PhD Graduates – 2022

The scope of end-of-life (EOL) communication is not well known among advanced practice nurses (APNs) who care for adults with end-stage renal disease (ESRD). Guided by the Theory of Planned Behavior, the aims of the study were to examine the independent effect of knowledge, attitude, and perceived behavioral control on APNs’ engagement in EOL communication and the mediating and moderating effects of attitude and perceived behavioral control between knowledge and EOL communication. A theoretically derived 17-item survey measuring the concepts of interest was developed and administered to a convenience sample of 127 APNs. Instrument validity and reliability testing were completed. Additional statistical analyses included descriptive statistics, Pearson’s correlation, and multiple linear regression. Independent predictors of engagement in EOL
communication among nephrology APNs were attitude about professional responsibility for EOL communication behavior, attitude towards patient and family EOL communication needs, and perceived behavioral control over EOL communication behaviors. Attitude about professional responsibility for EOL communication behavior and patient and family EOL communication needs, and perceived behavioral control over EOL communication behaviors were all found to both mediate and moderate the relationship between EOL communication behavior knowledge and engagement in EOL communication among nephrology APNs.

Forty years have passed since the criminalization of sexual violence (SV) perpetration, yet due to pervasive inequities, this law has not been consistently applied across all segments of society. Alarmingly high rates of SV persist in the United States, and SV remains the most underreported crime in the nation, resulting in low prosecution and high recidivism rates of perpetrators. Traumatology literature suggests that certain sub-groups of SV survivors have a heightened risk for insensitive or overtly abusive treatment from individuals to whom they report the crime, including law enforcement, mental health, or medical professionals. However, methodological inconsistencies and non-representative samples generated disputes about the extent, claims, and disclosure of SV phenomena. Consequently, these inconclusive results have led to a general social fatigue and probable gross underestimation of SV reporting and disclosure, and the professional response. This study was a secondary data analysis of the 2010 National Intimate Partner and Sexual Violence Survey. The Ecological Systems Theory and an expansion of the Communication Privacy Management were used to form the conceptual framework. Four hypotheses predicted variability in SV disclosure and perceptions of the help-seeking experience with professional providers to whom SV survivors disclosed, based on several predictors, namely gender, race, ethnicity, and sexual orientation of the survivors. Analyses used linear mixed models. Results demonstrate that SV survivors who were male gender, non-White race, and lesbian, gay, or bisexual (LGB) sexual orientation each predicted lower rates of formal SV disclosure. Ethnicity, sexual orientation, age, educational attainment, economic status did not have a significant association with perceived helpfulness. Gender and race, albeit, less so, predicted perceived helpfulness of formal providers. However, an interaction was found between Hispanic respondents and greater odds of decreased levels of perceived helpfulness of police officers than of psychologists/mental health counselors. Results echo most assertions made over four decades ago, revealing that non-White SV survivors are significantly less likely to disclose their experience to professionals than White SV survivors. These findings conflict with more recent, methodologically problematic studies, which claim racial differences in SV disclosure patterns have essentially disappeared indicating a critical need for continued intervention and reform to remedy these disparities. Similarly, these results diverge from recent studies that maintain the SV disclosure experiences of LGB and heterosexual survivors are alike. Lower rates of SV disclosure in the LGB survivors signal a need for explicit inclusive training of law enforcement, healthcare workers, and mental health providers that will protect LGB survivors and those at risk, guide professional behaviors and responses to SV, and reduce stigma. Further, organizations with existing inclusion and equity policies must ensure that such policies are wholly adopted and integrated into their healthcare context. Large effect sizes between male gender and non-disclosure indicate the need to reformulate and disseminate male-targeted education on awareness, policy and practice initiatives. The results of this study will be shared with policymakers such that more robust support of SV-related preventive and response measures, by way of newly available Violence Against Women Act (VAWA) funding, can be created and disseminated in an equitable and inclusive manner to those least likely to come forward for help.

Purpose: The purpose of this study was to examine the relationship between social determinants of health (SDH) and the diagnosis of type two diabetes mellitus(T2DM) among Asian Indians (AI) in the United States. Rationale: The global AI diaspora is experiencing disproportionately high rates of T2DM. Multiple studies in the US have indicated that AIs have the highest prevalence of T2DM when compared to the other races after adjusting for confounding factors such as age and body mass index (BMI). Paradoxically, the prevalence of T2DM among AIs is not limited to the traditional risk factors of high BMI and waist circumferences. Methods: The theoretical underpinning of this review is the Conceptual Framework of SDH by the Commission on Social Determinants of Health (CSDH) by WHO. This was a quantitative study with an observational, cross-sectional study design. This study was a secondary data analysis using the data from the Behavioral Risk Factor Surveillance Survey (BRFSS) of the Centers for Disease Control and Prevention (CDC) from 2013-2017. Non-institutionalized adults of 18 years and above participated in the study. Deidentified data were obtained from the New Jersey Department of Health (NJDOH) was obtained after IRB approval. Participants who were self-identified as AIs were included in the analyses. Statistical analysis included descriptive statistics, chi-square analyses, logistic regression analyses, and mediation analyses. Results: The results indicated that the odds of having a positive DS were 66% lower with the use of the internet (OR =0.34, 95% CI: 0.14-0.84). The odds of having a positive DS were 4 times higher for AIs who reported having medical checkup in the last 2 years (OR = 4.40, 95% CI, 1.05-18.48) and 4 times higher for those who have a personal doctor (OR = 4.03, 95% CI: 2.03-8.00). There was no mediation detected among the variables. As additional findings, there was a high proportion of increased BMI (69.2%) among AIs. Moreover, odds of having a positive DS were 4 times higher among AIs older than 45 years. (OR = 3.89, 95% CI: 1.78-8.52, p = <.001). Conclusions: There is substantial evidence in the literature about the relationship of SEP and behavioral factors with the diagnosis of T2DM. However, there is a dearth of studies on this topic among AIs in the US and these relationships are not consistent as per the current knowledge. This study indicates there is a significant relationship between the internet, personal doctor, and the diagnosis of diabetes status among AIs in NJ. There was no statistically significant relationship between behavioral factors and T2DM in this study. The nature of the relationships established in this study should be explored further using survey tools specifically developed for AIs and longitudinal studies.

Palliative care is specialized health care to support patients with serious illness. Hospice is a philosophy of care that focuses on symptomatic relief for patients with life limiting illness. Both modalities assist patients in achieving goals of care throughout the trajectory of advanced cancer. This specialized care can decrease symptom burden and improve quality of life for patients. Despite this, only a small percentage of eligible patients utilize these services. Factors which increase utilization of these resources remain poorly understood. End of life spending remains high as does incongruence of patient wishes and outcomes.

This study is a secondary analysis of the 2018 State Inpatient Database guided by the conceptual framework of the Theory of Health Care Utilization and the Theory of Unpleasant Symptoms. The sample contained 28,697 cases with metastatic cancer. Within the sample 15.4% of patients received IPCC, and 9.3% had a hospice referral. The sample had a 9.3% occurrence of pain and a 10.9% occurrence of depression. This study concludes both demographic variables and clinical factors contribute to IPCC and hospice referral use. The need factor of pain had a strong relationship with both IPCC and hospice referral. The need factor of depression relationship approached significance in IPCC and was significant in hospice referral. The adjusted IPCC model found age, income category, payer status, and pain were significant factors. The adjusted hospice referral model found age, income category, race, primary language, payer status, pain, and depression were all significant factors.

This study provides evidence that disparities persist in end of life care and extends evidence that symptomatic factors impact both IPCC and hospice referral. Additional research should be conducted to examine clinical screening practices for symptomatic need factors in IPCC and hospice referral with the goal of decreasing disparities across demographic groups.

Diaper need is an increasingly important social determinant of health measure for families with young children. Previous research examining associations of diaper need focused on parent outcomes and sampling occurred pre-pandemic. In this study we examined the associations of diaper need and family outcomes among an under-resourced, neurodiverse sample. Seventy-six percent of the sample of the participants reported some diaper need and 39.5% reported high diaper need. Common coping strategies included using a towel or other cloth as a diaper, not using a diaper, and keeping the child in the diaper for longer than usual. Families experiencing food insecurity were 14 times more likely to experience diaper need compared to food secure families (OR = 13.78; p < .001). High diaper need was associated with greater parent stress (β = 2.45, p = .001) and parent perception of poor sleep (β = -7.98, p = .01). Any diaper need was associated with shorter, more disrupted sleep (β = -12.73, p < .001) and lower total sleep scores (β = -6.16, p < .001). Developmental concern, but not diagnosed disability was associated with food insecurity (OR=2.32, p=.04; OR=1.29, p=.58, respectively). We did not find a significant association between high diaper need and child irritability. The associations between diaper need and family outcomes suggest that an inadequate supply of diapers adversely affects parent stress levels and child sleep patterns.  

Background:
Maternal morbidity and mortality in the United States continue to be a worsening public health crisis with persistent racial disparities for Black Mothers during the COVID-19 pandemic. Innovations in mobile health (mHealth) technology are being developed as a strategy to prepare mothers for potential post-birth complications by connecting birthing Mothers to their healthcare providers during the critical first six weeks of the postpartum period.

Objective:
The study explored the preliminary efficacy, feasibility, and experiences with the mHealth intervention by mothers and stakeholders who were directly involved in the mHealth text-based intervention program.

Methods:
A mixed-method triangulation design combined a quasi-experimental study of 12 diverse mothers and a descriptive qualitative study using individual interviews of 13 mothers and 7 stakeholders in a large suburban teaching hospital in New Jersey between January and August 2021. Changes in postpartum knowledge, self-efficacy, discrimination, and postpartum depression were calculated by delta percentage changes. Qualitative data were analyzed by a directed content analysis approach to assess the barriers and factors in implementation.

Results:
The intervention group (N=7) had an 84% response rate to text messages. Similar rates of readmission and follow-up at standard six-week postpartum visits were seen in both groups. Intervention feasibility was hampered by technical difficulties resulting in low fidelity of text message enrollment (50%), daily delivery (29%), and processing (68%). The intervention group showed more changes in postpartum knowledge, self-efficacy, discrimination, and postpartum depression compared with the non-intervention group (N=5). Qualitative data from interviews revealed three major themes: a) Mothers experienced barriers from personal situations at home and with services in the hospital and community that were intensified by the COVID-19 pandemic; b) The COVID-19 pandemic negatively impacted hospital services, priorities, and individual staff; and c) Mothers and stakeholders had positive experiences and perceptions of mHealth intervention.

Conclusions:
The socio-ecological framework provided a holistic lens for analyzing the multilevel influences on individual experiences for mHealth intervention. mHealth intervention utilization and reach were influenced by interrelated barriers operating at multiple levels. Recommendations for future implementation included literacy and language assessment, staff training, hospital and community collaboration, organizational commitment, and feedback from constituents and stakeholders to drive process improvement and delivery of the intervention equitably and effectively.
 
Keywords:
maternal mortality, health disparity, mHealth, self-efficacy, health literacy, patient engagement, discrimination, postnatal depression, post-birth warning signs

Introduction
Disparities in cervical cancer screening and prevention modalities exist in women living with HIV (WLH) in the United States. Immunosuppression related to HIV causes persistent infection with Human Papillomavirus (HPV). WLH are also more likely to be infected with oncogenic HPV strains and as a result, experience increased risk of cervical cancer even at the earliest sign of cervical precancer. Their risk remains elevated and WLH are 4-5 times more likely to develop cervical cancer and are less likely to be successfully treated for cervical cancer. Routine cervical cancer screening is recommended due to cervical cancer being an AIDS-defining illness.

Study Purpose
The purpose of this study was to examine cervical cancer screening prevalence and to examine multilevel (individual, interpersonal, community, structural and healthcare system level) barriers and facilitators that influence receipt of Pap test among racially and ethnically diverse WLH in New Jersey and who receive care at one of seven Ryan White Funded Part D sites.


Methods
This study used a convergent mixed methods approach. A retrospective chart review utilized CAREWare 6 administrative reports, for the years of 2015 – 2019. A 13-item, semi structured questionnaire was also distributed to 16 participants amongst the seven Ryan White Part D clinics throughout New Jersey and collected information on healthcare and structural determinants to HIV care and treatment. Content analysis was performed on the transcribed semi structured interviews.

Results
A total of 925 women met the inclusion criteria for the years of 2015 – 2019. The results show high Pap test utilization yet low rates of HPV co-testing and HPV vaccination. Bivariate analyses demonstrated indicators of HIV care, HIV diagnosis attributes, screening for sexually transmitted infections and demographics related to age, were associated with Pap test receipt. At the structural level, access to care and clinic engagement were associated with Pap test receipt. Lastly, healthcare institutional such as availability of same day, co-located obstetrics and gynecology services and Pap tests, were associated with Pap test receipt.Qualitative results present a comprehensive, multilevel examination of barriers and facilitators to cervical cancer prevention. These interviews found numerous facilitators and barriers at multiple levels that affected Pap screening including, heightened awareness due to HIV status, psychosocial issues, financial costs, caregiving responsibilities, social support, access to transportation, provider stigma and healthcare team support.

Conclusion
Entering the fourth decade of the HIV pandemic, women living with HIV remain at increased risk of gynecological complications due to their HIV positivity status. This study found high rates of overall Pap test utilization however HPV co-testing and HPV vaccination rates were low. This study also found multilevel barriers and facilitators at multilevel that are important to examine for future work related to modifiable interventions to end disparities within a group at increased risk for cervical cancer.