Alumni Dissertations and Theses

 
 

Alumni Dissertations and Theses

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  • Trauma, mental health, and substance use among homeless families: The importance of shelter environment

    Author:
    Nisha Beharie
    Year of Dissertation:
    2015
    Program:
    Public Health
    Advisor:
    Mary Clare Lennon
    Abstract:

    Homelessness is at historical levels in the United States and New York City has not been immune to this nationwide trend. Homeless populations are not only increasing in number but are remaining in the shelter for longer periods of time. Homelessness, itself has been shown to have negative consequences on mental health and physical health, but its effects are particularly significant for families with children who have greater needs and who are more susceptible to negative experiences at early ages that can have lifelong impact. Despite this recent data there has been very little to no research on the potential impact of the shelter environment on the mental or physical well-being of homeless families. Thus, this dissertation research aims to fill this gap in the current literature by conducting a secondary analysis of the HIV Prevention Outreach for Parents and Early Adolescents (HOPE) study to test: 1) the association between three shelter related variables (i.e., time in the shelter, the perceived social environment of the shelter, and difficulty following shelter rules) and psychosocial outcomes for caregivers (i.e., mental health, parental stress, and substance use among caregivers), 2) the association between three shelter related variables (i.e., time in the shelter, the perceived social environment of the shelter, and difficulty following shelter rules) and psychosocial outcomes for youth (i.e., depressive symptoms, and substance use among caregivers), 3) the potential moderating effect of this perceived social environment of the shelter and difficulty following rules on the association between trauma and psychosocial outcomes for both youth residents and their caregivers. The sample for this research consisted of youth (ages 11 – 14) and their caregivers (n = 452) residing in 10 shelters in New York City. Hierarchical regressions were employed to test various models within the three aims of the study. In addition, sampling of residents within shelters and youth within families was accounted for in the analysis. Results of the analysis conducted indicate that the length of time in the shelter was not significantly associated with psychosocial outcomes for youth and caregivers with two exceptions, namely caregiver mental health and parenting stress. Perception of the shelter environment was strongly associated with all psychosocial outcomes for caregivers and their youth, with the exception of caregiver substance use. Difficulty following shelter rules was significantly associated with all psychosocial outcomes for both youth and caregivers (although the youth substance use finding was counter to what was initially hypothesized). Trauma was also significantly associated with all psychosocial outcomes as well with the exception of parenting stress, and caregiver substance use. The findings from the third aim of the study revealed that his perceived social environment of the shelter did not prove to be a significant moderator of the association between trauma and psychosocial outcomes for youth and caregivers with the exception of youth substance use. Difficulty following rules was also not found to be as significant moderator with the exception of parenting stress and youth substance use. However both findings are counter-intuitive and discussed further in the concluding chapter. Thus, the findings support a more direct-effect relationship between the perceived social environment of the shelter and psychosocial outcomes as well as direct effects of difficulty following shelter rules and may also be indicative of a buffering effect. In addition, the findings of all three aims suggest an importance in the manner in which shelter is provided above and beyond providing a temporary residence.

  • The Role of Advocates in State-Level Competitive Food Legislation Formation: A Comparative Case Study

    Author:
    Lauren Dinour
    Year of Dissertation:
    2012
    Program:
    Public Health
    Advisor:
    Nicholas Freudenberg
    Abstract:

    In the absence of strong federal oversight over competitive foods--those items available in school vending machines, à la carte lines, school stores, and fundraisers--many states have enacted legislation to limit the availability and accessibility of unhealthy competitive foods. Evaluations of these policies show their promise in improving the healthfulness of school food environments, considered an important strategy for reducing childhood obesity. Yet little is known about the decision-making processes by which such legislation is formed and adopted. Using a comparative case study design, this study describes and analyzes how and why state-level competitive food legislation adopted in 2010 changed during the legislative process, as well as identifies and characterizes the primary stakeholders in support and opposition of these bills and their relative effectiveness in influencing bill language and content. Five retrospective case studies were conducted, analyzed, and written independently using a standard protocol. Primary data from semi-structured key informant interviews were complemented with secondary data obtained through document review. Upon completion of the individual case studies, comprehensive summary tables were compiled and analyzed for recurring and unique themes, enabling conclusions to be drawn across cases. Cross-case analysis yielded 10 key findings related to the dynamics of the legislative process and the roles played by various stakeholders. Of note, fiscal concerns regarding increased expenditures--but not lost revenues--are influential in the weakening of bill language and content. In addition, strong support from a large and diverse coalition may increase political influence, yet lead to weakened bill language in efforts to appease multiple interests. Examination of decision-making constructs revealed that advocates situated in highly cohesive and minimally constrained policy subsystems are more effective at influencing bill language and content than advocates in less cohesive and highly constrained policy subsystems. Likewise, advocates situated in coalitions characterized by high lobbying activity are not necessarily more effective in influencing bill language and content than advocates in coalitions with low lobbying activity. These and other findings can assist advocates, policymakers, and researchers in identifying potential strategies, barriers, collaborators, and opponents when seeking to create more healthful school food environments within their state.

  • AN EXAMINATION OF THE EFFECT OF VISION-RELATED FACTORS AND AVAILABILITY OF HEALTH CARE RESOURCES ON DEPRESSION, FUNCTIONAL STATUS, AND FALLS AMONG NEW YORK CITY SENIOR CENTER ATTENDEES

    Author:
    Lauren Evans
    Year of Dissertation:
    2015
    Program:
    Public Health
    Advisor:
    William Gallo
    Abstract:

    There is substantial variability across different geographic regions and demographic groups in health outcomes and health resource availability. This dissertation examines the relationship between self-reported ocular disease and depression, functional status, and falls in a diverse sample of senior center attendees in New York City. Further, these analyses explored whether the availability of health care resources at the area level affects the observed relationship between ocular disease and these other adverse outcomes. This dissertation project addresses two main gaps in the current research, specifically, the need to better understand elders' experiences with these conditions in different geographic regions and demographic groups (the study sample is a low-income sample in New York City, and is racially/ethnically/linguistically diverse), and to explore whether these relationships are modified by the availability of primary care resources. Data for this dissertation come from a subsample of n=1,393 participants in the Senior Center Health Status Survey (SCHSS), conducted by the Brookdale Center for Healthy Aging & Longevity of Hunter College in 2008. This data was linked to data provided by the Primary Care Service Area (PCSA) Project of the Dartmouth Institute for Health Policy and Clinical Practice to allow for an examination of provider density. Results indicate that this population experiences high rates of depression, functional status limitations and falls. Although provider density and ocular disease were not significantly associated with these outcomes as hypothesized, the analyses nevertheless reveal factors associated with increased risk of these adverse health outcomes. Targeting individuals with these risk factors and addressing certain modifiable risk factors remain important strategies to prevent and treat these outcomes.

  • Food Purchasing Decisions in a Grocery Store Setting

    Author:
    Hayley Figueroa
    Year of Dissertation:
    2013
    Program:
    Public Health
    Advisor:
    Betty Wolder Levin
    Abstract:

    The items that find their way into our shopping carts and subsequently, into our homes are selected for a variety of reasons. A great deal of research has been conducted on consumer habits around fast-food consumption and take-out, and the role of each in the obesity epidemic, but little is known about how grocery-shopping decisions are made or the extent to which health is a part of that decision-making process. Using participant observation techniques and semi-structured interview, the investigator accompanied 31 residents of Brooklyn, NY while they shopped. The participants, who came from two neighborhoods of contrasting socioeconomic status, Downtown Brooklyn and East New York, spoke of the importance of a number of factors including cost/value, health, quality, taste, location/access, class and culture; and how these factors affect decision-making. Two interesting themes emerged from the data that are reflective of historical and social influences on the foodscapes of two generations of shoppers. Older study participants, held to a certain set of values, beliefs, and attitudes regarding food, which differed substantially from those of their younger counterparts in the sample. Among the youngest of participants, the data revealed that they fell into two groups; shoppers for whom time and convenience were of primary importance and shoppers for whom food purchases were a reflection of their social and political identities. Also emerging from the data was evidence that, in general, participants' knowledge of food is shallow and the decisions they make in the grocery store are largely based on inauthentic knowledge. Based on this sample, a depth of knowledge around the food system produced more authentic knowledge that led to healthier purchases.

  • Malaria in NYC Residents: Examining the determinants of chemoprophylaxis use and adherence among immigrants who travel abroad to visit friends and relatives (VFR)

    Author:
    Lucretia Jones
    Year of Dissertation:
    2012
    Program:
    Public Health
    Advisor:
    Luisa Borrell
    Abstract:

    Malaria in NYC Residents: Examining the determinants of chemoprophylaxis use and adherence among immigrants who travel abroad to visit friends and relatives (VFR) Lucretia E. Jones, MPH Background: Malaria is an infectious disease caused by Plasmodium parasite spread by the bite of an Anopheles mosquito in tropical areas. Though not transmitted in the United States (US), New York City (NYC) reports approximately 200 diagnoses of malaria annually predominantly in immigrants who traveled home to visit friends and relatives (VFR).1 This study aimed to examine the associations between 1) reasons of travel and taking chemoprophylaxis, and 2) type of chemoprophylaxis used and adherence; and to understand the reasons why travelers do not take malaria preventive measures. Methods: Two quantitative methods were used for this research study: 1) secondary data analysis of NYC malaria surveillance data 2004-2010 (n=1335), and 2) an in-depth open ended interview of a sample (n=32) of newly diagnosed malaria cases diagnosed in 2011. Descriptive and chi-square statistics were calculated for selected characteristics. Logistic regression was used to estimate the strength of the association between a) reason for travel and chemoprophylaxis use and b) type of drug taken and adherence before and after controlling for age, gender, race, borough of residence, and travel region. SAS 9.2 was used for statistical analysis. Results: No chemoprophylaxis was taken by, 84% of malaria cases and only 5% took and adhered to the complete regimen. The odds of not taking any chemoprophylaxis was 1.5 (OR: 1.48; 95% CI: 1.09-2.01) greater among VFRs than those that traveled for other reasons. However, after adjusting for age, gender, race, borough of residence, and travel region, this association was no longer significant. When compared to those who reported taking chemoprophylaxis daily, the odds of not adhering to the full regimen was 4.1 times (unadjusted ) greater for travelers who stated chemoprophylaxis use, but the name of drug was unknown. A sub-sample of 2011 malaria cases found 59.4% did not take any chemoprophylaxis and 28.1% adhered. People's knowledge, attitude, and beliefs were more important in influencing chemoprophylaxis use (25% of the sub-sample stated that they did not know about malaria or chemoprophylaxis, and 34.4% knew but still did not take chemoprophylaxis) than having health insurance (84.4% had health insurance). Conclusion: Outreach and education are recommended to travelers, immigrant communities, and healthcare providers on malaria awareness, the importance of pre-travel medical advice for the appropriate chemoprophylaxis and the necessity of taking and adhering to the dosage. To increase chemoprophylaxis use and adherence, malaria prevention programs must focus on individuals' knowledge, attitude, and beliefs regarding malaria risk and disease severity.

  • THE CONTRIBUTION OF SCHOOL-LEVEL FACTORS TO CONTRACEPTIVE USE AMONG ADOLESCENTS IN NEW YORK CITY PUBLIC HIGH SCHOOLS

    Author:
    Deborah Kaplan
    Year of Dissertation:
    2013
    Program:
    Public Health
    Advisor:
    Diana Romero
    Abstract:

    Every year approximately 17,000 adolescents ages 15-19 become pregnant in New York City. Most of these pregnancies are unintended and only a small percent of adolescents use effective contraception, with wide disparities by race/ethnicity and poverty level. While many studies have identified factors associated with contraceptive use, most research has focused on individual level factors, with little attention to the contribution of the school environment to sexual risk behavior and contraceptive use. This study investigates the effect of school-level factors on contraceptive use among adolescents in NYC public high schools before and after controlling for individual-level factors, and whether this effect varies with race/ethnicity. Using a cross-sectional design, the NYC Youth Risk Behavior Survey (YRBS) individual-level datasets for 2007, 2009 and 2011 were linked to a school-level dataset. Variables were selected based on empirical findings on factors associated with sexual behaviors, including contraceptive use, by adolescents. The analytic sample included all YRBS respondents aged 14 or older who reported having sexual intercourse in the past three months and had complete responses to the YRBS questions on contraceptive use at last sex (N=8,054). The chi square test of significance was used to evaluate significant associations between independent variables and contraceptive use in bivariate analyses; variables with a p value < 0.1 were included in the multivariable analyses. Binary and multinomial logistic regression analyses were conducted to estimate the strength of the associations of school-level factors with contraceptive use among sexually active adolescents. Findings included that use of any contraception and/or hormonal contraception at last sexual intercourse was associated with attending schools with a higher six-year graduation rate, higher percent of students strongly agreeing they were safe in their classrooms, higher percent of teachers at the school for over two years, and having a School-Based Health Center (SBHC) in the building. No known study has examined the contribution of school-level effects to contraceptive use in a dataset linking YRBS and school-level datasets. Implications of research findings are that schools providing a supportive, engaging and safe environment can protect students from sexual risk behaviors and increase contraceptive use among sexually active adolescents.  

  • The revolving door pattern of jail incarceration and homelessness and its influence on mortality and morbidity among New York City adults

    Author:
    Sungwoo Lim
    Year of Dissertation:
    2014
    Program:
    Public Health
    Advisor:
    Lorna Thorpe
    Abstract:

    Objectives The purpose of this dissertation study was to identify timing and sequencing of jail incarceration and homelessness by utilizing sequence analysis and to test whether a particular trajectory contributes to mortality risk and discontinuity of HIV care. Methods The main data source was an existing matched dataset, constructed using administrative data from the New York City (NYC) Departments of Health and Mental Hygiene, Correction, and Homeless Services. The study cohort consisted of 15,620 NYC adults with recent histories of both jail incarceration and homelessness. Monthly experiences of jail incarceration, homelessness, and community-dwelling in 2001-03 were summarized into trajectory groups using sequence analysis. Then, the study examined associations between trajectory groups and all-cause, drug-related, and HIV mortality risk during the subsequent two years using Standardized Mortality Ratio (SMR) and marginal structural modeling. The study further focused on the sub-set of the cohort living with HIV/AIDS, and tested whether trajectory groups were associated with retention in HIV care and viral suppression. Results Sequence analysis identified six trajectory groups of incarceration/homelessness. A majority of the study cohort had sporadic experiences of brief incarceration and shelter stays (Temporary pattern), whereas the others had mixed experiences in various lengths and frequencies. The SMR analysis found that all-cause, drug-related, and HIV mortality risk among individuals with the Temporary pattern was significantly higher than that of non-incarcerated/non-sheltered NYC adults of the same age, sex, race/ethnicity, and neighborhood poverty. Similarly, after accounting for confounding in marginal structural modeling, the elevated mortality risk was associated with the Temporary versus persistent shelter stay patterns (Continuously homeless pattern). Of 1,173 individuals living with HIV/AIDS, the Temporary pattern was independent of retention in HIV care, but significantly associated with lower prevalence of viral suppression, compared with a pattern of prolonged shelter-free and jail-free period (Decreasingly homeless pattern). Conclusions Sporadic experiences of brief jail incarceration and homelessness among NYC incarcerated/sheltered adults were associated with excess risk of mortality and low prevalence of viral suppression. The study highlights the importance of public health efforts to modify patterns of incarceration/homelessness experiences, along with behavioral interventions, in order to reduce risk of adverse health conditions.

  • Assessing the Impact of Restrictions to Medicaid Coverage of Methadone and Buprenorphine on Opioid Users’ Access to and Utilization of Substance Use Treatment

    Author:
    Courtney McKnight
    Year of Dissertation:
    2015
    Program:
    Public Health
    Advisor:
    William Gallo
    Abstract:

    Opioid use and dependence have increased dramatically since the early 2000s. As of 2013, an estimated 2.4 million people were considered to be dependent on opioids. Medication assisted treatment (MAT), such as methadone and buprenorphine, is the most effective form of treatment for opioid dependence; yet, since 2002, MAT use has decreased steadily. Medicaid is the largest purchaser of MAT in the United States; however, Medicaid coverage of MAT varies by state. As of 2008, fourteen states did not cover either methadone or buprenorphine, or both. This dissertation examines the factors associated with Medicaid coverage of methadone and buprenorphine, and explores the impact of this coverage on the length of time individuals waited to enter substance use treatment, and the extent to which Medicaid coverage of methadone is associated with MAT utilization. This dissertation utilized a combination of individual-level, program-level and state-level data. Individual-level data came from the Treatment Episodes Data Set-Admissions (TEDS-A). Program-level data were obtained from the Uniform Facility Data Set (UFDS) and the National Survey of Substance Abuse Treatment Services (N-SSATS). State-level data regarding Medicaid coverage of MAT were obtained from three sources: (1) McCarty et al’s study, “Methadone Maintenance and State Medicaid Managed Care Programs”; (2) Ducharme at al’s study, “State policy influence on the early diffusion of buprenorphine in community treatment programs”; and, (3) the State Financing for Medication Assisted Treatment study. The main findings of this study indicate that state wealth is correlated with Medicaid coverage of MAT, Medicaid coverage of MAT is associated with an increase in treatment wait time and Medicaid coverage of methadone is associated with greater odds of MAT use. This dissertation did not include any analyses since the passage of the Patient Protection and Affordable Care Act (PPACA), which in 2014, required that all public and private health insurance programs cover substance use treatment services. While this prioritization will undoubtedly increase access to substance use treatment, not all services must be covered. Given this, variability in the accessibility of treatment will likely persist. Further research should continue to monitor the accessibility and utilization of substance use treatment, with particular focus on MAT.

  • THE CITY UNIVERSITY OF NEW YORK (CUNY) DIABETES RISK STUDY: PERCEPTIONS OF A MULTI-ETHNIC COLLEGE POPULATION

    Author:
    Lorraine Mongiello
    Year of Dissertation:
    2012
    Program:
    Public Health
    Advisor:
    Nicholas Freudenberg,
    Abstract:

    Background and Problem: College years are the time when many form detrimental health behaviors that increase diabetes risk. An understanding of students' perceptions about their risk is necessary to determine how best to address issues of healthy eating and physical activity at CUNY. Methods and Objectives: Quantitative data from a student health survey (n=1,579) and qualitative analysis of five student focus groups (n=53) were used to achieve the study's objectives which were to determine the prevalence of risk factors for diabetes overall and by selected characteristics and to ascertain perceptions of diabetes risk, the level of diabetes risk knowledge and the presence of self-efficacy. Additionally, this study aimed to identify individual, community and institutional barriers which students face that limit their ability to adapt a healthy lifestyle. Results: Approximately 40% of students were identified as being at high risk for diabetes; these students were significantly more likely to attended a two-year college (p=.002), be older (p=.048) and have a lower income (p<.001). Of the high risk students, 39% did not recognize their risk. These students were more likely to be male (p=.010), be an immigrant (p<.001) and not report a family history of diabetes (p=.029). Blacks had the highest number of risk factors followed by Hispanics and Asians. On average, the students were able to identity only three of 10 well established diabetes risk factors. Few were aware of the increased diabetes risk among non-white populations and Asian students were the least likely to perceive the risk associated with their race. Students born outside the country were less active than their native-born counterparts (p<.001), as were women (p<.001) and Asian students (p=.030). Interpersonal and intrapersonal factors, primarily lack of time, but also lack of motivation and lack of social support were the reasons most students cited for lack of exercise while the campus environment emerged as the primary theme for poor food choices in the focus groups. Conclusions: CUNY administrators and policymakers must make diabetes prevention a priority as the university is an ideal setting to provide the multi-level interventions needed to reduce the future burden of diabetes in NYC.

  • Organizational Preparedness and Community Readiness for a Public Health Emergency Among Community Service Provider Organizations in East Harlem, New York City

    Author:
    Ann-Gel Palermo
    Year of Dissertation:
    2012
    Program:
    Public Health
    Advisor:
    Luisa Borrell
    Abstract:

    Community service provider organizations operating in vulnerable and minority communities are ill-prepared for a public health emergency and are largely left out of formal preparedness activities. This study had two aims: 1) to examine the association of certain organizational attributes among community service provider organizations operating with levels of organizational preparedness in East Harlem, New York City; and 2) to assess the extent to which this community is ready to engage in public health emergency preparedness activities. Organizational leaders were identified from organizational membership lists of three community groups (n=83). An online cross-sectional survey was administered to 31 organizational leaders over a 5-week period to measure organizational preparedness, individual-level preparedness, organizational confidence, and specific organizational leader and organizational characteristics. Descriptive statistics, linear, and logistic regression analyses were used to address the Aim 1 of the study. For Aim 2, six organizational leaders were randomly selected from the survey sample based on their level of organizational preparedness and participated in an in-depth interview informed by the Community Readiness Model (CRM). The CRM anchored statement rating method was used to determine the stage of overall community readiness. A qualitative analysis of the interviews was conducted using a grounded theory approach to identify themes, barriers, and opportunities for improved public health emergency preparedness. Our findings showed a 1.3 increase in organizational preparedness when associated with the level of individual preparedness and a .99 increase when associated with organizational confidence after controlling for selected characteristics. When the outcome was treated as categorical (high versus low levels of organizational preparedness) the results were nearly identical (1.37, C.I.: 1.02-1.84 for individual preparedness; and 1.33, C.I.1.03-1.72 for organizational confidence). East Harlem is at Stage 2:Denial/Resistance within the stages of community readiness (range from 1 to 9 towards a higher stage of readiness). Four major themes, knowledge, assumptions, and community contextual factors, emerged related to public health emergency preparedness and moving towards a more prepared community. Overall, East Harlem's community service provider organizations remain ill-prepared and the community is at a critically low stage of community readiness to engage in a public health emergency preparedness activities.