The purpose of this study was to better understand the relationship between elements of patient-centered care and patient/provider comfort with conversing about food insecurity and related social determinants of health. A mixed methods study was conducted. Patients and healthcare providers were surveyed on their experiences with patient-centered care and comfort discussing food insecurity and related social concerns. Telephone interviews were conducted to gain a richer understanding of the concepts under investigation. In the survey and telephone interviews, both samples were also asked about changes in communication during COVID-19 times. Quantitative findings show that patient involvement in care and cultural sensitivity are two important patient-centered variables that positively impact patient comfort being screened for food insecurity. Qualitative findings support this inference, and also denote the importance of other patient-centered care elements, such as empathy, trust, and effective communication. For healthcare providers, process-oriented variables, such as having food insecurity screenings built into the patient history assessment and sufficient training administering screenings were important factors that facilitated comfort screening patients for food insecurity and related concerns. Both populations stated several changes in communication resulting from COVID-19. For example, both samples noted an increase in communication through various channels. However, this increased communication did not necessarily reflect an increase in quality of communication. Patients described quicker and less personal interactions with healthcare providers. Providers observed increased difficulty in conveying empathy and support through nonverbal cues because of wearing masks and communicating through computer screens. The findings of this study provide important implications for healthcare practitioners and community organizations that aim to increase screenings for food insecurity in outpatient medical settings and highlight additional challenges that may be faced resulting from COVID-19.

Opioid-related deaths have increased rapidly over the last couple of decades due to the overprescribing of prescription opioids and the availability of illicit drugs from family members, friends, or street dealers. To address this crisis, this research will attempt to identify how health literacy levels affect knowledge, attitudes, and behaviors. Hence, this study is informed by the Knowledge-Attitude-Behavior (KAB) Model. The KAB model is used to determine the influence of knowledge and attitudes on behaviors, which includes prescription drugs, illicit drugs, and fentanyl. This dissertation aims to explore the relationships between health literacy, knowledge, attitude, and behavior for opioids (prescription and illicit). This study will also explore how these relationships differ by socioeconomic status and demographics. This study used a survey methodology to engage college students from a southeastern university as the participants of this study. The findings of this study show there is an association between health literacy and the KAB model. Additionally, there is an association between the components of the model and gender, ethnicity, and lifetime behavior, which supports what is found in the literature. The results from this study will be useful for opioid researchers and public health organizations so opioid-related information is disseminated in a plain language format to the public. The dissemination of information is significant because it will guide the opioid knowledge of college students and can essentially influence their behavior.

Diabetes Miletus (DM) is one of the major health problems in the United States. Despite all efforts made to combat this disease, its incidence and prevalence are steadily increasing. One of the common and serious side effects of treatment among people with diabetes is hypoglycemia (HG), where the level of blood glucose falls below the optimum level. Episodes of HG vary in their severity. Nevertheless, many require medical assistance and are usually associated with higher utilization of healthcare resources such as frequent emergency department visits and physician visits. Additionally, patients who experience HG frequently have poor outcomes such as higher rates for morbidities and mortality. Although many studies have been conducted to explore the risk factors associated with HG as well as others that looked into the level of healthcare utilization and outcomes among patients with HG, most of these studies failed to establish a theoretical foundation and integrate a comprehensive list of personal risk factors. Therefore, this study aimed to employ Andersen's health Behavior Model of health care utilization (BM) as a framework to examine the problems of HG. This holistic approach facilitates enumerating predictors and examining differential risks of the predisposing (P), enabling (E) and need-for-care (N) factors influencing HG and their effects on utilization (U) and outcomes (O). The population derived from the national inpatient sample of the Healthcare Cost and Utilization Project (HCUP) database and included all non-pregnant adult diabetic patients admitted to hospitals' Emergency Departments (EDs) with a diagnosis of HG from 2012-2014. Based on the BM framework, different factors influencing HG utilization and outcome were grouped under the P, E, or N component. Utilization was measured by patients' length of stay (LoS) in the hospital and the total charges incurred for the stay. Outcome was assessed based on the severity ranging from mortality (the worst), severe complications, mild complications, to no complications (the best). Structural Equation Modeling (SEM) followed by Decision Tree Regression (DTREG) were performed. SEM helped in testing multiple hypotheses developed in the study as well as exploring the direct and indirect impact of different risk factors on utilization and outcome. The results of the analysis show that N is the most influential component of predictors of U and O. This is parallel to what was repeatedly found in different studies that employed the BM. Regarding the other two components, P was found to have some effect on O, while E influences the total charge. Interaction effects of predictors were noted between some components, which indicate the indirect effect of these components on U and O. Subsequently, DTREG analysis was conducted to further explore the probability of the different predictor variables on LoS, total charge, and outcome. Results of this study revealed that the presence of renal disease and DM complications among HG patients play a key role in predicting U and O. Furthermore, age, socio-economic status (SES), and the geographical location of the patients were also found to be vital factors in determining the variability in U and O among HG patients. In conclusion, findings of this study lend support to the use of the BM approach to health services use and outcomes and provide some practical applications for healthcare providers in terms of using the predictive model for targeting patient subgroups (HG patients) for interventions among diabetic patients. Moreover, policy implications, particularly related to the Central Florida area, for decision makers regarding how to approach the growing problem of DM can be drawn from the study results.

The epidemiologic transition has shifted major causes of mortality from infectious disease to chronic disease; however, infectious diseases are again re-emerging as a major global concern (Diamond, 1997; Karlen, 1995; McNeil, 1976). This research aimed to identify potential areas of infectious disease influence that are not health-related in order to help governments and policymakers establish new policies, correct current policies, or further address these issues in order to effectively prevent and combat infectious disease. This study employed a retrospective, cross-sectional, non-experimental design via structural equation modeling (SEM) and examined tuberculosis incidence rates at the country-level. Secondary data from open-source, international databases like World Bank's World Development Indicators, World Governance Indicators, and World Health Organization for the year 2014 was utilized. Results revealed that the latent constructs of political stability, health system indicators, and detection policies directly affected tuberculosis incidence rates; they also exhibited an indirect effect due to covariation. Economic stability did not direct affect tuberculosis incidence, but it indirectly influenced incidence through the covariation of political stability, health system indicators, and detection policies. As a country's political stability increased, tuberculosis incidence decreased. As positive health system indicators increased, tuberculosis incidence decreased. Countries with more Xpert detection policies in place experienced an apparent increase in tuberculosis incidence.

A significant concern in healthcare is that of patient privacy and how organizations protect against unauthorized access to protected health information. The federal government has responded by instituting policies and guidelines on requirements for protection. However, the policy language leaves areas open to interpretation by those following the guidelines. Reporting to the Office for Civil Rights and/or the patient can open an organization to risk of financial and possible criminal penalties. There is a risk of harm to their reputation which could impact patient visits and market share. Therefore, Privacy Officers might view risk in different ways and therefore handle breach reporting differently. Privacy Officers are responsible for determining an individual organization's breach reportability status. Their processes may vary dependent on their knowledge of the policy, the status of previous reported breaches, and their framing of an incident. This research aims to explore the following factors: (1) personal and organizational knowledge, (2) prior breach status, (3) and scenario framing, to explore if Prospect Theory is applicable to the choices a Privacy Officer makes regarding breach determination. The study uses primary data collection through a survey that includes loss and gain scenarios in accordance with Prospect Theory. Individuals listed as Privacy Officers within the American Health Information Management Association (AHIMA) were the target audience for the survey. Univariate, Bivariate, Multivariate, and Post Regression techniques were used to analyze the data collected. The findings of the study supported the theoretical framework and provided industry and public affairs implications. These findings show that there is a gap where Privacy Officers have to make their own decisions and there is a difference in the types of decisions they are making on a day to day basis. Future guidance and policies need to address these gaps and can use the insight provided by this study.

The political focus of equitable health outcomes in the United States have long centered on access to medical care. However, there is compelling evidence that access to medical care is only the bare minimum necessary to achieve health, and the true influence of health insurance on health is still unclear. Widely accepted models of health estimate that less than 20% of health outcomes can be attributed to clinical care, while greater than 50% is related to social and economic determinants of health, with income being the most consistent predictor. As a result, this study investigated whether earned income is related to insurance status on the one hand and self-rated health on the other; whether the association between income and self-rated health is indirectly influenced by the presence of health insurance –namely private health insurance; whether there are differences in self-rated health between the privately insured, the publicly insured, and the uninsured; and if duration of uninsurance was inversely associated with self-rated health. As hypothesized, higher income was associated with having health insurance, and in particular private insurance. Among all included predictor variables, higher income and private insurance are the strongest predictors of higher self-rated health, and lower income and Medicaid were the strongest predictors of lower self-rated health. This study affirms that the health of persons with Medicaid is more similar to persons who are uninsured, and the health of persons with private insurance is more similar to those with Medicare. The association between income and self-rated health is indirectly influenced by health insurance. Age and education exerted the strongest overall influence on self-rated health: older respondents had lower self-rated health, and more educated respondents had higher self-rated health. And as uninsurance duration increased, self-rated health decreased. Additional studies are recommended to improve health insurance policy.

All students have the right to education. Students with disabilities need support from health providers to achieve their potential at school. Barriers to health service provision exist including shortages of providers, waitlists for services, complexities of coordination between the health and education sectors, and more recently the COVID-19 pandemic. Given these barriers, some schools have been using telehealth to increase access to school-based health services; however, the literature is still emerging in this area. In this thesis, I used scoping review methods to explore the literature pertaining to telehealth use in schools. The first manuscript describes the characteristics of telehealth use in schools as depicted in 57 included articles. The findings elucidated who is providing services using telehealth and with whom, when they are using telehealth, how they are using telehealth, and why they are using telehealth in the schools. Based on the findings, I identified practice and research recommendations. The second manuscript delves into the factors that influence telehealth use in schools. We used diffusion of innovations theory to categorize statements in the 57 included articles to identify factors that influenced telehealth implementation in schools. These categories included the features of the telehealth itself (the innovation), the communication about telehealth, the process of deciding to use telehealth (time), and the social system. The findings pointed to at least four key factors that influence implementation of telehealth in schools. The final concluding chapter integrates the findings from the two studies with overarching ideas about technology complexity, access to services, and current knowledge. Additionally, implications for schools, health providers, and specifically occupational therapists are provided along with policy implications. / Thesis / Master of Science Rehabilitation Science (MSc) / School-based health providers experience barriers to servicing children and youth. These barriers reduce access to services. Telehealth is a way to provide services that may increase access to health services in schools. This thesis explored the current research about telehealth use in schools. The first study looked at the characteristics of use such as who is using telehealth, how are they using telehealth, and why are they using telehealth. The second study looked at what factors influence use of telehealth in the schools. The findings from these two studies describe what is currently known about telehealth use in schools. With this information, health providers can decide when, with whom, and how to provide telehealth in the schools. Researchers may use these studies to fill gaps in knowledge about how to best use telehealth in the school setting.

Thesis (Ed.M.)--Boston University

Health disparities by race in the United States have been persistent over decades and one possible reason for that could be that physicians are communicating differently with different races. The purpose of this study was to systematically review literature regarding the relationship of patient race/ethnicity with physician-patient communication. The overall project of which this is a part is a mixed methods review, but my part of the study involved only studies using observational data such as audio and video recordings of physician-patient encounters. This study investigated research that compares physician communication with patients across a wide range of ethnic groups, including multiple communication behaviors. Eighteen different content analysis-based studies were identified and analyzed. Most of the studies drew a comparison between White patients and Black patients. Physicians were more likely to use more positive affective behavior with White patients than Black patients. All of the other analyses did not show a difference by race. Overall, few studies showed whether any racial differences affect health outcomes of patients.

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