Hepatitis C Virus (HCV) is an infection that can have grave consequences when left untreated. Hepatitis C can be easily eradicated with direct acting antiviral therapy. People who inject drugs (PWID) and inmates are among those with the highest incidence of HCV. However, cure rates among this population remains low. This is, in part, related to an interruption in the HCV care cascade such that only 30% of PWID are linked to care and only 8% of those receive treatment. Inadequate screening and failure to be linked to HCV care remain the largest impediments to treatment success. There is limited research on barriers and facilitators to primary care, where screening may take place, and linkage to HCV care among PWID. Few studies have evaluated vulnerable populations such as those living in rural communities or inmates. The purpose of this dissertation was to develop a broader understanding of barriers and facilitators to healthcare utilization among PWID at the primary care and specialist levels (linkage to care). Three manuscripts addressed important gaps in knowledge. The first was a review of the literature to describe the state of science on linkage to care among PWID. All but one reviewed study recruited from countries with universal healthcare, urban areas, and opioid substitution facilities. The review of the literature revealed that little is known about the barriers/facilitators to linkage to HCV care faced by rural-dwelling PWID from countries without universal healthcare. The second manuscript is a study to determine whether predictors of linkage to care identified in urban-dwelling PWID from countries with universal healthcare predicted seeking HCV care among PWID living in rural Appalachia. Data were obtained from a subsample of 63 HCV positive PWID who recently used opioids, were between the ages of 18-35 years, and lived in one of five rural counties in Kentucky. Logistic regression revealed that recent injection drug use was the only predictor of seeking HCV care. However, remote use of opioid substitution therapy and no transportation issues approached clinical significance. Although not evaluated in our second manuscript, seeing a primary care provider (PCP) is associated with an increased likelihood of being linked to care and higher rates of screening/diagnosis. Among rural dwelling PWID, there are subpopulations that may face unique barriers to linkage to care. One sub-population that may be particularly vulnerable are female PWID who are incarcerated. Therefore, the purpose of the third study was to determine predictors of primary care use using data from 302 female inmates from rural Appalachia with a history of injecting drugs. Age, insurance issues, and health problems that interfere with responsibilities were predictors of PCP use. In this dissertation, I have addressed important gaps in the literature by determining barriers and facilitators to seeking HCV care and primary care use among PWID from rural Kentucky. Additional studies are needed using a larger sample of rural PWID to confirm our findings. In addition, further studies should evaluate system and provider level barriers to linkage to care and PCP use among rural PWID.

<p>Over the last century, developed countries have been successful in enhancing maternal health and reducing Maternal Mortality Ratio (MMR). By 2018, MMR across OECD countries and World Bank Group Regions have converged towards very low levels, averaging more than 5 deaths per 100,000 live births. The United States has become an outlier among the developed countries in maternal deaths and compares unfavorably to a number of poorer countries where the ratio has declined. In 2017, the US ranked worst in MMR among the 39 industrialized nations. United States has experienced almost a 142 percent increase in MMR from 1987-2018. According to the Centers for Disease Control and Prevention (CDC), every year in the US, more than 700 women die due to the pregnancy or childbirth-related complications, with 60 percent of these deaths being preventable. Within the US, MMR varies considerably, leaving large disparities across states as well as between all racial groups. This research study aims to understand the interplay of spatial and racial impacts on the variation of maternal mortality ratios within the US. The paper estimates Ordinary Least Squares (OLS) and Spatial Lag Models for MMR using cross-sectional US state data for 2012-2017, taken from CDC. The results show that the dominant root causes of high maternal mortality differ between black and white women. </p> <p> </p>

A modern conceptualization of psychotic disorders is as neurodevelopmental disorders, with different stages characterized by discrete clusters of symptoms. This conceptualization includes a stage of pre-psychotic prodrome, a target of contemporary research as an attempt to intervene before the development of psychosis. However, these at-risk individuals rarely present to the mental health services before transitioning into psychosis, even more so for male patients. In this study, a method of inductive thematic analysis has been employed to inquire into the pathways to care for young men at Ultra-High Risk (UHR) for psychosis to gain knowledge of- and generate hypotheses about pathways to care for this group. Data was collected using semi-structured interviews (n = 9) over video conference or telephone. Three core-themes were developed as “Willingness to Disclose Distress”, “The Gatekeeping Confidant”, and “The Boiler”, with “Openness” as a core organizing category permeating the core-themes. Together, the themes represent findings on both the importance of relations in help-seeking, as well as how the young men commonly employ non-disclosure, and how this lack of openness delays pathways to care, often resulting in adversities for the participants. Findings provide implications for further inquiry into how to increase the likelihood of young men to disclose distress, as well as providing additional rationale for the development of Mental Health Literacy in the public to make peers as well as participants more able to recognize symptoms of the pre-psychotic prodrome, when, where and how to seek help.

Introduction: A culturally competent survey currently does not exist to characterize the burden of Adverse Childhood Experiences (ACEs) among a HIV/AIDS population receiving care at a local Center of Excellence (COE). Methods: A qualitative study was conducted including 11 interviews involving opinions on national surveillance questions to develop a culturally competent survey. Purposive sampling, reactive probing, and analysis of transcribed interviews were completed using structured coding to determine which questions were kept, modified, or removed in the final survey. Results: The final 55-question survey contained more generalized ACE questions, topics pertaining to barriers to HIV care, and a list that patients could select from to indicate what they need to improve their HIV care. Conclusion: The final survey provided the opportunity to characterize the burden of ACEs at a COE. Future directions involve piloting the survey as a quality improvement tool with the goal of increasing retention rates through more individualized HIV care.

Access to primary health care services is a significant issue for many communities seeking to improve the health of their populations. This single case study describes the 12-year journey of 2 adjoining rural counties in 2 states towards meeting the primary and specialty care needs of the uninsured and underinsured population. Data were triangulated using historical documents, first-person interviews, and health utilization data. The community leadership moved through various models including a free clinic and a university-sponsored health center before finally establishing a federally qualified health center, which now serves 40,000 citizens in these counties. The site is now hosting new programs funded by research grants in alliance with area universities. Success is contributed to an unwavering desire to provide a medical home for the underinsured and underinsured, a shared vision, recognition that continued success was dependent on a funding source, recognition that practices and processes must be in place to assist with navigation for those in need of services to seek care at the appropriate venue, and a belief that the infrastructure built to provide care was sustainable. All participants recognized the importance of funding for sustainability. Positive social change has occurred from the emergence of a multidisciplinary center to serve the community's uninsured and underinsured, thus improving access to care, management of chronic conditions, and access to behavioral health professionals. Findings from this study may inform other communities faced with similar problems and can inform legislators of the importance of federally qualified health centers in the provision of health care to vulnerable populations.

Indiana University-Purdue University Indianapolis (IUPUI) / Introduction: The U.S. is faced with a primary care (PC) workforce shortage; an estimated 43 percent of the population has unmet health care needs and 18.2 percent of the adult population lacks a usual source of care (USC) provider. The workforce shortage limits even those with a USC from receiving the full scope of recommended clinical services. One promising solution is reforming scope-of-practice (SOP) policies for PC nurse practitioners (NPs). Objectives: The primary objective of this dissertation was to assess the impact of NP SOP policy implementation on NP practice patterns and patient access to PC by evaluating NP time spent delivering patient care, NP role as USC providers, patient travel times, and appointment availability. Methods: The studies discussed in this dissertation leveraged cross-sectional data from the National Sample Survey of Nurse Practitioners (NSSNP), time-series data from the Medical Expenditure Panel Survey (MEPS), and the Nurse Practitioner Professional Practice Index (NPPPI) to quantify variations in state policy environments. We used generalized mixed effects models to examine relationships in the cross-sectional data analyses and two-way fixed effect models to evaluate longitudinal data. Results: Our analyses revealed several key findings: NP SOP policies do impact the percentage of time NPs spend providing direct patient care; the NP workforce role as USC providers has increased as SOP policies have changed; states with supportive reimbursement policies have more NPs working as USC providers; and states with fewer NP supervision requirements have shorter patient travel times to USC providers. Conclusion: The U.S. health care system must continue to evolve to address the growing demand for PC services. While strategies to increase the supply of PC providers may be an effective long-term solution, our findings suggest that NP SOP reform may be a viable and complementary strategy to increasing the capacity of the PC workforce, providing more immediate relief. / 2 years

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