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Indiana University-Purdue University Indianapolis (IUPUI) / The dissertation consists of three essays attempting to assess the impact of expanded health insurance policy on cancer care continuum and measure the unbiased program effects after taking care of mis-measured cancer screening self-reports. The first essay examines the impact of the Affordable Care Act’s Medicaid expansion on time to oral cancer treatment initiation since diagnosis, quality of hospital care such as length of stay in the hospital, planned and unplanned readmissions post-surgery, and care outcome such as ninety-day mortality since surgery. The study uses two-way fixed effects linear model analysis under a difference-in-difference estimation setting to show that Medicaid expansion eligibility reduced overall oral cancer treatment initiation timing since diagnosis, including radiation initiation as well as first surgery of the primary site. It also shortened the length of stay in the hospital post-surgery. The second essay assesses the value of electronic medical records from Indiana health information exchange (IHIE) and survey self-reports of Indiana residents seen at Indiana University Health in measuring population-based cancer screening for colorectal, cervical, and breast cancer. Between the two measures of screening, the study examines association using Spearman’s rank correlation and concordance using Percent Agreement and Gwet’s Agreement Coefficient. Health information exchange and self-reports, both provided unique information in measuring cancer screening, and the most robust measurement approach entails collecting screening information from both HIE and patient self-report. In this study, we find evidence of measurement error in self-reports in terms of reporting bias. The majority of the publicly available datasets collect information on cancer screening behavior through patient interviews which are self-reported and may suffer from potential measurement errors. The third essay uses a nationwide population-based database and examines the true, unbiased impact of Medicaid expansion on cancer screening for breast, colorectal, cervical, and prostate cancers after correcting for any bias due to possible misclassification of the self-reported screening status. This study conducts a modified two-way fixed effects probit model under a difference-in-difference estimation setting to identify and correct the errors in the self-reports and estimate the unbiased program effect which shows positive impact on cancer screening with increased effect sizes.

Upon interviewing a sample of youths, researchers who study exposure to violence are often faced with a substantial number of reports of exposure to violence and no way to confirm the veracity of these claims. The remarkably high levels of violence exposure reported by young preschool children (Richters & Martinez, 1990), paired with the low concordance between parents and children concerning what violence the child had witnessed and experienced (Howard, Cross, Li & Huang, 1999; Shahinfar, Fox & Leavitt, 2000), suggests that child self-reports of exposure to violence may not be entirely veridical. Since self-reports appear to be the only feasible method of measuring lifelong exposure to violence, determining the possible causes of false reports and investigating possible predictors should be a significant aspect of studying youth exposure to violence. With this thesis, I have investigated the veracity of child self-reports by comparing responses to a life-long exposure to violence questionnaire administered first between 1997 and 1999, and a second time two years later. Inconsistent reports, wherein an initial report of exposure to a particular violent instance was not confirmed by re-reporting at the second interview, were prevalent on a variety of violence-assessment items, including witnessing a murder and being the victim of a physical attack. For instance, when initially interviewed, approximately one in seven Chicago children aged 8 to 17 reported witnessing a shooting at least once during their lives. Alarmingly, 50% of these children did not confirm this instance of violence when interviewed again two years later. In an effort to identify self- or parent-reported characteristics and behaviours predictive of inconsistent responses concerning witnessing a shooting, I conducted several series of Binomial and Multinomial Logistic Regression analyses. Explanatory variables were selected to be representative of two main likely reasons for inconsistent self-reports: misremembering due to forgetting over time and the inaccuracy of children's memories, and misinformation due to an impulsive propensity towards lying or exaggeration. My findings suggest that, in comparison to individuals who confirmed their initial reports of having 'witnessed a shooting', individuals who retracted their initial claims were generally younger, from a higher socio-economic status level neighbourhood, admittedly lacked guilt after misbehaving, desired a lot of attention, and reported less impulsivity as measured by delinquency and behavioural impulsivity scales. / Thesis / Master of Science (MSc)

Many environmental behavior models have been proposed to predict or explain environmental behavior in the past two decades. Due to limitations in practice, these models were mostly tested on a basis of self-reported measures of environmental behavior. How would these models perform if an observed measure of environmental behavior was used? What are the differences between the results of testing a model with a self-reported environmental behavior (SB) measure and the same model with an other-reported environmental behavior (OB) measure? And, what do these differences imply? A major model, Ajzen¡¦s (1985) theory of planned behavior (TPB), was tested with SB and OB measures respectively with structural equation modeling (SEM) analysis. Data were collected through questionnaires and participant observation in which students living in dormitories in a university were trained to observe their 172 roommates¡¦ five environmental behaviors. The other-reports of these roommates¡¦ environmental behavior made by the observers were based on their observation as well as experiences in living with and understanding of their roommates. Results showed that there existed significant frequency gaps between behavioral intention (BI) and SB and between SB and OB. The difference between SB and OB frequency was about 1.25 points on a 7-point scale. The BI-SB correlation (.87) was much larger than BI-OB correlation (.31) implying that SB was better predicted than OB was by BI. It was found that the subjects¡¦ SB tended to be conservative compared with BI and that OB was provided even more conservatively by the observers. BI could be the common cause of both SB and OB or SB could intervene in the relationship between BI and OB. A few significant differences were found in the results of testing the TPB model with SB and OB. The preference for the behavior might have played an essential role in predicting one¡¦s SB. The model had a very large proportion of variance explained (.814) because of the strong connection between BI and SB. It also seemed to have a better model fit when SB was used while the model¡¦s capability in predicting behavior was greatly reduced due to the large disparity between BI and OB when OB was used. Finally, it seemed that social desirability was a not cause of the SB-OB gap.

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Over the last 5 decades, the retrospective pretest has been used in behavioral science research to battle key threats to the internal validity of posttest-only control-group and pretest-posttest only designs. The purpose of this study was to compare outcome measures resulting from four research design implementations incorporating the retrospective pretest: (a) pre-post-then, (b) pre-post/then, (c) post-then, and (d) post/then. The study analyzed the interaction effect of pretest sensitization and post-intervention survey order on two subjective measures: (a) a control measure not related to the intervention and (b) an experimental measure consistent with the intervention. Validity of subjective measurement outcomes were assessed by correlating resulting to objective performance measurement outcomes. A Situational Leadership® II (SLII) training workshop served as the intervention. The Work Involvement Scale of the self version of the Survey of Management Practices Survey served as the subjective control measure. The Clarification of Goals and Objectives Scale of the self version of the Survey of Management Practices Survey served as the subjective experimental measure. The Effectiveness Scale of the self version of the Leader Behavior Analysis II® served as the objective performance measure. This study detected differences in measurement outcomes from SLII participant responses to an experimental and a control measure. In the case of the experimental measure, differences were found in the magnitude and direction of the validity coefficients. In the case of the control measure, differences were found in the magnitude of the treatment effect between groups. These differences indicate that, for this study, the pre-post-then design produced the most valid results for the experimental measure. For the control measure in this study, the pre-post/then design produced the most valid results. Across both measures, the post/then design produced the least valid results.

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Even though influenza vaccinations were provided free to all healthcare workers in the United States, healthcare workers were not 100% compliant. The non-compliance with influenza vaccinations may expose their patients, their families, and the public at large to a high-risk source of influenza infection. This study's research questions included how registered nurses perceived influenza and influenza vaccination; registered nurses' self-reported incidents with influenza vaccination; and factors that contributed to registered nurses' non-compliance with influenza vaccination. Guided by the theory of reasoned action and the theory of planned behavior, the purpose of this qualitative study was to determine the factors that contributed to the non-compliance of registered nurses with receiving the influenza vaccination. Twenty participants from a healthcare facility in Florida were interviewed using an interview guide. Audio data was transcribed to text data; text data was coded and thematically analyzed by using ATLAS.ti software. Results revealed that 70% of registered nurses were afraid of influenza vaccination, while 80% of them saw influenza vaccination as ineffective; 90% of them had bad experiences or have seen colleagues/friends who have had bad experiences after influenza vaccination. In addition, 40% of registered nurses claimed that they already had good immunity, while 20% of them declined influenza vaccination because of personal choices. Research findings from this study may be utilized to bring positive social change to society at large. The findings may be utilized to enhance existing strategies or policies or even help formulate new policies and strategies that would address the concerns of HCWs, especially registered nurses.

Introduction: There has been a continuous development of new technologies in healthcare that are derived from national quality registries. However, this innovation needs to be translated into the workflow of healthcare delivery, to enable children with long-term conditions to get the best support possible to manage their health during everyday life. Since children living with long-term conditions experience different interference levels in their lives, healthcare professionals need to assess the impact of care on children’s day-to-day lives, as a complement to biomedical assessments. Aim: The overall aim of this thesis was to explore and describe the use of instruments about health-related quality of life (HRQOL) in outpatient care for children with long-term conditions on the basis of a national quality registry system. Methods: The research was conducted by using comparative, cross-sectional and explorative designs and data collection was performed by using different methods. The questionnaire DISABKIDS Chronic Generic Measure -37 was used as well as semi-structured interviews and video-recordings from consultations. Altogether, 156 children (8–18 years) and nine healthcare professionals participated in the studies. Children with Type 1 Diabetes (T1D) (n 131) answered the questionnaire DISABKIDS and children with rheumatic diseases, kidney diseases and T1D (n 25) were interviewed after their consultation at the outpatient clinic after the web-DISABKIDS had been used. In total, nine healthcare professionals used the HRQOL instrument as an assessment tool during the encounters which was video-recorded (n 21). Quantitative deductive content analysis was used to describe content in different HRQOL instruments. Statistical inference was used to analyse results from DISABKIDS and qualitative content analysis was used to analyse the interviews and video-recordings. Results: The findings showed that based on a biopsychosocial perspective, both generic and disease-specific instruments should be used to gain a comprehensive evaluation of the child’s HRQOL. The DISABKIDS instrument is applicable when describing different aspects of health concerning children with T1D. When DISABKIDS was used in the encounters, children expressed positive experiences about sharing their results with the healthcare professional. It was discovered that different approaches led to different outcomes for the child when the healthcare professionals were using DISABKIDS during the encounter. When an instructing approach is used, the child’s ability to learn more about their health and how to improve their health is limited. When an inviting or engaging approach is used by the professional, the child may become more involved during the conversations. Conclusions: It could be argued that instruments of HRQOL could be used as a complement to biomedical variables, to promote a biopsychosocial perspective on the child’s health. According to the children in this thesis, feedback on their results after answering to web-DISABKIDS is important, which implies that healthcare professionals need to prioritize time for discussions about results from HRQOL instruments in the encounters. If healthcare professionals involve the child in the discussion of the results of the HRQOL, misinterpreted answers could be corrected during the conversation. Concurrently, this claims that healthcare professionals invite and engage the child.

Functional vision refers to the use of vision to perform day-day tasks and is assessed by the ability to perform these tasks. Assessment of functional vision is an integral component of the management of children with visual impairment. The results of the assessment help in designing appropriate educational and rehabilitation intervention strategies. The L V Prasad-Functional Vision Questionnaire (LVP-FVQ) is a reliable and valid tool for assessing self-reported functional vision performance (FVP) in children. Self-reports are obviously the child's perception of his or her ability to perform certain tasks but they may not reflect actual performance. Various studies of FVP in adults have used actual performance measures of everyday tasks, but very few studies, even in adults with visual impairment, have compared self-reports and performance measures and none have included identical tasks on the 2 methods of assessment. To date, no study has assessed FVP using performance measures of daily tasks in the paediatric population. Therefore, the aims of the current study were: (1) To develop performance measures of FVP and compare them with self-reports of FVP from the LVP-FVQ in a prospective cohort of Indian school-going children with visual impairment. (2) To investigate the effect of a psychological attribute, self-concept, on self-reports, performance measures and the relationships between the 2 measures. (3) To investigate the relationship between clinical measures of vision and FVP. Performance measures of FVP for children with visual impairment were developed for 17 day to day tasks for comparison with self-reports of the same tasks for the LVP-FVQ. The LVP-FVQ was verbally administered by the researcher to 178 Indian school-going children aged between 8 and 17 years with visual impairment. Similarly, the performance of each of the tasks by these children was measured by the researcher. The performance measures for most of these tasks were recorded on continuous scales and later categorized to match the ordinal ratings from the LVP-FVQ. The self-report and performance measure ratings for the 17 tasks were then converted into the same metric using a Rasch model allowing an accurate picture of whether and how these two measures of FVP compared with each other. Rasch analysis was used to estimate the person ability and item difficulty for FVP from the 2 methods of assessment. Self-reports showed stronger correlations with performance measures of FVP than were hypothesized. Similar to some studies in adults, binocular high-contrast visual acuity was found to be the single most significant predictor of a child's functional vision performance. Contrary to expectations, self-concept did not have a significant effect on the relationship between the 2 measures. A few reasons for the stronger than expected relationship between the 2 methods of assessment of FVP in children with visual impairment are suggested. Firstly, the use of identical tasks for self-reports and performance measures of FVP is likely to improve the relationship. Secondly, the LVP-FVQ was developed using focus groups of children with visual impairment, their parents, low vision specialists and rehabilitation professionals leading to good content validity. Since children were included in the development of the LVP-FVQ, the tasks were representative of a child's typical daily life. Thus, the performance measures were also suited to the day-day tasks of school-going children but were not tapping any social and psychological issues relating to visual impairment. Thirdly, the use of Rasch analysis which addresses many of the issues of unequal measurement and defines a hierarchy of items for self-reports and performance measures could have led to higher correlations in the present study. Finally, the high reliability and validity of self-reports and performance measures of FVP in the present study may have contributed to the higher than expected correlations. None of the demographic variables or self-concept affected the relationship between self-reports and performance measures of FVP, but self-concept had a weak significant association with self-reports. This result is unique to this study and warrants further investigation. Binocular high-contrast visual acuity alone, the most common visual function measured in ophthalmic clinics, explained between one-third and two-thirds of the variance in functional vision performance. This confirms the expected trend that with worse visual impairment, FVP is lower. The addition of the variable, self-concept, resulted in a very small increase in the variability explained for self-reported FVP. Similarly, the addition of other clinical measures of vision such as binocular low contrast visual acuity and colour vision resulted in a small increase in the variability explained for performance measures of FVP. The correlation between binocular high-contrast visual acuity and performance measures of FVP was statistically significantly higher than that between binocular high-contrast visual acuity and self-reports of FVP. There are a few possible reasons for this higher correlation. Firstly, performance measures are considered to be a more "objective" form of assessment, while self-reports are a child's perception of his or her ability and therefore lack a context, which may result in either over-estimation or under-estimation of actual ability. Furthermore, performance measures include dimensions such as the time taken to perform a task or other criteria specific to a task, while self-reports do not use such qualifiers. Secondly, the higher correlation may be the result of the visual complexity of some of the tasks. While self-concepts of children with visual impairment played a small but significant role in the self-reported FVP, studies in adults with visual impairment have suggested that other psychological factors such as mood, anxiety, motivation etc. are associated with an individual's perception of visual performance. Future studies are required to explore the possible role of these and other factors in FVP in Indian school-going children with visual impairment. This thesis makes a significant contribution to the field of paediatric low vision rehabilitation by providing performance measures of FVP and relating them to self-reports in children with visual impairment and their relationship with common measures of visual function. With self-reports, the child is reporting his or her perception of ability to complete a task, where performance measures examine the child's ability to complete a task by observing his or her performance. Thus, although the two methods are comparable, it is because of the different yields from each of these measures that they are not considered interchangeable. A combination of the 2 measures where practical would perhaps provide a richer depiction of the FVP of children with visual impairment. As developing countries such as India have limited resources allocated for eye care services where less than seven percent of the gross national product is spent on health care, self-reports can be utilized together with clinical measures of vision (mainly visual acuity) to assess the FVP in children with visual impairment in a community setting. However, both methods of assessment of FVP together with clinical measures of vision are essential if a comprehensive assessment of FVP is to be carried out in children with visual impairment. Information from these assessments can help clinicians better understand the functioning of children with visual impairment and incorporate them in the management of low vision in school-going children with visual impairment in India.