Full text for dissertations and theses included in this collection dates back to 2011. For older dissertations, check the library’s catalog CatalogUSMAI or Dissertations and Theses database.

Recent Submissions

  • Exploring Child Welfare Placement Pathways to Residential Treatment Settings: A Three Paper Dissertation

    McCarthy, Lauren; Lee, Bethany R. (2022)
    Residential treatment settings (RTS) provide access to services in a safe environment for child welfare involved youth with behavioral health challenges. Despite the potential benefits of RTS, there are concerns that have led to legislation aiming to reduce their use. Policy that aims to reduce the use of RTS should be informed by an understanding of how youth enter RTS. This three-paper dissertation aimed to increase our understanding of how youth placement histories are related RTS entry in the context of youth behavior and development using secondary analysis of state administrative child welfare data. This dissertation also aimed to understand how caregivers experience accessing mental health care for youth through interviews. The first paper explored aggregate patterns of placement transitions and individual factors associated with risk of RTS entry. Findings include that transitions are most likely to occur between similar types of placement settings and that developmental period at first entry to out-of-home care is associated with RTS entry. The second paper explored the presence of unobserved subgroups of child welfare involved youth based on placement histories and whether youth move through these groups over time. The second paper found two subgroups of placement histories, multiple placements in group settings and stability in family care settings. The second paper further found that child behavior and developmental period at first entry to care were associated with group membership and transitions. The third paper identified that caregivers gain empowerment in decision making when accessing mental health services, but that this empowerment declines when accessing acute inpatient services. The third paper further found that accessing RTS was a challenging journey that impacted caregiver well-being, and that the decision to place a child in RTS came following a safety inflection point. Implications include that youth who enter out-of-home care in pre- and early adolescence and their caregivers may require additional support to remain stable in family placement settings. Further implications include the need to improve caregiver access to knowledge about the mental health care system to improve empowerment when making decisions and more resources for acute mental health service settings.
  • 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.
  • Perceived Need for Care and Mental Health Service Use: The Moderating Effect of Race/Ethnicity and Military Veteran Status among a Population-based Sample of U.S Adults

    McNish, Nicole Latoya; Bright, Charlotte Lyn (2022)
    Background: Black, Indigenous, and People of Color (BIPOC) adults and military veterans are susceptible to chronic and severe mental illness given their higher likelihood of exposure to risk factors compared to the general population. Despite the consequences of untreated mental illness and federal initiatives aimed at expanding healthcare access, treatment utilization among both groups remains low relative to treatment need. Research has found significant racial and ethnic differences in perceived need for care (PNC) and severity of psychological distress, important antecedents of treatment seeking. However, the extent to which these factors apply to veterans has not been widely examined. Using the Behavioral Model of Health Services Use (Andersen, 1995) and Behavioral Model for Vulnerable Populations (BMVP, Gelberg et al., 2000), this dissertation aimed to address these gaps in the existing literature given their significance to ongoing research, policy, and intervention efforts. Methods: Data were drawn from the 2018 National Survey on Drug Use and Health (N = 43,026). Binary logistic regression was used to examine the associations of PNC and symptom severity with mental health service use among veterans and nonveterans of diverse racial and ethnic backgrounds with interaction terms for race/ethnicity and veteran status. Results: PNC and symptom severity are associated with higher probabilities of mental health service use. However, there are differences in the adjusted probabilities in mental health service use favoring White nonveterans. Veteran status moderates these associations such that the probabilities of mental health service use were stronger for veterans than nonveterans who reported PNC, except for Asian veterans. Conclusions: Veteran status moderates some longstanding racial and ethnic disparities in mental health service use. Further research is needed, particularly among Asian veterans, to identify factors that contribute to lower probability of mental health service use in comparison to White adults, and to identify ways to leverage the effectiveness of interventions employed among veterans in support of other vulnerable groups.
  • Understanding Financial Behavioral Health and Race (Racism), and their Association with Investment Risk Willingness

    Anvari-Clark, Jeffrey; Frey, Jodi J; 0000-0003-3234-8549 (2022)
    The conception of financial behavioral health (FBH) is new and lacks a common definition. This dissertation frames FBH as being comprised of financial precarity, financial self-efficacy (FSE), and financial well-being, and has the potential to influence multiple other behavioral health domains. The literature review shows how each component of FBH relates to other domains of behavioral health, including mental health, physical health, coping health, and social health. Stress and life course theory and insights on scarcity from the behavioral sciences are used to understand how FBH impacts the human condition, which, in a negative context, can manifest as money disorders. To explore FBH empirically, data from the 2018 National Financial Capability Study (N = 27,091; FINRA Investor Education Foundation, 2018) was used. First, a measure of financial precarity was constructed with both objective and subjective components, using exploratory and confirmatory factor analyses, and achieved adequate fit. Next, the relationship between FBH and its component parts was assessed, again with adequate fit. The study attempted to determine how a subset of Black and White survey respondents experienced FBH differently, according to collectivist or individualist financial values orientations. However, it was found through measurement invariance testing that although the FBH model had an excellent fit for White respondent data, it poorly fit the data from Black respondents. Due to the model variance, determining further impact of racial group affiliation on the outcome could not be conducted. The study concluded with a structural equation modeling analysis and determined that, controlling for key demographic variables, FBH accounted for 37% of the variance in investment risk willingness (R2 = .368; β = 0.256, p < .001). The project contributes a new measure of financial precarity and a basis for FBH. The variance between the sub-groups may indicate that the survey questions are inadequately capturing the collectivist experience by which many people treat their finances. The project shows how finances can have a psycho-behavioral impact on well-being and decisions, the influence FBH has on investment risk willingness, and suggests that low FBH may perpetuate wealth gaps.
  • Time-Use and Well-Being in Family and Other Unpaid Caregivers of Older Adults

    Baik, Sol; Lehning, Amanda J.; 0000-0002-5081-4956 (2022)
    Due to the intensive time commitment for caregiving, caregivers report limited freedom to engage with others, participate in physical activities, pursue leisure activities, and have adequate time for sleep. Few studies have focused on caregivers’ time-use across different activities, particularly how different patterns of time-use are associated with well-being. This study aimed to: (1) identify time-use profiles of family caregivers of older adults, (2) examine associations between identified time-use profiles and caregiver well-being, and (3) assess whether the effects of gender and race on caregiver well-being vary by the identified time-use profiles. I analyzed 1,640 family caregivers of community-dwelling older adults by combining secondary data from Round 7 (2017) of the National Study of Caregiving and the National Health and Aging Trends Study. I conducted latent profile analysis to estimate time-use profiles including covariates and outcomes. Three classes of caregivers emerged based on time-use patterns. The High Committed class (20%) spent the longest time in non-eldercare related committed activities, such as household activities and paid work. The High Discretionary class (49%) spent the highest amount of discretionary time, including social activities, physical activities, and other free-time activities. They also spent the least amount of non-eldercare committed time compared to the other two caregiver types. Lastly, the Balanced class (31%) allocated time relatively evenly in all activities. When comparing well-being outcomes between time-use profiles, caregivers in the High Discretionary class had worse self-rated health but lower levels of anxiety than the Balanced class. This study also found significant gender differences in depression, which varied by time-use profiles. Research on time-use and caregiver well-being may help identify at-risk caregiver groups based on lifestyle profiles and develop targeted policies to promote better caregiver well-being.
  • An Evaluation of the Effectiveness of Extended-Release Naltrexone

    Hochheimer, Martin; Sacco, Paul; Unick, George Jay; 0000-0001-6644-4841 (2022)
    Medications for the treatment of opioid use disorder (MOUDs) are considered the gold standard form of treatment for this condition. There are two forms of MOUD treatment, agonist, and antagonist. Agonist treatment has the medical system provide people with opioid use disorder methadone or buprenorphine which are long lasting opioids that do not produce a euphoric reaction with the goal of alleviating cravings and mitigating illicit use of opioids. Conversely, antagonist treatment blocks opioid absorption in the brain. Extended-release naltrexone (XR-NTX) is the most common antagonist treatment it is administered as a once-monthly injection. During the month after injection, patients who use opioids will not experience their effect and by negating the reward of opioid use the treatment discourages continued use. This study evaluated the effectiveness of buprenorphine and XR-NTX treatment on three characteristics: treatment retention, risk of opioid related acute care incidents, and changes in healthcare costs during treatment. Data from the Truven Health MarketScan® databases which records the date, type of interaction, and cost of every interaction that a person insured privately with one of over 250 insurance providers has with the healthcare system was used to identify a sample of approximately 30,000 people who were treated with buprenorphine or and 617 who were treated with XR-NTX for opioid use disorder. Treatment episodes were constructed based on filled prescription information and a frailty model survival analysis was fit both to a matched sample and the whole sample to length of treatment for each medication. The risk of acute care incidents was evaluated using a generalized estimating equation, and healthcare costs were evaluated using fixed-effects regression models. The study found that there are no significant differences in treatment retention between the MOUDS. Treatment with either medication was associated with an approximately 10% reduction, per day in treatment, of the odds of experiencing an acute care incident during one month. Healthcare costs increased while people were in treatment, with either MOUD, between approximately 0.85% and 1.5% for both opioid related and non-opioid related services.
  • Centering Black Lives: Exploring Oral Histories of Legacy African American Women in the Black Belt to Heal the Wounds of Racialization as Justice

    Sermon, Michelle Crowder; Negi, Nalini; 0000-0002-8542-1941 (2022)
    Narratives of unresolved racialized injury among Legacy African American(s) (LAA) women in the rural US south, or the Black Belt, offer meaning to observed disparities and healing to the contemporary and future lives of LAA in Black Belt communities. This dissertation study considered LAA women’s layered exposures to racialized adverse live experiences (ALE)/traumas with historical, cultural, intergenerational, race-based, and complex traumas, and the impact of this multidimensional trauma perspective, on wellness outcomes for rural African Americans. Adverse mental and physical health conditions among LAA are critically disproportionate in this population yet current research and treatment protocols to address these disparities are based in a Eurocentric worldview. For example, race is often examined in research as a demographic category without fully conceptualizing the impact of racialization. By applying the Black Lives Matter Healing Justice framework, this study centers the Black experience and aims to elucidates the relationship between racialization and ALE/trauma through the voices and lived experiences of LAA women in the Black Belt, captured in archived oral histories. Employing thematic, critical constructivist, and historical discourse analysis, this study also sought to reveal the language of racialized trauma, expressed in the archived oral/life histories of LAA women sharing their ALE of Jim Crow segregation and racial integration in the Black Belt. Findings suggest that Race-Place-Space collectively served as the foundation of the gendered and racialized experiences of this population. Relying on my personal reflective experiences as a LAA Black Belt woman and an assembled research advisory panel (RAP) as well as theory and extant literature, I discuss the meaning of Race-Place-Space, racialized trauma, and healing justice. Contributions and implications to social work practice and research are presented along with suggestions for future directions in research and practice centering the Black perspective.
  • Examining depression and social and emotional development outcomes in parents and children in migrant and seasonal farmworker families

    Siegel, Jennifer L.; Negi, Nalini; 0000-0002-1825-9518 (2022)
    Migrant and seasonal farmworkers (MSFWs) provide essential food production services in the U.S. yet often experience discrimination, stress related to migration and work, and financial insecurity. Such ecological risk factors unique to agricultural work and being an immigrant of color have previously been shown to heighten MSFW risk for depression. A glaring gap in the literature is that just over half of MSFWs are parents accompanied by their families, and half have children 5-years or younger. This study, guided by the Modified Integrative Model of Child Development for Latinx families, is one of the first to investigate the mental health and social and emotional development outcomes of MSFW families. Specifically, binary logistic regression was conducted using data from the 2017-18 Migrant Seasonal Head Start (MSHS) Study, to examine the relationship between discrimination, work experiences, and cultural resources with the depressive symptomology of caregiving MSFWs. Further, the association of these factors with child social and emotional development outcomes was investigated. MSFWs were mostly women (89%), married or cohabitating with a partner (79%), born outside the U.S. (83%) and mostly from Mexico (80%). All children were 36 months through 5-years of age, just over half were girls (51%), the majority born in the U.S. (93%) and had been enrolled in MSHS for an average of 1.5 years. Results indicated that MSFW caregivers with higher levels of MSFW stress, higher levels of acculturation, and who were separated/divorced had higher levels of depressive symptomology. Children with caregivers with higher levels of depressive symptomology had greater odds of scoring in the range of concern/clinical concern for cognitive social problems. Further, children whose caregivers reported greater importance of religion were less likely to score in the range of concern/clinical concern for emotional behavioral regulation problems. Contrary to this study’s hypothesis, parent depression did not mediate the relationship between contextual factors and child social and emotional development outcomes. Findings are highly significant as they advance understanding of a critically under-studied group and have implications for intervention strategies uniquely suited for this family population. Future research that explores MSFWs’ resiliency along with their structural vulnerability is recommended.
  • 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.
  • Youth Worker Perspectives on Building and Maintaining Relationships with Older Adolescents and Emerging Adults in Strongport

    Forrester, Patrice; Frey, Jodi J; 0000-0002-8180-454X; (2021)
    Youth worker relationships with program participants in community-based programs are integral to the promotion of positive youth development. There is a paucity of studies that specifically explore youth worker perspectives of their relationship development with older adolescents and emerging adults in the US. The purpose of this multi-method qualitative study was to examine how youth workers in community-based programs developed and maintained relationships with older adolescents and emerging adults living in a large city in the US. This study also explored what constrained or supported youth workers in developing relationships with older adolescents and emerging adults. The study was grounded in the constructivist paradigm and guided by Bronfrenbrenner’s (Bronfrenbrenner & Ceci, 1994) bioecological framework and anthropological theories of social suffering and embodiment. Twelve youth workers currently working with older adolescents or emerging adults in the same US city, and one key stakeholder, participated in this study. Data was collected through multiple qualitative methods, including interviews, photo-elicitation, document review, member checking, and researcher journal notes to obtain multiple perspectives of youth worker experiences of relationships with older adolescents or emerging adults. Demographic surveys were also used to provide information on youth workers’ self-reported social identities and organizational contexts that may have influenced their perspectives on relationships with older adolescents and emerging adults. This study found that youth workers build relationships with older adolescents or emerging adults in various ways that fit with their embodied social identities or relational style. All youth workers rooted their relationships with program participants on affirmation or trust. Youth workers also embodied authenticity during the relationship process that contributed to deeper relationship development. Facilitation of communication and creation of space that promoted safety or comfort were also used to develop relationships. Aspects of youth workers’ selves (e.g., desire to work with older adolescents) and their environments (e.g., program funding requirements) supported or constrained the development of relationships with older adolescents or emerging adults. Study results can inform key stakeholders in the youth worker field in strategies that support youth workers in building positive relationships with older adolescents and emerging adults for positive youth development.
  • Covariates Associated with Completing Short-Term Residential Treatment for a Substance Use Disorder Among Adults in the U.S.

    Ware, Orrin; Sacco, Paul; 0000-0002-3269-5324 (2021)
    Substance use disorders (SUDs) are associated with harmful outcomes across the biopsychosocial spectrum. Although completion of treatment for SUDs is associated with beneficial outcomes such as improved well-being and reduced mortality, premature treatment termination remains high in the United States. Short-term residential treatment is brief and for more severe SUD. This 3-paper dissertation focuses on exploring covariates of treatment completion in a short-term residential setting for adults with an SUD. Secondary data include the Treatment Episode Data Set Discharges 2017 and the Short-Term Residential Treatment Dataset, which contains data gathered from a Mid-Atlantic treatment facility’s electronic medical records. Paper 1 examines the associations of sociodemographic and substance use characteristics with completion of short-term residential treatment. This paper also has a primary focus on observing sex differences in treatment completion. Results from logistic regression models indicated that men were more likely to complete treatment than were women, nonpolysubstance users were more likely to complete treatment than were polysubstance users, and individuals with alcohol identified as their primary substance were more likely to complete treatment than were individuals with other primary substances. Paper 2 examines the associations between perceived stress, distress tolerance, and treatment completion in the short-term residential SUD treatment setting. Perceived stress and distress tolerance were negatively associated. Men had lower perceived stress and higher distress tolerance than did women. Those who completed treatment had lower perceived stress and higher distress tolerance than did those who were discharged from treatment prematurely. Lower perceived stress was found to predict treatment completion conditional to including a Perceived Stress × Distress Tolerance interaction variable. Distress tolerance did not moderate the relationship between perceived stress and treatment completion. Paper 3 examines a scale based on the theory of planned behavior to predict treatment completion in the short-term residential SUD treatment setting. In a path model, the theory of planned behavior’s constructs attitude and perceived behavioral control positively predicted greater intention to complete treatment. Intention to complete treatment and perceived behavioral control did not have a direct effect on treatment completion.
  • Parents’ Experiences and Perspectives of Early Childhood Mental Health Services and Child Welfare

    Keyser, Daniel; Ahn, Haksoon; 0000-0002-7812-7496 (2021)
    Children birth to five in the child welfare system often experience trauma and are at risk for mental health problems and developmental delays (Barth, Scarborough et al., 2007; Cooper, Banghart & Aratani, 2010; Painter & Scannapieco, 2013; Whitaker, 2015). However, despite the high need for services, few children in child welfare receive them (Horwitz et al., 2012; Stahmer et al., 2005). Qualitative studies have used interviews with service providers to identify themes related to mental health service barriers (Hoffman, 2016). However, a gap remains in understanding birth parents’ experience accessing mental health services for children birth to five involved in child welfare. The purpose of this dissertation is to understand the experiences and perspectives of parents of toddlers and preschoolers in child welfare accessing mental health services. A mixed-methods study using qualitative methods as the primary method was conducted. Ten African American birth parents participated. Participants had children 1.5 to 5 years old and involved in child welfare when accessing mental health services. The qualitative data explored parents’ experiences and perspectives of mental health and child welfare services. The quantitative data provided descriptive statistics to assess child behavior, parent stress, parent psychological distress, and mental health service satisfaction compared to national norms. The qualitative data and the quantitative data were integrated to understand parents’ experience with early childhood mental health and child welfare services. The qualitative results of this study showed three major qualitative themes; complex mental health needs, navigating systems: child welfare and mental health, and equity and understanding. Quantitative results suggested most participants had their children placed in foster care, a high level of mental health need for participants’ children, participants had lower psychological distress, but had elevated levels of parenting stress. The integrated data showed participants referred to early childhood mental health services did not immediately seek services, but when they did, they often navigated through several barriers before receiving services. Some participants did not seek services until a major traumatic incident. A conceptual model was developed for early childhood mental health service utilization. Implications for practice, policy, and future research are discussed.
  • Comparing the impact of community-based mediation vs. prosecution on assault recidivism among adults

    Harmon-Darrow, Caroline; Bright, Charlotte Lyn; Sharpe, Tanya L.; 0000-0001-5553-1034 (2021)
    Although violence continues to damage community and family life, crime reduction victories over the past 30 years have come with the cost of expanding criminalization of human life, especially in communities of color. Solutions that reduce both violence and over-criminalization are urgently needed. Community-based mediation for diversion of misdemeanor assault cases has been practiced around the country since the 1970s, but little is known about its ability to prevent further violence between participants or reduce assault recidivism. Secondary analysis was conducted with assault cases (n = 162) within a Maryland Judiciary dataset from a quasi-experimental longitudinal comparison group study of criminal court mediation recidivism. Bivariate analyses and logistic regression with inverse proportion of treatment weighting were conducted. Semi-structured qualitative phone interviews (n = 19) were conducted with mediation participants in three counties of Maryland’s Eastern Shore and Baltimore City. Community-based mediation for misdemeanor assault had a small and statistically non-significant association with return to court at six months, versus usual court processes. Had assaults between couples been excluded, recidivism for mediation cases would have been one third of those treated as usual. For interviewees, the justice system was capable of protection and of worsening the danger and damage, and in mutual cases, respondents wanted to cut ties with it. Mediation could only resolve the conflict if participants were offered: safety; free expression; clarity about the incident; solutions; and active, neutral mediators. Outcomes included no further violence or court charges between participants, little interaction, and for some: loss of housing and livelihood, emotional closure, or endings that needed to happen. Mediators, community mediation centers, and local prosecutors’ offices could improve screening for intimate partner violence and work together to divert more mediatable cases earlier in the process via police officers and court commissioners. Future studies of mediation recidivism should consider comparison groups of people who chose to use the service but their fellow participant declined, and mediation evaluations with a dependent variable of self-reported violence would be best suited to understanding community mediation’s ability to meet its founding mission of community-created peace.
  • The Role of Self-efficacy, Technology Acceptance, and Support, in E-Learning for Child Welfare Workers

    Gunn, Meredith W.; Bright, Charlotte Lyn; 0000-0002-4092-0026 (2020)
    Over the last 15 years, the use of online technology for training and workforce development has increased due to cost savings, convenience, ease of tracking, uniformity of training delivery and messaging, and accessibility. The Association for Talent Development indicated in its 2017 State of the Industry Report that 45% of all employee training was being delivered through technology. Despite its growth, much of the research on online workforce training is limited to training outcomes (e.g., passing the knowledge posttest in order to receive a certificate, certification, or Continuing Education Units) and trainee evaluations (e.g., trainee satisfaction surveys) with no higher level analysis regarding the role of the following: theory, learning or technology; enablers, like technological savvy or organizational support; and/or barriers, like technological difficulties or lack of organizational support in users’ success The specific aims of this study were: (1) to examine what user characteristics and/or factors associated with use of helpdesk support, video tutorials, and test reset, and (2) to identify what factors predicted online training completion. Data for this dissertation were obtained from the National Adoption Competency Training Initiative which was established in October 2014 through a 5-year, $9 million cooperative agreement with the Center for Adoption Support and Education, the U.S. Department of Health and Human Services, and the Administration for Children and Families, Children’s Bureau. The University of Maryland School of Social Work and The Institute for Innovation and Implementation were primary partners in the initiative. Regression analysis showed that older users were more likely to use the help desk, to have a test reset, and less likely than younger users to complete the training; mandated users were more likely to complete the training but were also more likely to require a test rest and to use the video tutorials; and race/ethnicity was significant across all research questions. Findings revealed factors that impact success with online learning, as well as areas for future research into the role of race/ethnicity, personal agency, and variation of training types (self-paced or timed) in online training success.
  • Fidelity and Alliance Effects on Youth Outcomes of Functional Family Therapy

    Cosgrove, John; Lee, Bethany R.; 0000-0003-1723-5909 (2020)
    This dissertation contributes to the scant and inconclusive literature on fidelity and alliance effects on outcomes of manualized youth behavioral health intervention. The aims of this study are to test the comparative effects of fidelity and alliance on (1) treatment progress, (2) change in behavioral health symptoms, and (3) recidivism among juvenile offenders receiving Functional Family Therapy (FFT) – a community-based family therapy intervention. The concurrent effects of fidelity and alliance on FFT outcomes have not been previously tested, which can help to better understand the relative importance of the technical and relational aspects of delivering an intervention effectively. This study involved secondary analysis of data collected for a statewide evaluation of FFT for delinquent youth in Maryland. Using a single-group longitudinal design, treatment progress and change in behavioral symptoms were observed at discharge, and recidivism was observed at 12 months post-discharge. Mixed-effects models regressed treatment progress, behavioral symptoms change, and recidivism on fidelity, alliance, and other covariates. Therapist random intercepts estimated between-therapist variance in each outcome when controlling for fidelity and alliance individually, and both simultaneously, to better understand the role of each in differentiating the effectiveness of FFT across different practitioners. Stronger alliance was associated with greater reductions in youth behavioral symptoms and recidivism for any offense. Higher fidelity was associated with further progress through treatment and reduced recidivism for adjudicated offenses. Neither fidelity nor alliance substantively explained between-therapist variance in outcomes. Results suggest that the relative importance of fidelity and alliance is contingent upon the goals of implementing the intervention, with alliance being more salient for clinical outcomes and fidelity for program retention and delinquency status. For public systems-involved youth with emotional and behavioral challenges, both clinical functioning and systems involvement are critical outcomes, underscoring that both fidelity and alliance are essential for effectively serving this population.
  • Social Workers and Disproportionate Minority Contact: A Mixed Methods Study

    Afkinich, Jenny Lee; Bright, Charlotte Lyn (2020)
    Disproportionate minority contact (DMC) is the disproportionate representation of racial minority youth at all levels of the juvenile justice system. DMC is evident in rates of initial arrests, referrals to court, delinquency findings/ adjudications, out-of-home placements, and transfers to adult criminal court. Race remains a significant predictor of legal outcomes for youth even when factors such as prior legal history and current charge severity are considered despite White and minority youth reporting similar levels of offending. This mixed methods study examined the relationship between community social workers employed by the South Carolina Department of Juvenile Justice (SC DJJ) in the agency’s county offices and DMC. Administrative data from SC DJJ was utilized to determine the extent of DMC in the state, to compare legal outcomes (i.e., receiving confinement dispositions and being waived to adult court) for youth in counties with community social workers to youth in counties that do not employ community social workers, and to compare the legal outcomes for youth in counties with community social workers over time. The results indicate that DMC continues to exist in South Carolina when measured via relative rate indices. Overall, there was little evidence that employing community social workers is sufficient to reduce DMC at the disposition or waiver stage. Qualitative interviews with nine of the 11 community social workers were used to identify and understand the mechanisms, barriers, and facilitators for reducing DMC. The findings suggest multiple nuanced ways the social workers can play a role in reducing DMC. The social workers identified two stages in the juvenile justice process in which they can and have had an impact on increasing equity: (1) out-of-home placement decisions for youth on probation or parole and (2) determining probation requirements. The social workers described a need for hiring additional social workers. They also believe they could train police officers and school officials about alternatives to making a referral to SC DJJ to reduce inequitable decisions at the front-end of the juvenile justice system. Implications for the study include an expanded role for community social workers and new ways to examine DMC quantitatively.
  • The Interrelationships of Adverse Childhood Experiences (ACEs), Alcohol use in Adulthood, and Intimate Partner Violence (IPV) Perpetration Among Black Men in the United States

    Lee, Kerry-Ann; Bright, Charlotte Lyn (2020)
    Historically, Black men have been found to perpetrate IPV at higher rates in comparison to other ethnic groups; however, studies of IPV perpetration have largely focused on samples of White individuals. There is a paucity of empirical research related to the interrelationships among ACEs, IPV perpetration, and alcohol use among Black men. This study used data from Wave 2 of the National Epidemiologic Survey of Alcohol and Related Conditions. Study aims were: (1) to examine the interrelationships of ACEs, alcohol use, and IPV perpetration; to investigate whether alcohol use moderates the relationship between ACEs and IPV perpetration; and whether interpersonal social support moderates the relationships between ACEs and IPV perpetration and between alcohol use and IPV perpetration; (2) to determine if higher cumulative ACE score is associated with increased alcohol use and IPV perpetration; (3) to determine if racial discrimination is significantly associated with increased alcohol use and IPV perpetration; and (4) to identify how subgroups of ACEs (individually or in combination) are associated with alcohol use and IPV perpetration among Black men in adulthood. The sample consisted of 2,326 Black men aged ≥ 20 years. Bivariate results indicated an interrelationship among ACEs, alcohol use, and IPV perpetration. Regression analyses showed that alcohol use exacerbated the ACEs and IPV perpetration relationship for men with no ACEs; but for men who had a history of ACEs, the effect of alcohol on IPV was less substantial. Contrary to study hypotheses, higher interpersonal social support was found to buffer the relationship between ACEs and IPV perpetration for men with three ACEs, but exacerbated the alcohol use and IPV perpetration relationship. Higher cumulative ACE score was significantly associated with alcohol use and IPV perpetration. Racial discrimination was not significantly associated with study outcomes. Latent class analysis yielded three classes. Membership in classes 1 and 2 was associated with IPV perpetration; however, only class 1 membership was associated with alcohol use when compared to class 3 membership. Findings revealed factors that may contribute to IPV perpetration among a sample of Black men. Future research with Black men should aid in the development of culturally-appropriate interventions.
  • Relationship Between Caregiver Social Support, Depressive Symptoms, and Child Asthma Outcomes in Low-Income, Urban, African American Families

    Margolis, Rachel; Bellin, Melissa H; Dababnah, Sarah (2020)
    Caregiver depressive symptoms are prevalent and put low-income, urban, African American children with asthma at risk for poor asthma medication adherence and control. Caregiver social support may improve medication adherence and asthma control directly or buffer against the negative effects of caregiver depressive symptoms. In Paper 1, I systematically reviewed the literature and identified nine studies examining the relationship between caregiver social support and child asthma outcomes. Most studies measured informal social support using self-report instruments and evaluated clinical indicators of asthma morbidity in ethnically diverse school-age children. Studies were limited by referral and recall bias. A pattern of significant results suggested that more caregiver social support is associated with better child asthma outcomes; however, due to the variety in asthma outcomes and the heterogeneity in their measurement, further research is needed to draw more definitive conclusions. In Paper 2, I examined the factor structure of the five-item Medication Adherence Report Scale (MARS), in a sample of caregivers of low-income, urban, African American children with uncontrolled asthma. Confirmatory factor analysis indicated that a five-item one-factor model marginally fit the data. The MARS demonstrated acceptable internal reliability. MARS was associated with caregiver-reported inhaled steroid adherence, but not with Asthma Medication Ratio, asthma control, or caregiver perception of asthma control in the regression model. These results suggest it may be more productive for clinicians to engage in consistent, non-judgmental communication with families about asthma medication rather than using the MARS. In Paper 3, I used generalized estimating equations and ordered logistic regression to investigate the longitudinal relationships among caregiver social support and depressive symptoms and two asthma outcomes: (a) medication adherence and (b) asthma control in the above sample. The analyses revealed that caregiver social support did not have an effect on either outcome, nor did it moderate the relationship with depressive symptoms in either model. Medication adherence and asthma control improved over time. Caregiver depressive symptoms predicted decreased medication adherence. Severe and moderate baseline asthma, very low income, and season (fall) were predictors of poorer asthma control. Clinicians should target depressive symptoms as a modifiable factor associated with child asthma outcomes.
  • 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.
  • 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.

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