Health services

Permanent URI for this collectionhttps://digital.lib.washington.edu/handle/1773/4928

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Evaluating the Impact of the Patient-Driven Payment Model on Medicare Coding Intensity, and Access, Care Delivery, and Outcomes for Metastatic Cancer Patients in Skilled Nursing Facilities
(2026-02-05) Amaravadi, Harsha; Mroz, Tracy M; Prusynski, Rachel A
The Patient-Driven Payment Model (PDPM), introduced in 2019, changed how Medicare pays for skilled nursing facility (SNF) care. Instead of primarily compensating for the amount of rehabilitative therapy delivered, PDPM bases payment on a patient’s clinical characteristics (e.g., diagnoses, functional ability, and clinical needs). This shift raised concerns about the accuracy of facility documentation of diagnoses, which can affect risk adjustment and the equitable implementation of the policy across facilities. PDPM was also designed to improve access for patients with serious and complex conditions. Under the prior volume-based payment system, people with metastatic cancer often experienced suboptimal SNF care. Cancer patients were often viewed as costly, which in some cases limited their access to SNFs. Of the cancer patients admitted to SNFs, many experienced high hospital readmission rates, low use of cancer treatments, and more aggressive end-of-life care. Although PDPM aimed to better align payment with patients’ clinical needs broadly, it is not focused on a single disease like cancer and does not directly link payment to health outcomes. It is therefore important to evaluate the impact of PDPM on outcomes, particularly for metastatic cancer patients, who stood to benefit significantly from the spirit of the policy. This study uses quasi-experimental methods specifically, a difference-in-difference design with a non-equivalent dependent control (Aim 1) and interrupted time-series analysis (Aim 2-3), to examine Medicare claims and clinical assessment data for all Traditional Medicare patients hospitalized between 2018 and 2021. It evaluates PDPM’s impact on documentation of clinical complexity for all patients (Aim 1) and on admissions, cancer-specific care delivery (Aim 2), and outcomes (Aim 3) for patients with metastatic cancer. Findings from Aim 1 show significant increases in diagnosis-based complexity measures — namely the Elixhauser score and number of diagnoses on the SNF claim — particularly among for-profit SNFs, as well as increased documentation of five highly reimbursable conditions, suggesting potential financially motivated coding changes. Aim 2 showed increased admissions of metastatic cancer patients to SNFs with little improvement in care delivery: chemotherapy and radiation use remained low, therapy volumes declined, and there was no change in length-of-stay. Aim 3 found no improvement, and some explicit worsening of cancer- and SNF-relevant health outcomes; specifically, higher in-facility mortality, higher all-cause hospital readmission rates, and no change in functional improvement or successful discharge to the community rates. These findings can inform future Medicare policy refinement, both patient-centered reforms to improve outcomes for metastatic cancer patients and broader adjustments to address behavioral responses to payment policies operationalized via documentation.
Advancing Reproducibility in Allostatic Load Research: A Component-Level Approach Using the WHI Cohort
(2026-02-05) Cirovic, Christine Alison; Fishman, Paul A
Background: Allostatic load (AL) is a multisystem index of physiological dysregulation due to chronic stress. While widely applied, its operationalization remains inconsistent, limiting reproducibility and equity in population health research. Streamlined indices using common biomarkers may enhance feasibility across diverse settings. Methods: This study used data from 159,230 postmenopausal women in the Women’s Health Initiative to evaluate the construct validity of a minimal AL index. Candidate biomarkers across cardiovascular, metabolic, and immune domains were screened for predictive utility with mortality outcomes. The final three-component index included systolic blood pressure, waist circumference, and white blood cell count. Cox proportional hazards models estimated associations with all-cause, cardiovascular, and immune-related mortality, adjusting for demographic and clinical covariates. Results: Higher scores were strongly associated with mortality outcomes. Hazard ratios for all-cause mortality were 1.34 (95% CI: 1.30–1.38), 1.75 (1.69–1.81), and 2.28 (2.16–2.41) for scores of 1, 2, and 3 compared with 0 (p-trend <0.00001). Similar patterns were observed for cardiovascular and immune-related mortality. Each component remained independently predictive when modeled simultaneously. Conclusion: A minimal AL index of systolic blood pressure, waist circumference, and white blood cell count demonstrated robust associations with all-cause, cardiovascular, and immune-related mortality. While not a substitute for more comprehensive indices, this streamlined measure offers a pragmatic and reproducible approach for operationalizing AL, with potential to expand applicability in large-scale and resource-limited contexts.
Advancing Digital Health Equity in a Safety-Net Health System: Identifying Barriers, Evaluating Training, and Assessing Impact on Diabetes Outcomes
(2025-10-02) Rapson, Taylor; Fishman, Paul
Digital health technology, including patient portal use and telehealth visits, has been increasingly utilized across healthcare settings, transforming how individuals access healthcare and contributing to improved quality of care. However, there are differences in which types of patients use digital health technology, stemming from multi-level factors at the structural, contextual, and individual levels. Without better evidence, improved methodology, and proactive interventions to reduce inequity and promote equity, these disparities will persist as the digital divide widens. This dissertation is centered on the experience of individuals at San Francisco Health Network, an urban safety-net health system. Across three papers, I employ novel qualitative and quantitative methods to address critical questions about marginalized populations and digital health technology use, thereby filling gaps in the literature and advancing digital health equity. In the first paper, I employ mixed methods to examine fundamental skill and usability barriers to digital health technology use. Notably, I highlight critical gaps in digital literacy, particularly in device navigation and processing complex tasks, that prevent effective use of these tools, and the need for usability-driven improvements to reduce digital barriers. The second paper uses a zero-inflated negative-binomial generalized linear mixed model to evaluate the impact of person-centered digital training on patient portal uptake and use, considering sociodemographic factors, clinical characteristics, and digital engagement. I identify that patients who participated in tailored training saw a 91% relative increase in average monthly portal users, compared to a 12% relative increase among those who received basic digital support only. More specifically, the basic digital support program especially benefited Spanish-speakers who demonstrated an 80% increase in login counts, although the tailored training significantly benefited participants with low baseline engagement and resulted in a fivefold increase in login frequency compared to pre-intervention rates. The final paper leverages the widespread adoption of digital health technology and remote care engagement in health systems and uses a linear mixed-effects model to examine how combined in-person and remote care utilization patterns impact longitudinal changes in A1c control, and whether these patterns differ across key sociodemographic factors. I found that multiple remote and in-person care utilization patterns were associated with modest but clinically meaningful differences in glycemic control. Specifically, the degree of A1c improvement followed a clear gradient across care patterns, with the least improvement among patients with little or no care and progressively greater gains as remote and in-person modalities were combined, underscoring the value of hybrid engagement for chronic disease management. However, these associations varied by sociodemographic characteristics, revealing disparities in access, adoption, and effectiveness of in-person and remote engagement across patient groups. Together, these papers outline the growing issue of disparities in digital health technology use and pinpoint solutions and evidence to support accessibility and equitable use. These papers highlight the skills needed to use digital health technology effectively, the role of digital skills training in promoting the use of these tools, and the benefits of engaging in care remotely on patient health outcomes. However, a common thread across all these papers is the persistent presence of disparities and barriers among marginalized populations, and how the influence of these barriers extends beyond disengagement with digital health technology but also affects health outcomes. In my concluding chapter, I summarize these findings and suggest areas for future research. As digital health technology becomes more widely adopted in healthcare delivery, and the risk of disproportionate uptake and use of digital health technology becomes more pronounced for marginalized populations, this dissertation provides a strong scientific framework through which new strategies to reduce disparities, and the digital divide can be developed. These results will inform healthcare systems about innovative and equitable interventions and strategies to reduce inequity in digital health technology uptake and use and promote equity.
Assessing the role of gentrification in shaping spatiotemporal determinants of food access
(2025-10-02) Dai, Jane; Jones-Smith, Jessica C
Gentrification is a contemporary mechanism of structural racism consisting of mutually reinforcing systems of housing, food, and work. This makes it difficult for minoritized communities to access resources, contributing to a system of food apartheid characterized by racialized disparities in food access. Gentrification can reinforce these disparities by: 1) displacing low-income households to areas far from affordable food retail, and 2) introducing greater density of unaffordable food retail in gentrifying areas. Despite evidence that neighborhood access to food matters for food security and health, there is a dearth of literature that examines the impact of gentrification on the neighborhood food environment, and less so how low-income households spend time traveling to access food in these food environments. This dissertation explored the role of gentrification in shaping spatiotemporal determinants of food access by employing a multi-methods design. Aim 1 found that while time spent commuting, procuring food, and preparing food have largely increased from 2003 to 2019 across most income groups, there were persistent racialized disparities within each income level. Aim 2, which focused on policymaker and stakeholder perspectives of gentrification's multifaceted impacts on neighborhood environments in Seattle, WA, found that food was not a policy priority in developing anti-displacement tools. Aim 3, an exploratory quantitative analysis, found that within Seattle, WA, neighborhoods that were higher-income and exclusive (not able to be gentrified), had less geographic access to all types of food retailers, including retailers likely to sell unhealthier food products. Moving forward, this dissertation will inform longitudinal and quasi-experimental analyses of gentrification's role in shaping neighborhood food environments and community food systems.
The Impact of Paid Family Leave Policies on Working Caregivers and Older Adults
(2025-10-02) Im, Jennifer; Weiner, Bryan J
One in two older Americans needs assistance with functional limitations that affect their ability to care for themselves. Functional limitations are associated with unmet self-care and social needs, which can increase their risk of adverse events such as falls, hospitalizations, and nursing home admissions. As older adults near the end of life, an estimated 74% need help with functional limitations. In the US, access to publicly-funded programs that provide long-term care services are limited; Instead, unpaid caregivers (primarily family members) serve as the backbone of long-term care. Trends suggest a growing share of caregivers are adult children, who must often balance employment and caregiving responsibilities for an aging parent. A potentially effective policy solution is to provide working caregivers with access to paid family leave (PFL). PFL programs provide access to paid leave for three distinct needs: i) when they are expecting a new child, as parental leave; ii) when workers experience a serious health issue of their own, as medical leave; iii) when caring for a family member with serious health issues, as caregiving leave. A handful of states were early adopters of PFL, namely California, New Jersey, and Rhode Island. Since then, the policy has spread to a total of thirteen states and the District of Columbia, as of 2025, signaling the salience of the issue for policymakers. Despite working caregivers being a key goal of PFL policies, research on their utilization and impact as a caregiving leave benefit remains scant. Using program administrative data and the Health and Retirement Study, this dissertation evaluates the impact of PFL policies in the care of older adults by working adult children. In Aim 1, I explore trends and characteristics associated with PFL utilization in Rhode Island and Washington. In Aim 2, I examine the impact of PFL on place of residence for worker's aging parents. In Aim 3, I examine the impact of PFL on working caregivers' health and wellbeing. As the population continues to age, the results yield rigorous evidence that can guide state planning decisions and inform ways to modify program benefits to increase access to PFL benefits and support working caregivers.
Structural Determinants of Health across Race, Sexual Orientation, and Gender: A Mixed Methods Application of Public Health Critical Race Praxis
(2025-10-02) Fan, Carolyn A; Barrington, Wendy E
Purpose: This dissertation uses Public Health Critical Race Praxis (PHCRP) to understand how structural determinants (including structural racism and discrimination (SRD) and community cultural wealth (CCW)) impact the health of U.S. adults across race, sexual orientation, and gender. The purpose of this research is to effect positive structural change to promote the health and wellbeing of queer and transgender Black, Indigenous, and other people of color (QTBIPOC). Specific Aims: The aims of the dissertation are as follows: (1) Conduct a systematic scoping review to describe how PHCRP is applied methodologically in published health literature and summarize strategies for applying anti-racist principles in health research; (2) Examine individual and joint associations between structural racism, structural cisheterosexism, and QTBIPOC status on measures of health-related quality of life (HRQoL) and health services outcomes among U.S. adults; and (3) Identify how QTBIPOC community members describe the ways in which structural determinants impact the health of their community through a content analysis of QTBIPOC-authored independently-published print media. Methods: This mixed methods study utilizes three unique data sources to answer its research questions. Aim 1 is a qualitative systematic scoping review of four major health databases. Aim 2 is a quantitative analysis of national Behavioral Risk Factor Surveillance System (BRFSS) data, linked with state-level indices of structural racism and structural LGBTQ+ discrimination. Aim 3 is a qualitative analysis of QTBIPOC-authored independently-published print media from the Zine Archive & Publishing Project (ZAPP) Collection at the Seattle Public Library. Importance: This dissertation is innovative in approach, population, methodology, and impact. The use of PHCRP, focus on multiply marginalized populations, examination of structural-level factors, novel datasets, and applicability to a variety of stakeholders distinguishes this study. This study will serve as a model for anti-racist and intersectional public health research.
Perceptions and Practices of Administering Long-Acting Injectable Antipsychotics in Community Pharmacies
(2025-10-02) English, Clayton; Helfrich, Christian D
Background: Use of long-acting injectable antipsychotics (LAIAs) for schizophrenia are associated with improved medication adherence and reduce relapse and hospitalizations compared to oral antipsychotics; however, despite these advantages LAIAs remain underutilized. Community pharmacies could improve access and reduce logistical barriers to LAIA administration; however, relatively few deliver this service, and we do not yet fully understand why. Objective: To assess the contextual fit of administering LAIAs in community pharmacies, identify determinants influencing implementation, and inform implementation strategies to optimize and increase LAIA delivery across Washington State. Methods: Key informant interviews were conducted with community pharmacy staff in Washington State using a hybrid deductive–inductive qualitative approach to explore determinants and compatibility of LAIA administration. Interviews were conducted using a semi-structured guide informed by Proctor's Implementation Outcomes Framework. Using rapid analysis, transcripts were summarized in a structured matrix and coded into a priori domains. Barriers and facilitators were inductively categorized and then deductively-mapped to the Consolidated Framework for Implementation Research (CFIR) domains; recommendations were identified to inform future implementation strategies. Results: Ten interviews were conducted with nine community pharmacists and one pharmacy technician. Current practices varied across participants administering LAIAs in community pharmacies. Reimbursement and payment for LAIA administration emerged as the top barrier. Appointment-based models were seen as facilitators by improving predictability for staffing and medication inventory. Participants recommended streamlining reimbursement and turnkey toolkits for training, care coordination, and communication between prescribers. Conclusion: For community pharmacies within Washington State, payment models and reimbursement present a critical barrier to LAIA administration. Optimizing billing processes, improving funding and contracting mechanisms, and engaging payers may expand LAIA services. These represent both outer-setting and inner-setting factors, meaning that optimizing LAIA administration in community pharmacies will require system-level, multi-stakeholder involvement and research.
A Prospective Micro-Costing Analysis of a Novel Opioid Overdose Diversion Center
(2025-10-02) Robinson, Annalivia; Fishman, Paul
Importance: The opioid epidemic continues to be an ongoing public health threat which has resulted in an enormous death toll and has placed significant burden on multiple aspects of our public health system. Responding to overdoses requires ample resources from our emergency medical care system, but many current hospital systems are not resourced to provide wrap around care to promote ongoing recovery to overdose patients. Multiple social service and public service organizations have collaborated to develop a novel opioid overdose diversion center, the ORCA center, to dually help reduce the resource burden on King County's medical system and deliver tailored services to people with Opioid Use Disorder (OUD) who experience overdose. This innovative clinic will not only provide immediate medical care to overdose patients but will engage with patients to identify key community resources and medication for OUD which will help them achieve recovery. However, the costs associated with the provision of this care are currently unknown. Objective: To determine the costs associated with this innovative opioid overdose diversion clinic. Design: A prospective micro-costing analysis. Setting: Seattle, WA Main Outcome and Measures: Total cost and cost per patient over three years of service delivery. Results: Total estimated costs for the ORCA Center range from $8,132,950.29 in year one to $6,297,818.10 in year three, with per-patient costs declining from $6,898.18 in year one to $2,670.83 in year three. Conclusion: Fixed costs for the development of a novel opioid overdose center result in a concentration of costs in the initial development year of the ORCA center. However, even with an anticipated increase in the service population, total costs per year and costs per patient are expected to decrease in subsequent years. Future cost analyses of the ORCA center are required to further refine cost parameters associated with this novel opioid overdose diversion center.
Information Sharing by Caregiver Language in Pediatric Serious Illness Care Conferences
(2025-08-01) Martos, Melissa; Meischke, Hendrika
Background: Children using a language other than English are known to experience poorer medical care, including at end-of-life. Information sharing is essential to achieve optimal communication outcomes, but little is known about effects of caregiver language. Objective: We explored differences in quantity and complexity of bidirectional information sharing in English and interpreted care conferences for seriously ill children. Design/Methods: Care conferences for pediatric patients with serious illness from linguistically diverse families at a single institution were audio-recorded, transcribed, and analyzed using content analysis. Provider and caregiver information-sharing statements were characterized as biomedical, logistical, or psychosocial; caregiver categories also included patient wellness and values/goals. Provider communication practices known to impact information sharing were also tabulated. Mann-Whitney-U tests compared median quantity of information shared by conference language. Results: We analyzed 29 care conferences from 2018-2021, including 11 (39%) professionally interpreted conferences. On average, providers made 156 statements per conference while parents made 71 (p<.001). Providers made significantly fewer biomedical statements in interpreted conferences than English ones (117 vs 176, p=0.01). Caregivers made a similar number of statements per conference, regardless of language (78 vs 66, p=.95). Meanwhile, use of provider practices supporting information sharing, such as gathering information preferences, were rare. Conclusions: Providers spoke far more than caregivers, and rarely used practices that support information sharing, regardless of language. They also shared significantly fewer biomedical statements in interpreted conferences than English ones. Strategies to reduce disparities in information sharing may support equitable outcomes for patients and families from all language backgrounds.
Physician Performance in the Merit-Based Incentive Payment System: Implications for Health Disparities
(2025-08-01) Joo, Joseph H.; Wong, Edwin S
The Merit-based Incentive Payment System (MIPS) is ostensibly designed to promote better care across participants. However, MIPS risks exacerbating disparities among participants with fewer resources to invest in performance metrics like care delivery improvements or quality reporting. Unfortunately, little is known about how group practice characteristics impacted MIPS scores and associated reimbursement in later years of implementation. Two practice-level characteristics (location in urban areas and larger patient populations) and two community-level characteristics (some college education and health care spending) were positively associated with MIPS scores. In contrast, patient population case mix and the proportion of Medicare/Medicaid dual-eligible patients were negatively associated with MIPS scores at the practice-level. These findings underscore the potential risk that MIPS may exacerbate health disparities by penalizing practices caring for lower-income populations adversely affected by social drivers of health.
Are Pharmaceutical Supply Chain Vulnerabilities a Threat to Public Health?
(2025-08-01) Larsen, Nicole; Fishman, Paul
Policymakers have deemed the current state of the United States pharmaceutical supply chain a risk to public health and economic and national security. The ongoing issue of drug shortages calls into question the resilience of the pharmaceutical supply chain. High geographic concentration and low redundancy heighten its vulnerability to geopolitical tensions, natural disasters, and public health threats. Underlying these risks is a critical dependence: 45% of finished dosage form (FDF) units and 60% of the active pharmaceutical ingredients (API) used in US medications are manufactured in India or China. Market dynamics have driven the manufacturing of drugs offshore, particularly the key ingredients used in generic drugs. Given these factors, federal trade policies and potential tariffs under the current administration merit consideration, as they could create pharmaceutical supply chain disruptions and consequences for patients and manufacturers.
Youth Preferences Towards Contraceptive Methods in Canada
(2025-08-01) Madden, Ciara R; Munro, Sarah
Introduction: In this thesis, I will seek to address the knowledge gap regarding youth preferences towards contraceptive methods, from the perspectives of youth aged 15-25 in Canada. While contraception usage and rates have been mapped in previous research, less is known about youth preferences toward individual contraceptive methods. Methods and Analysis: This paper is an extension of the Ask Us project, a prospective, mixed-methods study that sought to understand contraception access, experiences, beliefs, preferences, knowledge, and needs of youth in Canada, from the perspectives of youth and youth service providers. The Ask Us Project involved in-depth interviews with youth and contraception service providers. The study took place in 2024, and youth aged 15-25 from across Canada were selected to participate, alongside contraceptive care providers. As mentioned previously, youth were selected as this population experiences excess barriers in contraceptive care access. Results: Youth will encounter a common reason or choice that forces them to think about starting or switching a method: experiencing painful or irregular periods, hormonal acne, or needing to prevent pregnancy. After deciding to start or switch contraceptive methods, side effects and accessibility are features that matter most to youth. Input from providers, peers, community members, and media influences youth contraceptive choice, but ultimately, the decision itself is totally and confidently made by the youth. Finally, youth put their contraceptive choice into action by making deliberate, rational, and intentional choices within this period of growth, change, and transition. Shame, stigma, and cost may be hindering factors in youth achieving their preferences. Conclusion: Youth positionality in Canada ultimately frames the entire contraceptive care experience detailed in this paper. The information learned from this paper should be used to improve youth access to contraceptive preferences and to inform healthcare professionals on the decisions, features, influences, and choices that lead youth to these preferences.
From Clinics to Communities: Community Health Workers’ Perspectives on Taking on the Behavioral Health Care Manager Role for Community-based Geriatric Depression Treatment
(2025-08-01) Wang, Margaret Zhuoer; Hannon, Peggy
Collaborative care models (CoCM) improve late-life depression outcomes and access, but face implementation barriers into healthcare systems. Task-shifting the behavioral health care manager role (BHCM) of CoCM to community health workers (CHWs) in community-based settings may help expand quality depression care. We conducted a qualitative phenomenological study using semi-structured interviews with 15 certified CHWs from clinical and community-based organizations. Guided by the Theoretical Framework of Acceptability, we explored CHWs’ perspectives on strengths, attitudes, perceived self-efficacy, concerns and recommendations for taking on the BHCM role. CHWs reported that their rapport with the community, resource networks, and cultural alignment are strengths. They supported taking on this role to increase mental health access and expressed their prior health promotion and public health background aligns with the BHCM role, though additional training and supervision are needed to deliver psychosocial interventions, monitor symptoms, and infrastructure and role facilitation are needed to build capacity within community organization.
Chronic Pain and Social Pain: Loneliness, Healthcare Utilization, and Associated Characteristics in a Cross-Section of Patients Receiving Opioids for Chronic Pain
(2025-08-01) Williams, Florence A; Fihn, Stephan
Introduction: Loneliness is detrimental to several domains of health and quality of life, and is sometimes linked to higher healthcare utilization (HCU). Individuals prescribed opioids for chronic pain experience loneliness more frequently than the general population. Patients with chronic pain utilize more health services than the general population. Discovering characteristics associated with loneliness in this patient population could help prioritize the delivery of appropriate interventions and reduce unnecessary healthcare utilization.Methods: This is an analysis of cross-sectional survey data collected as part of the screening process for a clinical trial testing a social navigation intervention. The population was patients being prescribed long-term opioids for chronic pain. Characteristics associated with loneliness were identified via Ꭓ2 tests and logistic regression. Associations between loneliness and number of primary care visits, emergency room visits, and behavioral healthcare visits were measured using negative binomial regression. Regression models were adjusted for predictors of health service use selected from the Andersen Model of Health Service Utilization. Results: The sample size was n=278. Characteristics associated with loneliness were social isolation( OR=1.33, 95%CI=1.18-1.51), pain severity, (OR=1.04, 95% CI=1.01-1.07), and living alone (OR=1.21, 95% CI=1.06-1.39). Being aged 65+ was associated with lower odds of loneliness (OR=0.768, 95% CI=0.650-0.908). Loneliness was not associated with increased primary care or ER visits. Loneliness appeared to have a moderate association with increased behavioral health visits (IRR=1.99, p=0.030), but this result was not significant under a Benjamini-Hochberg correction. Conclusion: Given the prevalence of loneliness and chronic pain, there is a need for more research. Future researchers should consider revisiting this topic using longitudinal study designs with larger sample sizes.
Trends in the Use of Emergency Medical Services for Reproductive Emergencies in the United States
(2025-08-01) Duerre, Reiley A; Fishman, Paul A
Following the 2022 Supreme Court ruling in Dobbs v. Jackson Women’s Health Organization, access to reproductive healthcare has become increasingly fragmented. With this decreased access comes potentially increased risk of reproductive complications requiring emergency medical treatment. This cross-sectional descriptive study used data from the National Emergency Services Information System from 2019 and 2023 to compare EMS activations for reproductive complaints before and after the Dobbs ruling. For both years, reproductive complaints were most common among Black/African American patients. Such complaints were also most common in the South Census Region, with the West South Central division having the largest increase in proportion of reproductive activations with abortion-related complaints, as identified using ICD-10 codes. In tandem with other research, these results point toward a greater need to prepare EMS providers to care for reproductive emergencies.
Paying it Forward: An Exploration of Mentor Experiences Among Women Sheet Metal Workers
(2025-08-01) Monsey, Lily; Meischke, Hendrik W
Tradeswomen are underrepresented in the construction industry and face gendered occupational risk factors that impact mental and physical health. Mentorship is a tradeswomen-identified strategy to support the retention and wellbeing of incoming workers to cope with negative gendered experiences. We conducted a five-year randomized control trial to evaluate the efficacy of a mentorship program for women sheet metal workers, which included an online mentorship training for mentors. Here, we explore the experience of mentors in the program, including their reflections about how the mentorship training and program impacted them, their mentees, and their communities. Ten interviews were conducted and thematically analyzed using deductive codes informed by Social Cognitive Theory (SCT) and inductive codes that emerged from the data. Mentors described their motivation to support mentees through the lens of their gendered experience in the field and reported understanding and using skills from the training with their mentees and in their own lives, including the development of communication skills and increased confidence. They expressed motivation to engage in tradeswomen-supportive programming at the local level because of participating in the program. Mentors also reported significant barriers to mentorship, including lack of time, lack of responsiveness from mentees, and cultural norms in the trades. These findings provide insight and context into the dimensions of the mentor role in an occupational-health focused intervention. These results inform recommendations for future tradeswomen-supportive programming; they also shed light on the role of individuals as intermediaries in supporting health promoting behavior.
Community Perspectives on a Community-Based Contingency Management Program for Quinault Indian Nation Adolescents and Young Adults
(2025-08-01) Simon, Claire; Williams, Emily
American Indian/Alaska Native (AI/AN) communities are disproportionately impacted by harms from substance use and mental illness. Contingency management (CM) reduces substance use by providing positive reinforcement to reward abstinence. We partnered with the Quinault Indian Nation (QIN) to explore perspectives on a culturally adapted community-based CM program for adolescents and young adults (AYA) that provides positive reinforcement to reward engagement in cultural activities that build cultural connection. This study was guided by community-based participatory principles and a community advisory board (CAB) of QIN members. We conducted 15 semi-structured, 30–60-minute interviews with QIN community members. Interviews asked about community connection and community needs and preferences for a culturally adapted contingency management program. Interview transcripts were double coded by three qualitative researchers and analyzed using a combination of Rapid Assessment Process and thematic analysis. Our sample included 6 AYA and 9 adults/elders from the QIN community. Five themes emerged: 1) community connection involves reflecting community values in daily life, 2) QIN AYA have fewer formal and informal pathways to learn cultural practices and traditions, 3) QIN AYA frequently face logistical and/or structural barriers when trying to access cultural activities, 4) shyness, isolation, and competing interests may also hinder QIN AYA engagement in cultural activities, and 5) new approaches to fostering cultural connection are needed to promote health and wellbeing. QIN community members reported AYA face significant barriers to engaging in cultural activities that build cultural connection. While contingency management offers a possible framework to increase community and cultural connection, community member perspectives focused more broadly on upstream factors that may prevent substance use and mental health problems in the future.
Associations Between Openness to Church-Based Firearm Safety Interventions and Evangelical Identity and Political Party Affiliation Among Protestant Christian Firearm Owners
(2025-08-01) Phung, ThuyMi; Spigner, Clarence
The existing body of research evaluating firearm safety interventions has underexamined church-based firearm safety interventions. Emerging qualitative studies have shown that such interventions may be an effective strategy for promoting firearm safety practices among Protestant Christian firearm owners. Using quantitative methods, this study examined whether Evangelical Christian identity and political party affiliation were associated with Protestant Christian firearm owners’ openness to church-based firearm safety interventions. Ordinal regressions demonstrated that openness to four interventions were associated with both Evangelical Christian identity and political party affiliation: 1) a hands-on class held in church, 2) a firearm safety program held in church, 3) a firearm safety program held in church led by a member of the congregation, and 4) a firearm safety program held in church that uses Scripture. Compared to non-Evangelicals, Evangelical Christians had greater odds of reporting willingness to participate in the four church-based interventions. Similarly, Republicans had greater odds than Democrats of reporting willingness to participate in the same four interventions. These findings support prior qualitative research, underscoring the potential of church-based firearm safety interventions for Protestant Christian firearm owners as well as highlighting characteristics that may impact the extent of their openness. Future research should explore additional factors that may influence engagement and participation in church-based interventions to optimize firearm safety interventions and outcomes within Protestant Christian communities.
Does The Available Evidence Support Guidelines for Pre-Pregnancy Weight Loss? A Scoping Review
(2025-08-01) Kvitek, Victoria Lomax; Fishman, Paul A
While the risks of being pregnant and giving birth in a higher BMI class (> 24.9 kg/m2) are well documented, the ways to mitigate this risk are not. Current recommendations suggest entering pregnancy at a “healthy” or “normal” weight, conventionally defined as having a BMI between 18.5-24.9 kg/m2. However, it is unreasonable to expect women whose BMI is significantly above 24.9 kg/m2 to lose enough weight to enter the “normal” BMI range before they conceive. Moreover, in the United States, 40% of women of childbearing age have a BMI > 30 kg/m2. A set of standard recommendations is needed as to how much weight such women should lose before conceiving, whether they should attempt to lose weight in the early months of pregnancy if they conceive unexpectedly, and how they should attempt this weight loss to support a healthy pregnancy and birth. This review explores whether such recommendations can be made using the available evidence on pre-pregnancy weight loss and outcomes of the incident pregnancy. We focus on exposure to preconception weight loss and weight loss attempts (i.e. via dietary restriction), evaluating studies that examine maternal and fetal health outcomes in women who experienced pre-pregnancy weight loss and/or dieting. We conclude that the evidence does not consistently support recommendations that women with BMI > 24.9 kg/m2 lose weight before becoming pregnant to reduce their risk for complications. Rather, we draw on alternative frameworks for care--including Health At Every Size (HAES), weight neutrality, and evidence concerning weight cycling and weight stigma--to advocate for a weight-neutral approach to pre-conception maternal health counseling.
Health Impacts of Intergenerational Caregiving Among Pre-Retirement-Aged Adults in the United States
(2025-08-01) Gao, Zhao; Mudrazija, Stipica
This project investigates the physical health consequences of dual caregiving—simultaneously caring for children and aging parents—among U.S. adults aged 51 to 64. Grounded in the stress process model, this study leverages nationally representative longitudinal data from the RAND Health and Retirement Study (HRS) and RAND Family Files (1998–2018) to assess how dual caregiving status relates to self-rated health and the number of chronic conditions over time. Descriptive analyses tracked changes in health outcomes across 11 waves, highlighting consistent disparities between dual and non-dual caregivers, with the gap widening in recent years. Mixed-effects linear regression models were employed to evaluate these associations while adjusting for key covariates: age, gender, education, household income, employment status, and survey wave. Sensitivity analyses incorporated birth cohort as a substitute for age to account for generational health differences. Findings indicate that dual caregivers experience significantly poorer self-rated health and a higher burden of chronic disease, even after adjusting for socioeconomic and demographic factors. The effects remained robust in cohort-adjusted models, confirming the independent health risks associated with dual caregiving. These results point to a cumulative physiological toll likely driven by overlapping care demands, time scarcity, and financial stress. This research contributes to the public health literature by identifying dual caregivers as a distinct, high-risk population within the broader context of aging and caregiving in the United States. Policy implications include the urgent need for expanded access to paid family leave, workplace flexibility, and caregiver health monitoring—supports currently available in only 13 states. Interventions tailored to the unique pressures of dual caregiving could reduce health disparities and support aging-in-place strategies for both caregivers and care recipients.

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