This study aimed to provide an in-depth understanding of the way in which the macro, meso, and micro levels of the health care system affects nutrition care practices of family physicians (FPs) and nurse practitioners (NPs). It also examined how current practices compare to the clinical practice guidelines on the management and prevention of obesity. Three different types of team-based primary care settings were included: 2 Family Health Teams, 3 Community Health Centres and 1 Nurse Practitioner-Led Clinic. Within each type of setting, six to eight FPs and NPs were interviewed (for a total n= 20). Site-specific documents and government reports were also analyzed. Findings suggest that the team-based nature improves nutrition care due to the accessibility to dietitians and cost-free service. Electronic Medical Records was an important enabler for chronic disease management. Duration of medical visits and increasing prevalence of complex patients were barriers for addressing nutrition and weight. Despite the importance of addressing obesity in primary care, the topic was approached in terms of chronic disease management rather than prevention. FPs and NPs spared the dietitian on site for patients who have more severe chronic conditions. Nevertheless, the presence of a dietitian on site increased the likelihood of primary care providers bringing up the topic of nutrition. Addressing site-specific barriers could improve nutrition care practices for weight management and chronic disease prevention in the primary care setting.

Despite generous universal social health insurance with little formal restrictions of outpatient utilisation, Austria exhibits high rates of avoidable hospitalisations, which indicate the inefficient provision of primary healthcare and might be a consequence of the strict regulatory split between the Austrian inpatient and outpatient sector. This paper exploits the considerable regional variations in acute and chronic avoidable hospitalisations in Austria to investigate whether those inefficiencies in primary care are rather related to regional healthcare supply or to population characteristics. To explicitly account for inter-regional dependencies, spatial panel data methods are applied to a comprehensive administrative dataset of all hospitalisations from 2008 to 2013 in the 117 Austrian districts. The initial selection of relevant covariates is based on Bayesian model averaging. The results of the analysis show that supply-side variables, such as the number of general practitioners, are significantly associated with decreased chronic and acute avoidable hospitalisations, whereas characteristics of the regional population, such as the share of population with university education or long-term unemployed, are less relevant. Furthermore, the spatial error term indicates that there are significant spatial dependencies between unobserved characteristics, such as practice style or patients' utilization behaviour. Not accounting for those would result in omitted variable bias.

acase@tulane.edu

acase@tulane.edu

Introduction: Previous literature indicates that foreign-born women have lower rates of cervical cancer testing and higher mortality rates when compared to U.S.-born women. Factors that influence receipt of cervical cancer screening among foreign-born women include acculturation and human papillomavirus (HPV) knowledge. Methods: In this cross-sectional study, the 2007 California Health Interview Survey (CHIS) was used to examine the impact of acculturation on cervical cancer screening and HPV knowledge and the 2000-2008 Surveillance Epidemiology and End Results (SEER) database was used to determine differences in stage of diagnosis and survival time. The study population included a total of 3,603,412 foreign-born and 6,749,557 U.S-born women in the CHIS between the age of 18 to 65 and a total of 10,733 U.S.-born and 5,069 foreign-born women in the SEER database. Logistic regression was used to examine the predictors for cervical cancer screening and Cox’s proportional hazards ratios were used to determine the effect of covariates on survival time. Kaplan-Meier survival analysis generated survival curves. Results: Acculturation levels were positively associated with ever having a Pap test, ever hearing about HPV, knowledge that HPV causes cancer and HPV does not cause AIDS, but not with current receipt of a Pap test, knowledge that HPV can be sexually transmitted and that HPV can go away without treatment. Women with low (0.38, (CI, 0.22, 0.66)) and medium (0.50, (CI, 0.39, 0.81) levels of acculturation were less likely to ever receive a Pap test and less likely to ever hear of HPV compared to highly acculturated women. Foreign-born women had a lower risk of death than U.S.-born women. Conclusions: Despite a reported lower risk of death, foreign-born women, particularly those less acculturated, may benefit from targeted interventions to increase cervical cancer screening utilization and general HPV awareness. / acase@tulane.edu

A large body of evidence suggests that short inter-pregnancy intervals negatively impact birth outcomes; however, relatively little is known about the extent to which these impacts persist beyond birth or affect children's post-natal growth and cognitive development. This thesis uses data from the Cebu, Philippines Longitudinal Health and Nutrition Survey to examine the impact of short inter-pregnancy intervals (both preceding and subsequent to the index child) on the growth and development of index children from birth to 21.5 years. The following outcomes were of interest: birth weight; birth length; linear growth from 0-2, 2-11.5, and 11.5-21.5 years; attained height at 21.5 years; cognitive performance at 8.5 and 11.5 years; and educational attainment at 21.5 years. The results show that inter-pregnancy intervals of less than 12 months negatively impact birth outcomes and early linear growth. The effect sizes were as follows: 84-93 g for birth weight; 0.23-0.32 cm for birth length; 0.83-0.94 cm for attained height at 10.5 months; and 3.0-4.2 cm for attained height at 6.75 years. These effects did not generally persist later in life and did not extend so far as to negatively impact children’s cognitive performance and educational attainment. It was sociological effects associated with sib-ship size not biological effects associated with a short inter-pregnancy interval that negatively impacted children’s cognitive development and educational attainment, with each older sibling associated with a 0.5-1.0 point deficit in IQ score and each younger sibling associated with a 1.0-2.0 point deficit in IQ score at 8.5 and 11.5 years. These results indicate that the promotion of appropriate inter-pregnancy spacing is not sufficient alone to improve child development in developing countries. To address children’s cognitive development also requires addressing family size. Further efforts are therefore needed to generate and meet demand for family planning in developing countries with high fertility rates. / acase@tulane.edu

Women in rural western Kenya experience depression, yet few formal treatment options exist. What other options for support are available to these African women suffering from depression? How do these women navigate this “therapeutic landscape” of modern and traditional care? What is the role of social capital, including faith-based and community-based networks? I used a mixed methods case study approach to explore how women in Siaya, Kenya experience depression and navigate the therapeutic landscape – the forms of health provision as understood by the women who use them – to deal with poor mental health. I conducted in-depth interviews with women suffering from depression, members of their social networks, and key informants, ranging from clinicians and healers, to community elders, depression survivors, and community group and religious leaders. I used focus group discussions to elicit contextual information and daily mobile phone diaries to collect information on small, day-to-day health actions and social network interactions. I encountered a “treatment desert” shaped by an inadequate government health system, a deteriorating indigenous healing system degraded by Christianity and modernity, and a religious healing tradition that is considered unacceptable by most women in the study site. This therapeutic landscape is rocky and difficult to navigate and low social cohesion limits the support a woman receives from her in-laws, extended family, friends, group members, and neighbors. While churches and community groups are more reliable in times of need, financial and time barriers limit their utility for promoting mental health. Given this landscape, women’s responses to depression are predominantly inward-focused, consisting of prayer, keeping quiet, and staying busy. I suggest interventions that offer lay delivery of proven therapies and build collective social capital to address this chronic burden of poor mental health among rural African women. Ultimately, the low social cohesion seen in my study is rooted in material poverty and gender inequality, including oppressive and restrictive marriages. Efforts to build the social capital women need to tackle depression should be accompanied by attention to these structural factors that degrade social cohesion. / acase@tulane.edu

Village Malaria Workers (VMWs) play an important role in the prevention and treatment of malaria as frontline volunteers in Cambodia, a nation implementing decentralisation initiatives and that is reliant on task shifting to address health worker shortages. Studying the performance of VMWs and understanding the social capital that they are able to mobilise, including enabling and reinforcing factors while fighting malaria in Cambodia’s Pailin province, will benefit performance enhancement and program scale up. This dissertation examines the factors associated with the perceived performance of VMWs, which has the potential to provide practical guidance for Cambodian health system managers and local health practitioners to capitalize on locally-available human resources to implement their health initiatives as per the country’s decentralisation plans. The study was done in 2 districts of Pailin province in Cambodia. The findings were based on 35 semi-structured surveys, 13 key informant interviews, 6 focus group discussions, 3 group interviews and 2 in-depth interviews covering VMWS and stakeholders from the commune council, village health support groups, health center management committee, provincial health offices, a referral hospital, a pharmacy, village chiefs, and administrative officials. The interviews and discussions were conducted using set guides, which allowed for flexibility and asking for follow-up questions as well as probing for more information and clarification. Pre-determined themes were used in designing the instruments, and data from the survey, focus groups, and interviews were thematically coded for manual data analysis. This study showed that VMWs’ performance is affected by a variety of factors that emerge from the complex context in which they work. These include socio-demographic variables; their health system knowledge; access to enabling and reinforcing factors, including family and social support; personal motivation; resource availability, including budget, supplies, and equipment; ways of being selected; access to learning, training and capacity-building opportunities; and institutional communication and implementation of decentralised health program. Factors such as perceived corruption also were seen to affect VMW’s performance. The participants suggested various ways to address these challenges. In order to improve the performance of VMWs, people’s participation in all local governance arms, including the CC, VHSG, HCMC and the HC, needs to be strengthened. The roles and expectations regarding citizen participation need to be clarified using simple messages. Training and capacity-building support needs to be made available for learning key new skills as relevant. The equipment and supplies necessary for work as well as adequate reimbursement of transportation allowances need to be provided along with instilling a proper system of VMW supervision and mentoring that adequately recognises those that are high performing. Targeted capacity assessments for VMWs and the VHSG, HC and HCMC need to be undertaken followed by needed training and mentoring in order to address areas that need further support to enhance productivity. A volunteer selection process needs to follow the rules described in the CPP policy ensuring deliberate attempts to open up entry points for public service to those that have been excluded on the basis of formal qualifications, lack of kinship, or political affiliation. / acase@tulane.edu

acase@tulane.edu

Background An ongoing public policy concern in the United States is disparities in health care for racial/ethnic minority populations. The National Healthcare Disparities Report (NHDR) addresses these disparities for chronic diseases such as diabetes that impose economic and health burdens on society that need to be partly managed by health care policies. One understudied aspect of diabetes care is racial/ethnic disparities in the pharmacological management of the disease. Objective The objective of this study was to determine whether racial/ethnic disparities exist in the pharmacological treatment of diabetes, and if so, how do individual characteristics such as socioeconomic status (SES) influence the differences. Methods This study used national survey data collected through the 2010 Medical Expenditure Panel Survey (MEPS). Racial/ethnic disparities in diabetes treatment were examined using a methodology based on the Institute of Medicine (IOM) definition of disparity that adjusts for health status factors while allowing SES factors to mediate differences. The effects of independent variables on receipt of antidiabetic medication prescriptions among individuals who self-reported a diagnosis of diabetes were examined. Regression analyses were performed on unadjusted data and on data transformed by a rank-and-replace method to approximate the IOM definition. Results Among 1,844 survey respondents with self-reported diabetes, significant differences were found for race/ethnicity, education, health insurance, and the co-morbidities of heart disease and eye problems/retinopathy. Race/ethnicity was a significant predictor of the receipt of antidiabetic prescriptions, with Hispanics being more than 2 times as likely as non-Hispanic whites to have received a prescription. This difference was magnified in the IOM model that controlled for health status. In the IOM model, no significant differences were observed between non-Hispanic whites and non-Hispanic blacks or other minorities. Having health insurance, higher education, or eye problems/retinopathy were also significant predictors of receiving antidiabetic prescriptions. Conclusion Using a methodology that adjusts for factors related to health status while allowing factors related to SES to mediate racial/ethnic differences, disparities were observed between non-Hispanic whites and minorities, particularly Hispanics, in the likelihood of receiving a prescription for antidiabetic medication. The agreement of these results with the few studies on the pharmacological management of diabetes is mixed, and suggests the need for additional studies. Application of a rigorous definition of racial/ethnic disparities and the implementation of methodologies that adjust for health status while allowing mediation by SES factors are needed to address important gaps in the treatment of diabetes. / acase@tulane.edu