While many public health and medical studies use big data, the potential for big data to further population health has yet to be fully realized. Because of the complexities associated with the storage, processing, analysis, and interpretation of these data, few research findings from big data have been translated into practice. Using small area estimation synthetic data and electronic health record (EHR) data, the overall goal of this dissertation research was to characterize health-related exposures with an explicit focus on meaningful data interpretability. In our first aim, we used regression models linked to population microdata to respond to high-priority needs articulated by our community partners in New Bedford, MA. We identified census tracts with an elevated percentage of high-risk subpopulations (e.g., lower rates of exercise, higher rates of diabetes), information our community partners used to prioritize funding opportunities and intervention programs. In our second and third aims, we scrutinized EHR data on children seen at Boston Medical Center (Boston, MA), New England’s largest safety-net hospital, from 2013 through 2017 and uncovered racial/ethnic disparities in asthma severity and residential mobility using logistic regression. We built upon a validated asthma computable phenotype to create a computable phenotype for asthma severity that is based in clinical asthma guidelines. We found that children for whom severity could be ascertained from these EHR data were less likely to be Hispanic and that Black children were less likely to have lung function testing data present. Lastly, we constructed contextualized residential mobility and immobility metrics using EHR address data and the Child Opportunity Index 2.0, identified opportunities and challenges EHR address data present to study this topic, and found significant racial/ethnic disparities in access to neighborhood opportunity. Our findings highlighted the perpetuation of residence in low opportunity areas among non-White children. The main challenge of this dissertation, to work within the limitations inherent to big data to extract meaningful knowledge from these data and by linking to external datasets, turned out to be an opportunity to engage in solutions-oriented research and do work that, to quote Aristotle, “…is greater than the sum of its parts”. Through strategies ranging from engaging with community partners to examining who and what data are captured (and not captured) in EHR health and address data, this dissertation demonstrated potential ways to leverage big data sources to further public health and health equity.

BACKGROUND: The World Health Organization’s Surgical Safety Checklist (SSC) is used in over 130 countries to improve patient safety by reducing preventable surgical complications. Previous studies have demonstrated that there is significant variation in adherence to and implementation of the SSC in high-income contexts, which impacts its effectiveness and puts thousands of patients at risk for adverse outcomes. A mixed methods study of multiple high-income contexts was conducted to 1) identify barriers and facilitators to SSC implementation, 2) develop recommendations to improve the likelihood of implementation success, and 3) identify a framework to guide future implementation efforts for the SSC and similar interventions. METHODS: Survey (n=2,032) and interview (n=51) data collected from health care administrators and surgical team members practicing in five high-income countries were analyzed. Descriptive statistics, Chi-squared tests, Fisher’s exact tests, and McNemar’s tests were used to explore and compare differences in survey responses. Thematic content analysis of interview data was used to assess implementation barriers and facilitators and checklist processes both within and across study countries. Predominant themes that emerged across study countries were mapped to the i-PARIHS framework to identify common gaps in current implementation practices. RESULTS: Study participants cited use of well-liked and well-respected peer champions, receiving education on the background and rationale for the SSC, and use of a shared leadership model for performing checklist processes as facilitators to successful implementation. However, time pressures in the operating room, reported disconnects between SSC patient safety goals and organizational priorities, and lack of local evidence of checklist effectiveness were cited as barriers to implementation. Key findings mapped well to the i-PARIHS framework, which facilitated the identification of specific areas of improvement for current implementation efforts. CONCLUSION: Informal leadership, better alignment of SSC use with organizational priorities, and use of relevant performance metrics appear to be a key factors in the success of SSC implementation. Implementers should consider using abbreviated network and stakeholder analyses to identify highly influential SSC champions, utilize patient safety metrics to develop local evidence of checklist effectiveness, and use the i-PARIHS framework to assess their context and develop a tailored implementation plan. / 2023-09-10T00:00:00Z

BACKGROUND: Forest-going and other high-risk populations (HRPs) contribute to sustained malaria transmission in the Greater Mekong Subregion. New strategies to increase access to malaria services for these populations are required if the 2030 regional elimination target is to be met. This study assessed the feasibility, acceptability, and provider capacity for a peer navigator-led malaria focal test and treat (FTAT) intervention targeting HRPs in Champasak Province in southern Lao People’s Democratic Republic (Lao PDR). METHODS: This research was conducted alongside a larger cluster-randomized controlled trial assessing the effectiveness of FTAT. Between April-November 2018, we conducted 38 interviews and 4 focus group discussions with diverse stakeholders, including HRPs, peer navigators, local health staff, and malaria officials, and 20 observations with a subset of 10 peer navigators. Using a hybrid deductive-inductive approach, data were thematically analyzed in Dedoose software and triangulated across methods, stakeholder types, and timepoints. The Consolidated Framework for Implementation Research guided the assessment, analysis, and interpretation of FTAT capacity, feasibility, and acceptability findings. RESULTS: Peer navigators were highly capable of and confident in conducting the FTAT intervention (malaria testing, treatment, education, and interviewing), and stakeholders perceived the intervention to be largely feasible and acceptable. Reported benefits of FTAT included increased HRP access to free, on-site malaria testing and treatment; increased malaria knowledge among HRPs; peer to peer learning; and increased access to real-time data for program planning. Identified challenges included high FTAT implementation costs, poor road and travel conditions, and initial fear or reluctance among some HRPs to participate in FTAT, while high HRP cooperability and demand for FTAT were key facilitators to FTAT feasibility. CONCLUSION: The peer navigator-led FTAT intervention is a feasible and acceptable approach to increasing access to malaria care among HRPs in southern Lao PDR. Demonstrated to be highly capable, effective, and accepted, lay or peer health workers could play an instrumental role in a broader strategy to achieve and sustain malaria elimination in the region. Adapting the intervention based on local resource availability may be required for programmatic scale-up, given the cost barrier.

There is a growing disparity between the demand and supply for health workers globally which is projected to result in a health worker shortage of 15 million by 2030. The growing disparity is fueled by low health expenditure budgets, urban migration, weak incentives for entering the healthcare field, and an aging global population. The Global Health Workforce Alliance has suggested mid-level providers, like the physician assistant, as a part of the solution to the looming global shortage. However, physician assistants are not internationally recognized, which creates a challenge for implementing the profession in countries not familiar with the profession. The lack of international recognition has also made it difficult for institutions like the World Health Organization to acquire data on international physician assistant impact. Physician assistant implementation additionally faces pushback from traditional health professions. The physician assistant concept has been adopted in over 15 countries. The international adoption of the profession is relatively recent compared to the profession’s inception in the United States in the 1960s. Therefore, there is a dearth in data on the international impact of physician assistants. Patient satisfaction is an important measure for quality of care and health system performance. The few existing studies on patient satisfaction indicate that patients are satisfied with care provided by physician assistants in Canada, the United Kingdom, Ireland, Australia, New Zealand, and the Netherlands. However, there are significant design flaws in the limited research. The design flaws include not specifying which health worker was in question, use of fictional patient- provider scenarios, and use of qualitative data that can result in misleading conclusions. Thus, this proposed study will incorporate a study design that addresses design flaws in the existing research on patient satisfaction with physician assistants outside of the United States. The study will be a large-scale quantitative standardized patient satisfaction survey that will be disbursed in Canada and the United Kingdom. The study aims to measure patient satisfaction with different elements of the patient-provider encounter as well as the overall quality of care provided by the physician assistant. The study also aims to measure willingness of patients to see a physician assistant at the patient’s next medical provider encounter. Physician assistants can help to reduce the global health workforce shortage. The proposed study will address the need for understanding how patients are perceiving the impact of physician assistants during global expansion of the profession. If the findings from the proposed study align with findings from existing research, then one can infer that there is growing consumer demand for physician assistants. Evidence of growing consumer demand may influence policy surrounding acceptance and recognition of physician assistants internationally, and therefore serve as the catalyst for deploying physician assistants to help address the global health workforce shortage.

Transgender and gender diverse (TGD) individuals experience high levels of stigma in a variety of settings and contexts, including during healthcare encounters. Persistent stigma and discrimination accumulating over a lifetime lead to hardships that increase health risks, such as engaging in harmful substance use and becoming infected with HIV. Yet, it is not yet clear if there is a relationship between stigma and engaging in HIV prevention clinical services among TGD individuals, and how substance use and HIV sexual risk behaviors might mediate this relationship. Further, little is known about the experiences and preferences of TGD patients when discussing substance use and HIV risk during primary care encounters and how providers address these health topics. Using a combination of elements from four distinct conceptual models which postulates components of syndemics, functions of communication, and clinical care delivery to TGD adult patients, this dissertation adds to the literature through three aims: Aim 1 uses structural equation modeling to test whether substance use, HIV sexual risk behaviors and gender-affirming hormone therapy mediate any observed association between TGD-related stigma and utilization of HIV prevention clinical services (i.e., HIV prevention services or programs, pre-exposure prophylaxis use). This analysis includes a sample of 529 TGD adults in Massachusetts and Rhode Island who were HIV-negative or had an unknown HIV serostatus. Aim 2 uses semi-structured interview data with 25 TGD adults to explore experiences and communication preferences when discussing substance use and HIV risk during primary care encounters. Aim 3 uses in-depth interviews with 15 primary care providers to describe how they report discussions about substance use and HIV risk with TGD adult patients and characterizes how these communication approaches align with varying orientations of self-efficacy and subjective norms. Findings from this dissertation reveal several ways stigma manifests during clinical encounters and underscores the need for improving patient care experiences by alleviating provider knowledge deficits and fostering institutional support within clinic environments. / 2024-12-12T00:00:00Z

Cervical cancer is considered a threat to global public health and disproportionally affects people living with HIV. The World Health Organization has aimed to reduce the burden of cervical cancer worldwide. Because of this goal, the National Cancer Institute has created the CASCADE Network, a network with four main pillars to aid in reducing the burden cervical cancer has on women living with HIV, by targeting HPV screening as persistent HPV infections increase the risk of cervical cancer. Weill Cornell Medical College is a research base that has joined the CASCADE Network to develop studies to assist the network in achieving its goals. Our research base conducted and analyzed clinical site interviews, site surveys, and a review of current literature to develop a research protocol. From this, we found that the clinical sites must enhance their HPV screening methods and clinic capabilities to significantly lower the burden cervical cancer plays. A proposed protocol was developed for a mixed-methods study to examine the implementation and potential impact of HPV DNA testing for cervical cancer screening in resource-constrained settings. This proposed protocol will act as a framework for future studies to address the limitations of cervical cancer screening in low-resource areas. This paper describes the protocol development for a CASCADE research base housed within Weill Cornell Medical College.

Patients in the United States who do not speak English as their first language must contend with many socioeconomic and medical obstacles. These barriers impact how they receive, access, and understand their healthcare needs. These factors also influence the frequency of patients missing their (or their child’s) medical appointments. In the medical literature, missed appointments are referred to as Missed Care Opportunities (MCO). Many problems arise when patients miss their scheduled clinical appointments. Previous research has been conducted to better understand why patients miss their appointments. However, most of the available literature focuses on aggregate MCO. Subset analysis stratified by language typically includes only “English”, “non-English/Spanish”, and “Other”. Most studies have not systematically looked at other languages because of the predominance of non-English/Spanish speakers in the United States today. For this reason, this study's focus is to better understand the impact of language on MCO in the ambulatory Gastroenterology, Hepatology, and Nutrition clinics at Boston Children’s Hospital. The hypothesis of this study is that the MCO rate is more significant in patients from marginalized communities, including patients who do not speak English as their first language, come from an economically disadvantaged background, or have a minority background. The plan for this study is to translate the statistical findings to develop initiatives to serve this community better and reduce the MCO rate.

No description available.

BACKGROUND: Poor quality health services have been identified as a threat to global health security. In 2018, the World Health Organization (WHO) and others recommended that countries develop national quality policies and strategies (NQPS) to address this issue. Multi-level, practice-based evidence on NQPS implementation is, however, limited, especially in Sub-Saharan Africa. A mixed methods NQPS study was conducted to systematically (1) identify the institutional barriers and facilitators to implementation, (2) examine the process of implementation, including factors affecting adoption at the national, regional, and hospital levels, and (3) examine the effect of implementation on hospital quality of care in Ghana. METHODS: The study design was informed by the RE-AIM QuEST framework. Data were collected through a survey (n=36) and in-depth interviews (n=56) with implementation leaders at the national, regional, and hospital levels. Hospital quality of care data were obtained from a national database. Data were analyzed using thematic and time series analysis. Emerging themes on barriers and facilitators were further categorized using the i-PARIHS framework. RESULTS: Key facilitators included support from donor partners and individual commitment to health quality. Facilitators were overshadowed by several barriers. Notable barriers emerged in these areas at all levels: funding, governance, the national quality culture and history, policy design, dissemination, monitoring, and evaluation. Moral distress and production pressures were among some of the unique barriers at the hospital level. Regulatory requirements strongly influenced the adoption of the NQPS. Lack of dedicated implementation funding and limited implementer knowledge discouraged adoption. Hospitals “implementing” aspects of the NQPS performed better on quality-of-care indicators than those “not implementing” it. However, this difference cannot be attributed to the NQPS with certainty as the policy was yet to be fully disseminated to the hospital level. Most hospital implementation activities appeared to be coincidental rather than deliberate attempts to implement the NQPS. CONCLUSION: Findings indicate there is an interest in implementing the NQPS in Ghana; however, numerous barriers, particularly those in the larger health system context, such as funding, impeded implementation at all levels. To facilitate the adoption and implementation of NQPS, the policy instrument must be well-developed through an inclusive process and disseminated to all health system levels. An enabling health environment with strong political will, effective governance, local ownership, funding, and other resources is critical for success. Expected implementers need to have the requisite technical expertise and support, including protected time. / 2026-01-08T00:00:00Z

Intravenous drug use is now associated with one-third of all new AIDS cases reported in the U.S. Factors associated with HIV transmission among intravenous drug users (IVDUs) include the frequency of sharing of injection equipment, the sharing of injection equipment in shooting galleries and cocaine use. Research in this area has been hampered by methodologic problems including difficulties in the selection of drug-use variables to measure and analytic problems associated with the highly intercorrelated nature of drug-use behaviors. This research considers the use of summary or composite variables in studies of HIV infection and in the evaluation of risk reduction programs targeted at IVDUs. Specifically, the research examines the use of two methods of summarizing high risk behaviors for HIV infection; an 'empirical' method based on the input from expert judges and a 'statistical' method based on Principal Components and Factor Analysis. Eight summary variables based on these methods were contrasted and their association with HIV infection considered in a population of 396 IVDUs recruited through a drug detoxification program and 386 IVDUs recruited through a county jail in Worcester, Massachusetts. Major study findings include the identification of statistical summary variables representing sharing behavior, duration of IV drug use, the frequency of injecting drugs at home, and cocaine use. Each of these dimensions was associated with HIV infection in the IVDU population enrolled in the drug program while the duration of IV drug use, the frequency of injection, and cocaine use were associated with HIV infection in the jail population. Empirical summary variables summarized some, but not all, of the dimensions of IV drug use represented by the statistical summaries. In each population one of the empirical summary variables was identified as the best single predictor of HIV infection although these relationships were not generalizable to the other population.