Richard M. Fairbanks School of Public Health Theses and Dissertations

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    Towards Achieving the 95% Treatment Coverage for Hard-to-Reach Populations Living with HIV and AIDS in Lusaka, Zambia Using Community Retail Pharmacies to Improve Access to Antiretroviral Therapy
    (2023-08) Magomana, Trymore; Tierney, William M.; Yego, Faith; Kamanga, Gift; Pastakia, Sonak D.
    Objective: The HIV and AIDS epidemic still contributes to high mortality and morbidity in Zambia. Antiretroviral (ART) is the backbone of HIV epidemic control. Current ART delivery models have multiple barriers to access and availability. This study explored the feasibility of implementing ART delivery through private retail community pharmacies in Zambia's urban settings based on key stakeholders' perceptions. Methods: This qualitative study utilized a mix of focus group discussions and key informant interviews. Three focus group discussions were conducted with pharmacists practicing in Zambia. Three key informant interviews were conducted with NGO representatives whose primary work is in HIV and AIDS treatment, testing, and prevention. Two key informant interviews were conducted with government representatives from the Zambia MOH involved in HIV and AIDS treatment, testing, and prevention. Deductive theme generation based on research questions was used to analyze the data collected from key informant interviews and focus group discussions. Results: Implementation of ART delivery through private retail community pharmacies in urban settings in Zambia is feasible. Participant perceptions focused on mechanisms, policies, and considerations that must be addressed to implement ART delivery through private retail community pharmacies successfully. Participants indicated that implementing ART delivery through private retail pharmacies requires funding continuing education for participating pharmacists, capacity building for pharmacy infrastructure, and linkage of ART delivery to other HIV and AIDS services like counseling, dieting and nutrition, and viral load monitoring. Conclusion: This study generated new information on the attitudes and perspectives of stakeholders about implementing ART delivery through private retail community pharmacies in Zambia. Implementing ART distribution in private retail community pharmacies in Zambia is feasible, provided key implementation determinants are addressed. The implementation of ART delivery through private retail community pharmacies will help address challenges associated with Zambia's current ART delivery models and improve ART access and coverage.
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    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.
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    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.
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    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, Lisa
    Community 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.
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    Recommendations to Startup CEO for Workplace Improvements to Reduce Burnout and Improve the Quality of Work-Life
    (2023-05) Alucozai, Milad; Stone, Cynthia; Tierney, William; Maslach, Christina
    Background and Purpose: Recent evidence suggests that entrepreneurs are more at risk of burnout. There is a gap in scholarly case studies beginning with the relationship of burnout within a startup organization. This research will benefit this startup and others, with leaders looking to help their employees thrive. Methods: LifeOmic employees (n=115) were asked to participate in this study, of which 75 (65%) respondent rate completed the individual survey questionnaire was constructed through the incorporation of the Maslach Burnout Inventory (MBI), the Areas of Worklife Survey (AWS) tools, and demographic questions. Results: Regarding exhaustion, cynicism, and professional efficacy, LifeOmic employees had an average scale score of 2.3, 1.7, and 4.8, respectively. In addition, five latent work experience profiles were identified as the following: burnout (8%), disengaged (7%), overextended (11%), ineffective (31%), and engaged (44%). All these scores showed no statistical significance across demographic categories. Conclusion: The latent profiles showed similar characteristics to those Leiter and Maslach identified (2016). However, our study reported overextended as our secondhighest latent profile compared to the ineffective profile. Plan for change with recommendations to the leadership team recognized community and workload problems that act as stressors leading to higher levels of exhaustion, ultimately leading to the overextended profile.
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    Traumatic Brain Injury Surveillance and Research with Electronic Health Records: Building New Capacities
    (2023-03) McFarlane, Timothy D.; Dixon, Brian E.; Malec, James; Vest, Joshua; Wessel, Jennifer
    Between 3.2 and 5.3 million U.S. civilians live with traumatic brain injury (TBI)-related disabilities. Although the post-acute phase of TBI has been recognized as both a discrete disease process and risk factor for chronic conditions, TBI is not recognized as a chronic disease. TBI epidemiology draws upon untimely, incomplete, cross-sectional, administrative datasets. The adoption of electronic health records (EHR) may supplement traditional datasets for public health surveillance and research. Methods Indiana constructed a state-wide clinical TBI registry from longitudinal (2004-2018) EHRs. This dissertation includes three distinct studies to enhance, evaluate, and apply the registry: 1) development and evaluation of a natural language processing algorithm for identification of TBI severity within free-text notes; 2) evaluation and comparison of the performance of the ICD-9-CM and ICD-10-CM surveillance definitions; and 3) estimating the effect of mild TBI (mTBI) on the risk of post-acute chronic conditions compared to individuals without mTBI. Results Automated extraction of Glasgow Coma Scale from clinical notes was feasible and demonstrated balanced recall and precision (F-scores) for classification of mild (99.8%), moderate (100%), and severe (99.9%) TBI. We observed poor sensitivity for ICD-10-CM TBI surveillance compared to ICD-9-CM (0.212 and 0.601, respectively), resulting in potentially 5-fold underreporting. ICD-10-CM was not statistically equivalent to ICD-9-CM for sensitivity (𝑑𝑑𝑑𝑑̂=0.389, 95% CI [0.388,0.405]) or positive predictive value (𝑑𝑑𝑑𝑑̂=-0.353, 95% CI [-0.362,-0.344]). Compared to a matched cohort, individuals with mTBI were more likely to be diagnosed with mental health, substance use, neurological, cardiovascular, and endocrine conditions. Conclusion ICD-9-CM and ICD-10-CM surveillance definitions were not equivalent, and the transition resulted in a underreporting incidence for mTBI. This has direct implications on existing and future TBI registries and the Report to Congress on Traumatic Brain Injury in the United States. The supplementation of state-based trauma registries with structured and unstructured EHR data is effective for studying TBI outcomes. Our findings support the classification of TBI as a chronic disease by funding bodies, which may improve public funding to replace legacy systems to improve standardization, timeliness, and completeness of the epidemiology and post-acute outcomes of TBI.
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    Real-World Evidence Studies on the Association of Serum 25-Hydroxyvitamin D Levels with Pain Intensity and Opioid Use
    (2022-12) Choong, Casey Kar-chan; Han, Jiali; Dixon, Brian E.; Xu, Huiping; Duszynski, Thomas J.; Zhang, Jianjun
    Vitamin D deficiency has been linked to chronic pain and increased opioid use. Realworld data such as electronic medical records and administrative claim data contain large amounts of clinical data and present an opportunity to study the relationship of serum 25- hydroxyvitamin D [25(OH)D] with pain intensity and opioid use. The first study assessed the association between serum 25(OH)D) levels and pain intensity. Compared to patients with normal 25(OH)D levels, those who had insufficient or deficient levels were more likely to experience moderate or severe pain, with multivariable-adjusted odds ratios (95% confidence intervals) of 1.19 (1.05-1.36) and 1.51 (1.28-1.79), respectively. Similar findings were obtained using propensity scores in the matched analyses. In the second study, we investigated the association between serum 25(OH.)D levels and opioid use among opioid-naïve patients. We revealed that those who had insufficient or deficient levels of 25(OH)D were more likely to receive an opioid prescription, with multivariableadjusted odds ratios of 1.10 (1.02-1.17) and 1.18 (1.09-1.28), respectively, compared to patients with normal 25(OH)D levels. Vitamin D deficiency was also associated with a longer duration of opioid use. In the third study, we performed machine learning to identify patient characteristics associated with persistent moderate-to-severe pain (PMSP), explicitly investigating if low serum 25(OH)D levels were a risk factor for heightened pain intensity among obese patients. Low levels of 25(OH)D were consistently identified as a key predictor from a large number of candidate variables in the machine learning models. We detected a significant positive association between serum 25(OH)D levels and PMSP in the logistic regression analysis. Compared to patients with normal levels of 25(OH)D, those who had insufficient or deficient levels of 25(OH)D were more likely to report PMSP, with multivariable-adjusted OR (95% CIs) of 1.15 (1.10-1.21) and 1.28 (1.21-1.35) respectively. We replicated the findings in the first study in a different cohort that showed that low serum 25(OH)D levels might play a role in pain perception. This research contributes to an improved understanding of the role of vitamin D on pain, and opioid use. Individuals who experience pain and need opioid therapy may benefit from optimizing their serum 25(OH)D levels.
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    Understanding Factors Related to Decision Making by State Health Officials in a Public Health Emergency
    (2022-10) Barishansky, Raphael M.; Halverson, Paul; Menachemi, Nir; Yeager, Valerie
    Background and Purpose - State Health Officials (SHOs), as the leaders of state governmental public health agencies, play a critical role in their respective states. Their decisions guide the overall actions of their organizations in executing programs, policies and activities that ultimately affect the health of the state’s population. This study will add to the research and serve as a potential guide to future SHO training, specific to decision making, in a public health emergency Methods – Twenty-one individuals, who are either currently working as SHOs or who were former SHOs, were interviewed to understand their perspectives on issues that may impact their response to a public health emergency: decision-making, interaction with the public and the media and the role of politics in public health, and other areas of consequence. Results – While the study was focused more broadly, all of the respondents specifically mentioned the COVID19 pandemic as the most complicated public health emergency they have responded to as a SHO. All respondents also mentioned that they did not have a specific decision-making tool to utilize during this emergency and primarily relied on a consensus-driven decision-making process. Additionally, issues such as the challenges of managing the media and the politicization of public health during this pandemic, were mentioned by many of the respondents. Conclusion - These findings pointed to the need for a step-by-step decision-making tool to be utilized by SHOs in a public health emergency. This has the potential to lead to a more methodical approach to SHOs decision-making during a public health emergency, including a focus on various operational aspects such as understanding the role of the media in a public health emergency, managing elected officials in a public health emergency, and lessons learned from past public health emergencies.
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    Mineral Intake, Dietary Quality, and Body Adiposity in Relation to Pancreatic Cancer Risk in the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial
    (2022-08) Hoyt, Margaret Leeann; Zhang, Jianjun; Song, Yiqing; Gao, Sujuan; O'Palka, Jacquelynn
    Pancreatic cancer is the third leading cause of cancer-related deaths and is projected to rank second by 2030 in the United States. However, the etiology of this malignancy remains elusive, with family history, chronic pancreatitis, type 2 diabetes, and cigarette smoking as only established risk factors. Therefore, it is urgent and important to identify risk factors, especially modifiable ones (e.g. diet), for the primary prevention of this lethal disease. In this dissertation, we have investigated the associations of mineral intake, dietary quality, and body adiposity with the risk of pancreatic cancer among participants in the Prostate, Lung, Colorectal, and Ovarian Cancer (PLCO) Screening Trial. Calcium, magnesium, and phosphorus are essential minerals that modulate energy metabolism and glucose homeostasis and may thus be involved in pancreatic carcinogenesis. In the first manuscript, we found that total calcium intake was associated with a reduced risk of pancreatic cancer. In addition, a significant linear inverse association was observed for total magnesium intake. The Healthy Eating Index, 2015 (HEI-2015) and the Dietary Quality Index- revised (DQI-R) have been developed to assess the overall quality or patterns of diet. In the second manuscript, we did not find significant associations between HEI-2015 or DQI-R scores and pancreatic cancer risk. However, a higher intake of some score components (i.e., calcium, vegetables, and whole grains) conferred a lower risk. Although mounting biological mechanisms have linked overweight and obesity to the development of pancreatic cancer, it is largely unclear whether prediagnostic body mass index (BMI) trajectory is associated with the risk of this disease. In the third manuscript, we revealed that prediagnostic adulthood BMI trajectory was not associated with pancreatic cancer risk, but a suggestively or significantly increased risk were identified for individuals who were overweight at age 20 or obese at age 50, compared with those who had a normal weight at the two respective time points. Taken together, the findings of research presented in this dissertation contribute to an improved understanding of the crucial roles of diet and adiposity in the etiology of pancreatic cancer, which may offer some new avenues for the prevention of this intractable malignancy.
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    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.