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Can Healthcare Make Wealth Fair? Utilizing Community Benefit Reporting to Address Racial Wealth Inequity
Get PDFThe US’ distribution of wealth is strikingly unequal, especially by race. For every 0.16 and Hispanic families have $0.22. Nonprofit health systems have the potential, proximity, and purpose to address the racial wealth gap, especially in “eds and meds” cities like Philadelphia. This study has three goals: (1) determine the factors that have the greatest impact on wealth mobility, (2) identify the wealth mobility factors Philadelphia nonprofit hospitals are addressing, (3) assess how changes to community benefit reporting would impact hospital investments in wealth building factors. This dissertation used a literature review to identify the factors that contribute to absolute and relative intragenerational wealth mobility. The study focused on nonprofit hospitals in the Philadelphia metropolitan area. A review of publicly available information on hospital websites, municipal bond disclosures, and ProPublica produced a comprehensive view of hospital activity for these factors. Key informant interviews with 10 hospital executives at 6 (of the 8) nonprofit health systems in the Philadelphia area revealed how specific environmental conditions would impact hospital decision making and investing. Of the 11 factors that consistently built (and eroded) wealth in the literature, health systems could only impact six – income, occupation, education, homeownership, business ownership, and neighborhood effects. Profitable health systems, which were also larger and had flagship hospitals in the city of Philadelphia, generally had the most wealth mobility activity and impact. Overall, the greatest hospital wealth building activity occurred for income, education, and occupation. Hospitals executives largely rejected the scenarios that a more expansive community benefit definition, publicizing wealth mobility rankings, or government pressure would lead to increased investment in wealth mobility factors. However, interviews identified a promising catalyst that involved a 1) wealth addendum that communicated a hospital’s total wealth building activity (above and beyond the Schedule H Form 990), 2) local government participation, 3) philanthropic support, and 4) savvy, supported leaders. These findings, and the accompanying plan for change, present a practical path forward to marshal increased support and resources for nonprofit hospitals to equitably build wealth (and thereby improve health) in their local communities.Doctor of Public Healt
Assessing the Impact of a Postpartum Intrauterine Device Intervention on Contraceptive Decision-making in Tanzania, Sri Lanka, and Nepal
Get PDFHistorically, the global family planning field has evaluated programs and defined success based on increases in contraceptive use, thereby relying on the assumption that contraceptive use is a positive outcome for all people with the capacity to get pregnant. Scholars have warned that this approach de-centers individual contraceptive preferences and desires, and called for new rights-based, person-centered outcomes. Still, few family planning programs have been evaluated based on measures of reproductive autonomy. Further, programs that promote long-acting reversible contraception (LARC) may be particularly vulnerable to violations of autonomy, given that users of these methods conventionally rely on a trained provider for method discontinuation. This dissertation uses data collected from the Postpartum Intrauterine Device (PPIUD) Study, a step-wedged cluster randomized trial of a provider-focused PPIUD intervention conducted in Nepal, Sri Lanka, and Tanzania from 2015-2018. Using data from Sri Lanka, we assess whether the PPIUD intervention was associated with perceived pressure to adopt contraception 18-months after delivery. Using data from all three countries but restricting to only those who adopted PPIUDs immediately after delivery, we describe PPIUD removal and access to removal in the 18-months following insertion. About 5% of participants in the PPIUD Study in Sri Lanka reported perceived pressure to adopt contraception 18 months following delivery. The PPIUD intervention in Sri Lanka was associated with increased perceived pressure to adopt contraception. Among the sample of participants who adopted PPIUDs immediately following delivery in Nepal, Sri Lanka, and Tanzania, about three quarters had their PPIUD in use at the end of the study period. Just under a quarter of participants (22%) had sought PPIUD removal in the 18 months following insertion. Of those who sought removal, a quarter faced a barrier to removal; most reported barriers were provider-imposed. In conjunction with existing literature, this work supports the idea that barriers to autonomous contraceptive decision-making are structural, rooted in larger public health and demographic goals that aim to promote contraceptive use. Our findings also highlight the importance of measuring and evaluating family planning programs using rights-based, person-centered outcomes that capture quality of contraceptive care and autonomy in contraceptive decision-making.Doctor of Philosoph
Utilizing A Palliative Care Needs Assessment For Adult Allogeneic Hematopoeitic Stem Cell Transplants
Get PDFBackground: Approximately 1.4 million individuals in the United States are diagnosed with hematological malignancies. Due to the complex nature of these conditions, patients often require intensive therapies like hematopoietic stem cell transplants (HSCTs). While HSCTs have curative potential, they also entail significant morbidity and mortality risks. Palliative care can enhance patient outcomes but is underutilized. There is a pressing need to better identify the timing and severity of unmet palliative care needs from the perspectives of patients and clinicians. Methods: This quality improvement project aims to use an evidence-based palliative care outcome scale to assess the needs of adult allogeneic HSCT recipients at an academic medical center in the southeastern United States. Adult allogeneic HSCT recipients and clinicians were surveyed every seven days using the Integrated Palliative Care Outcome Scale (IPOS) to evaluate patient needs across four palliative care domains. The surveys assessed patients’ and clinicians’ previous experiences with palliative care, perspectives of patients and clinicians, and demographic information for both groups. IPOS scores and demographic data were compared between patients and clinicians. Results: This program included 16 enrolled patient participants and nine clinicians over a 10-week survey period. Findings indicated significant IPOS disparities in the physical scores (p = 0.0004), specifically regarding weakness and lack of energy, constipation, drowsiness, and poor mobility symptoms. The emotional/spiritual item “Do you feel at peace?” also yielded statistically significant differences amongst the two groups (p = 0.0042). Qualitative analysis revealed that patients and clinicians prioritize different aspects of clinical care, and that clinicians are divided on the presence of unmet PC needs (N = 4, 44% versus N = 4, 44%). Conclusion: Findings highlight a critical gap between patient-reported needs and clinician perceptions of palliative care timing and appropriateness in HSCT. Routine assessments could foster timely and targeted interventions while improving patient experience, health outcomes, and overall satisfaction with care.Doctor of Nursing Practic
Improving LGBTQ Inclusivity in Primary Care: A Program Evaluation
Get PDFProviding inclusive care to the LGBTQ community is important in preventing healthcare discrimination, preventing LGBTQ healthcare avoidance, and reducing the physical and mental health disparities seen in this community (Adelson et al., 2021). A primary care clinic is expecting to see an increase in their LGBTQ population as one of their providers is preparing to begin offering gender affirming care. This DNP project implemented a program evaluation of the clinic’s current LGBTQ inclusive practices and policies to identify discrepancies between current practice and evidence-based recommendations. The clinic will be able to use the results of the program evaluation to make evidence-based changes in their practices that will promote positive health experiences and improved healthcare delivery for their LGBTQ population.Doctor of Nursing Practic
Uric Acid and Cognitive Impairment: Exploring the Impact of Obesity and Genetic Risk
Get PDFCognitive impairment (CI) in aging populations poses significant public health challenges that will grow with ongoing demographic shift. Uric acid (UA), a major metabolite and the end product of purine metabolism has shown inconsistent association with CI and the true nature of the CI-UA relation remains unclear. This dissertation investigates the CI-UA association and how obesity and genetic factors may impact this association. Using data from three data sets— Blueberries: Exciting Research Relevant to You (BERRY), Baltimore Longitudinal Study of Aging (BLSA), and Wake Forest Alzheimer’s Disease Research Center (WFADRC)—this work examines the roles of body mass index (BMI) (Aim 1), Apolipoprotein (APOE) genotype (Aim 2), and polygenic risk scores (PRS) (Aim 3) in modulating the CI-UA association. In BERRY, UA:BMI interaction was significant, specifically, UA concentrations correlated positively with higher cognitive test scores at BMI 22, and inversely at BMI 32 (F = 4.09, EDF ≈ 1, p < 0.05). In BLSA, there was a linear UA:BMI interaction predicting odds of CI (OR 1.37 [95%CI 1.04, 1.81] p < 0.05), indicating elevated UA and BMI were both linked to lower odds of CI, but their combined effect was less protective than an additive relationship. No significant interactions were found in WFADRC or pooled data. APOE genotype was not found to predict CI itself, nor did it significantly alter any CI-UA association. Further analysis showed that CI PRS, derived from genome-wide association analysis of the data, predicted UA concentration and UA tertile. Every unit increase in CI PRS was associated with a 1.16 mg/dL (SE 0.24, p<0.0001) greater UA concentration, and with a 16.81-fold increase in odds of being in the highest UA tertile versus lowest (OR 16.81 [95%CI 4.67, 60.59] p <0.001). UA PRS did not predict CI in any models. This finding suggests possible shared genetic pathways between CI and UA or pleiotropic effects. This work highlights the complex and context-dependent nature of the CI-UA association, with genetic factors and obesity playing distinct roles. Further research is needed to clarify these interactions, which may inform future clinical strategies for CI prevention and treatment.Doctor of Philosoph
THE CENTROMERE EFFECT IN D. MELANOGASTER
Get PDFThe centromere effect (CE) is a meiotic crossover (CO) patterning phenomenon that ensures CO suppression in pericentromeric regions. Despite being a critical safeguard against nondisjunction and aneuploidy, the mechanisms behind the CE remain unknown. My dissertation research focuses on this gap in knowledge at two levels. First, I ask how spatial/structural aspects of chromosome biology contribute to the CE. I use phenotypic recombination mapping to investigate whether dosage changes in centromere number and repetitive DNA content affect CE strength. I also study the importance of centromere-clustering on pericentromeric CO suppression using flies exhibiting substantial centromere declustering in meiotic nuclei. Despite what previous studies suggest, my results show that the Drosophila CE is robust to changes in centromere number, repetitive DNA content, and centromere-declustering, leading us to conclude that the CE is unlikely to be spatially controlled. These observations inspired me to switch vantage points and look at the CE at a more local level, focusing on the contributions of various genetic mutants. Previous research has shown that various regions of the Drosophila pericentromere, encompassing proximal euchromatin, beta and alpha heterochromatin, undergo varying levels of crossover suppression, raising the question of whether distinct mechanisms establish the CE in these different regions. To address this, I asked whether different pericentromeric regions respond differently to mutations that impair various features implicated in establishing the CE. I look at flies mutant for an essential synaptonemal complex (SC) gene, two meiotic recombination genes, and a heterochromatin formation gene, expecting different regions of the pericentromere to display differing sensitivity to each class of mutant. Surprisingly, I observed a significant redistribution of pericentromeric crossovers from proximal euchromatin towards heterochromatin in the SC and meiotic recombination mutants, and no change in pericentromeric crossover distribution in the heterochromatin mutant. This suggests that meiotic machinery is more important for heterochromatic crossover suppression than chromatin state. Combined, both studies point towards the CE being unaffected by spatial factors and instead being primarily mediated genetically and through the meiotic program, providing novel insight into the mechanisms behind this CO patterning event in Drosophila.Doctor of Philosoph
High Dimensional Neuroimaging Data Integration and Inference
Get PDFThe presence of multi-block (multi-omic, multi-source) data has given rise to the field of data integration. Disciplines such as genomics, oncology, anthropology, and in particular cognitive neuroscience, offer alluring applications to any method claiming to advance the integration literature. Here, we explore and extend Data Integration via Analysis of Subspace (DIVAS), a novel integration technique. DIVAS combines new insights in angular subspace perturbation theory with recent developments in matrix signal processing and convex-concave optimization into one algorithm for exploring partially-shared structure. Contributions of this work to DIVAS include refining the optimization initialization, ensuring order agnostic behavior, generalizing the noise variance estimation, and proving a continuity result for the rotational bootstrap procedure. Exploration includes applying DIVAS to Human Connectome Project brain connectivity data. More specifically, we integrate structural and functional connectivity data alongside cognitive performance, substance use, and genetic data as part of a unified analysis. This gives rise to the important finding that genetics isthe single data modality most predictive of brain connectivity, outside of brain connectivity itself. Nearly 14\% of the variation in functional connectivity (FC) and roughly 12\% of the variation in structural connectivity (SC) is attributed to shared spaces with genetics. Moreover, investigations of shared space loadings provide interpretable associations between particular brain regions and drivers of variability. Novel Jackstraw hypothesis tests are developed for the DIVAS framework to establish statistically significant loadings. For example, in the (FC, SC, and Substance Use) subspace, these novel hypothesis tests highlight largely negative functional and structural connections suggesting the brain’s role in physiological responses to increased substance use. Our findings are validated on genetically relevant subjects not studied in the main analysis. The final chapter of this dissertation is dedicated to \textit{Moral Machine Learning}, a novel course developed and implemented at UNC. It currently satisfies the data, culture and society credit of the data science minor as well as elective credit in the statistics and analytics minor. With regard to content, statistical applications are increasingly inducing ethical considerations, which are often not able to be resolved via statistics alone. These considerations include data privacy concerns, proper interpretation of data and methods, as well as algorithmic bias. This chapter will present a subset of the developed course notes corresponding to the data privacy section of the course, a consideration that is directly relevant for any research involving human subject data. This chapter will also include a pedagogical manuscript that details how this course can be taught at other similar large research institutions. As such, the instructional methods included are designed with implementation at a large research institution in mind but are fully intended to be transferable to any setting adopting such an interdisciplinary course into its curriculum. Formative and summative assessment mechanisms will be presented alongside future directions and potential pitfalls of such a course. Motivating the proposed course is a desire to fill the comparative void in moral reasoning for statistics and data science curricula.Doctor of Philosoph
UTILIZING SYSTEMS IMAGING TO CHARACTERIZE CELL-TYPE AND STRESS-DEPENDENT ORGANELLE SIGNATURES OF NEURONS AND ASTROCYTES.
Get PDFNeurons and astrocytes play critical yet divergent roles in brain physiology and neurological conditions. However, there is a paucity of studies that directly compare both cell types at the intracellular level. Comparative examination can reveal novel cell-specific molecular regulation and intracellular organization that underlie the diverse roles neurons and astrocytes play in healthy brain function and disease pathogenesis. Here, I utilize multispectral microscopy of organelles as a new comparative approach. Intracellular organelles are integral to cellular function and can reveal aspects of cellular physiology by studying their abundance, morphology, interactions, and distributions. I utilized multispectral microscopy to simultaneously visualize six organelles – endoplasmic reticulum (ER), lysosomes, mitochondria, peroxisomes, Golgi, and lipid droplets – in live primary neurons and astrocytes. I then developed a quantitative analysis approach called “Organelle Signature Analysis” to quantify features of organelle morphology, interactions, and distributions from multispectral images of single cells. The resulting organelle signatures contain 1418 metrics per cell and can be used to statistically compare across experimental conditions. For my dataset of 173 z-stack and 98 time-lapse images of neurons and astrocytes, organelle signature analysis revealed clear cell-type specificity in organelle morphology and interactions. Neurons were characterized by prominent mitochondrial composition and interactions, while astrocytes contained more lysosomes and lipid droplet interactions. Additionally, following acute oxidative and ER stress, both cell types exhibited cell- and stress-specific responses. Neurons displayed a more robust organelle response than astrocytes, and in many cases, the responses were opposite between cell types. The organelle signatures of neurons and astrocytes at baseline and following acute stress provide a systems-level characterization of neuron and astrocyte organelles that can serve as a reference for understanding cell-type-specific physiology and disease in these cell types. The microscopy and quantitative datasets generated through this work are available to the community on BioImage Archive (http://www.ebi.ac.uk/bioimage-archive) under accession number S-BIAD1445 for further exploration, analysis, and hypothesis generation. Additionally, the organelle signature analysis method is available as an open-source Python package called infer-subc (https://github.com/SCohenLab/infer-subc) and can be widely applied to examine organelles from diverse experimental model systems and a variety of experimental conditions.Doctor of Philosoph
APHORISTIC DEMOCRACY: APHORISMS AND SUPPORT FOR DEMOCRATIC NORMS
Get PDFWhile socialization is important to the formation of political opinions, scholars know little aboutthe specific information that is passed along to children during this process. I argue that oneway to measure this is through tapping a subset of cultural information units, or “memes,” thatconvey life lessons: aphorisms. Using original survey data, I test whether measuring orientationstoward aphorisms helps explain the variation in abstract political attitudes. I show that aphorismsare influential in structuring political cognition and help explain support for or opposition to thepreservation of democratic norms. Additionally, aphorisms’ effects are conditional on the extent towhich an aphorism taps an underlying worldview that is politically relevant. Lastly, I show that evenwhen controlling for one’s worldviews, three out of six aphorisms tested exhibit consistently strongeffects on democratic attitudes: “Don’t judge a book by its cover,” “Children ought to be seen andnot heard,” and “It is better to be feared than loved.” In sum, this paper demonstrates the utility ofaphorisms as a measurement tool in public opinion and contributes to the socialization literatureby examining how the latent imprint of non-political socialization, measured through aphorisms,structures public opinion. I conclude by hypothesizing about the effectiveness of aphoristic languagein elite rhetoric and exploring other potential areas of future research.Master of Art
TRANSFORMATIVE SCIENCE EDUCATION: BRIDGING THEORY AND PRACTICE IN INNOVATIVE SCIENCE CURRICULA
Get PDFAs science education shifts toward more inclusive and practice-oriented approaches, teachers are increasingly expected to engage students with real-world, socio-scientific issues (SSI) such as climate change, water scarcity, and food sustainability. Yet, systemic constraints and limited exposure to innovative instructional models often make this transition difficult. This dissertation explores how instructional materials—such as the Grand Challenges (GC) curriculum—can serve as a catalyst for equity-focused and inquiry-driven science instruction, while also examining the interpretive work teachers do to implement such curricula in practice.Structured as a three-article dissertation, this study offers design, enactment, and professional implications of innovative science curricula. The first article is a scoping review that synthesizes how equity and justice are embedded in science instructional materials, drawing on four discourses of equity to propose concrete design principles. The second article presents an empirical case study examining how two middle school science teachers adapt and implement the GC curriculum, using Stein et al.’s (2007) framework of written, intended, and enacted curriculum to analyze teacher decision-making. The third article builds on this analysis by tracing teachers’ professional growth through the Interconnected Model of Professional Growth (Clarke & Hollingsworth, 2002) and Expectancy-Value Theory (Eccles & Wigfield, 2002), focusing on how perceived costs and values influence curricular commitment and instructional change.Collectively, these studies demonstrate that successful implementation of innovative science curricula requires more than well-designed materials—it demands institutional flexibility, sustained professional support, and recognition of the social and political contexts in which teachers work. By bridging curriculum design with teacher enactment and growth, this work offers insights and practical recommendations for advancing transformative science education in real classrooms.Doctor of Philosoph