Deaths from opioid overdose have increased dramatically in the past decade, representing an epidemic in the United States. For individuals with opioid use disorder (OUD), agonist medications such as methadone and buprenorphine represent an evidence-based treatment that has been shown to reduce opioid-related morbidity and mortality. Historically, the provision of buprenorphine treatment in office-based settings has relied on frequent in-person contact, which influenced patients’ access to and retention in care. However, in response to the COVID-19 pandemic, providers of office-based buprenorphine treatment rapidly adapted their care processes, increasingly relying on telemedicine visits. This dissertation employed mixed methods to study the implementation and effectiveness of telemedicine in office-based buprenorphine treatment provided in safety-net settings, or those that provide health services to patients regardless of their ability to pay. Qualitative methods were used to explore provider and patient experiences with the use of telemedicine in an office-based buprenorphine treatment clinic associated with an academic safety-net hospital, while quantitative methods were used to examine the effects of telemedicine adoption on outcomes for patients with OUD attending federally-qualified health centers (FQHCs) in Massachusetts. Results from provider interviews indicated the implementation of telemedicine in office-based buprenorphine treatment precipitated openness to more flexibility in care practices, though providers expressed concerns regarding telemedicine and related adaptations that centered around patient safety. Results from patient interviews indicated telemedicine enabled engagement in care, though patients differed in their views on: 1) the appropriateness of telemedicine based on one’s stage of recovery, 2) how telemedicine impacted their relationships with providers, and 3) their preferences for telemedicine visits moving forward. Results from both patient and provider interviews indicated safety-net patient populations experienced unique challenges when using telemedicine, particularly due to difficulties with technology and privacy. Finally, results from the quasi-experimental study of telemedicine adoption across a network of FQHCs indicated it was associated with: 1) increases in all-cause and OUD-related outpatient care engagement, 2) increases in retail buprenorphine fills and days supplied, and 3) either no changes or decreases in all-cause and OUD-related emergency department visits and inpatient admissions. These findings suggest telemedicine has the potential to improve patients’ engagement in office-based buprenorphine treatment while not compromising safety; however, qualitative data emphasizes the perceived benefits of hybrid, patient-centered approaches to care, particularly in safety-net settings. Overall, results of this dissertation support the maintenance of changes to policy and practice that facilitate the use of telemedicine in office-based buprenorphine treatment beyond the COVID-19 public health emergency. / 2025-01-03T00:00:00Z

The growth rate and percent of GDP spend on health care has brought necessary attention to discussions on cost and quality within the health industry. This research posits that in order to tackle issues within these cost and quality-conscious discussions, consumers require increased literacy in the health insurance shopping and utilization processes. Health insurance literacy is relatively new terminology. In regard to consumer literacy measures in purchasing, the findings in Chapter 1 demonstrate that studies on health insurance literacy are inconsistent, with no consensus on which metrics are most appropriate to measure health insurance literacy. While there is a generally agreed upon definition of health insurance literacy, there is currently no standard scale to determine one’s literacy level. Additionally, literacy, in a broader construct, can assist consumers in making better informed choices about how to engage with and manage their health insurance. One particular example of a poor utilization habit is the use of the Emergency Room (ER) for non-emergent conditions. The findings in Chapter 2 demonstrate that educated consumers can be influenced to choose alternative sites for ER care. This research suggests that taking measures to advance health insurance literacy can improve both shopping and utilization behavior and, in turn, positively impact health care costs and efficiencies. The conclusion of this research theorizes on the best approach to influence literacy in health insurance; ultimately furthering the body of research that moves toward a more efficient, effective, and literate health insurance industry. / Business Administration/Interdisciplinary

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Master of Arts / Department of Economics / Dong Li / Comprehensive worksite wellness programs were first introduced in the United States in the late 1970s and early 1980s, with the goals of improving health, reducing health care expenditures, and demonstrating senior management’s commitment to the health and well-being of workers (Ozminkowski et al, 2002). As the annual cost of employer-sponsored family health coverage increased four percent between 2012 and 2013 (Kaiser Family Foundation, 2013), many companies are turning to worksite wellness programs. Wellness programs have shown not only to reduce health care costs, but also decrease absenteeism and increase employee satisfaction. The studies on the benefits of wellness programs are not conclusive; there seems to be a general lack of good data collection and analysis. This report discusses what determines an employer’s likelihood of offering a wellness program, what determines an employee’s participation in a wellness program, and a benefits analysis of wellness programs.

Master of Science / Industrial & Manufacturing Systems Engineering / David H. Ben-Arieh / Telemental health systems, a form of telemedicine, use electronic communication media to provide patients in remote locations access to psychological and psychiatric specialists. The structure of telemental health systems has a major impact on their performance. Discrete-event simulations offer useful results concerning capacities and utilization of specific resources. Simulation, however, cannot provide theoretical properties of analyzed systems. Petri net representations of systems can overcome this shortfall, offering a wide range of easily-analyzed and useful properties. Their ability to model resource conflict, parallel activities, and failure modes fits nicely with the reality of telemental health systems. Analysis of behavioral properties of Petri nets can provide meaningful information for system analysts. The most useful properties include net boundedness, liveness, and non-reachability of certain undesirable states. The thesis discusses methods to find all these properties. Specifically, it provides property-preserving net reductions to facilitate analysis of boundedness and liveness and describes an integer programming model to solve reachability and coverability problems. Moreover, this thesis outlines a simulation analysis of synchronous and asynchronous telemental health systems. The paper then describes a Petri net model of a generic telemental health delivery system. The paper subjects the model to an integer programming model and net reduction. The integer programming model indicated that the number of resources in the system remains static, full utilization of resources at a given time is possible, conflict over resources is possible, and improper work prioritization is possible within the model. Net reduction and analysis with open-source software showed that the model is bounded and live. These results can aid telemedicine system architects in diagnosing potential process issues. Additionally, the methods described in the paper provide an excellent tool for further, more granular analysis of telemedicine systems.

<p> <b>Background:</b> As the world becomes more urban and slums continue to grow in developing countries, research is needed to measure utilization of health services, health outcomes, and access to health care providers among urban slum residents. Estimating trends in urban health among slum residents relative to other urban inhabitants provides evidence of health disparities for priority-setting by program implementers and policy-makers. Research on the negative effects of slum environments on human health has started to emerge, yet there remains a paucity of evidence on morbidity trends over time and inequalities between slum residents and other urban residents. The goal of this study is to quantify maternal and child health care access, utilization and outcomes among urban slum dwellers in selected countries in sub-Saharan Africa and South Asia over time. These three areas are addressed in three separate dissertation manuscripts. </p><p> <b>Methods:</b> This dissertation offers an in-depth analysis of household and health facility data to measure trends in maternal and child health care utilization and health outcomes among slum residents over time, as well as inequalities in access, utilization and outcomes between other urban and rural populations. Manuscripts 1 and 2 apply a unique spatial inequality approach to existing population-based household data from the Demographic and Health Surveys (DHS) to identify a sample of slum residents. Manuscript 1 assesses trends in maternal and child health care (MCH) utilization and health outcomes using DHS data in Bangladesh, Ethiopia, Kenya, Malawi, Nepal, Nigeria and Tanzania between 2003 and 2011. In Manuscript 2, a trend analysis is performed in Kenya to examine diarrheal disease and acute respiratory infection (ARI) in children under-five in both slums and other urban and rural areas during the roll-out of a national slum upgrading program. Manuscript 3 further explores local-level dimensions of health care access from two slums in Kenya, generating evidence on service availability and readiness in slums. In this section, we analyze health facility data collected using a modified version of the World Health Organization&rsquo;s (WHO) Service Availability and Readiness Assessment (SARA). </p><p> <b>Results:</b> Manuscript 1 reports significant disparities between slum dwellers and other urban residents&rsquo; utilization of key maternal health interventions&mdash;appropriate antenatal care (ANC), tetanus toxoid vaccination, and skilled delivery&mdash;in Bangladesh, Ethiopia, Kenya and Nigeria. In addition, child health outcomes examined in Manuscript 1 suggest that the prevalence of diarrheal disease in children under-five is declining among other urban and rural residents, but not significantly among slum residents. Nigeria was the only exception, with significant declines in diarrheal disease prevalence in slums over the study period. Because ARI improvements are found across populations, the data suggests this condition is not unique to slum settings. The trend analysis in Manuscript 2 supports these findings&mdash;ARI is declining steadily over time not only among slum residents, but also among other urban and rural residents as well. Diarrheal disease prevalence, on the other hand, has not changed significantly over time, with stable levels among slum dwellers between 1993 and 2014. In Manuscript 3, analysis of general service availability and readiness in two locations&mdash;the Nyalenda slum of Kisumu and the Langas slum of Eldoret&mdash;reveals that slums perform far below recommended benchmarks set by WHO. When we compare service availability and readiness indicators with regional, urban, and national averages, in general slums in Kisumu and Eldoret perform poorly. However, there were some instances&mdash;typically involving standard precautions for infection control&mdash;where Kenyan slums actually performed better than comparison sites. </p><p> <b>Conclusions:</b> This research provides a comprehensive view of health systems dimensions in urban slums in sub-Saharan Africa and South Asia. Manuscript 1 confirms evidence of an urban penalty and emphasizes a need to focus on maternal health care utilization in slums. Manuscript 2 detects little improvement in child health outcomes among slum dwellers in Kenya during the roll-out of the country&rsquo;s national slum upgrading program. An integrated approach to health and urban policy development is recommended based on these results. Manuscript 3 identifies areas of service availability and readiness in two Kenyan slums that fall below global targets and are in need of improvement in order to achieve desired health outcomes. Taken together, this study makes a significant contribution to the crucial demand for research on growing marginalized urban populations in developing countries.</p>

<p> Minority populations in the United States (U.S.) suffer an unequal burden of morbidity and mortality due to health disparities. The purpose of this descriptive cross-sectional study was to identify factors associated with disparities in self-rated health (SRH) among Asian and Hispanic immigrants. The acculturation theory and intersectionality framework were used to select predictors of SRH that included age, gender, ethnicity, socio-economic status, depressive symptoms, C-reactive protein (CRP) level, acculturation status, social position, and acculturative stress and discrimination events. A systematic review of the literature was completed and data from the 2009-2010 National Health and Nutrition Examination Survey and the 2002-2003 National Latino and Asian American Study were reviewed. This study found that acculturation status was associated with reporting disparities in SRH for both Asian and Hispanic immigrants. Limited English proficiency and being foreign-born was associated with worse SRH for Korean, Chinese, and Mexican immigrants, and in aggregate samples of Asian and Hispanic immigrants, compared to non-Hispanic Whites. Additionally, limited English proficiency was associated with worse SRH for Vietnamese immigrants. Among Mexican immigrants, higher levels of acculturation were associated with better SRH. Other key findings among Mexican immigrants were that depressive symptoms, increasing age, female gender, and elevated CRP were predictors of worse SRH compared to U.S.-born, non-Hispanic Whites. However, female gender and higher CRP were not predictors of worse SRH when level of acculturation was controlled for. For Chinese immigrants, acculturative stress was associated with worse SRH in an additive model while the interactions between social position and discrimination, and between gender, acculturative stress, and social position and education were predictive of worse SRH in multiplicative models. In summary, age, gender, ethnicity, socio-economic status, depressive symptoms, CRP, acculturation status, social position, and acculturative stress and discrimination were associated with disparities in SRH among two ethnic minorities in the U.S. These findings can be used to improve awareness and understanding of these immigrant populations who are vulnerable to poor health outcomes. Additionally, outcomes can assist in developing interventions to reduce the influence of social structures on health and to capture the true complexities of immigrants&rsquo; lives.</p>

<p> Men in sub-Saharan Africa are less likely than women to use HIV services and, thus, are more likely to die from AIDS. While much of the literature argues that men&rsquo;s views of masculinity keep them from services, I use the theory of gendered organizations to provide another perspective. In this dissertation, I use a mixed methods approach to examine the gendered organization of facility-based HIV testing services in southern Malawi and how the organization of services creates additional barriers to men&rsquo;s use of care. </p><p> I combine four types of data: (1) survey data with facility clients to assess if quality of care differs by sex of client; (2) in-depth interviews with healthcare providers and policy makers to examine perceptions of men as clients; (3) participant observation in health facilities to understand how institutional protocols are enacted at the local level; and (4) international and national policy documents to situate local health institutions within broader global constructs of gender and HIV priorities. </p><p> I find that heterosexual men have become an invisible category within both international and national HIV policy. When they are included, they are described as the problem, not part of the solution to HIV epidemics. On the ground, the organization of HIV testing services has followed suit. </p><p> Health institutions, like other organizations, are not gender-neutral. Men in southern Malawi were not recruited for health services, were less likely than women to receive health education when they did attend a facility, and were less likely to have access to HIV testing because services were, at times, only offered during hours for antenatal services. Furthermore, HIV testing was often located near antenatal services, again contributing to the perception that testing was designed for women &ndash; because it was. Based on these findings, I argue that HIV testing is gendered across three levels of the health institution: (1) the organizational HIV policies; (2) the physical environment in which testing occurs; and (3) interactions within facilities that require clients to enact qualities typically viewed as feminine in order to successfully receive care (e.g., waiting long hours, being compliant, and being a caregiver).</p>

<p> Purpose: The purpose of this study is to explain the major barriers to medication access in rural seniors. How seniors access their prescription medications and make choices access helps to explain what seniors consider to be major barriers. This project has five goals: (1) describe what barriers rural seniors perceive that hinder access to their medicines and thus interfere with adherence to prescribed medication regimens; (2) understand what seniors perceive to be facilitators to accessing their prescriptions; (3) learn how or if social support networks play a role in helping rural seniors make decisions about how to use their resources to get their medications; (4) define the process that rural seniors use to move from potential access &mdash; the desire to get their medications, to revealed access &mdash; the actual ability to get their medications; and (5) describe what health care providers believe are the barriers that rural seniors face to getting their medicines. </p><p> Methods: I interviewed 19 low-income seniors in five towns in the San Luis Valley using semi-structured interviews, along with one pharmacist from each of seven pharmacies. A card study was conducted in nine clinics of the Valley Wide and Rio Grande systems. The interviews were coded using the grounded theory method. The card study survey was administered to primary care providers in eight clinics to gauge understanding of elderly patients' potential for barriers to access of medications. </p><p> Results: The primary finding is that poor structural health literacy (SHL) is the major barrier to access of medications, and to healthcare access generally. SHL is a factor in the more widely discussed barriers such as cost and transportation. </p><p> Discussion: SHL increases the chances that seniors will have access to healthcare by helping seniors learn how to take advantage of programs that enhance their ability to afford medications. Public Health agencies must work with community leaders to ensure that seniors are aware of their options for accessing medications, including financial and transportation options.</p>

An adequate measure of Control Over Nursing Practice (CONP) at the organizational level of the nurse's work unit was needed. The purpose of this study was to estimate the reliability and validity of a new unit-level version of an existing CONP scale using a descriptive survey design. A convenience sample of 91 staff Registered Nurses from two urban hospitals voluntarily completed two versions (individual-level and unit-level) of the CONP scale, and an index of work satisfaction.