, using active transport to work, sufficient intake of fruits and vegetables, sufficient sleep, and non-smoking were positively related to general health status of city residents. This study also identified the synergistic interaction between sufficient daily sleeping and environment factors related to the level of physical activity on residents’ good health status. Overall, these findings will provide evidence for better understanding the health-related unmet needs of residents in US cities, and also create valuable context and support for development and targeting of more efficacious public health interventions and messaging.
The Association Between Citrus Consumption and Skin Cancer: An Analysis of Risk and Nutrient-Gene Interaction
(2020-12) Marley, Andrew Raymond; Han, Jiali; Sibg, Yiqing; Li, Xin; Li, Ming; Champion, Victoria L.
Purpose. In the US, melanoma and non-melanoma skin cancer (NMSC) rates have increased substantially in recent decades. While many skin cancer risk factors have been established, the impact of dietary citrus, which is naturally abundant in photocarcinogenic psoralens, remains enigmatic. The purpose of this research was to investigate associations between citrus consumption and risks of melanoma and NMSC, and to conduct a genome-wide study to identify genetic variants that may modify this association. Methods. Participants from the UK Biobank were leveraged for these analyses. Citrus consumption was collected via five rounds of 24-hour recall questionnaires, with complete citrus data available for n=210,126 participants. Ascertainment of melanoma and NMSC cases were identified by international classification of disease codes via linkage with national registries. Logistic regression was used to estimate odds ratios and 95% confidence intervals for the associations between citrus consumption and skin cancer outcomes. Individual citrus products were assessed for independent associations with skin cancer risk, and established skin cancer risk factors were tested for interaction. Joint 2-degree-of-freedom (df) and 1-df tests were used to assess interaction between total citrus consumption and genetic variants. Results. After controlling for covariates, high total citrus consumption was significantly associated with increased melanoma risk, an association primarily driven by orange and orange juice consumption. Skin color was found to be a significant effect modifier for the association between total citrus consumption and melanoma risk, but only before adjusting for multiple comparisons. No significant associations were observed for high total citrus consumption or consumption of any individual citrus products and NMSC risk. Significant associations for half a serving of citrus consumption and NMSC risk were likely due to chance or confounding. Index SNPs on chromosomes 3, 9, and 16 were significant according to the joint 2-df test, and 7 SNPs on chromosome 16 displayed evidence of a citrus-gene interaction. Conclusion. My analyses provide evidence in support of high citrus consumption significantly increasing risk of melanoma, but not NMSC. I also identified SNPs on AFG3L1P that may modify this association. Future research should further explore these associations, particularly for NMSC and to confirm my genetic findings.
Associations between traits (blood pressure and body height growth) and reproductive timing related genetic variants from genome-wide association studies
(2017-07-18) Mo, Daojun; He, Chunyan; Tu, Wanzhu; Song, Yiqing; Stone, Cynthia S.
Recent genome-wide association studies (GWAS) have identified many common genetic variants that are associated with women’s reproductive timing characteristics including ages at menarche and at natural menopause. However, the associations of these variants with other human health related phenotypes such as blood pressure, cancer, diabetes, obesity, and body height growth have not been well studied. No published studies to our knowledge have directly assessed the genetic influence of reproductive timing related variants on the aforementioned common traits. A better understanding of pleiotropic effects of these variants is important because it will help elucidate the precise mechanisms of common traits/diseases such as hypertension which have not been fully understood so far, and give clues for developing better solutions for disease prevention and treatment. We, therefore, conducted three studies to explore genetic variant effects on blood pressure and body height growth. In the first study, we analyzed data from a local cohort of 601 healthy adolescents from Indianapolis schools. Mixed effect model analysis revealed that 11 reproductive related single nucleotide polymorphisms (SNPs) were significantly associated with blood pressure in the study subjects. In order to assess if these genetic effects extended to the adult blood pressure, we performed the second study to investigate the genetic effect on blood pressure in adults. We used the summary statistics obtained from the two large international GWAS consortia, the Blood Pressure Consortium and the ReproGen Consortium. Bivariate analyses showed that more than 100 SNPs were associated with both blood pressure and reproductive timing. As the blood pressure development is closely related to somatic growth, we conducted the third study to exam the genetic effect of reproductive-timing related variants on the linear growth from the aforementioned local cohort. We identified 8 genetic variants significantly associated with the catch-up of linear growth in the study subjects. In conclusion, these three studies collectively provided evidence in support of the pleiotropic effects of the reproductive timing variants, suggesting the common genetic basis underlying the correlated traits. Future research is needed to validate the findings.
Associations Between Vitamin D Biomarkers and Cardiometabolic Outcomes Among Women
(2020-02) Xia, Jin; Song, Yiqing; Nan, Hongmei; Tu, Wanzhu; Han, Jiali
There is growing evidence that vitamin D endocrine system may be associated with multiple cardiometabolic outcomes, such as gestational diabetes mellitus (GDM), type 2 diabetes, and other relevant cardiometabolic comorbidities, as well as some intermediate cardiometabolic biomarkers. African Americans tend to have lower 25-hydroxyvitamin D[25(OH)D] levels and higher cardiometabolic risk than whites. However, the temporal relation between vitamin D status and cardiometabolic outcomes remains unclear due to the lack of longitudinal data. Further, whether adding information on parathyroid hormone (PTH) can explain black-white disparities in cardiometabolic health is unknown. In this dissertation, I first prospectively and longitudinally investigated vitamin D status during early to mid-pregnancy in relation to GDM risk in a multiracial cohort of women from the Eunice Kennedy Shriver National Institute of Child Health and Human Development Fetal Growth Studies-Singleton cohort. I also analyzed the data from the Women’s Health Initiative-Observational Study to 1) cross-sectionally examine race (black-white)-specific linear and non-linear relations of 25(OH)D and PTH with a panel of cardiometabolic biomarkers, including high-sensitive C-reactive protein, estimated glomerular filtration rate, and homeostatic model assessment of insulin resistance and beta-cell function, and 2) cross-sectionally and prospectively evaluate the combined associations of 25(OH)D and PTH with risk of diabetes and related cardiometabolic comorbidities (obesity, hypertension, chronic kidney disease, and cardiovascular disease) in U.S. white and black postmenopausal women. This research provides evidence of the temporal association between vitamin D status and cardiometabolic risk among women from racially/ethnically diverse groups, and possible black-white differences in these associations. The findings enhance our understanding of the contribution of vitamin D-PTH endocrine system to racial disparities in cardiometabolic health.
Availability of Behavioral Health Crisis Care and Associated Changes in Emergency Department Utilization
(2024-06) Burns, Ashlyn Brooke; Yeager, Valerie; Menachemi, Nir; Vest, Joshua R.; Mazurenko, Olena; Salyers, Michelle
One in eight emergency department visits involves a behavioral health crisis. Yet, emergency departments are rarely equipped to meet the needs of patients experiencing a behavioral health crisis. Innovative care delivery models, such as behavioral health crisis care services delivered by mental health treatment facilities, offer a promising alternative to the emergency department. As decisions are being made around reimbursement and expansion of behavioral health crisis care models, empirical evidence on the relationship between these services and emergency department utilization is needed. The purpose of this dissertation is to 1) assess availability of behavioral health crisis care services across the United States; 2) identify community-level characteristics associated with availability of behavioral health crisis care services; and 3) quantify changes in emergency department utilization associated with availability of behavioral health crisis care services. In doing so, this dissertation identifies gaps in the nation’s existing behavioral health crisis care system and highlights the value of ensuring access to these life-saving services. As national implementation of the new 988 Suicide and Crisis Lifeline is underway, findings from this dissertation may help inform efforts to transform the crisis continuum and ensure access to care for all individuals experiencing a crisis.

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