The purpose of this study is to closely analyze opioid overdose response efforts on county, state, and federal levels in designated Appalachian regions in order to better understand program methodology standards that ensure success in combating the opioid epidemic in Appalachia. All data sources used are publicly available and contain de-identifiable population health information. During research on this topic, how to define the opioid epidemic, identification of root causes, and existing response effort methodology were addressed. The existing response methods of county, state, and federal programs are expensive and hard to implement with limited success. While the complexity of response efforts can be beneficial to have many options for addressing the issue, it can also quickly muddle the most effective methods to success. The most notable programs that saw a quick decline in overdose death rates included those that coordinated between multiple types of entities such as schools, health departments, and correctional departments; as well as those offering harm reduction programs such as naloxone distribution. Other successful programs included re-training and re-education both with regional providers on appropriate opioid prescriptions and with the community on proper use, handling, and disposal of opioids. The most effective methods to reduce health disparities relating to the opioid epidemic in the Appalachian region are extensive collaboration, re-education, and harm reduction across the communities most deeply affected by the crisis. Any future response efforts should address these key success indicators.

While K-12 schools have been making efforts to integrate culturally responsive curriculum and instruction, the voice and representation of Black female students has been largely ignored. Overdisciplinary practices, high dropout rates, a likelihood to be incarcerated, exposure to sexual violence, and familial obligations have negatively impacted the academic achievement of some Black female students. Thus, educational leaders can try to find ways to acknowledge the unique needs of Black female students through reconceptualizing curriculum. The purpose of this study was to examine current curricula within a particular school district for strategies and practices that may be responsive to the needs of Black female students, as well as to include the voices of Black female students who attended schools in the same district to examine their perspectives. The reconceptualist theoretical framework, as well as existing literature on Black female students’ needs, and culturally responsive curriculum methodology was used to create a coding framework. A qualitative content analysis (QCA) was conducted with the collected data (i.e., existing curricula and interviews from Black female students) using the coding framework. Four categories emerged and maintained throughout the QCA for reconceptualizing the curriculum in response to the needs of Black female students: student ownership, collaborative and authentic experiences, critical pedagogy, and cultural responsiveness and cultural competence. Educational leaders can integrate strategies, such as goal-setting, cooperative learning, including diverse perspectives in materials, and assessing students’ prior knowledge, into the formal curriculum to respond to Black female students’ academic needs.

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Background: Unity in pursuit of the Triple Aim: better health, better care, and lower per capita cost, can be achieved through a well-designed health care delivery system. The accountable care organizations (ACOs) model is considered a key component of health care delivery system improvement because the model fosters better coordination of care through clinical integration and financial accountability. Within the six Centers for Medicaid & Medicare Services (CMS) ACO programs, the Medicare Shared Savings Program (MSSP) ACO has the largest size with a total of 432 ACOs formed; the service subjects of the MSSP ACO are the fee-for-service beneficiaries. Recently, academicians and researchers have been attracted to exploring ACOs' formation and performance. However, most of the early ACO research types are either descriptive or case study. Also, early researchers had limited access to ACO data sets, so they could utilize only regional and demographic factors to identify the predictors of ACO formation. Purpose: An integrative theoretical framework, Rogers' diffusion of innovation theory and Duncan's POET model, was used to examine ACO formation and performance. The first purpose of this study was to determine the relative influences of contextual variables and ACO characteristic variables on how early an ACO model was adopted. The second purpose was to examine how executives' perceptions of ACO performance and the ACO first-year performance are influenced by the contextual variables, ACO characteristic variables, and timing of the adoption of an ACO model. Methods: A cross-sectional design was formulated to gather data from a survey supplemented by secondary data with the analysis unit at the organization level. Study participants in the ACO survey included 2012, 2013, 2014, and 2015 ACO cohorts. Logistic regression was performed to examine the effects of POET and Rogers' five core characteristics in the early adoption of an ACO model (dichotomous). Additionally, multiple linear regression analysis was used to examine the effects of POET and the timing of adoption of an ACO model in the perceptions of ACO performance. ACO first-year performance dataset consisted only of ACO cohorts from 2012 through 2014. Finally, confirmatory factor analysis and structural equation modeling were conducted to examine the measurement model of the ACO first-year performance and a full latent variable model, respectively. Major Findings: A survey of ACO executives/managers between October 2015 and February 2016 was conducted. The 447 MSSP ACOs in my mailing list yielded a response rate of 13.65 % (n=61). Of the 61 MSSP ACOs, 42 (52.5%) were late adopters whose contractual agreement with CMS started in 2014 or 2015, and 36 (59.0%) were with hospital-based composition. Among ACOs that participated in my survey, their current degree of IT adoption in functionalities (62.27 vs. 52.50 points), usage levels (65.19 vs. 49.49 points), and integration levels (62.24 vs. 53.37 points) were better than their initial years. The multiple logistic regression presented that MSSP ACOs were more likely to be early adopters of a CMS if their service areas had high unemployment rates (OR=2.23; 95% CI: 1.13 - 4.39). In the multiple linear regression analysis, the executives in the early ACOs perceived their organizations as more effective than the late adopters, with 12.65 points higher in an aggregate of eight ACO quality domains (p = .005). Three hundred and seventeen MSSP ACOs, with contractual agreements with CMS before 2015, had retained their year-one performance records (the actual ACO performance with eight quality domains). The variability in the actual ACO performance was explained by the predictor variables of the study with an R-square of 15%. The actual ACO performance was likely to be improved if ACOs had more Medicare assigned beneficiaries or had the hospital-based composition. On the other hand, if ACOs' service areas were located in areas of high poverty concentration, a high unemployment rate, or a lower competitive index, their ACO performance was relatively lower than their counterparts. Implications: The findings suggest that managers should consider strategies to increase economies of scale in size and to have hospital involvement in their ACOs in order to increase effective management. Inadequate capital for information technology improvements is the biggest barrier inhibiting healthcare providers' willingness to join an ACO. Regardless of rural or urban areas, financial support is still important for those potential ACO participants who are planning to invest in necessary infrastructure. ACOs that involved hospitals also showed better performance than those ACOs without hospital involvement. This information may help health policy makers to define core principles of the best ACO model in the future. Conclusions: This study makes a unique contribution using a theoretically integrative framework with Rogers' diffusion of innovation theory coupled with Duncan's POET model to examine ACO formation and ACO performance. In the early ACO adopters, three-fifths of the ACOs had hospital involvement; and the levels of their current IT degree in functionalities, usage levels, and integration levels are higher than the late ACO adopters. This study demonstrates that contextual variables, such as unemployment rates at ACO service areas, relatively influence how early an ACO model was adopted. Executives in the early ACOs had higher perceptions of overall organizational effectiveness as compared with the late adopters. The first-year performance of 2012, 2013, and 2014 ACO cohorts is positively influenced by the size of assigned Medicare beneficiaries and hospital-based ACO and is negatively influenced by the poverty rate, unemployment rate, and market competition scores (Herfindah-Hirschman Index).

Hospitals engage in undertakings on a continual basis to enhance IT capabilities, diffusion of innovations, hospital-physician integration, and standardization to improve their performance. This empirical study explored the interdependence of three macro-level structural factors and their independent impact on the hospital performance measures efficiency and patient safety, with standardization as an important mediator. The researcher conducted a cross-sectional analysis of multiple data sets from public user files on the acute care hospital industry. The theoretical underpinnings of the study included the structure-process-outcome theory and institutional isomorphism theory. The statistical analysis comprised confirmatory factor analysis (CFA) and covariance structural equation modeling (SEM). The study comprised data for 2,352 acute care hospitals in the United States, which represented more than half of the hospital population. As expected by the hypotheses, the study demonstrated that IT capability, hospital-physician integration, and innovativeness directly affect the variability in standardization, but they did not directly influence the variation in hospital efficiency and patient safety. This revealed that hospitals should focus on standardization because it is the mediating process between structural variables and performance variables. The results indicated a strong negative influence of standardization on hospital efficiency and a weak positive influence on patient safety. The study confirmed the triadic model that "structure" influences the process, which in turn influences organizational outcomes. As standardization through coercive, mimetic, and normative pressure mechanisms becomes more common through system integration and increased collaborative governance, more research on how the implementation of standards may perpetuate isomorphism or uniformity is imperative. The researcher recommends future studies to employ a longitudinal study design to explore the determinants of a variety of performance and outcome indicators, such as patient satisfaction, timeliness of care, the effectiveness of care, and equity/financial performance in addition to patient safety and hospital efficiency.

Since the enactment of the HITECH Act in 2009, the US has invested billions in building a robust health information technology (HIT) infrastructure that is secure, capable of the electronic transfer of data and allows for real-time access of patient medical data, among others. This empirical study explored the driving forces (coercive, mimetic, and normative) in the adoption of HIT (i.e. EHRs and HIEs) by local health departments (LHDs) and how it has impacted the population health of counties in the US. The researcher conducted a cross-sectional, quantitative study using secondary data sources. The study included data on 505 local health departments and 433 counties' population health data. Institutional theory guided this research and generalized estimating equations, logistic regression, and multiple linear regression were utilized to analyze health IT adoption by LHDs and its impact on county-level health outcomes. Results showed that normative forces, measured by the employment of IS specialists was most impactful in the adoption of both EHRs and HIEs. Mimetic forces, measured by the completion of a CHA and coercive forces measured by the implementation of the HITECH Act were not found to be statistically significant in the adoption of EHRs or HIEs. Finally, EHR adoption was statistically significant at improving population health at the county level. This research study has contributed in three areas: 1) to fill a knowledge gap on the impact of health IT adoption by LHDs on health outcomes; 2) to formulate a theoretically grounded framework to study population health and its variability; and 3) to identify target areas for public health interventions. In conclusion, a substantial amount of resources dedicated in creating a robust health IT infrastructure requires close analysis of the impact health IT has on the population health of our nation.

Research supports risky sexual behaviors are especially pervasive traits in high risk groups such as gay and bisexual men; and despite representing a mere 12% of the total LGBTQ population, Black men who have sex with men (BMSM) are at highest risk for transmitting and contracting HIV and other non-HIV sexually transmitted diseases. Even knowing this, the disparity of research coverage of BMSM compared to White MSM is staggering. Recent research has indicated MSM are at even greater risk than before since the advent of mobile dating apps. Online partnering via mobile apps has been linked to overlapping sexual partner networks and outcomes such as greater numbers of sexual partners and a higher likelihood of practicing unprotected anal sex. As such, this study aimed to investigate how BMSM's sexual sensation seeking behaviors may be influenced by use of mobile dating apps and PrEP, as well as provide indication of BMSM attitudes related to sexual partner networks and their role as a risk factor. The study uses primary data collection via an online survey tool and univariate, bivariate, and multivariate analysis techniques were employed to analyze the collected data. Results revealed there is not a difference in sexual sensation seeking behaviors based on the number of mobile dating apps used, and that PrEP use and PrEP knowledge do not have an independent influence on sexual sensation seeking behaviors. However, there is a statistically significant influence on BMSM SSS by confirmed PrEP use and an average understanding of PrEP. Qualitative results expanded current research understanding of why BMSM utilize mobile dating apps as well as BMSM sexual partner networks and how they influence BMSM sexual sensation seeking habits.

The U.S. is recognized for uniquely high incarceration rates. Over recent decades, there has been a concurrent dramatic increase of jail detainees with mental disorders. Provision of adequate mental health services for jail inmates is constitutionally mandated, and has legal, ethical, quality of care, and fiscal implications for jails, families, communities, and detainees. Significant variation exists in the provision of mental health services across jails, and increased understanding of the factors that influence the adoption of such services may help guide jails to implement beneficial services, and ensure that such services reflect, reflect quality standards. This study used a mixed methods strategy to examine the influence of theoretically determined variables on the adoption of jail mental health services, and the quality assessment of such services. Data was gathered by survey instrumentation, secondary data review, and in-depth interviews with jail leaders. The study found that isomorphism has a significant effect on the structural adequacy of jail mental health services, innovation characteristics have a negligible relationship to structural adequacy and process integrity, structural adequacy mediates the effects of isomorphism on process integrity, and jail size has a significant effect on structural adequacy. This study advances the knowledge base in its specification of the roles of internal, external, and demographic factors in the adoption of jail mental health services, and in the testing and application of Donabedian's healthcare model to assess the quality of such services.

Social media aids communication among users worldwide. However, a notable gap exist among social media users, healthcare professionals utilizing social media in the work place. While the concept of harnessing social media as a professional tool is not novel, healthcare professionals have yet to embrace the practice as standard workflow. This study identifies factors influencing clinicians' behavioral intent to adopt social media for patient engagement and communication. A new framework, the Healthcare Social Media Adoption Framework (HSMA), guided this mixed-method approach to assess 7 factors identified by theory and literature as adoption influencers. A custom, web-based survey collected data from 60 full-time, pediatric clinicians (47 quantitative) at the case institution (a pediatric hospital). Additionally, individual interviews of 6 participants provided their prospective on using social media for patient communications and engagement. Results: Privacy concerns were the only statically significant factor; with an inverse relationship to positive adoption intent, indicating higher privacy concerns influence lower behavioral intent to adopt social media for patient engagement and communication. The qualitative analysis revealed privacy concerns encompass two themes, personal privacy for patient and providers (boundaries), and cybersecurity. The qualitative inputs also uncovered perceived unprofessionalism as a new factor influencing clinician adoption. The implications for these findings indicate a need for both healthcare organizations and healthcare regulators to establish cyber-security defenses for security and use protocols for privacy to aid the diffusion and adoption acceptance of social media use by pediatric healthcare professionals. This research has contributed in four areas: 1) fill a knowledge gap by identifying new factors that influence the behavioral intent of pediatric clinicians to adopt social media; 2) confirm/reject behavioral intent influences found in the literature; 3) formulated a new HSMA framework that measures functional, cognitive, and social aspects of social media adoption; and 4) prioritizes policies and global standard focus.

Concern about the impact of science, technology, engineering, and mathematics (STEM) programs on society are not new. STEM employment in the United States has grown twice as fast as other fields during the last decade. School districts have been encouraged to consider STEM-focused schools to meet this demand and have responded by offering STEM magnet program options. This mixed-methods study used Lewin’s Theory of Change and Fullan’s ideas on Coherence as the theoretical frameworks to examine how students who participate in a high school STEM magnet program perform academically. Academic performance was measured using grade point average (GPA) and graduation rate. We compared the number of mathematics and science courses students in a STEM magnet program completed to the number of courses completed by students not participating in a STEM magnet program. Additionally, we surveyed teachers and administrators to learn their perceptions of student success factors in STEM magnet programs. There was a positive difference in graduation rates with a low effect size. The differences in the number of math and science courses completed were not practically significant. Moreover, magnet students earned a statistically significant higher GPA than non-magnet students. Furthermore, teachers reported a high degree of teacher efficacy, while administrators rated themselves higher on general leadership ability than on STEM leadership. We recommend clearly defining STEM education, additional professional development for teachers and administrators, streamlining accountability for STEM programs, and continuing to invest in STEM education as a pathway to producing college and career ready students.