Public Health Commons^™

A Medical Perspective On Policy Prohibiting Gender-Affirming Care For Missouri Minors: A Policy Review, Hayley Lange

Capstone Experience: Master of Public Health

The Save Adolescents from Experimentation (SAFE) Act is a law enacted in August of 2023 that bans gender-affirming medical care for individuals under eighteen years old in Missouri and states any medical provider who gives medical gender-affirming care to a minor will have their professional medical license revoked. The impact of medical professionals withholding proven gender-affirming care is a clear concern for the medical community, advocates, and other care professionals.
/="/">
/="/">PURPOSE: The purpose of this policy review is to compare the content of the Missouri Save Adolescents from Experimentation (SAFE) Act with states with similar policies and standard-of-care …

One Year Follow Up Of A Cross-Sectional Study Of Hookworm Infection And Response To Deworming In Beposo, Ghana, Taylor Clarkson

Capstone Experience: Master of Public Health

Hookworms are soil-transmitted helminths that infect over 500 million people worldwide, primarily those in low-income countries. Infection with hookworm can cause anemia, malnutrition, and stunted physical and cognitive development. Deworming campaigns have attempted to combat hookworm infections in endemic areas for decades. However, there is growing variability in the effectiveness of deworming drugs, and post-treatment reinfections are abundant. There are significant gaps in our understanding of critical host-parasite factors that mediate hookworm infection, reinfection, and response to deworming treatment in endemic communities. A five-year prospective study was undertaken to better understand drivers of hookworm infection in rural Ghana and thus …

Hiv Testing Among High-Risk Individuals In The Us: 2022 Brfss, Alissa Lorchick

Capstone Experience: Master of Public Health

Objective

Human Immunodeficiency Virus (HIV) infection is a global epidemic, and public health efforts are moderately effective to date. This cross-sectional study aimed to determine association between high-risk behavior (intravenous drug use, risky sexual behaviors) and odds of testing for HIV utilizing 2022 Behavioral Risk Factor Surveillance System (N= 445,132).

Methods

Using SAS 3.82, the age-stratified logistic regression model for exposure (high-risk behavior) and outcome (HIV testing) included covariates gender, race, income, mental health and checkup frequency.

Results

High-risk individuals had greater odds of testing compared to low-risk individuals (crude POR 2.98 [2.81 – 3.17]), with greatest odds observed among …

Evaluating The Association Of Influenza Vaccination On Long-Term Covid-19 Symptoms In U.S. Adults, Ratnakar Pingili

Capstone Experience: Master of Public Health

Objective. To evaluate the association of influenza vaccination in the past 12 months with Long COVID effects and clinical and sociodemographic factors.

Methods. Cross-sectional study with data from the 2022 Behavioral Risk Factor Surveillance System (BRFSS), covering 415,132 non-institutionalized U.S. adults with a confirmed COVID-19 diagnosis and influenza vaccination reported within the last 12 months. Logistic regression was conducted between influenza vaccination (exposure) and Long COVID (outcome), controlling for demographic variables, pre-existing health conditions, and socioeconomic status.

Results. Of 120,603 participants, 21.89% reported Long COVID symptoms and 42.04% had received an influenza vaccine. Findings indicate a statistically significant 13% reduction …

Disparities In Seasonal Influenza Immunization Between Hispanic And Non-Hispanic White Populations Within The United States: Findings From The 2022 Behavioral Risk Factor Surveillance System, Susanna Stageberg

Capstone Experience: Master of Public Health

Objective: To determine if inequities in influenza immunization exist between Hispanic and non-Hispanic White populations living in the United States.

Methods: Statistical analyses were executed to study the association between ethnicity and influenza immunization. Logistic regression was performed to determine probabilities related to vaccination. Data from the 2022 Behavioral Risk Factor Surveillance System (BRFSS) was utilized.

Results: Hispanic respondents had higher odds of not being vaccinated against the flu when compared to non-Hispanic White respondents (COR = 1.82, 95% CI [1.73, 1.91]). Ethnicity, household income, education, insurance status, age, sex, preferred language, and primary care provider status …

Association Between Depression And Coronary Heart Disease: A Cross-Sectional Study Using Behavioral Risk Factor Surveillance System (Brfss), 2022, Juliana Monono

Capstone Experience: Master of Public Health

Objectives: To examine the association of depression and coronary heart disease in U.S. adults.

Methods: This cross-sectional study uses the Behavioral Risk Factor Surveillance System (BRFSS), 2022 data for non-institutionalized U.S adults aged 18 and older. The exposure variable is depression, the outcome is coronary heart disease (CHD), and covariates are age, race, education, and physical activity. Performed univariate, bivariate, and multivariate analyses to assess the association between depression and CHD.

Results: The analytical sample size consisted of 427,217 individuals. A total of 88,841(20.7%) of the population reported having coronary heart disease, while 338,376(70.3%) reported having no …

Examining The Association Between Smoking Frequency And Long Covid: A Brfss Study, Bhavya Patel

Capstone Experience: Master of Public Health

Objectives: To examine the relationship between self-reported smoking frequency and the presence of Long COVID among individuals who tested positive for COVID-19.

Methods: A cross-sectional study was conducted using a sample of 44,738 COVID-positive participants from the 2022 Behavioral Risk Factor Surveillance System (BRFSS) dataset. Logistic regression was utilised to compute prevalence odds ratios (pOR) and was adjusted for potential sociodemographic confounders.

Results: Individuals who smoked daily were found to have a greater likelihood of reporting Long COVID in comparison with nonsmokers (Crude pOR=1.22; CI= [1.10-1.35]). However, in the adjusted regression model, daily smoking was no longer significant (Adjusted pOR=1.04; …

Association Between Long Covid-19 And Insurance Status Using The Behavioral Risk Factor Surveillance System (2022), Elizabeth E. Osbourn

Capstone Experience: Master of Public Health

Objective. To determine if insurance status can directly predict self-diagnosed Long COVID and what sociodemographic factors are significantly associated with a self-diagnosis of Long COVID among those who tested positive for COVID-19.

Methods. This cross-sectional study uses data from the 2022 Behavioral Risk Factor Surveillance System to conduct a multivariate logistic regression model analysis. Out of 445,132 participants, 110,402 participants were identified to be used in this study.

Results. After testing positive for COVID-19, 21.7% of individuals were self-diagnosed with Long COVID. After controlling for confounders, insurance status wasn't significant (p-value: 0.8458). However, in crude analysis, individuals with Medicaid (cPOR:1.44; …

Cervical Cancer Screening And Affordability Of Medical Care: A Cross-Sectional Study, Sarah M. Johnson

Capstone Experience: Master of Public Health

Objective: To determine if, among women aged 21-65, there is a positive association between avoiding healthcare due to cost and not being up to date on cervical cancer screening.

Methods: This cross-sectional study utilized the 2022 Behavioral Risk Factor Surveillance System dataset. A total of 123,275 women, aged 18-69 without a hysterectomy, were analyzed with bivariate and multivariate analyses. The outcome was length of time since last cervical cancer screening. The exposure was avoiding healthcare in the last 12 months due to cost.

Results: Women who avoided healthcare due to cost had higher odds of not being up to date …

A Cross-Sectional Analysis Of Self-Reported Long Covid And Binge Drinking Amongst Covid-Positive Individuals Using The Behavioral Risk Factor Surveillance System (Brfss), 2022, Maire Kirley

Capstone Experience: Master of Public Health

Objective: Identify an association between Long COVID (exposure) and binge drinking (outcome) amongst COVID-positive individuals.

Methods: COVID-positive respondents (n=116,120) were sampled from the 2022 Behavioral Risk Factor Surveillance System (BRFSS). Univariate analysis assessed distribution of Long COVID, binge drinking, and covariates sex, age, race/ethnicity, education, income, rural/urban residency, veteran status and BMI. Bivariate analysis determined crude prevalence odds ratios (POR) between exposure, outcome, and covariates. Multivariate logistic regression determined adjusted prevalence odds ratios (aPOR) and 95% confidence intervals (95% CI) for exposure, outcome and covariates.

Results: No association found between Long COVID and binge drinking (aPOR: 0.94 (95% CI: 0.87, …

Heartache Beyond The Physical: Unraveling The Nexus Between Myocardial Infarction History And Depressive Disorders In Us Adults, Sonika Khanal

Capstone Experience: Master of Public Health

Objective: To estimate the prevalence of depressive disorders among US adults and explore the association between a history of Myocardial Infarction (MI) and depressive disorders, considering potential risk factors and demographic variables.

Methods: A cross-sectional study was conducted from 2022 Behavioral Risk Factor Surveillance System data, including 390,429 US adults. Logistic regression was used to estimate the association between the history of MI and depressive disorders, adjusting for age, gender, race, smoking status, health insurance, education level, and BMI. Effect modification by age was assessed.

Results: The prevalence of depressive disorders was 21.19%, with 4.46% reporting a …

Examining The Relationship Between Deafness And Mental Health Status: An Analysis Of The Behavioral Risk Factor Surveillance System (Brfss) 2022, Brianna Stroud-Williams

Capstone Experience: Master of Public Health

Objective: The objective of the research is to examine the association between mental health status as measured by number of mentally healthy days in the past month and deafness and binge drinking.

Methods: The Behavioral Risk Factor Surveillance System (BRFSS) study was conducted via telephone survey in 50 states, including the District of Columbia and US territories. The sample size is 402,156 participants. Univariate, bivariate, and multivariate regressions, odds ratio, and 95% confidence interval were used to measure the data.

Results: Deaf respondents have 1.56 times the odds of having poor mental health than those who are not deaf. (95% …

The Impact Of Household Income On The Development Of Long-Covid After Covid-19 Infection, Clayton Mowrer

Capstone Experience: Master of Public Health

Objective

Long-COVID can occur following coronavirus-19 infection and can have debilitating consequences. It is unclear how household income (a social determinant of health) might impact the development of long-COVID. This study aims to characterize and compare the prevalence of long-COVID in persons who have been diagnosed with COVID-19, according to household income.

Methods

Using data from the 2022 Behavioral Risk Factor Surveillance System Questionnaire, 124,313 respondents who reported a diagnosis of COVID-19 infection were analyzed for the development of long-COVID (outcome) and compared across annual household income (exposure). Other demographic and socioeconomic factors were similarly analyzed.

Results

The prevalence of …

Factors Predictive Of The Development Of Surgical Site Infection In Thyroidectomy, A Replication Study Of Myssiorek (2018), Kaitlyn M. Kenig

Capstone Experience: Master of Public Health

The original study aimed to show that thyroidectomy does not result in surgical site infection (SSI) in most cases, and thus routine prescription of antibiotics is not necessary. The study looked to see what risk factors could predict the incidence of SSI. This would highlight those individuals who were at most risk of developing SSI, and then antibiotics would only be prescribed to these individuals instead of all or most individuals who undergo thyroidectomy.

This study used NSQIP data to look at incidence of SSI and look for risk factors that may be predictive of SSI. Only surgeries that were …

A Replication Study-Postoperative Complications In Bariatric Surgery Using Age And Bmi Stratification: A Stusy Using Acs-Nsqip Data (2014), Aruna Sree Posanipalle

Capstone Experience: Master of Public Health

This study aims to replicate the findings of Sanni et al.'s (2014) research on postoperative complications in bariatric surgery patients. The original research utilized age and BMI stratification and data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) to identify the relationship between these variables and postoperative complications. The findings of the original study revealed significant associations between age, BMI, and postoperative complications. The replication plan aims to confirm these associations and identify the factors that lead to postoperative complications in patients undergoing bariatric surgery. The replication study proposes a comprehensive plan consisting of three …

Exploring The Impact Of A History Of Depression On Physical Activity In The United States: A Cross-Sectional Study, Behavioral Risk Factor Surveillance System (Brfss), 2022, Maxime Kwizera

Capstone Experience: Master of Public Health

Objective: To determine the association between a history of depression and engagement in physical activity among U.S. adults.

Method: Data were from the 2022 Behavioral Risk Factor Surveillance System survey (N=441,348). Univariate and bivariate analyses were performed to determine the distribution of sample characteristics and crude prevalence odds ratios. Weighted multivariate logistic regression stratified by age group assessed the relationship between physical activity engagement and covariates.

Results: In our sample, 20.63% had a history of depression, and 23.89% of adults reported not exercising within the past 30 days. Adults with a history of depression had 1.42 times the odds …

Exploring Binding Pockets In The Conformational States Of The Sars-Cov-2 Spike Trimers For The Screening Of Allosteric Inhibitors Using Molecular Simulations And Ensemble-Based Ligand Docking, Grace Gupta, Gennady M. Verkhivker

Mathematics, Physics, and Computer Science Faculty Articles and Research

Understanding mechanisms of allosteric regulation remains elusive for the SARS-CoV-2 spike protein, despite the increasing interest and effort in discovering allosteric inhibitors of the viral activity and interactions with the host receptor ACE2. The challenges of discovering allosteric modulators of the SARS-CoV-2 spike proteins are associated with the diversity of cryptic allosteric sites and complex molecular mechanisms that can be employed by allosteric ligands, including the alteration of the conformational equilibrium of spike protein and preferential stabilization of specific functional states. In the current study, we combine conformational dynamics analysis of distinct forms of the full-length spike protein trimers and …

A Randomized Controlled Study Of The Effects Of Targeted Health Education On Uptake Of Contraceptives Among Women Of Reproductive Age In Nnewi City, South-East Nigeria, Yanmeer Tyotswam, Rosebella Iseme-Ondiek, Eliphas Makunyi

Population Health, East Africa

Objective: There is a need for contraception uptake among people to enable them to fulfil their right to determine the timing, number and spacing of their children. In regions with poor contraceptive prevalence rates, lack of effective education has been largely implicated, and Nigeria falls among such regions. Thus, the present study is designed to examine the impact of an educational intervention on uptake of contraceptives among women aged 18–49 years seeking care at the Nnamdi Azikiwe University Teaching Hospital Nnewi.

Methods: Being an interventional study to underscore the effect of targeted health education on uptake of contraceptives, …

A Radiotherapy Community Data-Driven Approach To Determine Which Complexity Metrics Best Predict The Impact Of Atypical Tps Beam Modeling On Clinical Dose Calculation Accuracy, Fre'etta Mae Dayo Brooks, Mallory Carson Glenn, Victor Hernandez, Jordi Saez, Hunter Mehrens, Julianne Marie Pollard-Larkin, Rebecca Maureen Howell, Christine Burns Peterson, Christopher Lee Nelson, Catharine Helen Clark, Stephen Frasier Kry

Faculty, Staff and Student Publications

PURPOSE: To quantify the impact of treatment planning system beam model parameters, based on the actual spread in radiotherapy community data, on clinical treatment plans and determine which complexity metrics best describe the impact beam modeling errors have on dose accuracy.

METHODS: Ten beam modeling parameters for a Varian accelerator were modified in RayStation to match radiotherapy community data at the 2.5, 25, 50, 75, and 97.5 percentile levels. These modifications were evaluated on 25 patient cases, including prostate, non-small cell lung, H&N, brain, and mesothelioma, generating 1,000 plan perturbations. Differences in the mean planned dose to clinical target volumes …

Obstacles To Optimal Antenatal Corticosteroid Administration To Eligible Patients, Kara M Rood, Lynda G Ugwu, William A Grobman, Jennifer L Bailit, Ronald J Wapner, Michael W Varner, John M Thorp, Steve N Caritis, Alan T N Tita, George R Saade, Dwight J Rouse, Sean C Blackwell, Jorge E Tolosa

Faculty, Staff and Student Publications

Background

Administration of antenatal corticosteroids (ANCS) is recommended for individuals expected to deliver between 24 and 34 weeks of gestation. Properly timed administration of ANCS achieves maximal benefit. However, more than 50% of individuals receive ANCS outside the recommended window.

Objective

To examine maternal and hospital factors associated with suboptimal receipt of ANCS among individuals who deliver between 24–34 weeks gestation.

Study Design

Secondary analysis of the Assessment of Perinatal Excellence (APEX), an observational study of births to 115,502 individuals at 25 hospitals in the US from March 2008–February 2011. Data from 3123 individuals who gave birth to a non-anomalous …

Maternal Diabetes And Intrapartum Fetal Electrocardiogram, Beth A Plunkett, Steven J Weiner, George R Saade, Michael A Belfort, Sean C Blackwell, John M Thorp, Alan T N Tita, Russell S Miller, David S Mckenna, Edward K S Chien, Dwight J Rouse, Yasser Y El-Sayed, Yoram Sorokin, Steve N Caritis, Eunice Kennedy Shriver National Institute Of Child Health And Human Development Maternal-Fetal Medicine Units (Mfmu) Network

Faculty, Staff and Student Publications

Objective:

Fetal electrocardiogram (ECG) ST-changes are associated with fetal cardiac hypoxia. Our objective was to evaluate ST-changes by maternal diabetic status and stage of labor.

Methods:

Secondary analysis of a multi-centered randomized-controlled trial in which laboring patients with singleton gestations underwent fetal ECG scalp electrode placement and were randomly assigned to masked or unmasked ST-segment readings. Our primary outcome was the frequency of fetal ECG tracings with ST-changes by stage of labor. ECG tracings were categorized into mutually exclusive groups (ST-depression, ST-elevation without ST-depression or no ST-changes). We compared participants with pre-gestational diabetes mellitus (DM), gestational DM (GDM), and no …

Comparative Analysis Of Acceptance And Commitment Therapy’S Effectiveness In An Intensive Outpatient Program Setting, Efrain Frank Ellin Iii

Electronic Theses and Dissertations

This thesis presents a comparative analysis of acceptance and commitment therapy (ACT) and treatment as usual (TAU) within an intensive outpatient program setting, evaluating their effectiveness in enhancing various dimensions of psychological well-being. Guided by two main research questions, the study investigates whether ACT demonstrates greater or equal effectiveness compared to TAU and if it provides more immediate effects on psychological well-being within three weeks. Utilizing a quasi-experimental design, the research incorporates a comprehensive array of measurement tools to assess outcomes related to anxiety, depression, stress, psychological flexibility, cognitive flexibility, emotion regulation, mindfulness self-efficacy, and life satisfaction among participants. The …

Toward A Politics Of Care: Southeast Asian Refugee Organizing, Kinship, Care, And Reunion, James Huỳnh, Victoria Huỳnh, Mads Lê, Sheila Sy

Faculty, Staff and Student Publications

From a critical refugee studies orientation, our article redefines care within the context of myriad forms of state violence impacting Southeast Asian post-war refugee communities. Research reveals how harm is compounded at every step of Southeast Asian refugee journeys: war, forced displacement, resettlement, family separation, inherited health conditions, and generational trauma. How do we reckon with refugee trauma without conceding to it as an unchangeable fact of our lives? What knowledge might we gain by attending to the everyday work of survival in refugee communities? To answer these questions, the authors conceptualize care through (a) abolitionist organizing, (b) queer kinship …

Optimized Scoring Of End-To-End Dosimetry Audits For Passive Motion Management – A Simulation Study Using The Iroc Thorax Phantom, Alex Burton, Mathieu Gaudreault, Nicholas Hardcastle, Jessica Lye, Sabeena Beveridge, Stephen F Kry, Rick Franich

Faculty, Staff and Student Publications

Dosimetry audits for passive motion management require dynamically-acquired measurements in a moving phantom to be compared to statically calculated planned doses. This study aimed to characterise the relationship between planning and delivery errors, and the measured dose in the Imaging and Radiation Oncology Core (IROC) thorax phantom, to assess different audit scoring approaches. Treatment plans were created using a 4DCT scan of the IROC phantom, equipped with film and thermoluminescent dosimeters (TLDs). Plans were created on the average intensity projection from all bins. Three levels of aperture complexity were explored: dynamic conformal arcs (DCAT), low-, and high-complexity volumetric modulated arcs …

Sars-Cov-2 Viral Load In The Nasopharynx At Time Of First Infection Among Unvaccinated Individuals, Leigh H Fisher, Jia Jin Kee, Albert Liu, Claudia M Espinosa, April K Randhawa, James Ludwig, Craig A Magaret, Samuel T Robinson, Peter B Gilbert, Ollivier Hyrien, James G Kublin, Nadine Rouphael, Ann R Falsey, Magdalena E Sobieszczyk, Hana M El Sahly, Beatriz Grinsztejn, Glenda E Gray, Karen L Kotloff, Cynthia L Gay, Brett Leav, Ian Hirsch, Frank Struyf, Lisa M Dunkle, Kathleen M Neuzil, Lawrence Corey, Yunda Huang, Paul A Goepfert, Stephen R Walsh, Lindsey R Baden, Holly Janes, Covid-19 Prevention Network (Covpn)

Faculty, Staff and Student Publications

Importance: SARS-CoV-2 viral load (VL) in the nasopharynx is difficult to quantify and standardize across settings, but it may inform transmission potential and disease severity.

Objective: To characterize VL at COVID-19 diagnosis among previously uninfected and unvaccinated individuals by evaluating the association of demographic and clinical characteristics, viral variant, and trial with VL, as well as the ability of VL to predict severe disease.

Design, setting, and participants: This secondary cross-protocol analysis used individual-level data from placebo recipients from 4 harmonized, phase 3 COVID-19 vaccine efficacy trials sponsored by Moderna, AstraZeneca, Janssen, and Novavax. Participants were SARS-CoV-2 negative at baseline …

The Importance Of Framing The Context Of Black/African Americans' Livelihood To Enhance Health Outcomes And Mitigate Health Inequalities, Elvis Gyan

Theses, Dissertations and Culminating Projects

This study investigates the portrayal of Black/African Americans in Health Marriage and Relationship Education (HMRE) programs, which predominantly follow Eurocentric models while examining how social and structural determinants (e.g., community context) influence stress levels, general health, and relationship satisfaction through two main objectives. Firstly, it aims to scrutinize the acknowledgment of biases towards non-Eurocentric communities in published Administration of Children and Families HMRE programs, analyzing 39 research studies. Secondly, it examines the interplay between perceived community context, stress as a mediator, general health, and relationship satisfaction among Black/African Americans across three distinct articles by testing hypothesized process models. Results for …

Factors Affecting The Use Of Food Pantries By California State University Students, Beyza Aktepe

Electronic Theses, Projects, and Dissertations

Food insecurity is one of the major public health issues world-wide including the United States. A significant proportion of students within the California State University (CSU) system, approximately 41.6%, experience food insecurity. The purposes of this study was 1) to determine the factors and barriers that affect the use of campus food pantries by university students on seven CSU campuses, 2) to determine the improvements that can be implemented in the on-campus food pantries, 3) to evaluate the effectiveness of the management of food pantries, and 4) to evaluate the effectiveness and utilization of nutrition education services provided in conjunction …

Reframing Addiction As A Coping Response: A Needed Shift In Modern Public Health Paradigms, Anthony King

UNLV Theses, Dissertations, Professional Papers, and Capstones

What are the primary risk factors that compel one person towards addiction and not another? After decades of research, there is still no clear consensus. Some experts say addiction is a brain disease; others say it is a willful act, or even an outright crime. Nevertheless, the three research studies contained within this dissertation suggest an alternative, more parsimonious public-health-centered framework for viewing addictive behavioral patterns: as a biopsychosocial coping strategy for past and present stressors. In Study 1, this idea was examined by evaluating how symptoms of posttraumatic stress disorder (PTSD) were associated with problem gambling severity, different gambling …

Unraveling The Relationship Between Social Vulnerability Index And Covid-19 Prevalence In Southern Nevada, Andrea Lopez

UNLV Theses, Dissertations, Professional Papers, and Capstones

The COVID-19 pandemic was a catastrophic global event that exacerbated public health issues and disparities, especially in socially vulnerable communities. Thus, this study examines areas classified by the CDC's Social Vulnerability Index (SVI) metric, which assesses vulnerable communities experiencing adverse events through sixteen social determinants that impact health. The purpose of this study will be to determine if (1) COVID-19 testing rates and/or COVID-19 vaccination rates mediate SVI and COVID-19 prevalence rates and (2) if COVID-19 testing rate and COVID-19 vaccination rates serially mediate SVI and COVID-19 prevalence rates. In order to achieve this, census tracts within Southern Nevada will …

Behavioral Health, Mental Health, And Overall Well-Being Of Informal Caregivers Before And After The Covid-19 Pandemic, Zahra Mojtahedi

UNLV Theses, Dissertations, Professional Papers, and Capstones

Informal caregivers, such as relatives or close friends, are vital for maintaining the welfare of the individuals they provide care for. However, caregiving can be difficult and stressful that adversely impacts caregivers’ health. The extra stress brought on by the COVID-19 pandemic can potentially aggravate health problems, particularly mental health. The current research aimed to nationally analyze whether the COVID-19 pandemic was significantly associated with behavioral health (physical activity and smoking), mental health (worrying, nervousness, hopelessness, little interest, and psychological distress score), and the perception of overall well-being among informal caregivers in the United States. Whether behavioral health could mediate …