• Beyond Efficacy, Toxicity, and Cost: Patients Define Cancer Care Value in the United States

      Franklin, Elizabeth; Shdaimah, Corey S.; DeForge, Bruce R. (2020)
      Per-capita health-care costs in the United States outpace those of all other countries. Oncology care is particularly expensive, with costs that have nearly doubled over the past twenty years. Cancer care costs are expected to continue to grow exponentially and comprise a considerable proportion of overall health spending costs. While there have been some “blockbuster” or “game changing” treatments, many others offer seemingly minimal benefits. As such, there has been a heightened focus on the concept of cancer care “value,” with multiple organizations promulgating value frameworks designed to assess the perceived value of medications derived from various health economics perspectives. Yet, value is an elusive target, and there is not consensus regarding the dimensions that should be included in such assessments. Value frameworks have the potential to impact patient access to care, yet it is unclear to what extent patient preferences, values, and goals have been incorporated into the value assessments. This study explores how cancer patients and survivors define the concept of “value” in cancer care and if those definitions align with current value frameworks and assessments. This research study was conducted through primary data collection and sought to describe and clarify experiences (such as receiving a cancer diagnosis, engaging in treatment decision making, and moving forward throughout survivorship) as they have unfolded in the lives of cancer patients and survivors. Findings will be used to inform the future direction of value assessments and ultimately, policies that impact the lives of cancer patients and their families.
    • An examination of Social Dominance Orientation and Cultural Competence of Social Workers

      Shaikh, Naeem; DeForge, Bruce R.; 0000-0002-3476-2703 (2018)
      Social Dominance Theory (SDT) attempts to explain oppression, discrimination, and inequalities by focusing on group-based social hierarchies. A social hierarchy is defined as the social legitimacy of one dominant group over one or more other groups. SDT suggests that social workers should be low in social dominance orientation (SDO), i.e., their psychological orientation or preference for hierarchies; however, some social worker scholars have posited that the profession acts as an agent of social control. Prior research shows that there can potential conflicts between social workers, and between social workers and clients because of differences in political ideology and religious affiliation. Similar differences have the potential to adversely influence social workers self-perceived cultural competence. In addition, SDO has only been examined in graduate social work students, and there is little or no previous research that examines the relationship of social workers religious or political variables with SDO and cultural competence. This study aimed to test some assumptions of SDT, examine if social workers' political ideology, religious, and political affiliation influenced their perceptions of SDO and cultural competence, and fill other gaps in the knowledge base of cultural competence. Qualtrics was used to collect survey data from 497 social workers registered with the Oregon Board of Licensed Social Workers. Respondents were found to be low in SDO and high in cultural competence and a significant but negative and weak relationship was identified between the two variables. Results of multiple regression analyses showed that gender, ethnicity, being a not strong Democrat, social desirability, general social ideology, and issue-based economic ideology predicted SDO whereas age, race, cultural competence training, general economic ideology, social desirability, affiliation with Republican or Other (non-Democratic) Party, and SDO predicted cultural competence. Number of cultural competence trainings attended was the most important predictor of higher cultural competence. Social desirability was the only common predictor of SDO and cultural competence. Findings for gender differences in SDO suggest support for SDT's invariance hypothesis of SDT but there no racial or ethnic differences in SDO which is inconsistent with findings from previous studies. Implications for social work practice, education, and research are discussed.
    • Examination of Social Exclusion as a Construct and Its Impact on Mortality and Survival Time among Older Adults

      Lee, Joonyup; Cagle, John G.; DeForge, Bruce R. (2020)
      Although social exclusion may be an important predictor of mortality, there is a lack of empirical evidence on the impact of social exclusion on mortality/survival time among older adults in the U.S. The study reported in this dissertation examined the effects of social exclusion on mortality and survival time using a nationally representative sample of adults over 50 years of age. The primary goal was to better understand how social exclusion affects mortality and survival time among older adults. Data were drawn from the 2010 and 2014 Health and Retirement Study (core wave, exit wave, and psychosocial supplement) and focused on older adults aged 65 years or older (8,439 participants). Social exclusion indicators were based on previous conceptual and empirical frameworks, and a total of 21 possible indicators were measured. On the basis of correlation analyses, three indicators were excluded due to very low correlation coefficients or statistical nonsignificance. The remaining indicators nested in four social exclusion domains (material resources, social, health, and community). Average inter-item correlations supported the reliability of the remaining 18 indicators, and multiple regression models supported the validity of the four domains. The results of a Cox regression model revealed that the material resources domain had a higher influence on mortality than did the other three domains. Six individual indicators (wealth, car availability, social activity, social membership, self-rated health, and disability) were associated with mortality, adjusting for demographic variables. Kaplan–Meier survival analyses based on each indicator showed that all social exclusion indicators were significantly associated with survival rate with the exception of social support, city/town satisfaction, and neighborhood safety. The findings from this dissertation indicate that social exclusion affected mortality and survival time among older adults in the U.S. However, not all indicators were associated with mortality and survival time. The results of the dissertation imply that policies can be modified to improve social participation and access to transportation and that multidimensional services or interventions focusing on the more influential social exclusion indicators are needed (e.g., connecting resources, facilitating social connections). Further, there is a need to reconcile the differences between conceptual and empirical domains/indicators.
    • The Interplay of Home Visitors’ Personal and Professional Identities in Effectively Screening and Supporting Women around Sensitive Topics

      Burruss-Cousins, Karen M.; DeForge, Bruce R.; 0000-0003-3665-1211 (2022)
      Home visiting programs provide information, support, resources, and tools that empower new parents to promote positive maternal and child health outcomes. During home visits, there is a unique opportunity to screen for intimate partner violence (IPV), reproductive coercion, and unintended pregnancy with women in unguarded settings (i.e., the women’s homes) while providing ongoing services via a therapeutic relationship. Using individual interviews and a deliberative discussion focus group, the current study examined the research question, to what degree do home visiting staff members’ personal and professional identities impact their ability to effectively screen and support pregnant women and new mothers around the topics of unintended pregnancy and intimate partner violence including reproductive coercion? Interviews and a deliberative discussion focus group were conducted virtually with staff members from Healthy Families America (HFA) programs in Maryland. Six major themes emerged from the interviews and focus group: personal versus professional experience, therapeutic alliance building, keeping families engaged, use of supervision, addressing intimate partner violence/reproductive coercion in families, and home visiting in the time of a health pandemic. Participants shared how their personal and professional identities helped shape their perceptions of their roles within the home visiting field including the terms, its meaning, and the expectations of that role. The findings suggest that home visitors need additional training around reproductive health since they routinely interact with pregnant women and new mothers who are at-risk for poor pregnancy-related health outcomes that may be due to the lack of control or intention related to reproduction. Participants expressed general knowledge, comfort, safety plan creation, and resource linking around the issue of IPV. Participants had received extensive training on administering the Relationship Assessment Tool (RAT), which is the IPV screener for HFA. However, relatively few program recipients endorsed that their HFA program recipients are experiencing IPV using the RAT. Therefore, HFA staff would benefit from advanced level training utilizing more clinical skills around the topic of IPV including advanced screening skills.
    • Mental health risk factors and protective mechanisms for post-secondary educational attainment among young adult veterans

      Smith-Osborne, Alexa; DeForge, Bruce R.; Deal, Kathleen Holtz (2006)
      This exploratory study examines the impact of mental health status on post-secondary educational attainment among young veterans of the first Gulf War, and the associated protective and risk mechanisms. Investigation of mental health impact on post-service enrollment or successful reentry into higher education for this population has been limited. Drawing upon resiliency theory, life span/life course theory, and social geography theory, the author hypothesized that selected factors in the personal, interpersonal, and organizational domains could play mediating or moderating roles in the relationship between post-service psychiatric symptoms and level of educational attainment.;Data from the 2001 National Survey of Veterans (NSV) were analyzed. The sample included 2075 veterans: 349 females and 1726 males, 71% Caucasian and 29% minority, most of whom had served at least two consecutive years on active duty, almost half in a combat zone. Fifty-five percent of the veterans reported experiencing depressive symptoms in the past month, and thirteen percent had received mental health treatment in the past month. A series of regression analyses were performed to explore the hypothesized relationships. Treatment in the past year for psychiatric disorders was not associated with educational attainment as defined by highest grade ever completed (p = .935). However, a logistic regression analysis that examined college educational benefit use since leaving the military showed that the likelihood of a Gulf War veteran using VA educational benefits for postsecondary education was positively related to the use of non-VA sources of financial aid (p < .0005), and to being treated for PTSD in the past year (p = .001). The odds of a veteran who used non-VA financial aid of also using VA post-secondary educational benefits were 2.589 times greater than the odds for a veteran who did not. The odds of a veteran who was treated for PTSD in the past year of using those VA benefits were 2.138 times greater odds for veterans who were not treated. Protective mechanisms in the personal and organizational domains mediated the relationship between mental health status and educational attainment, while protective mechanisms in the interpersonal domain partially mediated this relationship.
    • Oncology social workers and tobacco-related practice: An exploratory study

      Parker, Karen; DeForge, Bruce R. (2010)
      Tobacco use, particularly cigarette smoking, causes approximately 430,000 deaths annually in the United States and is considered to be the number one preventable cause of death (Centers for Disease Control and Prevention (CDC), 2010b; Department of Health and Human Services (DHHS), 2000; Fiore et al., 2008). Nearly one-third of all cancers are due to tobacco use (ACS, 2010b); therefore, it is likely that many cancer patients and survivors smoke. While a tobacco-related illness, particularly cancer, may be a motivating factor to help some smokers quit, approximately one-third of smokers continue to smoke after a cancer diagnosis (Gritz, Fingeret, Vidrine, Lazev, Mehta, & Reece, 2006). This study utilized a cross-sectional design to study the tobacco-related knowledge, attitudes, education/training, workplace factors, self-perceived competence (self-efficacy), and practice of oncology social workers. A self-administered, Internet-based survey was sent to members of the Association of Oncology Social Work; the final response rate was 12%. Five of the eight independent variables were significantly (p<.01) correlated with tobacco-related social work practice (dependent variable). These include tobacco-related knowledge (r=.349); continuing educational units (training) (r=.339); workplace facilitators (r=.554); tobacco-related attitudes (r=.343); and self-perceived competence (r=.642). A multiple regression model was developed to predict tobacco-related oncology social work practice. Only one variable, self-perceived competence, remained significant in the final model (B=0.891, p<.001). The overall variance accounted for (R2) in the model was .554. Perceived self-competence was found to mediate the relationship between workplace facilitators and tobacco-related oncology social work practice (Sobel test statistic=3.70; p<.0001). Improved understanding about how oncology social workers can increase their self-perceived competence in tobacco-related practices is essential to increasing their activity in this area.
    • Parents' Daily Hassles Stress and Child Avoidant Coping during Deployment: A Structural Equation Nonrecursive Model to Investigate the Non-deployed Parent-Child Dyad In National Guard Families

      Beall, Margaret Howell; DeForge, Bruce R. (2016)
      Deployment is an event that military spouses and children cannot control. Repeated and lengthy deployments are associated with higher stress. Intense or prolonged stress is associated with maladaptive coping and physical, emotional, and relationship problems. Extant studies do not explain how parent stress and child avoidant coping do or do not impact one another. This dissertation's structural equation model tested the hypothesis that parent stress and child avoidant coping have a bidirectional relationship. Parent age, parent education, parent satisfaction with unit support, months of deployment were hypothesized to predict parent stress. Child age and child social support were hypothesized to predict child avoidant coping. The results suggest that parent stress and child avoidant coping do have a bidirectional relationship. The length of deployment did predict parent stress. Child age and child's social support predicted child avoidant coping. Finding that parent stress and child avoidant coping have a bi-directional relationship has implications for social work practice. Interventions that focus on the interaction of parent stress and child avoidant coping may be more efficacious than interventions that focus on parent stress or child avoidant coping independently. Further research should be done to investigate that supposition.
    • Predictors of mental health in a neighborhood of Managua, Nicaragua: A gendered analysis

      Jani, Jayshree; DeForge, Bruce R. (2008)
      The Global Burden of Disease Unit estimates that by the year 2020, mental and neurological disorders will cause almost 15% of the disabilities among the people of the world. Multi-national studies demonstrate that women are twice as likely as men to experience major depression, and have a higher prevalence of other common mental disorders (CMD) (World Health Organization, 2006). The World Health Organization (2000) urges that gender be incorporated into country specific mental health research because of its socially contextualized nature. Due to the high correlation between CMD and poverty, it is predicted that there are higher rates of CMD in developing nations (Chant, 2003). Yet, there is a paucity of research examining mental health in third world countries. As part of social work's mission to promote the general welfare of society on a global level (NASW, 1996), research investigating the well being of people living in third world countries is warranted. This dissertation is guided by feminist theory which calls for a critical, historical, gendered analysis of the interconnection between macro political, social and economic realities and their impact on people's everyday lives. This perspective was synthesized into an adapted testable model (Beiser, 2006) to examine predictors of mental health in Barrio 3-80 of Managua, Nicaragua. This study includes four research objectives focused on gender roles, self-esteem, and social support as predictors of CMD. With approval of the Nicaraguan government, data were collected from 227 adult residents of the neighborhood through face to face individual interviews. Quantitative data were analyzed using hierarchical multiple regression analysis. Six participants also answered a set of qualitative questions. A high level of CMD was discovered among all respondents, but women were found to have significantly higher CMD scores. Self-esteem was negatively correlated to CMD and was the only significant predictor of CMD. Self-esteem scores were high. Income was not related to self-esteem or CMD. The findings highlight the substantive agency of "oppressed" women regardless of a lack of formal power within a traditional power structure. The importance of culturally and contextually appropriate measurement and theory and other implications for social work are discussed.
    • Professionals and their Organizational Roles in Pathways to Care for Early Psychosis: Where Are the Social Workers?

      McNamara, Karen Anne; DeForge, Bruce R. (2014)
      Problem: Expediting pathways to effective treatment may reduce the duration of untreated psychosis, thereby improving long-term functioning for individuals experiencing early psychosis. Previous research rarely addresses the role of social workers along the pathway to care for these individuals, with few studies conducted in the United States. Understanding professional roles may provide strategies to shorten pathways and expedite effective treatment for individuals experiencing early psychosis. Method: This exploratory study used a cross-sectional design to examine professional designations and organizational roles of service providers referring individuals to a research program providing specialty early intervention services for psychosis. Of individuals referred (n=320), 169 were assessed for eligibility, 74 were eligible for admission, and 60 were admitted. Tests of association were used to evaluate relationships between roles and professional designations of referring professionals, service-seeker demographics, and clinic eligibility and admission for referred service-seekers. Logistic regression analyses were conducted to evaluate whether professions, roles, or demographic factors predict service-seeker eligibility and admission. Results: Most referrals came through social work professionals (36%) and professionals not licensed to prescribe (54%). Professional designations and organizational roles were strongly associated (V = .700, p <.05). Highest referring role/profession combinations included prescribing psychiatrists (20%), and case-manager social workers (19.4%). The odds of being eligible were: 1) greater for individuals with some college than with no college, 2) less likely for individuals referred from outpatient settings than inpatient settings, and 3) greater for individuals referred from non-prescribing professions than individuals referred from prescribing professions or teams of both. The odds of being admitted were greater for individuals referred from inpatient settings. Conclusions: Social workers and other non-prescribers may be positioned to implement interventions to expedite pathway to care in the United States. Understanding the impact of roles and professions on eligibility and admission requires further research with larger samples in community settings. The ability to refer eligible individuals may be unnecessary for community-based treatment. Community settings may welcome high referral volumes when individuals do not meet criteria for FEP. Offering treatment to individuals at risk for psychosis and monitoring for FEP may be a better approach to reducing DUP.
    • The role of type of sport, race, and gender in the identity, self-concept, and grade point average of Division One student-athletes

      Gill, Emmett Lee, Jr.; DeForge, Bruce R. (2006)
      This study used the 1996 cohort of the NCAA's Basic Academic Skills Study (BASS) to explore the relationships of among gender, race, expected grade point average, academic identity, athletic identity, and self-concept of student-athletes. Identity and self-concept are proposed as proxy variables for exploring student-athlete development. To address the research questions, a secondary analysis was performed on the BASS dataset using multiple regression, MANOVA, and Repeated Measures MANOVA. The multiple regression analyses supported the hypothesis that type of sport, athletic identity, academic identity, and self-concept are significant non-aptitude related predictors of expected grade point average. Secondly, the two one-way MANOVA's revealed significant group differences in the academic identity of freshman female and male and white and non-white student-athletes. However, no group differences were found when comparing freshman student-athletes in revenue and non-revenue sports. Lastly, the Repeated Measures MANOVA indicates between the beginning of student-athletes freshman year and the end of their sophomore year there were significant increases in academic identity and decreases in athletic identity. The findings will aid future research on student-athlete development, and the creation of academic support and life skills programs (i.e., the NCAA CHAMPS Life Skills Program). This research supports the critical role that social workers can play in the academic development of student-athletes.
    • Rural Veterans: Pathways to Homelessness

      Jorden, Brenda J.; Belcher, John R.; DeForge, Bruce R. (2018)
      Veterans are overrepresented in homeless populations compared to non-veterans (Gamache, Rosenheck, & Tessler, 2001; Perl, 2015). Most homeless individuals live in urban centers and as a result most research studies have focused on urban homelessness leaving the rural homeless less studied and understood (Knopf-Amelung, 2013). The purpose of the current qualitative study was to explore the pathways to homelessness for a sample of rural homeless veterans. Fifteen veterans and 16 staff/administrators were interviewed to determine the causes of homelessness for veterans living in a rural area. A limited grounded theory approach was used to develop themes identified as causing homelessness. The primary pathway according to both groups was chronic substance abuse. Mental health and economic problems, and adverse childhood events were also major factors in veterans experiencing homelessness. Social support appeared to delay the onset of homelessness for some individuals. Not all veterans qualify for VA services, which leaves a segment of the population without access to VA services. Overcoming barriers to substance abuse and mental health services for rural homeless veterans is an area to focus research efforts. Creative ways to provide outreach to the hidden homeless are needed.
    • Surviving High School Transfers: A Multilevel Study of Student and School Characteristics Related to School Transfer, Graduation, and College Entry

      de Tablan, Dante; DeForge, Bruce R. (2022)
      Background: Transferring schools frequently happens across the United States from kindergarten to college. While student mobility studies have focused more on elementary and middle school grades, research at the high school level is limited. In addition, studies on transfer during high school related to postsecondary education are even more scarce. This dissertation investigates transfer risk associated with student and school characteristics and its association with high school graduation and college enrollment. Method: The dissertation used analytic samples from a cohort of 6,810 first-time ninth graders enrolled in Baltimore City Public Schools from 2012-2013 to 2017-2018. To examine the factors related to college entry, a second analytic sample included only students who obtained a high school diploma, a certificate of completion, or a GED (N = 4,297). The study employed mixed-effects parametric proportional hazards modeling to investigate student- and school-level characteristics associated with time to the transfer event, and multilevel binary logistic regressions to analyze student and school factors related to odds of high school graduation and college enrollment. Results: Thirty-four percent of students transferred schools during the study period. White students, those with missing 8th-grade math test scores, students who received a suspension, and employed students were at a reduced risk of transfer. Chronic absentees and those with standardized 8th-grade math scores had increased transfer risk. While the school percentage of students eligible for free and reduced meals related to a reduced transfer risk, the school special education rate was associated with increased transfer risk. Transferring schools was associated with lower odds of graduation and college entry, and percentage of school transfer was associated with lower odds of college enrollment. Transfer, as it related to graduation and college entry, varied across schools. Conclusion: School transfer is a multidimensional event related to adverse educational outcomes for many students. This dissertation identified student and school characteristics associated with time to transfer risk. Moreover, the study highlighted the adverse effects of transfer on graduation and college entry. Finally, a discussion of the limitations, strengths, and implications for research, policy, and practice are presented.