Richard M. Fairbanks School of Public Health Theses and Dissertations

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    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.
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    Regulatory Acceptable Real-World Effectiveness Endpoints: How Clarity Can Best be Achieved in the United States
    (2023-12) Beyrer, Julie; Hess, Lisa M.; Nan, Hongmei; Lederer, Nirosha M.
    Background: The therapies many patients need do not exist today. Real-world evidence (RWE) can accelerate patient access to treatment. However, lack of clarity on regulatory acceptable realworld effectiveness endpoints can result in delayed or lost new therapy opportunities to bring new treatments to patients. Research question: How can clarity on regulatory acceptable real-world effectiveness endpoints in the United States best be achieved? Methods: A qualitative research study was conducted by interviewing expert informants from diverse stakeholder types to explore their perceptions of gaps, solutions, action needed, and determinants for achieving clarity. Themes were derived using an inductive coding approach, followed by an appraisal of the potential macro-level solutions using Bardach's criteria for policy analysis. Results: Four macro-level solutions were identified: Food and Drug Administration (FDA) Advancing RWE Program, FDA report or dashboard for stakeholders to more easily locate FDA reviews and decisions about RWE, a tool to help stakeholders apply existing related FDA guidance, and FDA guidance on real-world effectiveness endpoints. Plan for Change: Recommended actions for implementing the four solutions and potential evaluation measures were derived from interview themes and Expert Recommendations for Implementing Change. Of the four solutions, an immediate opportunity that FDA and non-FDA stakeholders could initiate is a tool to help stakeholders apply existing FDA guidance, precedent, and endpoint validation principles from the scientific literature. Conclusion: Two solutions are already in progress to increase stakeholders experiences with RWE for regulatory decision making (e.g., FDA Advancing RWE Program and FDA report on RWE submitted for regulatory review). Parallel implementation of other solutions is likely needed (e.g., developing a tool to help stakeholders navigate the existing guidance and precedents on real-world effectiveness endpoints), with regulatory guidance on real-world effectiveness endpoints to follow. Good engagement and transparency across the stakeholder communities are essential to make the most meaningful impact.
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    How Can Public Health Leaders Improve School Compliance with the Indiana Department of Health Mandatory Vaccine Requirements for School-Aged Populations?
    (2023) Carlson, Megan Marie; Stone, Cynthia; Silverman, Ross; McCormick, David
    Primary and Secondary Schools in the United States have consistently served as a safety net to prevent outbreaks of vaccine-preventable diseases, with state policy enactment requiring vaccines for school entry. While states have long implemented vaccination mandates for schools as a public health measure, the enforcement of those mandates by states and schools has been inconsistent. Over the past few years, there has been a significant decline in the vaccination rates among Indiana children, which was recently accelerated by the COVID-19 pandemic. Public health officials and legislatures continue to adopt policies and laws to combat growing vaccine noncompliance and non-medical exemption requests. However, an essential component of this process is being overlooked, the implications for schools, particularly for schools without a medical professional on staff. The purpose of this study is to gather qualitative insights from school personnel regarding perceptions, challenges, and barriers impacting the enforcement of state-mandated school entry vaccines. The overall aim of this study is to draw on the experiences of these key participants and ‘experts’ to inform public health interventions or policy changes that will support improved vaccination reporting and compliance among school systems. The Consolidated Framework for Implementation Research (CFIR) framework was used to examine the implementation of the school vaccine mandate by school personnel who played a role in the vaccine requirement process. Semi-structured interviews were conducted with a range of personnel (n=25) supporting medical, non-medical, and administrative roles within a public or charter school or district. Interview Guides for the semi-structured interviews were developed focusing on known current processes of school vaccine mandates applied to constructs within the Inner Setting domain. Responses were categorized into themes based on eleven constructs from the CFIR Inner Setting domain. Findings show school personnel experience a variety of conditions, challenges, and barriers impacting their abilities to comply with state vaccine requirements. Findings also yielded several considerations for facilitators to improve vaccination uptake. A plan for change to improve vaccination rates through a policy analysis and subsequent policy change is presented.
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    Using a Social Ecological Framework to Understand Healthy Relationships and Unintended Pregnancy Risk Among Youth in Rural Communities and Youth Engaged in Systems
    (2023-11) Imburgia, Teresa Marie; Zhang, Jianjun; Cote, Michelle L.; Hensel, Devon J.; Ott, Mary A.
    Nearly 75% of adolescent pregnancies are unintended, putting those adolescents at risk for long-term physical, social, and mental health outcomes. Youth who live in rural areas and youth with system involvement are at increased risk of unplanned pregnancies and births. We used the social ecological framework to investigate the following known risks for unplanned pregnancies: early sexual onset, contraception non-use, and dating violence. First, we examined the behaviors and attitudes associated with early sexual onset and the intention to delay sex in rural middle school youth. Being older, having less agency for sexual refusal, system involvement, and more parent communication were associated with having sex and planning to have sex. This highlights the importance of early, comprehensive, and trauma-informed pregnancy prevention programs for younger adolescents. Second, we examined the impact of positive youth development (PYD) on the use of effective contraceptives for sexually active youth who are system involved. Only 13.9% used condoms alone and 41.5% hormonal contraception (+/- condoms) in the past three months. Multivariate ordinal logistic regression revealed that older age, female gender, and higher PYD skills were associated with the use of more effective contraceptives. The final study identified risk and protective factors for perpetration and victimization of dating violence among youth with system involvement. We observed high rates of dating violence across all participants, and gender differences in perpetration and victimization. Using Poisson regression models, both perpetration and victimization were related to higher levels of trauma, lower healthy relationship scores, having recent sex, and being a sexual minority. These studies indicate a need for early delivery of pregnancy prevention programs and services for higher risk youth that are trauma informed, sexually inclusive, and promote PYD and healthy relationships.
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    Healthcare-Associated Infections (HAI) in Kazakhstan: Can We Trust Reporting? A Mixed-Methods Study of Institutional Culture, Context and Leadership in Hospitals and State Public Health Agencies
    (2023-11) Aiypkhanova, Ainur; Marstein, Egil; Deryabina, Anna; Babich, Suzanne
    Background. Health care-associated infections (HAI) are among the most common adverse events in health care delivery globally, with up to 7% of patients in high-income countries and up to 15% in low- and middle-income countries acquiring one during their hospital stay [1]. However, HAI rates in Kazakhstan did not exceed a fraction of one percent for decades [2, 3]. While up to 70% of HAI are preventable through effective infection prevention and control (IPC) practices [1], not knowing the real rate reduces the sense of urgency for national and local leaders and delays action to improve patient safety. Such low HAI rates in Kazakhstan led public health leaders to suspect underreporting, prompting a WHO-sponsored pilot point-prevalence survey, which found a 3.2% HAI rate in 2022, 90 times higher than the reported rate of 0.35% for the same year [4]. This study aimed to find out why health care organizations (HCO) are not reporting HAIs to health authorities, and based on the influence of institutional culture, organizational and country context, how public health leaders can best improve HAI surveillance. Methods. This is a mixed-methods study that used triangulation and grounded theory to analyze data collected in 4 stages: 1) desk review of national policies; 2) secondary datasets collected in a national study of 78 hospitals; 3) qualitative primary data collected from 12 key informants (public health leaders); 4) repeated desk review. safety and get involved in IPC. Epidemiologists from public health agencies must become the source of methodological support and have their training needs met as well. While this study generated evidence in support of multiple recommendations, the water of systems change model [9] can help policymakers appreciate the importance of implicit change conditions such as the culture, often ignored in change efforts undertaken in the post-Soviet countries. Conclusions. HAI rate remains abnormally low in Kazakhstan due to the long-lasting effect of the Soviet approach to IPC and the resulting punitive culture and punitive policies that deter providers from reporting. Findings from this study should be used by national, regional and HCO leaders in Kazakhstan and other countries with similar context to prioritize and design system-wide improvements in IPC and HAI surveillance. Recommendations should not be limited to traditional leadership actions such as policy change, more training and introduction of evidence-based protocols and procedures, but also include an implicit change condition – culture change – to create an environment conducive of truthful reporting of adverse events such as HAIs.
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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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    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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    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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    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.