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Richard M. Fairbanks School of Public Health Theses and Dissertations
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Item Advancing the Implementation of CLAS Standards to Support Health of South Asian Americans(2023) Barnabas, Beatrice Benjamin; Stone, Cynthia; Nicholas, Celeste; Reed, StevenAsian 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.Item 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, ChristopherStudy 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.Item 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.Item 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.Item 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.Item Associations Between Vitamin D Biomarkers and Cardiometabolic Outcomes Among Women(2020-02) Xia, Jin; Song, Yiqing; Nan, Hongmei; Tu, Wanzhu; Han, JialiThere 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.Item 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, MichelleOne 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.Item Community Health Workers: An Examination of State Policies and Analysis of a Healthcare-Based Intervention for Diabetes Management(2023-06) Hansotte, Elinor Alice; Stone, Cynthia; Dixon, Brian E.; Silverman, Ross; Staten, LisaCommunity Health Workers (CHW) are trusted frontline members of the public health workforce with a unique understanding of the communities they serve. CHW interventions have been shown effective and economical in improving certain health outcomes, including diabetes-related complications and self-management. The ability of CHWs to relate to patients in a culturally appropriate manner positions them to better address social determinants of health and inequities than many allied health professionals. State-level CHW legislation varies by jurisdiction and can direct CHW processes including definitions, funding, and scope of practice. The Diabetes Project – Indianapolis Neighborhoods (DIP-IN) intervention employs clinic-based CHWs to work with high-risk patients with diabetes in three Indianapolis communities with disproportionately high diabetes prevalence rates. DIP-IN CHWs are based in select Eskenazi Health Federally Qualified Health Centers and deliver services to patients primarily through home visits or phone calls. This dissertation examines CHW policies and the impact of the DIP-IN CHW intervention on patient outcomes in relation to a comparison group. This dissertation includes three studies 1) a state-level policy surveillance exploring legislation that includes best practices for CHW policy, 2) a study using a difference-in-difference approach through the application of generalized linear mixed models to estimate the effect of DIP-IN on A1C and hospital outcomes, and 3) a study using multivariat regression and negative binomial modeling to estimate the impact of DIP-IN on COVID-19 hospitalization and length of stay. As financing influences duration and application of CHW interventions, this dissertation aims to explore the landscape over time of CHW legislation and evaluate a privately funded CHW program model intended to improve health outcome among high-risk patients with diabetes. It also aims to strengthen the knowledge base for CHW involvement in improving clinical-community linkages to support diabetes management.Item Dietary intake and urinary excretion of phytoestrogens in relation to cancer and cardiovascular disease(2014) Reger, Michael Kent; Zollinger, Terrell; Jones, Josette F.; Liu, Ziyue; Zhang, JianjunPhytoestrogens that abound in soy products, legumes, and chickpeas can induce biologic responses in animals and humans due to structural similarity to 17β-estradiol. Although experimental studies suggest that phytoestrogen intake may alter the risk of cancer and cardiovascular disease, few epidemiologic studies have investigated this research question. This dissertation investigated the associations of intake of total and individual phytoestrogens and their urinary biomarkers with these chronic conditions using data previously collected from two US national cohort studies (NHANES and PLCO). Utilizing NHANES data with urinary phytoestrogen concentrations and follow-up mortality, Cox proportional hazards regression (HR; 95% CI) were performed to evaluate the association between total cancer, cardiovascular disease, and all-cause mortality and urinary phytoestrogens. After adjustment for confounders, it was found that higher concentrations of lignans were associated with a reduced risk of death from cardiovascular disease (0.48; 0.24-0.97), whereas higher concentrations of isoflavones (2.14; 1.03-4.47) and daidzein (2.05; 1.02-4.11) were associated with an increased risk. A reduction in all-cause mortality was observed for elevated concentrations of lignans (0.65; 0.43-0.96) and enterolactone (0.65; 0.44-0.97). Utilizing PLCO data and dietary phytoestrogens, Cox proportional hazards regression examined the associations between dietary phytoestrogens and the risk of prostate cancer incidence. After adjustment for confounders, a positive association was found between dietary intake of isoflavones (1.58; 1.11-2.24), genistein (1.42; 1.02-1.98), daidzein (1.62; 1.13-2.32), and glycitein (1.53; 1.09-2.15) and the risk of advanced prostate cancer. Conversely, an inverse association existed between dietary intake of genistein and the risk of non-advanced prostate cancer (0.88; 0.78-0.99) and total prostate cancer (0.90; 0.81-1.00). C-reactive protein (CRP) concentration levels rise in response to inflammation and higher levels are a risk factor for some cancers and cardiovascular disease reported in epidemiologic studies. Logistic regression performed on NHANES data evaluated the association between CRP and urinary phytoestrogen concentrations. Higher concentrations of total and individual phytoestrogens were associated with lower concentrations of CRP. In summary, dietary intake of some phytoestrogens significantly modulates prostate cancer risk and cardiovascular disease mortality. It is possible that these associations may be in part mediated through the influence of phytoestrogen intake on circulating levels of C-reactive protein.Item The Effects of Healthcare Service Disruptions on the Community, Healthcare Services and Access to Care(2022-08) Mills, Carol Ann; Blackburn, Justin; Holmes, Ann M.; Unroe, Kathleen; Yeager, Valerie A.Access to healthcare services is important for improving health outcomes, preventing and managing illness, and achieving health equity. The geographic maldistribution of physicians has a negative impact on rural areas compared to urban, particularly as it relates to access to healthcare. Rural hospitals have been closing or converting to another form of healthcare service at an increasing rate, adding another element to the existing complexities in rural access to care. Although a hospital closure in any location may have a considerable impact on the community, the closure of a rural hospital may have disproportionately more substantial implications for the economy and employment, health outcomes, and access to care. The contributing factors preceding rural hospital closures have been studied, but less is known about the full impact of rural hospital closures on the community. There is some evidence of shortages in healthcare providers and services, and therefore communities may employ multiple strategies to mitigate the shortages and provide services, including utilizing telehealth/virtual services. This dissertation proposes to examine the effects of rural hospital closures on the community, healthcare services, access to care, and provide a qualitative assessment of telehealth as a strategy to bridge gaps in provider access. This dissertation includes three studies: 1) a systematic review of the literature to examine the impact of rural hospital closures on the community; 2) an empirical study that utilizes a generalized difference in difference design with county and year fixed effects to estimate the relationship between rural hospital closures and nursing homes; and 3) a qualitative study exploring the perceptions and experiences of the nurses that piloted a virtual care support project, providing insights into crucial elements important to the implementation of similar models and the role of telehealth in bridging healthcare workforce gaps.