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Full-Text Articles in Psychology

Mental Health Among Collegiate Athletes, Stella Elise Fairbanks May 2024

Mental Health Among Collegiate Athletes, Stella Elise Fairbanks

Honors Thesis

Mental health has become increasingly more linked with athletics, especially collegiate athletics. There has been an increase in public acknowledgment of the presence of mental health in sports, specifically, more athletes are speaking about their mental health struggles as well as more research is being conducted in order to gain a greater understanding of the relationship between mental health and athletics. This literature review discusses athletes’ personal experiences of their mental health struggles, the presence of stigma associated with mental health and athletics, and the results of the recent NCAA, National Collegiate Athletic Association, research. This thesis aims to uncover …


Exploring Arab Americans’ Preferences Towards Telemedicine As A Mental Health Treatment, George G. Kidess, Liam Browning, Nicole Oska, Liza Hinchey, Arwa Saleem, Sadie Knill, Malaak Elhage, Arash Javanbakht Mar 2024

Exploring Arab Americans’ Preferences Towards Telemedicine As A Mental Health Treatment, George G. Kidess, Liam Browning, Nicole Oska, Liza Hinchey, Arwa Saleem, Sadie Knill, Malaak Elhage, Arash Javanbakht

Medical Student Research Symposium

Introduction

Arab Americans—a large minority group in the United States—experience higher rates of mental illness and relatively lower rates of treatment compared to the general population. While some factors leading to this disparity have been proposed, data in the literature remains lacking. This study aims to explore Arab-American mental health perspectives with regards to their preferences towards telemental health as a treatment option.

Methods

Responses were collected through an anonymous bilingual Qualtrics survey from both Arab and non-Arab participants (n=294, ages 18+). Participants’ perceptions towards telemental health and mental illness stigma were assessed, performing comparisons between Arabs and non-Arabs, as …


Mental Health Attitudes And Perspectives Of Arab Americans: Beliefs Associated With Stigma, Treatment, And The Origins Of Pathology, Sadie Knill, Liam Browning, Nicole Oska, George Kidess, Liza Hinchey, Arwa Saleem, Malaak Elhage, Arash Javanbakht Mar 2024

Mental Health Attitudes And Perspectives Of Arab Americans: Beliefs Associated With Stigma, Treatment, And The Origins Of Pathology, Sadie Knill, Liam Browning, Nicole Oska, George Kidess, Liza Hinchey, Arwa Saleem, Malaak Elhage, Arash Javanbakht

Medical Student Research Symposium

Purpose:

Arab Americans are one of the largest ethnic groups in the United States. Despite elevated incidence of mental illness and diminished rates of treatment within this community, the mental health of Arab Americans, along with their attitudes towards mental health, has not received adequate study. Unique cultural interpretations of mental illness may engender stigma, exacerbating disparities in treatment. This study aimed to assess the attitudes and perspectives of Arab Americans concerning mental illness, with the goal of identifying and addressing barriers to treatment.

Methods:

Using an anonymous bilingual Qualtrics survey, we assessed Arab and non-Arab participants (n = 294; …


Investigating Arab American Perspectives On Barriers To Mental Health Treatment, Arwa Saleem, Liam Browning, Nicole Oska, George Kidess, Liza Hinchey, Sadie Knill, Malaak Elhage, Arash Javanbakht Mar 2024

Investigating Arab American Perspectives On Barriers To Mental Health Treatment, Arwa Saleem, Liam Browning, Nicole Oska, George Kidess, Liza Hinchey, Sadie Knill, Malaak Elhage, Arash Javanbakht

Medical Student Research Symposium

Purpose: Compared to the general population, Arab Americans experience higher rates of mental illness and lower rates of mental health treatment. While some causes of this discrepancy have been suggested, there are many gaps in the literature since Arab Americans are not recognized as an ethnic group in the United States. This study aims to analyze Arab-Americans’ outlook on mental health by identifying and addressing the barriers to receiving mental health treatment.

Methods: An anonymous bilingual Qualtrics survey was conducted and responses were collected from Arab and non-Arab participants (n=294, ages 18+). The participants’ viewpoints on barriers between Arabs and …


Identifying Barriers To Mental Health Services Utilization For Black Youth In The United States: A Qualitative Study, Emily Stein, Matthew Hutnyan, Neely Myers Jan 2024

Identifying Barriers To Mental Health Services Utilization For Black Youth In The United States: A Qualitative Study, Emily Stein, Matthew Hutnyan, Neely Myers

SMU Journal of Undergraduate Research

Mental health in Black communities and racial/ethnic disparities in mental health service utilization remain growing concerns. Evidence suggests that psychotic disorders may be more prevalent among Black individuals than white individuals and the Black community faces barriers to care that can negatively influence outcomes. To better understand these barriers, we interviewed mental healthcare providers (n = 11) and Black young adults with first-person experience of psychosis (n = 13) about the experiences of minority young adults with mental health treatment. We analyzed interview transcripts and, consistent with constructivist grounded theory methods, identified iterative patterns across individuals about barriers to care. …


Impact Of Covid-19 On Latinx And Black Communities, Carolina Zuluaga Jun 2023

Impact Of Covid-19 On Latinx And Black Communities, Carolina Zuluaga

Dissertations

This critical literature review project explored the impact of COVID-19 on Latinx and Black communities. According to the Centers for Disease Control and Prevention, as of September 28, 2022, around 16% of COVID-19 cases in the United States were among Latinx people, and 14% of cases were among Black people (Centers for Disease Control and Prevention, 2022). Since COVID-19 began, clinicians have become more conscious of the effects of health disparities within racial and ethnic minorities, which has warranted increased advocacy by educating health and mental health providers and creating and providing resources to these communities and clinicians. The review …


Impacts Of Stigma On Female Service Members, Alisha Weatherly-Kershaw Apr 2023

Impacts Of Stigma On Female Service Members, Alisha Weatherly-Kershaw

Doctor of Psychology (PsyD)

There are a variety of factors that prevent people from seeking mental health treatment. The stigma associated with mental health disorders or seeking treatment is a primary deterrent. This stigma is particularly impactful within the armed forces when they are assessed for fitness for duty. Because most research examines stigma’s impact on male military members, this study aims to identify the type of stigma that creates the most significant barrier to female service members seeking mental health treatment. Results indicate that stigmatizing perceptions of service members significantly impact female service members holding negative views towards seeking treatment.


Do Semantics Matter In Empathetic Person Perception Of Children Or Adults With Mental Illness?, Rylie Hansen, Caroline Polak, Emma Gries, Stevie Ostman, Gina A. Paganini, E. Paige Lloyd Feb 2023

Do Semantics Matter In Empathetic Person Perception Of Children Or Adults With Mental Illness?, Rylie Hansen, Caroline Polak, Emma Gries, Stevie Ostman, Gina A. Paganini, E. Paige Lloyd

DU Undergraduate Research Journal Archive

Experiences of stigma, discrimination, or aggression negatively affect the well-being of people experiencing symptoms of psychopathology. However, empathy is thought to undermine prejudice and discrimination and is linked with positive outcomes (e.g., greater well-being, more social support, etc.) among those with stigmatized mental illnesses. The current work investigates the influence of target age (adult or child) and language type (person-first or identity-first) on how much empathic concern perceivers report toward individuals with a hypothetical mental health condition. This research contributes to an ongoing debate about whether person-first or identity-first language carries stigmatizing or protective effects, while also considering a novel …


The Effect Of Language Type And Perceived Controllability On Stigma And Compassion, Maddie Leake, Christine Mcgrath, Trudy Mickel, Claire Shaver, Gina A. Paganini, E. Paige Lloyd Feb 2023

The Effect Of Language Type And Perceived Controllability On Stigma And Compassion, Maddie Leake, Christine Mcgrath, Trudy Mickel, Claire Shaver, Gina A. Paganini, E. Paige Lloyd

DU Undergraduate Research Journal Archive

Previous research suggests that mental health stigma creates significant barriers to treatment seeking and adherence, diminishes treatment outcomes, and motivates social rejection towards people experiencing mental illness; by contrast, compassion seems to offer protective effects, improving treatment outcomes and helping behavior. The current work extends the established literature by experimentally examining the independent and interactive effects of two factors theorized to influence stigma and compassion: controllability and language. Participants read vignettes about hypothetical mental illnesses explained with a genetic attribution (indicating low controllability) or a behavioral attribution (indicating high controllability) and completed measures of perceived controllability, stigma, and compassion. We …


Skin Stories And Family Feelings: The Contradictions Of Skin Picking In Mother And Daughter, Katrina Jacinto Jan 2023

Skin Stories And Family Feelings: The Contradictions Of Skin Picking In Mother And Daughter, Katrina Jacinto

Crossings: Swarthmore Undergraduate Feminist Research Journal

Skin picking, otherwise known as dermatillomania, is considered to be a medical disorder by the DSM-5. However, the embodied experiences of skin picking in myself and my mother do not align with the neat definitions offered by psychiatry. Through autoethnographic material and an ethnographic interview with my mother, I argue that skin picking is a bodily technique that is pathologized through stigma. In particular, I suggest that skin picking reveals the body as a polyvalent entity, in which the same features and practices take on different meanings in different bodies. This frames the discrepancies between mine, and my mother's, experiences. …


The Impact Of Psychiatric Labels And Sexual Orientation On Attitudes Toward People With Pedophilic Attractions, Gabriel Traub Jan 2023

The Impact Of Psychiatric Labels And Sexual Orientation On Attitudes Toward People With Pedophilic Attractions, Gabriel Traub

Senior Projects Spring 2023

This study explores whether framing pedophilic attractions as a mental disorder and/or manipulating the sexual orientation of these attractions impacts attitudes toward people with pedophilic attractions (PPA). This study used an experimental 2 (Pathological Language vs. Non-Pathological Language) by 2 (Heterosexual vs. Homosexual) between-subjects design, in which online participants read a vignette describing a fictional subject’s pedophilic attractions. Both independent variables were manipulated within the vignette, in that the subject’s attractions were either given a pathological or non-pathological explanation, and were either heterosexual or homosexual. To assess stigmatizing attitudes, participants reported their affective responses, agreement with beliefs/stereotypes about the individual, …


Illness Stigma, Social Connectedness, And Health In People Living With Chronic Illness: A Structural Equation Model, Abigail Brooke Crawford Jan 2023

Illness Stigma, Social Connectedness, And Health In People Living With Chronic Illness: A Structural Equation Model, Abigail Brooke Crawford

UNF Graduate Theses and Dissertations

The complexity of chronic or unexplained conditions may lead to potential stigma for those suffering long-term symptoms as they do not follow the expected pattern of recovery following diagnosis and treatment. Experiencing such illness-related stigma has potential for leading to a belongingness identity of detachment with implications for health across physical, social, and psychological dimensions. This study aimed to examine the relationship between stigma, social connection, mental health, physical health, and social functioning in a group of 231 participants with ongoing symptoms of chronic illness through structural equation modeling. The fit indices all suggest that the model reasonably fits the …


Nonsuicidal Self-Injury And Real-Life Self-Disclosure Among Internet Users, Matthew Tanner Jan 2023

Nonsuicidal Self-Injury And Real-Life Self-Disclosure Among Internet Users, Matthew Tanner

Antioch University Full-Text Dissertations & Theses

The purpose of this study was to explore several unknown issues regarding disclosure of nonsuicidal self-injury (NSSI) among users of social media. NSSI is a category of behaviors that cause intentional harm to the body without the intent to commit suicide. However, individuals who self-injure may unintentionally risk serious and even life-threatening harm. Moreover, the stigma and resultant shame associated with NSSI discourage reporting and thus complicate research into the behavior. This study examined the factors involved in individuals’ decisions to disclose NSSI. The current study uses primarily descriptive statistics from an internet-based survey to explore the following questions: (a) …


Examining Culturally Adapted, Values Based, Mental Health Stigma Reduction And Help-Seeking Messages For Asian Americans, Anna M. Ying Aug 2022

Examining Culturally Adapted, Values Based, Mental Health Stigma Reduction And Help-Seeking Messages For Asian Americans, Anna M. Ying

Graduate Doctoral Dissertations

Mental health stigma is a ubiquitous concern impacting help-seeking in the United States and worldwide, including in college students. Insufficient attention has been given to the cultural context of stigma and help-seeking in Asian Americans, constructs in which culture has inherent relevance. The current study was the first to develop and test the acceptability of an online culturally adapted, values-based stigma and help-seeking intervention for Asian American college students, intentionally framing the benefits of therapy and mental wellness as congruent with values-based behaviors, intending to reduce the social costs and stigma of impaired functioning. A sample of 115 East, South, …


Recognizing And Disrupting Stigma In Implementation Of Hiv Prevention And Care: A Call To Research And Action, Sarit A. Golub, Rachel A. Fikslin Jul 2022

Recognizing And Disrupting Stigma In Implementation Of Hiv Prevention And Care: A Call To Research And Action, Sarit A. Golub, Rachel A. Fikslin

Publications and Research

Introduction: There is robust evidence that stigma negatively impacts both people living with HIV and those who might benefit from HIV prevention interventions. Within healthcare settings, research on HIV stigma has focused on intra-personal processes (i.e. knowledge or internalization of community-level stigma that might limit clients’ engagement in care) or inter-personal processes (i.e. stigmatized interactions with service providers). Intersectional approaches to stigma call us to examine the ways that intersecting systems of power and oppression produce stigma not only at the individual and interpersonal levels, but also within healthcare service delivery systems. This commentary argues for the importance of analysing …


Helping Our Heroes: An Evaluation Of Mental Health And Organizational Policies Surrounding Suicide Prevention And Postvention Strategies For Nebraska First Responders, Maria S. Mickles May 2022

Helping Our Heroes: An Evaluation Of Mental Health And Organizational Policies Surrounding Suicide Prevention And Postvention Strategies For Nebraska First Responders, Maria S. Mickles

Capstone Experience

Suicide is ranked as one of the leading causes of death in the United States. Over 40,000 individuals die by suicide each year (Stanley, Hom, & Joiner, 2016; Vigil et al, 2021), and, in 2020, it was ranked in the top 9 causes of death for all ages (10-64), and second for those 10-14 and 25-34 years of age (Centers for Disease Control and Prevention, 2022). These statistics disproportionately reflect first responders (i.e., firefighters, dispatchers, law enforcement, EMS, paramedics, etc.), as they die by suicide more than the general public (National EMS Management Association, 2016). Within their line of work …


The Influence Of Integrated Behavioral Health Primary Care Setting On The Utilization Of Mental Health Services And Depression Treatment Response Among Men, Tendai Masiriri Apr 2022

The Influence Of Integrated Behavioral Health Primary Care Setting On The Utilization Of Mental Health Services And Depression Treatment Response Among Men, Tendai Masiriri

Dissertations

The 2010-2013 National Health Interview Survey showed that nearly 9% of men had daily feelings of anxiety or depression, yet less than 41% sought help for their symptoms (Blumberg et al., 2016). Men are more reluctant than women to seek help (Angst et al., 2002; Brownhill et al., 2005). The failure to seek help among men is associated with multiple factors related to stigma and gender, yet male suicide rates are approximately 3-5 times higher than their female counterparts. However, they have a higher likelihood of seeking help from a medical provider rather than a mental health provider. If men …


Causal Attribution, Personal Responsibility, And Regret In Lung Cancer Survivors, Justin Ulland, Anthony Cortez-Morales, Kevin R. Criswell Jan 2022

Causal Attribution, Personal Responsibility, And Regret In Lung Cancer Survivors, Justin Ulland, Anthony Cortez-Morales, Kevin R. Criswell

2022 Symposium

Introduction: Lung cancer is the second-most common cancer for males and females and the leading cause of cancer-related deaths in the United States. Ninety percent of lung cancer cases are associated with a smoking history. Less is known about (a) how lung cancer survivors with and without smoking histories attribute their cancer to secondhand smoke and (b) how those attributions may be associated with personal responsibility, regret, and stigma from medical staff/professionals. This secondary data analytic study examined 196 lung cancer survivors.

Method: Paper surveys included (a) whether secondhand smoking caused their cancer, (b) whether they perceived control …


It Takes Two: Professional Interconnections And Potential Collaborations Between Small-Town Family Attorneys And Couple/Family Therapists, Wendy Lenk Mcclary Jan 2022

It Takes Two: Professional Interconnections And Potential Collaborations Between Small-Town Family Attorneys And Couple/Family Therapists, Wendy Lenk Mcclary

Antioch University Full-Text Dissertations & Theses

Attorneys who specialize in family practice may experience significant rates of mood disorders and substance reliance. Law schools typically do not provide supportive coursework or mentoring to help students learn to manage their feelings and those of crisis-impacted clients. Lawyers may well consider that understanding emotional needs and providing emotional support does not fall within their codes of practice. Societal stigma may prevent family attorneys and their clients from seeking therapy. Small-town attorneys may be particularly vulnerable to professional stress and safety concerns. The purpose of this study was to explore and understand the lived experiences of family attorneys practicing …


The Impact Of Hiv-Related Stigma On The Racial/Ethnic Disparities Across The Hiv Care Continuum Among Adults Living With Hiv In Florida, Derrick James Forney Nov 2021

The Impact Of Hiv-Related Stigma On The Racial/Ethnic Disparities Across The Hiv Care Continuum Among Adults Living With Hiv In Florida, Derrick James Forney

FIU Electronic Theses and Dissertations

Background: Florida currently has one of the highest rates of new HIV infections in the U.S. As of 2019, Black and Hispanic HIV-positive individuals in Florida were significantly less likely to receive HIV care, remain in care, and achieve viral suppression than white HIV-positive individuals. Several studies have linked HIV-related stigma to poor outcomes among people living with HIV (PLWH). This study examined the impact of distinct HIV-related stigma subtypes on linkage to care, retention in care, and viral suppression among PLWH in Florida and if these associations differed across race/ethnicity.

Methods: Data from the 2015-2017 Florida Medical Monitoring Project …


Origins And Perpetuation Of Stigma Against Mental Illness, Audrey K. Barkeloo-Carter, Kirsten A. Gonzalez Ph.D. May 2021

Origins And Perpetuation Of Stigma Against Mental Illness, Audrey K. Barkeloo-Carter, Kirsten A. Gonzalez Ph.D.

Chancellor’s Honors Program Projects

No abstract provided.


Ptsd Perceptions In U.S. Military Members And Their Families: A Qualitative Study, Jennifer L. Thomson Mar 2021

Ptsd Perceptions In U.S. Military Members And Their Families: A Qualitative Study, Jennifer L. Thomson

Psychology Educator Scholarship

Post-traumatic stress disorder (PTSD) is a chronic and debilitating disorder characterized by hypervigilance and recurrent, intrusive memories of the traumatic event. Estimates for lifetime prevalence of PTSD diagnoses for United States military personnel vary widely from 10% to more than 30%. The current study aimed to investigate the attitudes and beliefs regarding PTSD and its diagnosis and treatment within U.S. military service members and their families. An online survey was administered to current and former members of the U.S. military and members of their immediate families. The results revealed low levels of mental health stigma and positive attitudes toward treatment …


The Effect Of The Pura Vida Lifestyle On Mental Health In Costa Rica, Gabrielle Sledge Jan 2021

The Effect Of The Pura Vida Lifestyle On Mental Health In Costa Rica, Gabrielle Sledge

Mahurin Honors College Capstone Experience/Thesis Projects

Costa Rica’s unofficial slogan “Pura Vida” (“Pure Life”) encapsulates how its people, Ticos, live. Ticos are known as a peaceful, homogenous people but a lack of mental health research limits assessment of Tico mental health status. The purpose of this study is to evaluate Ticos’ personal experiences and opinions to understand better how Costa Rica’s “Pura Vida” culture affects Ticos’ mental health and wellness compared to the United States. A 33-question survey addressing mental health experiences and perceptions was administered to a Costa Rican sample (n = 56) and a United States sample (n = 331). Additionally, 6 interviews were …


Examining The Impact Of Mental Health Education On Bias And Stigma In Cit Trained Officers, Jennifer L. Krause Jan 2021

Examining The Impact Of Mental Health Education On Bias And Stigma In Cit Trained Officers, Jennifer L. Krause

Walden Dissertations and Doctoral Studies

The purpose of this quantitative, correlational nonexperimental research was to examine the relationship between the mental health education received through Crisis Intervention Team (CIT) training and the perceptions of public mental health stigma, self-stigma, and attitudes toward seeking mental health services among law enforcement officers. The study’s theoretical framework integrated gender-role conflict theory and Goffman’s stigma theory in explaining the influence of the police culture on officers’ adoption of more traditional masculine roles. This research used three instruments: the Attitudes to Mental Illness questionnaire to measure perceptions of public stigma, the Self-Stigma of Seeking Help Scale to measure self-stigma, and …


Minority Stress And Alcohol Use In Sexual Minority Women's Daily Lives, Robin J. Lewis, Kelly A. Romano, Sarah J. Ehlke, Cathy Lau-Barraco, Cassidy M. Sandoval, Douglas J. Glenn, Kristin E. Heron Jan 2021

Minority Stress And Alcohol Use In Sexual Minority Women's Daily Lives, Robin J. Lewis, Kelly A. Romano, Sarah J. Ehlke, Cathy Lau-Barraco, Cassidy M. Sandoval, Douglas J. Glenn, Kristin E. Heron

Psychology Faculty Publications

No abstract provided.


The Psychosocial Impact Of Rare Diseases Among Children And Adolescents Attending Mainstream Schools In Western Australia, Esther A. Adama, Diana Arabiat, Mandie Foster, Ebenezer Afrifa-Yamoah, K. Runions, R. Vithiatharan, A. Lin Jan 2021

The Psychosocial Impact Of Rare Diseases Among Children And Adolescents Attending Mainstream Schools In Western Australia, Esther A. Adama, Diana Arabiat, Mandie Foster, Ebenezer Afrifa-Yamoah, K. Runions, R. Vithiatharan, A. Lin

Research outputs 2014 to 2021

Living with a long-term medical condition is associated with heightened risk for mental health and psychosocial difficulties, but further research is required on this risk for children and adolescents with a rare disease in the educational setting. The aim of this study is to describe parents’ perceptions of the psychosocial impact of rare diseases on their school-aged children in Western Australia. A cross-sectional survey of 41 parents of school-aged children and adolescents diagnosed with a rare disease completed an online questionnaire. Questions related to their perceptions of health-related stigma, bullying, social competencies and mental health difficulties faced by their child. …


Psychosis, Spirituality & Expressive Arts Therapy: A Literature Review, Julie Sousa May 2020

Psychosis, Spirituality & Expressive Arts Therapy: A Literature Review, Julie Sousa

Expressive Therapies Capstone Theses

This literature review explores varied treatment modalities for individuals who experience psychosis, carrying diagnoses such as schizophrenia, schizoaffective, bipolar I, or bipolar II. These individuals frequently experience marginalization and stigmatization in society. Unfortunately, this is often mirrored within the health care systems that provide treatment. These systems tend to focus heavily on symptoms, highly pathologizing client’s experiences, which can cause resistance to treatment. While psychopharmacology and traditional talk therapy are shown to be effective, they are not always sustainable. Varied treatment modalities are necessary. In order to promote more holistic treatment for these individuals, this literature review highlights recent global …


A Multifactorial Intervention To Reduce Weight Bias In Healthcare Providers, Rose M. Flinchum May 2020

A Multifactorial Intervention To Reduce Weight Bias In Healthcare Providers, Rose M. Flinchum

Evidence-Based Practice Project Reports

No abstract provided.


Associations Of Sex, Gender, And Gender Role Beliefs With Mental Health Attitudes, Ariel Erazo May 2020

Associations Of Sex, Gender, And Gender Role Beliefs With Mental Health Attitudes, Ariel Erazo

Graduate Theses and Dissertations

Mental health stigma is a strong deterrent for individual with mental illness utilizing mental healthcare. Individuals living with a mental illness experience shame and marginalization due to stigma. Stigma is perpetuated through stereotypes created and used by people in the majority. Studies have been done to assess individual’s attitudes toward mental healthcare seeking in regards to gender, age, race, and profession. This study aimed to look at traditional gender role beliefs, sex, and gender expression as predictors of individual’s mental health attitudes and individual’s views of mental health norms. Using a cross-sectional survey, 392 participants completed scales that included the …


Understanding Behavioral Health Stigma Within The Healthcare Workforce, Jason Robert Martin Jan 2020

Understanding Behavioral Health Stigma Within The Healthcare Workforce, Jason Robert Martin

Walden Dissertations and Doctoral Studies

Individuals who seek mental health treatment in the United States face significant barriers. One such barrier is the belief that those seeking mental health treatment are subpar people with some moral failure. One area where this phenomenon exists is the behavioral healthcare workforce. This study was conducted to understand the phenomenon of stigma that behavioral healthcare leaders exhibit toward behavioral healthcare patients using the Baldrige framework as its conceptual framework. Using a qualitative approach and case study design, interviews were conducted with 6 leaders within a large healthcare system in the suburbs of a major metropolitan area to evaluate their …